2. Influence of Hospital Safety Climate on Patient Satisfaction and Quality of Nursing Care
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Cite this Article: Wafaa Abd El-Azeem El-Hosany and Wafaa Fathi Sleem.
Influence of Hospital Safety Climate on Patient Satisfaction and Quality of
Nursing Care, International Journal of Management, 6(9), 2015, pp. 110-120.
Reporting of patient outcomes have become an important data collection tool and an
essential activity for improving patient satisfaction and quality of healthcare. Fast
reporting of patient outcomes means that emergency measures can be taken,
undesirable complications can be prevented, and consequently protecting patient from
harm . Despite its strengths, many outcome events are not reported. This could be
because of omitted medical records, lack of recognition, fears that staff would be
blamed and punished, worry about litigation and disciplinary actions, high workload,
attitudes to reporting events, and the belief that reporting can be harmful to the
reporter or his /her colleagues and that it will not improve the quality of care but
rather be judged negatively .
Improving reporting of patient outcome events has been successfully done through
appropriate implementation of safety climate including leadership, organizational
structural characteristics, work design, group behavior, and quality emphasis . HSC
is a subset of safety culture and it refers to the perceptions and attitudes of the
organization’s (e.g. hospitals) workforce and staff about patient safety and surface
features of the safety culture within the organization’s (e.g. hospitals) at a given point
in time .
Measuring HSC is important because the climate of an organization and the
attitudes of teams have been found to influence patient safety outcomes. These
measures can be used to monitor change over time and to implement intervention
programs aimed at improving patient safety. It may be easier to measure safety
climate than to measure safety culture .
Several safety climate instruments have been developed for measuring safety
climate in health care [6,7] whereas two safety climate instruments have been
developed for exploring safety climate related to medication safety on patient care
units [8,9]. Therefore, it is a pressing necessity to start an action for assessment of
HSC and its effect on patients’ satisfaction, outcomes and quality of healthcare at
Egyptian emergency hospitals.
Based on our knowledge, the two studies only examined relationships between
safety climate and barriers to reporting medication administration errors in some
Egyptian hospitals [10, 11]. One Egyptian study has been conducted on safety climate
and its connection to barriers of and attitudes to reporting patient safety events .
However, no previous studies, to our knowledge, of HSC and its influence on patient-
related factors including satisfaction, outcomes and quality of healthcare have been
conducted in Egypt.
Anticipated benefits from better HSC would stem from the ability of organizations
with strong safety climates to cultivate behaviors that enhance collective learning by
addressing unproductive beliefs and attitudes about errors, their cause and cure.
Obtaining better information about the relationship between hospital safety climate
and quality of care would be beneficial. By highlighting the importance of safety
climate, such information would facilitate the development of benchmarks and
initiatives to improve it. Further recognition of safety climate’s importance would
promote collaboration within and among organizations to compare the measures of
3. Wafaa Abd El-Azeem El-Hosany and Wafaa Fathi Sleem
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safety climate and share useful approaches. Such information would also help hospital
managers and clinicians target approaches to safety improvement of greatest potential
2. AIM AND DESIGN
2.1 Research aim: This research aimed to investigate influence of HSC on patient's
satisfaction and quality of nursing care
2.2 Research hypothesis: There are significant effects of HSC on patients’
satisfaction and quality of nursing care.
2.3 Research Design: Descriptive co relational design was utilized.
3.1. SUBJECTS AND METHODS
This study was conducted at Mansoura Emergency Hospitals. The hospitals were
affiliated to Mansoura Teaching University Hospitals and provide a wide spectrum of
health services at Delta Region.
3.2. Subjects: Two groups of subjects were included in this study:
The first group included convenient sample of nurses on duty with no age limitation
(n=100 nurses). The second group included average of total number of patients
admitted through one month (n= 95 patients).
3.3. Tools for Data Collection
Data was collected by using 3 assessment tools:
Tool (1) Hospital Safety climate questionnaire (HSC):
It consisted of two parts:
Demographic characteristics of the studied nurses, which comprised of age, years of
experience, marital status and educational qualifications.
