Analyzing Published Research

PICOT/Clinical question

– In the clinical setting, to what degree does the Hospital survey on patient safety culture (HSOPS) improve safety when compared to the facility specific quality indicator for catheter associated infections as it pertains to improved patient outcomes?

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International Journal of

Environmental Research

and Public Health

Review

Assessing Patient Safety Culture in Hospital Settings

Abdulmajeed Azyabi *, Waldemar Karwowski and Mohammad Reza Davahli *

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Citation: Azyabi, A.; Karwowski, W.;

Davahli, M.R. Assessing Patient

Safety Culture in Hospital Settings.

Int. J. Environ. Res. Public Health 2021,

18,

66. https://doi.org/10.

90/

ijerph18052466

Academic Editor: Paul B. Tchounwou

Received:

January 20

Accepted: 1 March 2021

Published: 3 March 2021

Publisher’s Note: MDPI stays neutral

with regard to jurisdictional claims in

published maps and institutional affil-

iations.

Licensee MDPI, Basel, Switzerland.

This article is an open access article

distributed under the terms and

conditions of the Creative Commons

Attribution (CC BY) license (https://

creativecommons.org/licenses/by/

4.0/).

Department of Industrial Engineering and Management Systems, University of Central Florida,
Orlando, FL 3

16, USA; wkar@ucf.edu
* Correspondence: Aym37@knights.ucf.edu (A.A.); mohammadreza.davahli@ucf.edu (M.R.D.)

Abstract: The current knowledge about patient safety culture (PSC) in the healthcare industry, as well
as the research tools that have been used to evaluate PSC in hospitals, is limited. Such a limitation
may hamper current efforts to improve patient safety worldwide. This study provides a systematic
review of published research on the perception of PSC in hospitals. The research methods used
to survey and evaluate PSC in healthcare settings are also explored. A list of academic databases
was searched from 2006 to 2020 to form a comprehensive view of PSC’s current applications. The
following research instruments have been applied in the past to assess PSC: the Hospital Survey
on Patient Safety Culture (HSPSC), the Safety Attitudes Questionnaire (SAQ), the Patient Safety
Climate in Health Care Organizations (PSCHO), the Modified Stanford Instrument (MSI-2006), and
the Scottish Hospital Safety Questionnaire (SHSQ). Some of the most critical factors that impact
the PSC are teamwork and organizational and behavioral learning. Reporting errors and safety
awareness, gender and demographics, work experience, and staffing levels have also been identified
as essential factors. Therefore, these factors will need to be considered in future work to improve PSC.
Finally, the results reveal strong evidence of growing interest among individuals in the healthcare
industry to assess hospitals’ general patient safety culture.

Keywords: patient safety culture; safety climate; behavioral learning; healthcare

1. Introduction

According to the World Health Organization, patient safety (PS) is about preventing
medical errors and their adverse effects on patients during healthcare delivery [1–3]. Unsafe
medical practices can lead to patient injury, death, or disability [4]. The proliferation of
such incidents has led to the recognition of the need to improve patient safety culture (PSC)
in the healthcare industry worldwide. Furthermore, patient safety has been considered
as one of the strategic components of healthcare management [5]. Kohn et al. [6] argued
that safety is a crucial and fundamental aspect of patient care research. Kohn et al. [6],
in a landmark of PS publications, advocate for error prevention and mitigation using a
systematic approach to PS management. Therefore, to ensure the highest level of safety
culture in the healthcare industry, it is also essential to understand the beliefs, attitudes,
norms, and values of PS and its thresholds [7].

The present study focuses on patient safety culture (PSC) in hospitals. This article’s
main objective is to discuss the research tools used to assess PSC and identify its essential
components. The preferred reporting items for systematic reviews and meta-analyses
(PRISMA) were used for this review to ensure reliable results. The PRISMA protocol
contains

items that aim to analyze and report scientific evidence reliably [8].

This paper is structured as follows: the methodology section explains research ques-
tions and research strategy; the results section represents the primary outcomes; the
discussion section answers research questions.

Int. J. Environ. Res. Public Health 2021, 18, 2466. https://doi.org/10.3390/ijerph18052466 https://www.mdpi.com/journal/ijerph

https://www.mdpi.com/journal/ijerph

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https://doi.org/10.3390/ijerph18052466

Homepage

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https://doi.org/10.3390/ijerph18052466

https://www.mdpi.com/journal/ijerph

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Int. J. Environ. Res. Public Health 2021, 18, 2466 2 of 36

2. Materials and Methods

This review aimed to evaluate current research on PSC in the healthcare setting. The
following two research questions have been posed:

1. What research instruments are used to study patient safety culture?
2. What are the essential dimensions of patient safety culture assessment?

The study follows the guidelines of PRISMA, as discussed by Moher et al. [8]. First, the
protocol was used to specify the search strategy and research questions. Next, the Hawker
Assessment Tool was used to assess the quality of the articles identified [9]. Sources for
the systematic review included peer-reviewed articles, proceedings, textbooks, conference
presentations, and reference books within the scope of PSC. At the exploration stage,
the bibliography search focused on academic databases, including CINAHL, MEDLINE,
Embase, ProQuest, Google Scholar, PsycINFO, and PubMed. Each of these databases
provided adequate information regarding PSC in hospitals.

Eligibility criteria for the search space were applied to articles published after 2006.
Articles were identified based on the combination of keywords 1-4, as illustrated in Table 1.

Table 1. Keywords used in the present review.

Row Step

Keywords 1 “safety culture” OR “safety climate” OR “patient safety culture” OR “patient safety climate” OR “patient safety”
Keywords 2 “perception” OR “measure” OR “evaluate” or “assess” OR “survey” OR “instrument ” OR “tool”
Keywords 3 “hospital ” OR “teaching” OR “tertiary”
Keywords 4 “nurse” OR “doctor” OR “physician” OR “staff” OR “health professional”

Search #1 AND #2 AND #3 AND #4

The eligibility criteria allowed us to narrow down the subject literature and to identify
publications that were relevant to the stated research questions. The articles selected
for this study met specific inclusion criteria; namely, these papers (a) were written in
English; (b) had been peer-reviewed; (c) identified or described PSC; (d) applied to hospital
settings; (e) utilized a survey tool to measure dimensions of PSC among acute care hospital
personnel; and (f) applied to general, secondary, tertiary, teaching, or university hospitals.
Exclusion criteria included (a) book chapters; (b) papers that, upon review, were found to
not be related to the research questions; (c) opinions, viewpoints, anecdotes, letters, and
editorials; (d) studies with small sample sizes; and (e) case studies that focused on only
one specific hospital unit or sector. Paper titles and abstracts were analyzed based on the
stated inclusion and exclusion criteria. Any discrepancies that arose during this phase
were resolved through a process of discussion and consensus.

Hawker et al. [9] noted that the quality of any given paper must be assessed against
a set of predefined criteria to determine whether it is appropriate for further study. They
also proposed that such an appraisal should be performed through the use of appropriate
appraising tools. The present study applied the Hawker Assessment Tool, which enables
the user to score the quality of papers reviewed. This tool has a uniform assessment form
for all types of papers, thereby providing consistency in the evaluation process. One of
the assessment factors is the consideration of whether the abstract offers a description of
the study. Other factors include the introduction of the paper under review, the paper’s
aims, background study, and findings. This tool also enables the user to analyze the study’s
implications concerning the topic under review and indicates how the findings can be
converted into policies. A maximum score of 36 [9] was used to assess the quality of
potential papers to be included in the present study. The range of the reviewed studies’
quality score ranges from a minimum of 9 points to a maximum of 36 points. To create the
overall quality grades, we used the following definitions: high quality (A),

–36 points;
medium quality (B), 24–29 points; and low quality (C), 9–24 points.

Int. J. Environ. Res. Public Health 2021, 18, 2466 3 of 36

A data extraction template from the Hawker Assessment Tool was used to collect
data regarding the properties of the adopted studies. This template allows for a literature
analysis with a minimal selection bias [10,11].

Through a search of all relevant databases, a total of 1339 publications were initially
identified. The databases searched included CINAHL, MEDLINE, Embase, ProQuest,
Google Scholar, PsycINFO, and PubMed. Further analysis was required to eliminate
duplicate titles, which resulted in 601 duplicates being discarded. This step was followed
by the application of exclusion criteria, as previously described. The abstracts for the
remaining

1 titles were read, which led to the selection of 137 relevant articles whose
entire texts were analyzed. It should be noted that no additional articles were added
after the references from the initially selected papers were examined. Figure 1 provides
a flowchart illustrating the article selection process. A total of 66 articles that met all
eligibility criteria and that had been published between 2006 and 2020 were selected for
the study.

Figure 1. Flow diagram of the methodology and selection process [8].

To identify research instruments used to study patient safety culture, two researchers
(authors) independently read the selected articles’ full texts to identify research instruments
and their aspects. Subsequently, the two authors compared their findings to develop unified

Int. J. Environ. Res. Public Health 2021, 18, 2466 4 of 36

results. Disagreements between the two researchers concerning research instruments and
their identified aspects were discussed and resolved in sessions with the third researcher.

3. Results

All included records were categorized according to objective, strength, limitation,
finding and quality score as it is represented in Table 2.

Int. J. Environ. Res. Public Health 2021, 18, 2466 5 of 36

Table 2. Publications included in the literature review.

Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2019, Saudi Arabia [12]

Investigate the perceptions
of healthcare professionals
toward PSC in hospitals
throughout the Hail region

• Variety of healthcare
professionals (nurses,
physicians, and
administrators/managers)
considered for collecting data.

• Response rate among
participants was 99.

Only four hospitals
considered for data
collection.

• Healthcare professionals have a positive perception of
patient safety.

• Organizational learning was the strongest area in PSC.
• Professionals with a greater number of employment

years were more willing to communicate.
• Among respondents, 63.53% stated that they had never

reported a case of patient safety.
• The low rate of reported cases was attributed to fear of

the cases being recorded in the respondent’s file.

HSPSC, 2012, Saudi Arabia, [13]

Identify general strengths
and recognize areas of
patient safety
improvements

• Variety of clinical and medical
staff (physicians, nurses,
technicians, pharmacists, and
others) considered.

Response rate
among participants
was 61%.
Only two general
hospitals considered

• Organizational learning/continuous improvement and
teamwork within units received positive outcomes at
79% and 77%, respectively.

• Non-punitive responses to errors and staffing had low
positive response rates at 22% and

%, respectively,
representing areas for improvement.

• The overall percentage of positive responses among
dimensions of patient safety was 58%.

HSPSC, 2016, Turkey, [14]
Explore and describe
nurses’ perceptions of PSC

• Response rate among
participants 74%.

• HSPSC Turkish version used.

Only nurses in four
hospitals (one
university hospital
and three general
hospitals), and
nurses consiered for
collecting data

• The mean positive response rate for the 12 PSC
dimensions of the HSPSC survey was 52%.

• Within units and organizational learning/continuous
improvement were reported.

• Non-punitive responses to errors and frequency of event
reporting were areas for improvement.

• Nurses who had worked for more than 10 years in their
profession showed significantly higher PSC scores in all
dimensions.

• Nurses working in ICUs had higher scores than those
working in other units in all patient safety dimensions.

• 50.2% of the nurses rated the level of patient safety as
good or excellent.

• Among nurses, 80.4% indicated that they had never
reported an error.

• The overall perception of patient safety was 51%.

Int. J. Environ. Res. Public Health 2021, 18, 2466 6 of 36

Table 2. Cont.

Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2012, Egypt, [15]

Assess PSC perceptions
among healthcare
providers and identify
factors that may critically
affect PSC

• Variety of healthcare
professionals (doctors, nurses,
and technicians) considered

• HSPSC Arabic version used.

No response rate
reported

• An average of 52% was attained for positive responses
for the 12 PSC dimensions of the HSPSC survey.

• Non-punitive responses to errors had 24.2% while
frequency of event reporting and staffing were 28.4%
and 38.4%, respectively.

• Poor teamwork across units was identified as having a
low response of 48.8%.

• Areas for improvement included organizational learning,
handoffs and transitions, communication, and support
from management.

• Patients started reporting errors after being educated,
demonstrating the accusatory culture.

HSPSC, 2013, Saudi Arabia, [16]
Identify factors that nurses
perceive as contributing to
the PSC

• Response rate was 83%.
Only Nurses in one
Tertiary care hospital
considered for
collecting data.

• Continuous organization learning and management
support formed the best areas for the support of patient
safety.

• Other variables such as reporting errors, staffing, and
communication required improvement for better patient
safety.

• Respondent variables such as gender, level of education,
age, years of experience, length of shifts, and Arabic
versus non-Arabic language created a variance in patient
safety consideration.

• Among the nurses interviewed, patient safety was rated
as good or excellent.

HSPSC, 2012, Egypt, [17]

Assess healthcare
providers’ perceptions of
PSC within the
organization and
determine factors that play
a role in PSC

• Variety of healthcare
professionals (physicians,
nurses, pharmacists,
technicians, and staff)
considered.

• Response rate was 69.1%
HSPSC Arabic version used.

• Dimensions with the highest scores included continuous
learning and teamwork, reported at 78.2% and 58.1%,
respectively.

• Non-punitive responses to errors had the lowest score of
19.5%, representing a dimension that requires
improvement.

• Adverse event reporting and recording was reported at
33.4%.

• The hospital is a training institution, exhibiting a bias for
continuous learning and low error reporting, as errors
are recorded in files.

Int. J. Environ. Res. Public Health 2021, 18, 2466 7 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2013, Iran, [18]
Assess the PSC at Islamic
Azad University hospitals

• Variety of clinical and
diagnostic staff (physicians,
nurses, midwives, assistants,
staff, and radiologists)
considered.

• Response rate was 87.5%.
HSPSC Persian version used.

• Teamwork within units scored 48% while non-punitive
error responses scored 12%.

• Areas identified for improvement included staffing and
non-punitive responses to errors.

• Among respondents, 35% had a positive view of patient
safety.

HSPSC, 2013. Palestine, [19]
Assess the prevalent PSC
in Palestinian public
hospitals

• Variety of clinical and
non-clinical hospital staff
(physicians, nurses,
paramedical and support
services, hospital managers,
and supervisors) considered.
HSPSC Arabic version used.

Response rate was
51.2%

• Dimensions with the highest scores were teamwork
within units, organizational learning/continuous
improvement, and supervisor/manager expectations
and actions promoting patient safety at 71%, 62%, and
56%, respectively.

• Non-punitive response to errors, frequency of reporting,
communication, management support, and staffing had
low scores at 17%, 35%, 36%, 37%, and 38%, respectively.

• Among respondents, 53.2% had not reported any errors
in the past year.

• General patient safety was ranked as excellent or very
good by 63.5% of the respondents.

HSPSC, 2010, Saudi Arabia, [20]

Evaluate the extent to
which the culture supports
patient safety at
Saudi hospitals

• Variety of health professionals
(nurses; physicians/physicians
in training; pharmacists;
dieticians; unit
assistants/clerks/secretaries;
respiratory therapists; physical,
occupational, or speech
therapists; technicians [lab,
radiology]
administration/management)
in 13 general hospitals (9 public
and 4 private) considered.

• General patient safety was rated as very good by 60%,
acceptable by 33%, and poor by 7% of the respondents.

• Composites that showed strength included continuous
improvement, feedback, teamwork within units, and
feedback and communication about errors.

• Staffing, under-reporting of errors, non-punitive
response to errors, and teamwork across hospital units
had low scores.

Int. J. Environ. Res. Public Health 2021, 18, 2466 8 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2019, Saudi Arabia, [21]

Evaluate the PSC in Saudi
hospitals and
improve patient safety and
quality of care by
implementing safety
systems and creating a
culture of safety

• Variety of hospital workers
(physicians; nurses;
pharmacists; dieticians; unit
assistants/clerks/secretaries;
respiratory therapists; physical,
occupational, and speech
therapists; technicians [e.g.,lab,
radiology],
administration/management)
considered

Only one Tertiary
hospital considered

• Feedback and communication about errors had high
scores, ranging from 40.7%–71.3%.

• Leadership, communication openness, error reporting,
and teamwork across units represented areas requiring
improvement.

HSPSC, 2018, Kuwait, [22]
Examine the association
between the predictors and
outcomes of PSC

• Variety of employees
(physicians, nurses, pharmacy
and laboratory staff, dietary
and radiology staff, supervisors,
and hospital managers) in 16
public hospitals considered

Response rate was
60.5%

• Continuous improvement, teamwork within units,
management support for patient safety, feedback and
communication about errors, and supervisor/manager
expectations and actions promoting patient safety were
highly scored among the respondents.

• General perception of patient safety was scored at 60.6%
while frequency of events reported was scored at 59.0%.

HSPSC, 2012, Saudi Arabia, [23]
Perform an unbiased
assessment of the impact of
accreditation on PSC

• Response rate was 69.5%.
• HSPSC Arabic version used

Only nurses in one
university hospital
considered for
collecting data

• A score of 45% was recorded for overall perceptions of
patient safety.

• The frequency of reporting events was 57%.

HSPSC, 2017, Saudi Arabia, [24]

Reassess PSC in a large
multi-site healthcare
facility in Riyadh,
Kingdom of Saudi Arabia,
and compare it with an
earlier assessment
conducted in 2012,
benchmarked against
regional and international
studies

• Variety of health professionals
(physicians, registered nurses,
other clinical or non-clinical
staff, pharmacists, laboratory
technicians, dietary department
staff, radiologists, and
administrative staff such as
managers and supervisors)
considered.

• The results comparied with U.S.

Only one Tertiary
care teaching
hospital considered.
Response rate was
56.7%

• Teamwork within units and organizational
learning/continuous improvement were strong areas
while staffing and non-punitive responses to errors
required improvement.

• A high level of correlation was observed among
feedback, managerial support, organizational learning,
and improved patient safety.

• Improvements in dimensions of patient safety from 2012
to 2015 indicated an improvement in performance.

• Overall perceptions of patient safety were reported at
59.5%.

• The frequency of reporting events was 68.8%.

Int. J. Environ. Res. Public Health 2021, 18, 2466 9 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2014, Iran, [25]
Assess the safety culture in
two educational hospitals

• Response rate was 88.8%.
• HSPSC Persian version used.

Only nurses in two
teaching
hospitals considered

• Non-punitive response to errors, frequency of events
reported, and staffing had the lowest positive scores of
patient safety dimensions.

• Among nurses from Afshar and Firoozgar Hospitals,
29% reported positive perceptions of patient safety.

HSPSC, 2015, Jordan, [26]
Assess PSC in Jordanian
hospitals from nurses’
perspectives

• Response rate was 82.2%.
• 21 hospitals (2 university

hospitals, 4 private hospitals,
and 15 governmental hospitals)
considered.

• HSPSC Arabic version used.

Only nurses
considered

• A high positive response was reported for teamwork
within units while teamwork across units, handoffs and
transitions, communication openness, and non-punitive
response to errors needed improvement.

• Nurses in government hospitals had lower perceptions
of patient safety compared with nurses in university
hospitals.

• Overall perceptions of patient safety were reported at
60.07%.

• Frequency of events reported was 69.15%.

SAQ, 2017, Palestine, [27]

Assess the perception of
nurses regarding PSC and
determine whether it is
significantly affected by
the nurses’ position, age,
experience, and working
hours

• Response rate was 91.9%.
• SAQ Arabic version used

Only nurses in four
public general
hospitals considered

• Job satisfaction and perception of management were the
top variables affecting patient safety.

• Variables such as age, nursing position, working hours,
and work experience created a variance in PSC
perception.

• Front-line clinicians had a less positive attitude towards
patients when compared with nurse managers.

• The longer the working experience, the higher the
likelihood of having a positive attitude towards patient
safety

• Nurses who worked the minimum weekly hours and
who were 35 years or older had better attitudes towards
all patient safety dimensions except for stress
recognition.

Int. J. Environ. Res. Public Health 2021, 18, 2466 10 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2015, Oman, [28]

Investigate nurses’
perceptions of PSC and
identify the factors needed
to develop and maintain a
culture of safety among
nurses

Only nurses in four
governmental
hospitals considered.
No Response rate
reported.

• Feedback and communication about errors, continuous
learning, and teamwork within units received high
positive scores.

• Staffing, non-punitive response to errors, and
management support attained low positive scores
among the respondents.

• An increased number of years of experience combined
with working in a teaching hospital increased the
perception of PSC.

• The rate of positive perceptions of safety was 50.7%
among respondents.

• Frequency of events reported stood at 58.8%.

HSPSC, 2014, Oman, [29]

Illustrate the PSC in Oman
and compare the average
positive response rates in
PSC between Oman and
the U.S., Taiwan, and
Lebanon

• Variety of health professionals
(nurses, physicians, technicians,
pharmacists, physiotherapists,
and dieticians) considered.

• The results compared with U.S.,
Taiwan, and Lebanon

Only five secondary
and tertiary care
hospitals considered.
No Response rate
reported.

• Organizational learning/continuous improvement had
the highest positive score.

• Non-punitive response to errors was poorly rated among
respondents.

• Response rates in Oman, Taiwan, the U.S., and Lebanon
were similar.

• The overall average positive response rate was 58%.
• Overall perception of patient safety was 53%.
• Frequency of event reporting was 65%.

HSPSC, 2013, Iran, [30]

Estimate the relation
between PSC and three
characteristics of teaching
hospitals (number of beds,
education condition, and
proficiency status)

• Variety of staff (nurses,
physicians, laboratory staff,
radiology staff, midwives,
operation room staff, and
general managers without any
specialty in therapeutic
procedures) in 25 hospitals (11
teaching hospitals and 14
non-teaching hospitals)
considered.

• Response rate was 76.8%

• Highly scored dimensions included teamwork within
units and organizational learning/continuous
improvement.

• Non-punitive response to errors and staffing were the
lowest positively scored dimensions.

• Overall perception of safety was 56.56%.
• Frequency of events reported was 42.85%.