HSC questionnaire developed by Gershon et al. [12, 13] was used. There were 46
HSC items included in the scale and covered 9 major dimensions. Response was
measured on 5 point likert scale ranged from strongly agree: strongly disagree.
Tool (2) Patient satisfaction questionnaire that consisted of two parts:
Demographic characteristics of the studied patients, which comprised of patients’
age, gender, affiliated departments and length of stay.
Patient satisfaction questionnaire developed by Eskander  was used to
assessing patients satisfactory perception related to care process from admission to
discharge from the hospital. The questionnaire included 58 items and covered 9
aspects. Response was measured in the form of yes, sometimes and no.
Tool (3) Healthcare providers’ questionnaire developed by Farag  was used to
determine quality approaches. The sheet comprised of 74 statements. The
questionnaire was divided into three approaches; two quality approaches (structure
and process) and one outcome approach (outcome of health care).
Two quality approaches consisted of 66 statements; 44 of them related to structure
and these classified into 7 main areas and the remaining 22 statements related to
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process and classified into 6 main areas.(2)One outcome approach consisted of 8
statements related to outcome of health care and classified into 3 main areas.
Statements under 3 approaches have a score from 1 to 10, where 1 is the least
important and 10 is the most important. Nurses have to score each statement
according to its important from her point of view.
3.4. Methods of data collection
Informed consent to conduct the study was taken from the administrative personal
of the University Hospital and Research Ethics Committee of Mansoura Nursing
The tools were translated into Arabic language. It was submitted to a jury
consisting of 3 professors in nursing administration to be tested for its content
validity. Reliability testing of these tools was assessed by Cronbach’s alpha test in
SPSS version 20.0.
A pilot study was carried out on 10% of study sample in order to test clarity of
questions, also to estimate the needed time to fill it, and all nurses and patients
involved in the pilot study were excluded from the study sample later on.
The researchers contacted the nurses and patients to explain the purpose and
procedure of the study and determine the available time to collect data. The
questionnaires were distributed to the studied sample. Data collection was completed
over four-month period, from January to April 2015.
The total sample of nurses was composed of 100 female nurses with mean age of
32.03 ±7.6 years. The majority of them were graduated from Technical Nursing
Institute (58.0%). The mean total experience of studied nurses was 12.4 ±8.1 years
with more than half of them had >10 years experience (52.0%).
The study also included 95 patients from different departments with mean age of
32.0 ±18.6 years. More than three quarter of them were males (75.8%). . The mean
length of stay of studied patients was 9.4 ±5.1 days with sixty percent of them stayed
for less than one week, as shown in Table 1.
Levels of hospital safety climate according to the response of participating nurses
were presented in Table 2. Only four percent of the studied nurses reported that the
safety program elements were highly sufficient to achieve hospital safety climate. The
most poorly developed item of hospital safety was design, maintenance, and
housekeeping of the work site, where 63.0% of the nurses reported it as the lowest
safety item. Meanwhile, the most highly developed item of hospital safety was
accessibility, availability, and quantity of safety equipment and supplies and
engineering controls, where 28.0% of the nurses reported it as the highest safety item.
Totally, HSC score was low (50%) or moderate (50%) as reported by the studied
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Table 1 Demographic data of the participating nurses (n=100) and patients (n=95):
Demographic data of nurses No. %
<30 47 47.0
30-39 32 32.0
40-50 21 21.0
Mean ± SD 32.03 ±7.615
Bachelor 25 25.0
Technical health Institution 2 2.0
Technical nursing Institute 58 58.0
Secondary nursing school 15 15.0
Total experience (years)
<5 23 23.0
5-10 26 26.0
> 10 52 52.0
Mean ± SD 12.4±8.1
Demographic data of patients
< 18 17 17.9
18- 27 34 35.8
28- 37 14 14.7
˃ 37 30 31.6
Mean ± SD 12.4±8.1
Female 23 24.2
Male 72 75.8
Orthopedic 38 40.0
Ear, nose and throat 11 11.6
Neurology 11 11.6
Neurosurgery 7 7.4
Cardio-vascular 6 6.3
Emergency unit 5 5.3
Surgery 5 5.3
Cardiothoracic surgery 5 5.3
Toxicology 4 4.2
Ear, nose and throat surgery 3 3.2
Length of stay
< 2weeks 57 60.0
2-4 weeks 24 25.3
> 4 weeks 14 14.7
Mean ± SD 9.38 ±5.090
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Table 2 Levels of hospital safety climate as reported by study nurses (n=100).