Int. J. Environ. Res. Public Health 2021, 18, 2466 11 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2013, Iran, [31]
Assess nurses’
perceptions of PSC in these
hospitals

• Response rate was 83.7%
Only nurses in two
teaching hospital
sconsidered

• Organizational learning/continuous improvement had
the highest positive score.

• Frequency of events reported, staffing, and non-punitive
response to errors had the lowest scores of PSC
dimensions.

• Overall perceptions of safety were 66.22% for the Afshar
hospital and 59.5% for the Firouzgar hospital

• The frequency of events reported was 34.90% for the
Afshar hospital and 50.17% for the Firouzgar hospital.

HSPSC, 2014, Saudi Arabia, [32]

Present findings of a
baseline assessment of PSC,
compare results with
regional and
international studies, and
explore the association
between PSC predictors
and outcomes, considering
respondent
characteristicsand facility
size

• Variety of staff (physicians,
nurses, clinical and non-clinical
staff, pharmacy and laboratory
staff, dietary and radiology
staff, supervisors, and hospital
managers) considered.

• Response rate 85.7% reported.
• The results compared with

other studies using

HSPSC

Arabic version

Only one tertiary
care university
teaching hospital
considered

• Teamwork within units and organizational
learning/continuous improvement had high positive
responses.

• Staffing, non-punitive response to errors, and
communication openness required improvement.

• A high correlation was indicated between smaller
facilities, events reported, and patient safety levels.

• Overall perception of safety was 65.3%.
• Frequency of events reported was 59.4%.

HSPSC, 2015, Turkey, [33]
Investigate nurses’
perceptions of PSC

• HSPSC Turkish version used.
Only nurses in one
public hospital
considered for
collecting data

• High positive scores for hospital management support
and manager/supervisor expectations and actions
supported an increase in patient safety.

• Frequency of event reporting for medical errors had the
lowest positive score.

• Organizational learning/continuous improvement,
hospital management support for patient safety,
teamwork within units, and supervisor/manager
received high positive scores.

• Hospital handoffs and transitions, non-punitive
response to errors, frequency of events reported, and
communication openness were poorly rated.

• Overall perception of safety was 61%.
• Frequency of events reported was 40%.

Int. J. Environ. Res. Public Health 2021, 18, 2466 12 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2016, Iran, [34]
Evaluate the current status
of PSC among hospitals in
three central Iran provinces

• Variety of staff (doctors, nurses,
administrative staff, and
paramedics) in the teaching
hospitals considered for
collecting data.

No Response rate
reported

• Organizational learning was reported as the strongest
dimension.

• Handoffs and transitions had the lowest score.
• Overall perception of safety was 62.93%.
• Frequency of event reporting was 55.63%.

HSPSC, 2012, Turkey, [35]

Assess health personnel
perspectives of PSC in a
900-bed university hospital
in Ankara, Turkey

• Variety of health professionals
(doctors, nurses, technicians,
secretaries, and other health
personnel) considered

• Using HSPSC Turkish version.

Only one university
hospital considered.
Response rate was
43%

• Teamwork within units had the highest positive
feedback.

• Frequency of events reported had the lowest average.
• Women nurses formed the majority of respondents, with

five years or less in terms of work experience in their
respective hospital.

• Overall perception of patient safety was 55%.
• Frequency of events reported was 25%.

HSPSC, 2010, Lebanon, [36]
Conduct a baseline
assessment of PSC in
Lebanese hospitals

• 12,250 staff (physicians, nurses,
clinical and non-clinical staff,
and others) in 68 hospitals
considered.

• The results compared with U.S.

• HSPSC Arabic version used.

Response rate was
55.56%

• Organizational learning/continuous improvement,
hospital management support for patient safety, and
teamwork within units were the strongest areas.

• Non-punitive response to errors and staffing received
low feedback.

• Small hospitals and accredited hospitals received higher
scores on several composites.

• Overall perception of safety was 72.5%.
• Frequency of events reported was 67.9%.

HSPSC, 2013, Japan and
Taiwan, [37]

Clarify the impact of long
nurse working hours on
PSC in Japan, the U.S., and
Chinese Taiwan using
HSPSC

• 14 hospitals in Japan, 884
hospitals in the U.S., 74
hospitals in Taiwan (acute care
hospitals) considered.

• The results compared with U.S.

Only nurses
considered for
collecting data.
Response rate was
Japan = 4047 (58.1%)
U.S. = 106,710
(37.0%)
Taiwan = 5714
(56.3%)

• Patient safety levels declined and number of events
reported increased as working hours increased

• Among the 12 sub-dimensions of PSC, teamwork within
units and staffing received poor ratings

Int. J. Environ. Res. Public Health 2021, 18, 2466 13 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2013, Japan and
Taiwan, [38]

Investigate the
characteristics of PSC in
Japan, Taiwan, and the U.S.

• Variety of health professionals
(nurses; patient care
assistants/hospital aides/care
partners; physicians;
pharmacists; dieticians; unit
assistants/clerks/secretaries;
respiratory therapists; physical,
occupational, or speech
therapists; technicians (EKG,
lab, radiology);
administration/management)
in 14 hospitals in Japan,
884 hospitals in the U.S.,
74 hospitals in Taiwan (acute
care hospitals)

• The results compared with U.S.

Response rate in U.S.
= 35.2%

• The U.S. had the highest overall positive perception of
patient safety grade.

• Continuous improvement in Japan and the reporting of
near-miss events in Taiwan received low scores
compared with the other countries.

• Overall perceptions of patient safety in Japan, the U.S.,
and Taiwan were 53%, 63%, and 52%, respectively.

• Frequency of events reported in Japan, the U.S., and
Taiwan was 68%, 61%, and 33%, respectively.

SAQ, 2015, India, [39]

Explore composite patient
safety climate, assess
various dimensions of
patient safety climate in
three hospitals, and
identify future directions
for developing a strong
safety climate

• Variety of health professionals
(clinicians, postgraduates,
residents, nurses, and
paramedical workers)
considered.

• Response rate was 100%

Only three tertiary
care hospitals
considered

• The study hospitals did not have disparities in the
patient safety index score.

• Different categories of medical workers reported
different levels for the perception of management and
stress recognition and teamwork.

• A high correlation exists for perception of management
and teamwork with the patient safety index score.

HSPSC, 2017, Sweden, [40]

Investigate the PSC in all
Swedish hospitals;
compare the culture
among managers,
physicians, registered
nurses, and enrolled
nurses; and identify factors
associated with high
overall patient safety

• Variety of staff (managers,
registered nurses, enrolled
nurses, and physicians)
considered

Only three work
areas: general wards,
emergency care, and
psychiatry care
considered.
Response rate was
47.4%

• Teamwork within units had the most positive feedback.
• Management support for patient safety received the

lowest score.
• Managers had the highest score for patient safety.
• Registered nurses had the lowest score for patient safety.
• Emergency care units showed more patient safety than

general wards.
• Overall perception of patient safety was 58%.
• Frequency of events reported was 54.4%.

Int. J. Environ. Res. Public Health 2021, 18, 2466 14 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2013 Netherlands, [41]

Examine similarities and
differences in hospital
PSC in three countries: the
Netherlands, the U.S., and
Taiwan

• Variety of staff (nursing staff,
medical staff, management and
administrative staff, other) in 45
hospitals in the Netherlands,
622 in the U.S., and 74 in
Taiwan (non-teaching and
teaching hospitals) considered.

• Comparing the results with
U.S., and Taiwan

U.S. Response rate
was 52%

• Handoffs and transitions required improvement in all
three countries.

• Respondents in U.S. hospitals reported higher levels of
PSC than the Taiwanese and Dutch.

• Differences in responses were evident in hospitals in
each country.

• Overall perceptions of patient safety in the Netherlands,
Taiwan, and the U.S. were 49%, 52%, and 64%,
respectively.

• Frequency of events reported in the Netherlands, Taiwan,
and the U.S. were 36%, 31%, and 60%, respectively.

HSPSC, 2017, Pakistan, [42]
Present descriptive
statistics for patient safety
standards

Only two public
hospitals considered.
Response rate was
38.4%

• 80% of respondents indicated there was no response to
reported errors in their wards.

• For respondents that reported errors, an accusatory
culture existed in the ward.

• 70% of respondents reported a lack of support.
• Feedback from respondents indicated that error

reporting and patient safety standards were not
favorable.

HSPSC, 201„ Japan, [43]

Examine the validity
and applicability of the
HSPSC in Japan and
compare the factor
structure to the original
U.S. study

• Variety of healthcare workers
(nurses, administrative workers,
physicians, technicians,
dieticians, pharmacists,
therapists, janitors, other) in 13
acute care general hospitals (1
university hospital and 12
teaching hospitals) considered.

• HSPSC Japanese version used.

• The AHRQ’s 12-factor model provides the best fit to the
Japanese HSPSC data for acute care hospital staff
compared with two 11-factor models proposed in
previous studies.

• The Japanese HSPSC had acceptable internal consistency
for the subscales.

HSPSC, 2013, Croatia, [44]

Determine whether all 12
dimensions of the U.S.
HSPSC are applicable,
valid, and reliable for
Croatian healthcare
workers

• Considering variety of
healthcare workers (doctors
and nurses).

• comparing the results with U.S

Only four Croatian
hospitals considered.
Response rate was
32.69%

• Organizational learning/continuous improvement and
staffing had low positive feedback.

• Confirmatory factor analysis confirmed a good fit to the
original U.S. model.

• Overall perception of patient safety was 57%.

Int. J. Environ. Res. Public Health 2021, 18, 2466 15 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2013, Sri Lanka, [45]
Assess the current PSC in a
tertiary care hospital

• Considering variety of
healthcare workers
(administrators, consultants,
postgraduate trainees, medical
officers, house officers, and
nursing officers)

Considering only
one tertiary care
hospital.
No Response rate
reported

• Organizational learning/continuous improvement and
teamwork within units had high positive scores.

• Staffing and workload had low scores.
• Patient safety overall perception was 81.3%.
• Frequency of event reporting was 36.3%.

HSPSC, 2012, China, [46]

Explore nurses’
perceptions of PSC and
factors associated with
those perceptions

Considering only
nurses in one
university teaching
hospital.
No Response
ratereported

• Organizational learning/continuous improvement and
teamwork within units had the highest scores.

• Low response rates were evident in perceived
trustworthiness of managers, non-punitive response to
errors, managers, organizational safety prioritization,
managers’ safety commitment, and nurses’ years of
experience in their units, which had strong correlations
with PSC

• Overall percentage of positive responses regarding
patient safety culture was 61.3%.

HSPSC, 2013, China, [47]

Explore the attitudes and
perceptions of PSC for
healthcare workers in
China and compare the
psychometric properties of
an adapted
translation of the HSPSC in
Chinese hospitals with
those of the U.S.

• Considering variety of health
professionals (physicians
[surgical clinicians and internal
clinicians] and nurses in 32
hospitals.

• Comparing the results with U.S.

• HSPSC Chinese version used.

• The staffing dimension had the lowest score.
• Organizational learning/continuous development and

teamwork within units had the highest scores.
• Overall perception of patient safety was 55%.

HSPSC, 2013, Slovenia, [48]

Study the psychometric
properties of a translated
version of the HSPSC in a
Slovenian setting

• Considering variety of health
professionals (clinical and
non-clinical staff)

• Comparing the results with
other studies

• HSPSC Slovene version used.

Considering only
three acute general
hospitals.

Response rate was
55%

• Units had a greater positive patient safety perception
compared with hospital level.

• The dimensions of teamwork across units, hospital
management support for patient safety, staffing, and
non-punitive response to errors required improvement.

• Overall perception of safety was 56%.
• Frequency of events reported was 69%.

Int. J. Environ. Res. Public Health 2021, 18, 2466 16 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2010, Belgium, [49]
Describe a PSC
improvement approach in
five Belgian hospitals

• 3940 and 3626 staff (nurses,
head nurses, nurse assistants,
physicians, head physicians,
junior physicians, pharmacists,
pharmacy assistants, middle
management, technicians,
paramedical staff, other)
considered.

• Response rates were 77% and
68%.

Five Belgian acute
hospitals (three
private hospitals
and one public
hospital)

• Hospital management support for patient safety needed
the most improvement.

• Progress was observed for supervisor expectations and
actions promoting safety.

• Teamwork within units had the highest scores.
• Staffing, non-punitive response to errors, and hospital

transfers and transitions received the lowest scores and
did not show signs of improvement.

HSPSC, 2017, Norway, [50]

Explore organizational
factors influencing patient
safety and safety behavior
among nurses and other
hospital staff

• Considering 3475 health
professionals [nurses (n = 750),
other personnel (n = 953)]

• Studying PSC relationships
with safety behavior.

• HSPSC Norwegian version
used.

Considering only
one university
hospital.
Response rate was
49%

• Higher values on hospital-level dimensions positively
influenced safety leadership and safety climate at the
unit level.

• The organizational factors correlate with the dimensions
and illustrate structural relationships that are relevant
for variations in the perception of patient safety and
safety behavior.

HSPSC, 2010, Taiwan, [51]

Assess the PSC in Taiwan
and attempt to provide an
explanation for some of the
phenomena that
are unique in Taiwan

• Considering 1000 health
professionals (physicians,
nurses, and non-clinical staff)
42 teaching hospitals.

• Response rate was 78.8%
• Comparing the results with U.S.
• HSPSC Chinese version used.

• Staffing had the lowest positive feedback.
• Teamwork within units had the highest score.
• Statistical examination presented differences between

the U.S. and Taiwan in the dimensions of frequency of
event reporting, feedback and communication about
errors, and communication openness.

• Overall perception of safety was 65%.
• Frequency of event reporting was 57%.

HSPSC, 2010, U.S., [52]
Examine the multilevel
psychometric properties of
the survey

• Considering variety of staff
(clinical and non-clinical) in 331
U.S. hospitals.

• Examine the validity and

reliability of the instruments.

Response rate was
55%

• Overall, the survey items and dimensions are
psychometrically sound at the individual, unit, and
hospital levels of analysis and can be used by researchers
and hospitals for assessing PSC.

• A strong correlation existed between patient safety grade
and overall perceptions of patient safety and
management support for patient safety.

• Correlation between frequency of event reporting and
non-punitive response to errors was poor.

Int. J. Environ. Res. Public Health 2021, 18, 2466 17 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

MSI-2006, 2015, Canada, [53]

Examine in detail
how ease of
reporting, unit norms of
openness, and
participative leadership
influence front-line staff
perceptions of PSC within
healthcare organizations

• Considering variety of health
professionals (nurses,
physicians, and pharmacists) in
13 hospitals.

• Response rate was 17%.
• Studying PSC relationships

with using different outcomes.

• Staff perception of patient safety climate was positively
correlated to participative leadership, ease of reporting,
and unit norms of openness.

• Demographic factors such as education level and age
influenced perceptions of patient safety climate.

SHSQ, 2013, Scotland, [54]

Obtain a measure of
hospital safety climate
from a sample of National
Health Service (NHS)
acute hospitals in Scotland
and determine whether
these scores are associated
with worker safety
behaviors
and patient and worker
injuries

• Considering 8113 NHS clinical
staff.

• Examining the validity and
reliability of the instruments.

• Studying PSC relationships
with using different outcomes.

Considering only six
acute hospitals in
Scotland.
Response rate was
23%

• Patient and worker injury measures and workers’ safety
behavior had a significant influence on hospital safety
climate scores.

• Generic safety climate items and patient-specific items
had strong impacts on safety outcome measures.

• Overall perception of safety was 56%.
• Frequency of incident reporting was 56%.

HSPSC, 2018, Philippines, [55]
Assess PSC among nurses
at a government hospital

• Response rate was 86.65%.
Only nurses in one
tertiary government
hospital considered

• Organizational learning and teamwork within units
received the highest scores.

• Non-punitive response to errors had the lowest positive
feedback.

• Overall perception of safety was 50.78%.
• Frequency of events reported was 54.12%.

HSPSC, 2011, Italy, [56]

Determine the level of
awareness regarding PSC
among health
professionals working at a
hospital in northern Italy

• Respondents consisting of five
professional groups
(directors/coordinators,
physicians, nurses/midwives,
physiotherapists, and
technicians).

• HSPSC Italian version used.

Only one hospital in
northern Italy
considered.

• Teamwork within units and organizational
learning/continuous improvement received the highest
scores.

• Non-punitive response to errors received the lowest
score.

• Overall perception of patient safety was 64%.
• Frequency of event reporting was 59%.

Int. J. Environ. Res. Public Health 2021, 18, 2466 18 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2018, South Korea [57]

Investigate the
relationships between
registered nurses’
perceptions of PSC in their
workplace and their
patient safety
competency—attitudes,
skills, and knowledge

• Response rate was 79.7%.
• Studying PSC relationships

with using different outcomes
their workplace and their
patient safety
competency—attitudes, skills,
and knowledge.

• Using HSPSC Korean version
and the Patient Safety
Competency Self-Evaluation
(PSCSE)

Considering only
nurses in in one
university hospital

• A strong correlation existed between teamwork within
units and overall safety competency.

• Attitudes had a strong correlation to teamwork across
and within units, and supervisor or manager
expectations.

• Skills had a strong correlation to learning and teamwork
within units.

• Knowledge had a strong correlation to organizational
learning.

HSPSC, 2013, Finland, [58]

Explore and compare
nurse managers’ s’ and
registered nurses views on
PSC to discover whether
there are differences
between their views

• HSPSC Finnish version used.

Considering only
nurses in four acute
care hospitals.
Response rate was
17%

• A lack of feedback was evidenced by reporting and
communication errors.

• Expectations and actions of nurse managers at the unit
level supporting patient safety had the best positive
response from both groups of respondents.

• Nurse managers at the unit level considered suggestions
from staff on how to improve patient safety.

• Feedback from the survey indicated inadequate
hospital-level management support for patient safety.

HSPSC, 2018, India, [59]

Assess the perceptions of
PSC among healthcare
providers at a public sector
tertiary care hospital in
South
India

• Considering variety of health
professionals (doctors, nurses,
other technical staff,
pharmacists, lab technicians,
dialysis technicians, operation
theater technicians, and
dressing technicians).

• Response rate was 91.7%

Considering only
one tertiary
government hospital

• Organizational learning/continuous improvement,
teamwork within units, and supervisor or
officer-in-charge expectations received the highest
positive responses while handoffs and transitions,
communication openness, and frequency of event
reporting received the lowest scores.

• Overall general perception was 60.8%.
• Frequency of events reported was 41.2%.
• Overall general perception among doctors, nurses, and

technical staff was 51.6%, 52.8%, and 66.1%, respectively.
• Frequency of events reported among doctors, nurses,

and technical staff was 31.5%, 36.7%, and 46%,
respectively.

Int. J. Environ. Res. Public Health 2021, 18, 2466 19 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2017, China, [60]

Use the HSPSC to survey
PSC in a county hospital in
Beijing to determine the
strengths and weaknesses
of PSC in this hospital

• Considering variety of staff
(physicians, nurses, and allied
health professionals).

• HSPSC Chinese version used.

Considering only
one county hospital.

• Frequency of event reporting, communication openness,
staffing, and overall perception of patient safety needed
potential improvement.

• Teamwork across units received a high level of positive
feedback.

• Physicians indicated low scores for the majority of the
dimensions.

• Overall perception of safety was 45.0%.
• Frequency of event reporting was 43.0%.

PSCHO, 2015, China, [61]

Describe staff’s
perceptions of PSC in
public hospitals and
determine how perceptions
of PSC differ between
different types of workers
in the U.S. and
China

• Considering variety of staff
(managers in administrative
offices and clinical departments,
non-management physicians,
non-management nurses, and
others, including medical
technicians and others with
non-management positions) in
six secondary, general public
hospitals

• Overall perception of patient safety was positive for
most dimensions.

• Hospital managers in both China and the U.S. reported a
better patient safety climate than other staff.

• Scales of fear of shame and blame had the highest
response for hospital workers in China.

• Fear of shame received the lowest feedback among
hospital workers in the U.S.

HSPSC, 2014, Portugal, [62]

Determine the validity
and reliability of the
AHRQ Hospital Survey on
Patient Safety Culture
(HSPSC) Portuguese
version

• Considering variety of hospital
staff.

• HSPSC Portuguese version
used.

Response rate was
21.8%

• Non-punitive response to errors, management support
for patient safety, and staffing had the lowest positive
scores.

• Teamwork within units had the highest score.
• Overall perception of patient safety was 54%.
• Frequency of events reported was 40%.

HSPSC, 2014, Jordan, [63]

Examine the impact of
patient safety educational
interventions among senior
nurses on their perceptions
of safety culture and the
rate of reported adverse
events, pressure ulcers,
and patient falls

• Studying PSC relationships
with using patient safety
educational interventions

Considering only
nurses in one
specialized hospital.
Response rate was
57%

• Improvements identified by senior nurses included
non-punitive response to errors and frequency of event
reporting.

• A reduction in the rate of adverse effects was noted.
• Pre-education perceptions of safety stood at 51.5% while

the post-education perception stood at 60.6%.
• Frequency of event reporting was 54.2% pre-education

and 64.3% post-education.

Int. J. Environ. Res. Public Health 2021, 18, 2466 20 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2015, Jordan, [64]

Examine nurses’
perceptions of the hospital
safety culture in Jordan
and identify the
relationships between
aspects of hospital safety
culture and selected safety
outcomes

Considering only
nurses in five
Jordanian hospitals.
Response rate was
61%

• Teamwork within units received the highest response
• Staffing and non-punitive response to errors had the

lowest scores
• Overall perception of patient safety was 43.3%
• Frequency of event reporting was 37%

SAQ, 2015, Denmark, [65]
Describe and analyze
the patient safety climate
in 15 Danish hospital units

• Considering variety of staff
(doctors, nurses, nursing assist-
ants/similar, physiotherapists,
occupational therapists,
administrative staff, and
hospital porters)

Considering only
five hospitals

• No differences in positive percentage rates were found
between nurses and doctors across age, gender, or work
experience.

• Significant differences were noted between front-line
staff and leaders.

• Individuals within a given unit had varied perceptions
compared to units within the hospital.