Components of hospital safety climate
Low moderate High
No. % No. % No. %
Safety program elements 46 46.0 50 50.0 4 4.0 13.9±4.3
Support for safety programs 53 53.0 40 40.0 7 7.0 27.2±8.9
Senior management support for safety 38 38.0 49 49.0 13 13.0 15.3±3.98
Communication and feedback about
48 48.0 43 43.0 9 9.0 23.9±6.3
Accountability and responsibility 43 43.0 46 46.0 11 11.0 8.1±2.97
Accessibility, availability and quantity of
safety equipment, supplies and
31 31.0 41 41.0 28 28.0 12.7±3.5
Design, maintenance, and housekeeping
of the work site
63 63.0 27 27.0 10 10.0 7.6±2.95
Training and education 59 59.0 35 35.0 6 6.0 10.1±3.7
Absence of job hindrances to safety 62 62.0 31 31.0 7 7.0 9.6±4.02
Total score 50 50.0 50 50.0 0 0.0 128.3±33.2
Levels of satisfaction about provided healthcare according to the response of
participating patients were presented in Table 3. About 64.0% of the studied patients’
reported high satisfactory levels regarding emergency department, 56.4% of them
reported high satisfactory levels regarding performed tests, 55.3% of them reported
high satisfactory levels regarding physicians, 53.7% of them reported high
satisfactory levels regarding nurses, and 51.0% of them reported high satisfactory
levels regarding workers. Overall, 29.5% of the patients were highly satisfied, 56.8%
were satisfied, and 13.7% were poorly satisfied.
Table 3 Levels of satisfaction as reported by study patients (n=95).
Low satisfactory Satisfactory High satisfactory
No. % No. % No. %
Nurses 10 10.5 34 35.8 51 53.7 23.2±4.4
Physician 11 11.7 31 33.0 52 55.3 18.1±3.8
Tests 16 17.0 25 26.6 53 56.4 8.8±2.5
Workers 6 6.4 40 42.6 48 51.0 6.5±1.7
Emergency department 14 14.9 20 21.3 60 63.8 8.9±2.4
Operation 12 12.6 41 43.2 42 44.2 6.2±1.6
Regarding information 31 32.6 28 29.5 36 37.9 14.6±4.0
Final results 16 16.8 37 38.9 42 44.2 6.2±1.7
Total satisfaction 13 13.7 54 56.8 28 29.5 94.5±13.3
The majority of responded nurses reported low quality of healthcare structure
regarding rules and regulation, human resources, channels of communication, patient
environment and total structure, while, less than half of them (48%) reported job-
related factors as fair and 59% of them reported supportive services as high quality.
Also, the majority of responded nurses reported low quality regarding the entire items
of quality of care process, except provision of care with efficiency, which reported as
high quality by 59% of them. Less than half of them (49%) reported the total process
as fair quality. Sixty nine percent of the studied nurses mentioned that the total score
of quality of care was low (Table 4).