HSPSC, 2015, Belgium, [66]

Measure differences in
safety culture perceptions
within Belgian acute
hospitals and examine
variability based on
language, work area, staff
position, and work
experience

• Considering variety of staff
(nurses; patient care
assistants/hospital aides/care
partners; physicians;
pharmacists; dieticians; unit
assistants/clerks/secretaries;
respiratory therapists; physical,
occupational, or speech
therapists; technicians [EKG,
lab, radiology],
administration/management)
in 89 acute Dutch- and
French-speaking hospitals.

• Studying PSC relationships
with using different outcomes

• using HSPSC Belgian version

Response rate was
51.7%

• Staffing, handoffs and transitions, and management
support for patient safety were noted as significant
problem areas.

• Overall, Dutch-speaking hospitals had more positive
perceptions of PSC than French-speaking hospitals.

• Respondents working in rehabilitation, pediatrics, and
psychiatry gave more positive feedback on PSC.

• Staffs working in the emergency department, multiple
hospital units, and operating theater had lower positive
feedback.

HSPSC, 2019, Algeria, [67]

Measure safety culture
dimensions in order to
improve and promote
healthcare in Algeria

• Considering variety of staff
(nursing assistants, nurses,
doctors, administrative staff,
other)

Considering only
one General hospital.
No Response rate
reported

• Organization learning/continuous learning and
teamwork within units had the highest scores.

• Communication openness and staffing had the lowest
scores.

• Overall patient safety perception was 76.3%.
• Frequency of events reported was 56.1%.

Int. J. Environ. Res. Public Health 2021, 18, 2466 21 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2009, U.S., [68]

Analyze the psychometric
properties of the Agency
for Healthcare Research
and Quality Hospital
Survey on Patient Safety
Culture (HSPSC)

• Considering variety of staff
(included nurses, physicians,
pharmacists, and other hospital
staff members)

• Response rate was 96%.
• Examining the validity and

reliability of the instruments.

Only three hospitals
(an academic
teaching hospital, a
managed care
organization
hospital, and a
private not-for-profit
community hospital)
considered

• Interitem consistency reliability was not less than 0.7 for
5 subscales; the least reliability coefficients were
demonstrated by the staffing subscale.

• The intraclass correlation coefficients were within
normal ranges.

• Similar patterns of high and low scores across the
subscales of the HSPSC were noted and compared to the
sample from Pacific region hospitals conveyed by the
Agency for Healthcare Research and Quality and
corresponded to the proportion of items in each subscale
that are reverse scored.

• Most of the unit and hospital dimensions revealed a
positive relationship with the Safety Grade outcome
measure.

HSPSC and SAQ, 2012, U.S., [69]

Examine the reliability and
predictive validity of two
patient safety culture
surveys- Safety Attitudes
Questionnaire (SAQ) and
Hospital Survey on Patient
Safety Culture
(HSPSC)-when
administered to the same
participants. Additionally,
to determine the ability to
convert HSOPS scores to
SAQ scores.

• Variety of non-physician
employees considered.

• Examining the validity and
reliability of the instruments

• using HSPSC and SAQ.
• Considering intensive care

units (ICUs) in 12 hospitals
within a large hospital system
in the southern United States

Response rate was
54%.
Only non-physician
employees
considered.

• Frequency of event reporting, perception of general
patient safety, and general patient safety grade had a
significant relationship with SAQ and HSPSC at
individual level, with correlations of r = 0.41 to 0.65 for
SAQ and from r = 0.22 to 0.72 for HSOPS.

• Neither SAQ nor HSPSC predicted the fourth HSOPS
outcome, i.e., the number of events reported within the
last year.

• Analyses on regression revealed that HSPSC safety
culture dimensions had the best ability to predict
frequency of event reporting and general perceptions of
patient safety while SAQ and HSPSC dimensions
predicted patient safety grade only.

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Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

HSPSC, 2010, U.S., [70]

Examine relationships
between the Agency for
Healthcare Research and
Quality’s (AHRQ) Hospital
Survey of Patient Safety
Culture and rates of
in-hospital complications
and adverse events as
measured by the AHRQ
Patient Safety Indicators
(PSIs)

• 56,480 staff from 179 hospitals
considered.

• Studying PSC relationships
with using PSI data.

• Exploratory analysis done showed that hospitals which
scored higher on patient safety culture had fewer
reported adverse events, after controlling for hospital
bed size, teaching status, and ownership.

• There was a significant correlation between hospital bed
size, teaching status, and ownership and the PSI
composite. Larger and private hospitals had higher
PSI rates.

• Almost all tested relationships were aligning to the
hypothesis (negative), and 7 of the 15 relationships were
statistically significant and HSPSC composite
average (47%).

• All significant relationships had standardized regression
coefficients between −0.15 and −0.41, denoting that
hospitals with higher positive PSC scores experienced
less in-hospital complications/adverse events as
measured by PSIs.

HSPSC, 2016, U.S., [71]

Analyze how different
elements of patient safety
culture is associated with
clinical handoffs and
perceptions of patient
safety

• 885 hospitals considered for
collecting data

• Positive patient safety perceptions were influenced by
effective information handoff, responsibility, and
accountability.

• There was positive correlation between feedback and
communication of errors and conveying of patient
information.

• Teamwork within units and the frequency of events
documented had positive correlation to the transference
of personal responsibility when changing shifts.

HSPSC, 2009, U.S., [72]
Investigate the existence of
a patient safety chain for
hospitals

• 371 hospitals considered Response rate was
59.3%.

• TFL has a role in creating a PSC through the actual
PSI execution.

• TFL has an indirect relationship with the implementation
of initiatives, and ultimately improved PSO.

• The characteristics of inspirational leaders are linked
with the creation and promotion of a safety culture,
making safety a priority and investing resources to PSI to
realize maximal improvements in PSO.

Int. J. Environ. Res. Public Health 2021, 18, 2466 23 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

SAQ, 2006, U.S., UK, and NZ, [73]

Describe the survey’s
background, psychometric
characteristics, provide
benchmarking data,
discuss how the survey can
be used, and note
emerging areas of research

• 203 sites were considered.
• Examining the validity and

reliability of the instruments.

• A six-factor model used at both the clinical area and
respondent nested within clinical area levels generated
attitudes.

• The factors were: Teamwork Climate, Safety Climate,
Perceptions of Management, Job Satisfaction, Working
Conditions, and Stress Recognition.

• With a scale reliability of 0.9, provider attitudes varied
significantly within and among organizations.

• Using SAQ to measure climate in clinical areas permits
comparisons between hospitals, patient care areas, and
types of caregivers, and tracking of change over time.

PSCHO, 2007, U.S., [74]

Describe the development
of an instrument for
assessing workforce
perceptions of hospital
safety culture and to assess
its reliability and validity

• 100 Hospitals considered.
• Examining the validity and

reliability of the instruments
response rate was
51%

• Nine constructs were acknowledged: three
organizational factors, two unit factors, three individual
factors, and one additional factor.

• Constructs showed significant convergent and
discriminant validity in the MTA. Cronbach’s a
coefficient ranged from 0.50 to 0.89.

PSCHO, 2009, U.S., [75]

Examine the relationship
between measures of
hospital safety climate
and hospital performance
on selected Patient Safety
Indicators (PSIs).

• 91 hospitals considered.
• Examining the validity and

reliability of the instruments.
• Studying PSC relationships

with PSIs.

Response rate was
52%.

• Hospitals showing better safety climate had lower
relative incidence of PSIs.

• Those with higher scores on safety climate dimensions
determining interpersonal beliefs regarding shame and
blame.

• Frontline worker’s perceived lower risk of experiencing
PSIs related to better safety climate, however, senior
managers did not agree on this.

PSCHO, 2011, U.S., [76]

Define the relationship
between hospital patient
safety climate (a measure
of hospitals’ organizational
culture as related to patient
safety) and hospitals’ rates
of rehospitalization within
30 days of discharge

• 67 hospitals considered.
• Examining the validity and

reliability of the instruments.
• Studying PSC relationships

with rates of rehospitalization.

Response rate was
38.5 %

• There was a noteworthy positive correlation between
lower safety climate and higher rates of readmission
among AMI (acute myocardial infarction) and HF (heart
failure) (p 0.05 for both models).

• Frontline workers perceptions of safety climate were
linked to readmission rates (p 0.01), however, the
management’s perceptions contradicted this.

• The results demonstrate that hospital patient safety
climate has a connection with readmission outcomes
patients with AMI and HF. The associations were specific
to management and leadership.

Int. J. Environ. Res. Public Health 2021, 18, 2466 24 of 36

Table 2. Cont.
Instrument/Year/Country/Reference Aim(s) Strength(s) Limitation(s) Finding(s) Quality Score

PSCHO, 2008, U.S., [77]

Determine whether
frontline workers and
supervisors perceive a
more negative patient
safety climate than senior
managers in their
institutions.

• 92 US Hospitals considered.
• Examining the validity and

reliability of the instruments.

• Frontline personnel’s safety climate perceptions were 4.8,
percentage points (1.4 times) more problematic than
senior managers’, and supervisors’ perceptions were 3.1
percentage points (1.25 times) more problematic than
senior managers’.

• Discipline had an impact on the differences at
management level: senior managers had less differences
than frontline workers. Additionally, the differences
were more pronounced for nurses than physicians and
other disciplines.

Int. J. Environ. Res. Public Health 2021, 18, 2466 25 of 36

A total of 1,690,225 participants took part in the reviewed studies. The response
rate ranged from 17% [53,58] to 100% [39]. However, some studies did not report the
response rate [15,28,34,45,46,67]. The study participants included nurses, doctors, and
administrators. Figure 2 shows the distribution of participants. Seventeen papers focused
on nurses, 38 studies included clinical and non-clinical staff, and 11 studies included clinical
staff only.

Int. J. Environ. Res. Public Health 2021, 18, x 19 of 31

A total of 1,690,225 participants took part in the reviewed studies. The response rate
ranged from 17% [53,58] to 100% [39]. However, some studies did not report the response
rate [15,28,34,45,46,67]. The study participants included nurses, doctors, and
administrators. Figure 2 shows the distribution of participants. Seventeen papers focused
on nurses, 38 studies included clinical and non-clinical staff, and 11 studies included
clinical staff only.

Figure 2. Focus of each study according to participants.

The reviewed articles reported several limitations concerning the applied methodol-
ogy and results. First, articles mainly used quantitative approaches to measure PSC,
where these methods are not efficient for measuring complex and dynamic attributes such
as culture. Second, cross-sectional designs were commonly used among included articles
with data collected at one point at a time. Therefore, it is not possible to determine the
causal relationships between PSC and the explanatory variables. Third, self-reported
questionnaires were applied to collect data, which introduced social desirability biases to
the reported research results. Fourth, seven articles did not report their participants’ re-
sponse rate, and 26 articles reported a relatively low response rate (less than 60%). The
majority of the reviewed papers concluded that their results could not be generalized be-
cause their studies represented unique cultures, the large variations of the applied re-
search instruments, variation in sample sizes, differences in the type of healthcare facili-
ties, and the diversity of study participants.

The global distribution of the included articles is represented in Figure 3. Several
studies targeted more than one country.