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Table 4 Levels of quality of nursing care according to the response of participating nurses
Items Low Fair High Mean ± SD
No. % No. % No. %
Distribution of Structure
rules and regulation 84 84.0 15 15.0 1 1.0 42.5±10.97
physical and financial resources 33 33.0 35 35.0 32 32.0 20.1±6.5
human resources 85 85.0 14 14.0 1 1.0 43.5±10.8
channels of communication 65 65.0 29 29.0 6 6.0 21.2±6.5
job related factors 46 46.0 48 48.0 6 6.0 41.3±9.9
patient environment 79 79.0 20 20.0 1 1.0 50.3±13.6
supportive services 22 22.0 19 19.0 59 59.0 15.2±4.4
Score of Structure 75 75.0 24 24.0 1 1.0 234.1±39.7
Distribution of Process:
provision of care with efficiency 18 18.0 23 23.0 59 59.0 23.6±5.4
assessment of patient condition on
64 64.0 27 27.0 9 9.0 10.7±3.6
developing plan of care 60 60.0 22 22.0 18 18.0 12.2±3.6
implementation of patient care 47 47.0 39 39.0 14 14.0 10.8±4.7
interpersonal communication with
70 70.0 29 29.0 1 1.0 36.98±9.4
continuous evaluation of patient
44 44.0 36 36.0 20 20.0 37.0±8.8
Score of Process: 46 46.0 49 49.0 5 5.0 131.3±25.1
Distribution of outcome indicators
Death rates in the department 29 29.0 34 34.0 37 37.0 6.1 ±2.3
Rates of patient's complications 24 24.0 27 27.0 49 49.0 5.6 ±2.3
Incidence of infection in the department 33 33.0 20 20.0 47 47.0 5.8±2.5
Poor patient satisfaction with provided
66 66.0 11 11.0 23 23.0 4.5±2.9
Low patients condition improvement 32 32 26 26.0 42 42.0 6.7±2.5
Low knowledge of patient about his
illness aspects, dealing with it & its
24 24.0 30 30.0 46 46.0 7.1±2.1
The provision of rehabilitation to cases
that need it before hospital discharge
36 36.0 28 28.0 36 36.0 6.3±2.4
Rates of return of the patient to the
hospital again with the same complaint
28 28.0 32 32.0 40 40.0 6.6±2.4
Score of Outcome: 20 20.0 50 50.0 30 30.0 48.7±8.6
The majority of nurses were also reported poor patients’ outcome indicators with
high death rates (reported by 37%), high complication rates (reported by 49%), high
infection rates (reported by 47%), low improvement rates (reported by 42%), low
knowledge of patient about illness (reported by 46%) and high re-admission rates
(reported by 40%). Overall, 95% of the included nurses documented fair to high poor
patients’ outcome indicators, as shown in Table 4.
Significant effects of HSC on patients’ satisfaction, and quality of care were
presented in Table 5. There was significant positive influence of HSC on patients’
8. Influence of Hospital Safety Climate on Patient Satisfaction and Quality of Nursing Care
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satisfaction levels, which means that the higher HSC, the higher patients’ satisfaction
levels. Also, the results reported significant effects of HSC on quality of healthcare
including structure, process and total quality, which means that the higher HSC, the
higher quality of healthcare levels. Poor patients’ outcome indicators were
significantly decreased with higher HSC and significantly increased with lower
hospital safety climate.
Table 5 Influence of hospital safety climate on patients’ satisfaction, and quality of care:
Hospital safety climate
Low satisfactory 2.523 0.45 0.11 1.01 0.112
Satisfactory/ high satisfactory 36.190 2.4 1.6 3.2 <0.0001**
Quality of healthcare structure
Low 13.3 -1.3 -1.9 -0.58 <0.0001**
Fair/ high 20.97 4.8 2.7 6.79 <0.0001**
Quality of healthcare process
Low 0.66 0.23 -0.3 0.79 0.416
Fair/ high 41.99 3.4 2.4 4.5 <0.0001**
Total quality of healthcare
Low 0.27 0.15 -0.41 0.71 0.60
Fair/ high 17.5 4.3 2.3 6.3 <0.0001**
Poor patients’ outcome indicators
Low 7.2 -0.81 -1.4 -0.22 0.007**
Fair/ high 27.3 2.5 1.6 3.4 <0.0001**
Hospitals with strong safety climates prioritize safety and integrate it into the daily
functioning of the organization and the routines of individuals and teams that work
within it. They also empower workers and provide psychological safety (i.e., comfort
to take interpersonal risks), which enables personnel to prevent, solve, and learn
collectively from problems that occur at the frontlines of care delivery. A number of
surveys produce quantitative measures of HSC [16, 2, 1]. There are a lack of
consensus on the key dimensions and sub-constructs for assessing HSC [17, 7].