Figure 3. Global distribution of the articles included in this analysis.

Figure 2. Focus of each study according to participants.

The reviewed articles reported several limitations concerning the applied method-
ology and results. First, articles mainly used quantitative approaches to measure PSC,
where these methods are not efficient for measuring complex and dynamic attributes
such as culture. Second, cross-sectional designs were commonly used among included
articles with data collected at one point at a time. Therefore, it is not possible to determine
the causal relationships between PSC and the explanatory variables. Third, self-reported
questionnaires were applied to collect data, which introduced social desirability biases
to the reported research results. Fourth, seven articles did not report their participants’
response rate, and 26 articles reported a relatively low response rate (less than 60%). The
majority of the reviewed papers concluded that their results could not be generalized be-
cause their studies represented unique cultures, the large variations of the applied research
instruments, variation in sample sizes, differences in the type of healthcare facilities, and
the diversity of study participants.

The global distribution of the included articles is represented in Figure 3. Several
studies targeted more than one country.

Int. J. Environ. Res. Public Health 2021, 18, x 19 of 31

A total of 1,690,225 participants took part in the reviewed studies. The response rate
ranged from 17% [53,58] to 100% [39]. However, some studies did not report the response
rate [15,28,34,45,46,67]. The study participants included nurses, doctors, and
administrators. Figure 2 shows the distribution of participants. Seventeen papers focused
on nurses, 38 studies included clinical and non-clinical staff, and 11 studies included
clinical staff only.

Figure 2. Focus of each study according to participants.
The reviewed articles reported several limitations concerning the applied methodol-
ogy and results. First, articles mainly used quantitative approaches to measure PSC,
where these methods are not efficient for measuring complex and dynamic attributes such
as culture. Second, cross-sectional designs were commonly used among included articles
with data collected at one point at a time. Therefore, it is not possible to determine the
causal relationships between PSC and the explanatory variables. Third, self-reported
questionnaires were applied to collect data, which introduced social desirability biases to
the reported research results. Fourth, seven articles did not report their participants’ re-
sponse rate, and 26 articles reported a relatively low response rate (less than 60%). The
majority of the reviewed papers concluded that their results could not be generalized be-
cause their studies represented unique cultures, the large variations of the applied re-
search instruments, variation in sample sizes, differences in the type of healthcare facili-
ties, and the diversity of study participants.
The global distribution of the included articles is represented in Figure 3. Several
studies targeted more than one country.

Figure 3. Global distribution of the articles included in this analysis. Figure 3. Global distribution of the articles included in this analysis.

Int. J. Environ. Res. Public Health 2021, 18, 2466 26 of 36

The map of the co-occurrence of terms in included papers is depicted in Figure 4.
The nodes represent specific terms, their sizes indicate their frequency, and links show
the co-occurrence of the terms. In the title and abstract of included papers, frequently
co-occurring terms created a cluster that appeared with the same color (green, blue, and
red color). The three core nodes of these clusters are safety climate, safety culture, and
survey. Furthermore, the relationship between the core node of “safety culture” and other
high-frequency terms is shown in Figure 5. The thickness of links between nodes represents
the strength of the co-occurrence relationships.

Int. J. Environ. Res. Public Health 2021, 18, x 20 of 31

The map of the co-occurrence of terms in included papers is depicted in Figure 4. The
nodes represent specific terms, their sizes indicate their frequency, and links show the co-
occurrence of the terms. In the title and abstract of included papers, frequently co-
occurring terms created a cluster that appeared with the same color (green, blue, and red
color). The three core nodes of these clusters are safety climate, safety culture, and survey.
Furthermore, the relationship between the core node of “safety culture” and other high-
frequency terms is shown in Figure 5. The thickness of links between nodes represents the
strength of the co-occurrence relationships.

Figure 4. The map of the co-occurrence of terms in the title and abstract.

Figure 5. The map of the co-occurrence between safety culture and other high-frequency terms.

Figure 4. The map of the co-occurrence of terms in the title and abstract.

Int. J. Environ. Res. Public Health 2021, 18, x 20 of 31

The map of the co-occurrence of terms in included papers is depicted in Figure 4. The
nodes represent specific terms, their sizes indicate their frequency, and links show the co-
occurrence of the terms. In the title and abstract of included papers, frequently co-
occurring terms created a cluster that appeared with the same color (green, blue, and red
color). The three core nodes of these clusters are safety climate, safety culture, and survey.
Furthermore, the relationship between the core node of “safety culture” and other high-
frequency terms is shown in Figure 5. The thickness of links between nodes represents the
strength of the co-occurrence relationships.

Figure 4. The map of the co-occurrence of terms in the title and abstract.

Figure 5. The map of the co-occurrence between safety culture and other high-frequency terms. Figure 5. The map of the co-occurrence between safety culture and other high-frequency terms.

Int. J. Environ. Res. Public Health 2021, 18, 2466 27 of 36

4. Discussion

In this section, two research questions are answered in two subsections of PSC instru-
ments and PSC dimensions.

4.1. PSC Instruments

This review identified five primary instruments that have been used to assess PSC
in hospital settings. The first instrument, the Hospital Survey on Patient Safety Culture
(HSPSC), was used in 54 studies. By contrast, the Safety Attitudes Questionnaire (SAQ)
tool was used in five studies, and the Patient Safety Climate in Health Care Organizations
(PSCHO) was used in five studies. The Scottish Hospital Safety Questionnaire (SHSQ) and
the Modified Stanford Instrument-2006 (MSI-2006) were used by one study each as shown
in Table 3.

4.1.1. Hospital Survey on Patient Safety Culture (HSPSC)

In 2004, the AHRQ developed the HSPSC within the United States (U.S.) Department
of Health and Human Services, which became a widely used survey. This survey allows
for an assessment of staff opinions concerning medical errors, adverse event reporting, and
other issues relevant to PS [12,13]. Although the original survey was primarily intended for
use by hospitals, it has been enhanced with various versions. This survey currently mea-
sures the safety culture of patients in ambulatory settings, outpatient health offices (such as
primary care), nursing homes, and public pharmacies. The HSPSC is available in different
languages, including Arabic, Spanish, French, and Dutch. The hospital questionnaire
version contains 42 items and assesses 12 composites that are treated as subscales.

4.1.2. Safety Attitudes Questionnaire (SAQ)

The SAQ was developed by Sexton and colleagues at the University of Texas in the
U.S. The SAQ comprises six main components (Table 3). The primary advantage of the
SAQ is that it can be applied to different healthcare settings. The complete version of the
SAQ uses a total of 60 components or items, with 30 items considered as standard across all
environments. The survey utilizes a five-point Likert scale ranging from strongly agree to
strongly disagree. In addition to the 30 standard items, this survey can incorporate another
6 items, with 3 additional items that focus on demographic studies. The statements utilized
by the short-form SAQ can also be addressed using the five-point Likert scale. The short
form is easily accessible and available in different languages, including English, Swedish,
Dutch, Norwegian, German, Arabic, and Chinese [73].

4.1.3. Patient Safety Climate in Health Care Organizations (PSCHO)

According to Singer et al. [74], PSCHO was designed with the aid of the Stanford
Safety Instrument. The PSCHO tool includes 38 items that are used to assess work units,
interpersonal factors, and inter-related organizational topics [74]. Using a Likert scale,
items are rated via a two-page form. PSCHO is considered to be the first tool that ana-
lyzed safety constituents and provided information by measuring the safety climate in
corporations outside hospitals. Information from this survey regarding management and
clinical personnel can be applied to a wide range of healthcare organizations. PSCHO has
undergone psychometrical tests and can be used to compare the performance of several
types of hospital units. The earlier form of this tool has been modified with respect to its
length [75] and has been adapted for use in multiple languages [61].

Int. J. Environ. Res. Public Health 2021, 18, 2466 28 of 36

Table 3. Five measurements of PSC dimensions.

Survey PSC Dimensions

HSPSC

Management support for PS
Teamwork within units
Teamwork across units

Communication openness
Frequency of events reported

Feedback and communication about errors
Organizational learning—continuous improvement

Nonpunitive responses to errors
Handoffs and transitions

Staffing
Supervisor/manager expectations and actions that

promote PS
Overall perceptions of PS

SAQ

Teamwork climate
Safety climate

Job satisfaction
Stress recognition

Perceptions of management
Working conditions

PSCHO

Engagement of senior managers
Organizational resources
Overall emphasis on PS

Unit safety norms
Unit support and recognition for safety efforts

Fear of blame
Fear of shame

MSI

Organization leadership for safety
Unit leadership for safety
Perceived state of safety

Shame and repercussions of reporting
Safety learning behaviors

SHSQ

Supervisors’ expectations and actions
Organizational learning/improvement

Teamwork within hospital units
Communication openness

Feedback and communication about error
Non-punitive responses to errors

Staffing
Hospital management support for PS

Teamwork across hospital units
Hospital handoffs

Frequency of incident reporting
Overall perceptions of safety

4.1.4. Scottish Hospital Safety Questionnaire (SHSQ)

The SHSQ was designed for the Scottish NHS clinical staff, with the main aim of
gauging the safety outcomes and climate for both patients and staff. The SHSQ includes
4 primary components: 44 items related to the hospital survey (HSPSC), 10 worker safety
behavior aspects, 2 items concerned with self-reported patient and worker injuries (see
Table 3), and 7 items that focus on demographics [54].

4.1.5. Modified Stanford Instrument-2006

The MSI-2006 Patient Safety Culture in Healthcare Organizations Survey [53] was
designed to evaluate 32 unique items encompassing five aspects. These aspects include, but
are not limited to, issues associated with seeking help, shame, and self-awareness (Table 3).

Int. J. Environ. Res. Public Health 2021, 18, 2466 29 of 36

Modification of the MSI-2006 tool has facilitated the assessment of perceptions of a wide
range of hospital staff, including direct care workers, technicians, health practitioners,
managers, and nurses. This tool also includes assessments of other aspects, such as support
service personnel, as these workers are an essential part of the hospital and healthcare
setting. MSI-2006 was developed for a wide range of hospital settings with the aim of
generating relevant and accurate data over the long term.

4.2. PSC Dimensions

To understand the effect of PS on healthcare organizations and their staff, the process
and structure of each system needs to be broken into subsystems. The type of instruments
and their varying dimensions, as well as the groups targeted in each study, were among
the most interesting points to be considered when attempting to understand PS.

Five instruments were used in the reviewed studies to measure PSC within the health-
care facilities examined. As indicated in Table 2, teamwork, organizational and behavioral
learning, reporting of errors and safety awareness, gender and demographics, work ex-
perience, and staffing levels were perceived as factors that significantly impacted patient
safety. Personal variables, such as the age and experience of medical professionals, were
also related to PS perceptions. By examining results from individual hospitals or groups
of hospitals, we identified the aspects of safety culture that need improvement, including
considerations of working conditions and management support.

The reviewed studies differ in their focus on relevant PS variables across different
hospitals in various geographical regions. However, many standard components of safety
culture indicators and risk factors have been identified [14,15,18].

4.2.1. Teamwork

Teamwork and mutual help provided by team members in task performance within
specific hospital units were the factors that represented PS through the use of different
instruments [77]. A high score of positive teamwork within units indicates the existence
of healthy work relationships and respect among members within a unit [67]. Moreover,
vertical hierarchy, horizontal hierarchy, and years of working within a unit influenced
the level of teamwork within units. The level of skill competency also affected teamwork
within units [57]. However, teamwork across units was reported to have low positive
scores [15,21]. Besides, attitudes towards colleagues from different units and managers’ or
supervisors’ actions and expectations towards PS affected teamwork performance across
units [18]. According to Hamdan and Saleem [19], skills and organizational learning were
significantly related to knowledge teamwork across units. However, supportive managers
or supervisors increased the level of teamwork across units. Moreover, colleagues who
worked closely together and supported each other in their work duties often resulted in
mutual respect [19]. Therefore, while it could be concluded that teamwork is one of the
important factors that impact PS, there are always opportunities for improvement.

After reviewing the studies, the HSPSC and SAQ instruments are the only two that
are focused on the teamwork dimension. Among the studies that used the SAQ, the pro-
nounced difference in PSC was notable among the front-line healthcare staff, supervisors,
and managers [65]. Furthermore, a great variance in PS perception was observed within
specific hospital units compared with differences between units. Chakravarty et al. [39]
reported low variations in scores between hospitals based on the PS index. However, their
study also revealed significant differences in individual measures of PS, including the
perception of management, teamwork, and stress recognition, when using the PS index
score [39].

The HSPSC provides more details about teamwork performance within and be-
tween units of hospitals. Additionally, teamwork is the most factor that has a rela-
tionship with the other characteristics of PS. Among studies using the HSPSC, high
scores were obtained for teamwork within units, especially in different developing coun-
tries [18,30,35,43,45,47,56,67]. These results confirm that the healthcare industry greatly

Int. J. Environ. Res. Public Health 2021, 18, 2466 30 of 36

relies on interdisciplinary teams of specialists with the skill sets needed to perform spe-
cialized tasks. Such teams also collaborate to achieve common safety goals [40]. Different
teams use shared resources and rely on communication to adapt to ever-changing health-
care environments. The behavior of these teams was analyzed through observational
studies. The results indicated that the teams’ clinical performance was influenced by how
they communicated, coordinated, and practiced effective leadership [40].

4.2.2. Organizational and Behavioral Learning

Organizational learning is also a critical factor that affects the PS. In most of the survey
studies examined, positive responses were given for organizational learning/continuous
improvement as a composite for PS [12,29,31,34]. Continuous improvement can be gained
from daily work routines and incidents. PS can also improve by enhancing relevant
personnel’s skills and knowledge based on incident analysis. Additionally, the junior staff
can learn from more experienced staff as they worked together [74].

Although organizational and behavioral learning had positive responses, the outcome
dimension, frequency of events reported, did not have positive responses in all the studies
included in this review. Therefore, the learning process in PSC should be enhanced by
establishing formal methods instead of informal practices to avoid harming patients. In
the U.S., as a result of the IOM’s report, the U.S. Congress passed the Patient Safety and
Quality Improvement Act in 2005, which aimed to improve quality and safety via the
collection and analysis of data on patient events. This shows that PS has to be enhanced by
the participation of healthcare providers and patients.

In 28 of the studies examined, 55% of the participants agreed that these factors were
important components of organizational learning and continuous improvement processes
at the examined healthcare facilities. These processes are also responsible for communicat-
ing and conveying information that is essential for PS and healthcare. Such processes occur
in both formal and informal learning environments within healthcare systems that perform
complex and interconnected operations, which should be considered to enhance the PSC.

4.2.3. Reporting of Errors and Safety Awareness

Two of the dimensions that received low positive scores were non-punitive responses
to errors and the frequency of event reporting [32]. That is because a large percentage of
respondents indicated that they do not report incidents to their managers or supervisors.
The reason behind this could be that staff members fear being reprimanded for an error
and the lack of safety awareness. Such a culture might cause the staff to hide issues that
could later influence the efficacy of PS. A culture that includes non-punitive responses to
errors could arise from managers, supervisors, and colleagues [46]. Another reason behind
this finding could be the risks of patients complaining; patient demands for compensation
might have also reduced the frequency of event reporting [52].

Moreover, another study that was conducted in Saudi Arabia illustrated that one of
the dimensions that indicated a high positive response was feedback and communication
about errors [24]. The factors requiring improvement included non-punitive responses to
error reporting and adequate personnel staffing [24]. The survey showed that the overall
perception of PS was 59.9%, while the reporting frequency was 68.8% [24]. Another study
that was conducted in Scotland by Agnew et al. [54] found that the overall perception of
PS was judged at 56%; the reported frequency of incident reporting was also 56%. Another
study in Saudi Arabia showed that the frequency of reporting adverse safety events was
57% [23]. Additionally, A study conducted by Khater et al. [26] among senior nurses in
Jordan showed a positive correlation between non-punitive responses to medical errors
and the frequency of medical error reporting. The result was a reduction in adverse events
regarding PS and risks of complaints from patients. The overall perception of senior
nurses was 51.5% before education and 60.6% after educational sessions. The frequency of
event reporting increased from 54.2% to 64.3% after implementing suitable educational
training [26].

Int. J. Environ. Res. Public Health 2021, 18, 2466 31 of 36

In a related study, Hellings et al. [49] described a PSC improvement approach imple-
mented in five Belgian hospitals. The results showed that management support for PS
increased along with supervisor expectations and actions that promoted safety practices.
Medical personnel from Dutch-speaking hospitals had a higher positive perception of PS
compared with French-speaking hospitals [49]. The survey also showed that respondents
working in pediatrics, rehabilitation, and psychiatry departments (units) provided more
positive feedback about perceived PSC. By contrast, medical professionals working in
emergency departments (units) provided lower positive feedback [49]. These differences in
the hospitals’ departments and languages are some of the reasons for reporting low scores
in the non-punitive responses to errors [49].

A positive perception of PS was observed among medical personnel in China and
U.S. managers. In both countries, these individuals expressed a higher level of perceived
PS compared with front-line personnel. However, Chinese staff had higher scores for
work-related fear of shame and blame compared with their American counterparts [61].
The U.S. hospitals have fewer cases of “fear of blame” compared to Chinese hospitals [61].

As noted earlier, a reduction in avoidable incidents with potential or actual medical
harm is a key objective in developing a robust PSC [31,34,36]. Harm can be measured by
the frequency of reported events. Effective reporting of safety incidents is essential for
identifying the causes of failures in a healthcare work environment. The present analysis
indicates a need to implement more effective reporting systems. Reporting provides
relevant information about the frequency of events that can adversely affect PS.

A culture of blame was evident in 22 studies, representing 43% of those examined. In
these studies, punitive responses to medical errors were prevalent and created a culture that
discouraged personnel from reporting safety incidents and occurrences [42]. Such a culture
impeded the hospitals’ ability to determine the causes of errors and, consequently, to learn
from previous mistakes [13,15,17]. In instances in which an influential safety culture exists,
workers can highlight potential risk factors and also identify failures when they occur
with a focus on PS [38]. Additionally, adverse events arise from multiple unintentional
causes. Blame was judged to be appropriate when addressing individuals who consistently
commit frequent and careless errors or who ignore established safety standards and policies.
Competent institutions should maintain a culture of accountability to ensure that patient
care is maintained at the highest levels.

A study conducted in Canada by Zaheer et al. [53] focused on supervisory and
senior leadership support for PS. The survey noted that ease in reporting provided the
hospital with a platform for learning and improving through reported incidents. Among
the supervisory and senior leadership, ease in reporting was recorded at 11% and 12%,
respectively. These findings suggest that hospitals should ensure that front-line staff are
aware of and contribute to their organization’s reporting systems. Ease in reporting should
provide organizations with an opportunity to improve strategy, commitment, and the
overall efficacy of PSC in sample facilities [53].

4.2.4. Gender and Demographics

PSC is a multidimensional concept that requires a strict analysis to identify its vital
elements. The perception of PSC is always measured through the dimensions of the
tools used. However, gender and demographic characteristics can be used to analyze
participants’ responses to a survey [16]. Many of the studies analyzed herein demonstrate
the correlation between PSC perception with gender and demographics.

Numerous differences in nurses’ perceptions of PSC arose due to demographic charac-
teristics, including gender, age, level of education, years of experience, the language used,
and length of work shift [27]. In general, female nurses had a more positive view of the
prevalent PSC than did their male counterparts. Moreover, nurses between the ages of 40
and 60 years had a more positive view of the PSC than nurses between 20 and 40 years
of age [53]. As 85.4% of the nurses had a Bachelor of Science in nursing, it is plausible
that their education levels did not affect their perception of PS [16]. However, as Hamdan

Int. J. Environ. Res. Public Health 2021, 18, 2466 32 of 36

et al. [19] observed, education is generally one of the most critical aspects of healthcare
delivery to patients worldwide.

Elsous et al. [27] evaluated nurses’ perception regarding PSC and investigated the
influence of age, hierarchal position, working hours, and experience. Job satisfaction and
perception by management concerning PS had a strong influence on these variables. Front-
line clinicians had a less positive attitude toward PS than did nurse managers. Moreover,
positive attitudes increased with years of experience. Work shift hours and ages of the
nurses had a direct effect on the perception of PS. Nurses working within the normal hours
allocated per week and aged 35 years or older showed a better PS perception [27]. The
study also reported no differences in safety attitude scores between nurses and doctors due
to gender, age, and work experience [27]. The studies of the potential effects of gender and
demographics on the perception of PSC should be expanded in the future.

4.2.5. Work Experience

Relevant work experience was strongly related to the perception of the PSC. Work
experience was also associated with the perceived quality of care among nurses [19].
Furthermore, more experienced healthcare providers had a better understanding of patient
care needs than did less experienced nurses [53]. A study conducted in the U.S. by
Hansen et al. [76] investigated the relationship between hospital PSC and rehospitalization
rates within 30 days of discharge. A survey done in 67 hospitals discovered that higher
readmission rates of acute myocardial infarction and heart failure patients were directly
related to a lower safety climate [76]. Additionally, frontline staff workers reported a lower
level of perceived safety climate with the readmissions, which were the management’s
responsibility [76]. In another study, a survey was conducted in 97 hospitals in the U.S. that
revealed that frontline workers perceived a climate of safety more frequently than did the
managers and the supervisors [77]. Furthermore, among the clinicians, nurses perceived
a safety climate more than physicians [77]. Based on that, it could be concluded that the
work environment plays a key role in perceiving the PSC.

Moreover, another study illustrated that language also has effects on perceiving the
PSC [16]. Non-Arabic-speaking nurses had more positive views of PSC than did Arabic-
speaking nurses [16]. This finding was unanticipated as the Arabic-speaking nurses and
their patients spoke the same language. The low PSC scores might have been due to
disparities in educational systems affecting PS perceptions. Furthermore, nurses working
on day shifts had more positive PSC perceptions than nurses working night shifts or
alternating shifts [16]. It was noted that day-shift nurses were more time engaging with
and involved in their patients’ progress, which resulted in a positive PSC [16]. Day-shift
nurses also interacted with their managers and became more familiar with relevant aspects
of the PSC [16]. Therefore, it could be concluded that work experience and the possibility
of knowledge exchange had a measurable impact on perceptions related to the PSC.