Aly  tried to develop an Egyptian questionnaire reporting patient safety events
and its barriers and he included nursing safety climate dimensions, but it wasn’t
sufficient to measure all aspects of hospital safety climate as Gershon’s tool do. The
HSC questionnaire developed by Gershon et al.,  appears to have sufficient
reliability and validity with acceptable psychometric properties for use as indicator of
nurses’ perceptions of HSC as mentioned and used by several authors (Turnberg and
Daniell  Deilkas & Hofoss,  Smith et al., .
Our study reported that the total HSC score was low (50%) or moderate (50%),
which indicates the poorly developed safety climate program inside El-Mansoura
In similar direction, there are many initiatives calling for teaching nurses about
safety climate issues. This goes in the same line with Chiang  who found that
nurses gave the highest agreement to education on quality and safety climate, and the
head nurse role with major emphasis on safety climate for patient and workers. In this
9. Wafaa Abd El-Azeem El-Hosany and Wafaa Fathi Sleem
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respect, Hus et al. stated that it is important to provide continuous in-service
educational programs on quality and safety which are required for nurses in order to
maintain safe work environment as well as for their clinical ladder . Improving
knowledge about safety climate through orientation and training program especially
for newly hired nurses is essential for emphasizing the safety in work place.
In this study, the most poorly developed item of hospital safety was design,
maintenance, and housekeeping of the work site, where 63.0% of the nurses reported
it as the lowest safety item. This may be due to the low financial and human
On the other hand, Abou Hashish and El-Bialy reported that nurses gave the
lowest mean score to the “blame system” in the safety climate components . This
could be attributed to the fact that it is possible that a blameless reporting culture is
still underdeveloped in the hospital of the study. Health care professionals especially
physicians as well as nurse managers tend to judge nurses’ performance depending on
reporting any error to them. Nurses could fear from and avoid being blamed for
making any error for the patient. Fifty nine percent of our studied nurse reported that
the training and education issue of HSC was poorly developed. In agreement of these
findings, Elliot highlighted that, nurses and nurse managers need to be educated on
hospital safety. A strong culture of patient safety needs to be in place to allow nurses
to learn about safety systems .
The majority of nurses were reported poor patients’ outcome indicators. Overall,
95% of the included nurses documented fair to high poor patients’ outcome
indicators. However, patient safety indicators rates might include false positive cases.
These false positive indicator rates were found in two studies by Bahl et al.  and
Glance et al. ).
Our data indicated that there was significant positive influence of hospital safety
climate on patients’ satisfaction levels. Also, the results reported significant effects of
hospital safety climate on quality of healthcare. Prior researches have demonstrated a
link between hospital climate and patients/ organizational outcomes, including
financial, system, quality of care, and safety performance (Stone & Gershon, 
Stone et al., . Evidence more closely related to safety climate has attributed their
safety records to strong safety culture, and from accident investigations, which have
identified the absence of important aspects of safety culture as a major cause. In
addition, relationships between safety performance and many of the specific
dimensions typically considered part of safety culture also have been suggested on
theoretical grounds. It has linked rates of injuries and accidents with safety climate
and related dimensions .
Our study reported that poor patients’ outcome indicators were significantly
decreased with higher HSC and significantly increased with lower HSC. One study
found that better safety climate corresponded to lower rates of patients’ incident
reports for hospitals Weingart et al., .
The results of another study performed by Singer et al. link HSC to indicators of
potential safety patients’ outcomes. Some aspects of safety climate are more closely
related to safety patients’ outcomes than others. Perceptions about safety climate
among some groups, such as frontline staff, are more closely related than perceptions
in other groups. They concluded that hospitals with better safety climate overall had
lower relative incidence of patient safety indicators .
However, careful analyses of the link between hospital safety climate and patient
outcomes at the organizational level of analysis have not been conducted.
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6. CONCLUSIONSAND RECOMMENDATIONS
HSC significantly influence patient-related factors including patient's satisfaction, and
quality of nursing care. The study recommended that more researches were needed in
order to investigate the association between other aspects of safety climate and
hospital-level patients’ safety and outcomes and also to identify the organizational
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