4.2.6. Staffing

The availability of human resources also impacts the perceptions of the PSC. A study
conducted in Scotland by Agnew et al. [54] aimed to analyze the relationship between the
medical personnel safety behavior and reported injury measures for patients and healthcare
providers. At the hospital level, the authors found a strong correlation between overall PS
scores and patient and personnel injury measures and behavior [54]. Therefore, the level of
hospital staffing, coupled with management support for PS, also influenced the perception
of PS within the studied facilities [54]. Generic safety climate factors and patient-specific
items showed a strong correlation with perceived safety outcomes [54]. To summarize, a
total of 24 studies reported on the issue of healthcare personnel understaffing. The staff
reported feelings of being overburdened and overloaded with their daily responsibilities
in approximately half of the hospitals [18,37,47,48,60,64,66]. Consequently, this issue had a
negative impact on the quality of care provided by the staff [45]. Therefore, the availability

Int. J. Environ. Res. Public Health 2021, 18, 2466 33 of 36

of adequate staffing plays a critical role in perceiving the PSC because employees’ focuses
might be harmed due to overload.

5. Study Limitations

The present study has some important limitations. This systematic review focused
only on articles written in English; moreover, a meta-analysis was not performed. The
results of the reviewed studies are difficult to generalize due to the application of a diverse
set of PSC measures with different dimensions. Furthermore, the reviewed studies also
varied in the type of participants included (doctors, nurses, and administrators), the
periods over which the measurements were conducted, the sampling strategies used, and
the cultural settings. For example, the results that focused primarily on results from nurses
were obtained from convenience samples of participants and as such cannot be generalized
to the entire nursing staff. Finally, this study did not account for language and cultural
disparities prevalent in the specific countries in which the reported studies were conducted.

6. Conclusions

Enhancing the perception of the PSC in health sectors plays a key role in improving
their overall quality, efficiency, and productivity. This paper contributes to the body of
knowledge related to PSCs by identifying important critical factors and illustrating the
instruments that have been developed and used to generate data. A comprehensive
review of perceiving the PSC in hospital settings was provided. A systematic literature
review was conducted using the PRISMA protocol for the period of 2006 to 2020. The paper
reviewed 66 studies that were identified based on carefully selected keywords. The Hawker
Assessment Tool was also implemented in this paper to enable the researcher to score the
quality of the papers reviewed. The paper analyzed PSC perception in the hospital setting,
determined available instruments, and identified the most critical factors that have an
impact on the PSC. Our findings revealed that teamwork and organizational and behavioral
learning are some of the factors that have a significant impact on the PSC. This paper also
illustrated that reporting errors and safety awareness, gender and demographics, work
experience, and staffing are additional critical factors that need to be considered further to
improve perceptions of PSCs.

In the future, the impact of culture on PS might be analyzed in greater depth. PS,
particularly in hospitals, is a dynamic and complex phenomenon. Therefore, it is rec-
ommended that research and surveys be performed every two to three years to ensure
the best practices for PS. Such an approach could also enhance the quality of healthcare
delivery. A large number of hospitals in many different countries have been studied and
the specific characteristics of the healthcare management systems in these countries greatly
vary. Consequently, for future studies, a broader study population crossing the national
boundaries would help to ensure that the findings can have an impact on the development
of high-quality, affordable healthcare worldwide.

Finally, it should be pointed out that although the reported survey questionnaires
described in the reviewed studies were anonymous, some respondents might not have
been candid in providing their answers. Some of the questionnaires were long and some of
the respondents may have become distracted during the process, lost interest, or answered
some questions inaccurately. Additionally, some inconsistencies in using different survey
tools due to cultural and language diversities were noted. For future, investigations
including qualitative evaluations of these relationships should be conducted. Finally, the
long-term effects of safety incidents on patients’ health and their long-term impact on
families have not been investigated. Future studies should evaluate the effects of such
experiences in hospital settings.

Author Contributions: A.A.: methodology and writing, including the original draft and revisions;
W.K.: conceptualization, writing (review and revisions), editing, and supervision; M.R.D.: writing
(review and revisions), editing. All authors have read and agreed to the published version of
the manuscript.

Int. J. Environ. Res. Public Health 2021, 18, 2466 34 of 36

Funding: Article processing charges were provided in part by the UCF College of Graduate Studies
Open Access Publishing Fund.

Institutional Review Board Statement: Not relevant to this study.

Informed Consent Statement: Not relevant to this study.

Data Availability Statement: Not relevant to this study.

Conflicts of Interest: The authors declare no conflict of interest.

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Introduction
Materials and Methods

Results

Discussion

PSC Instruments
Hospital Survey on Patient Safety Culture (HSPSC)
Safety Attitudes Questionnaire (SAQ)
Patient Safety Climate in Health Care Organizations (PSCHO)
Scottish Hospital Safety Questionnaire (SHSQ)
Modified Stanford Instrument-2006
PSC Dimensions
Teamwork
Organizational and Behavioral Learning
Reporting of Errors and Safety Awareness
Gender and Demographics
Work Experience
Staffing

Study Limitations
Conclusions

References

Evaluation of the association
between Hospital Survey on Patient
Safety Culture (HSOPS) measures
and catheter-associated infections:
results of two national
collaboratives

Jennifer Meddings,1,2,3 Heidi Reichert,1 M Todd Greene,1,3

Nasia Safdar,4,5 Sarah L Krein,1,3 Russell N Olmsted,6 Sam R Watson,7

Barbara Edson,8 Mariana Albert Lesher,8 Sanjay Saint1,2,3

▸ Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/bmjqs-
2015-005012).

For numbered affiliations see
end of article.

Correspondence to
Dr Jennifer Meddings,
Department of Internal
Medicine, University of Michigan
Medical School, 2800 Plymouth
Road, Building 16, Room 430
W, Ann Arbor, MI, 48019-2800,
USA; meddings@umich.edu

Received 4 November 2015
Revised 4 February 2016
Accepted 29 February 2016
Published Online First
25 May 2016

To cite: Meddings J,
Reichert H, Greene MT, et al.
BMJ Qual Saf 2017;26:226–
235.

ABSTRACT
Background The Agency for Healthcare
Research and Quality (AHRQ) has funded
national collaboratives using the Comprehensive
Unit-based Safety Program to reduce rates of
two catheter-associated infections—central-line-
associated bloodstream infection (CLABSI) and
catheter-associated urinary tract infection
(CAUTI), using evidence-based intervention
bundles to improve technical aspects of care and
socioadaptive approaches to foster a culture of
safety.
Objective Examine the association between
hospital units’ results for the Hospital Survey on
Patient Safety Culture (HSOPS) and catheter-
associated infection rates.
Methods We analysed data from two
prospective cohort studies from acute-care
intensive care units (ICUs) and non-ICUs
participating in the AHRQ CLABSI and CAUTI
collaboratives. National Healthcare Safety
Network catheter-associated infections per 1000
catheter-days were collected at baseline and
quarterly postimplementation. The HSOPS was
collected at baseline and again 1 year later.
Infection rates were modelled using multilevel
negative binomial models as a function of HSOPS
components over time, adjusted for hospital-level
characteristics.
Results 1821 units from 1079 hospitals
(CLABSI) and 1576 units from 949 hospitals
(CAUTI) were included. Among responding units,
infection rates declined over the project periods
(by 47% for CLABSI, by 23% for CAUTI,
unadjusted). No significant associations were

found between CLABSI or CAUTI rates and
HSOPS measures at baseline or over time.
Conclusions We found no association between
results of the HSOPS and catheter-associated
infection rates when measured at baseline and
postintervention in two successful large national
collaboratives focused on prevention of CLABSI
and CAUTI. These results suggest that it may be
possible to improve CLABSI and CAUTI rates
without making significant changes in safety
culture, particularly as measured by instruments
like HSOPS.

INTRODUCTION
Central-line-associated bloodstream infec-
tion (CLABSI) and catheter-associated
urinary tract infection (CAUTI) remain
common, morbid and expensive
healthcare-associated complications.1–5

Success in reducing CLABSI and CAUTI
is theorised to depend on improving two
different types of care: ‘technical’ compo-
nents of care such as aseptic catheter
insertion technique and use of standard
evidence-based checklists for insertion
and maintenance, and ‘socioadaptive’
components of care such as teamwork,
habits and willingness to change.6 ‘Safety
culture’ is a term to describe the proce-
dures, expectations, attitudes and beha-
viours of an organisation’s personnel as
they relate to safety; a team’s safety
culture can serve as a strength or barrier
for improving technical and socioadap-
tive aspects of care to improve safety.7–12

ORIGINAL RESEARCH

226 Meddings J, et al. BMJ Qual Saf 2017;26:226–235. doi:10.1136/bmjqs-2015-005012

http://dx.doi.org/10.1136/bmjqs-2015-005012

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http://www.health.org.uk/

http://qualitysafety.bmj.com

Safety culture is theorised to be very important in the
development and prevention of catheter-associated
infections such as CLABSI and CAUTI for several
reasons, described here using components measured
by the Hospital Survey on Patient Safety Culture
(HSOPS). The HSOPS tool is a multi-item survey
assessing 12 different dimensions of safety culture
such as teamwork, communication, non-punitive
response to error, staffing and management support.
For example, the strength of teamwork and communi-
cation between clinicians in a busy unit would be
expected to influence the comfort level of clinicians
to speak up and stop a procedure such as catheter
placement, if the procedure was not being performed
as recommended to optimise patient safety. The
comfort level of an employee to self-report an error
without a punitive response and acknowledge the
need for additional training to improve safe catheter
use is hypothesised to be important in reducing
inappropriate catheter placement and care.
Additionally, staffing is theorised to impact catheter-
associated complications because the temptation to
inappropriately use urinary and vascular catheters for
clinician convenience beyond the clinical need of the
patient can be influenced by nurse–patient ratios (par-
ticularly for care of patients with urinary incontin-
ence). Management support for patient safety is
hypothesised to influence how well supported clini-
cians feel by their multidisciplinary team in helping
with time-consuming tasks such as using less conveni-
ent alternatives to indwelling catheters, including
more frequent peripheral blood draws for the patient
without a central venous catheter, and the need for
more frequent turning and bathing for the incontinent
patient without a urinary catheter.
Two large national collaboratives to reduce

CLABSI13 and CAUTI,14 funded by the Agency for
Healthcare Research and Quality (AHRQ), recently
employed HSOPS to assess safety culture for two pur-
poses. First, unit team members and collaborative
coaches use the results to prompt team discussion,
evaluate progress and highlight challenges to refocus
efforts and resources. Second, collaborative leaders
use HSOPS results to track changes in safety culture
measures to assess how well interventions were imple-
mented across different sites and units.
However, despite HSOPS and related safety culture

surveys15–17 becoming common tools to assess safety
culture in large collaboratives, the extent to which
measures from these survey tools are associated with
changes in catheter-associated infection rates is
unclear.8 18 Furthermore, although as outlined above,
safety culture is strongly hypothesised to be very
important to reduce hospital-acquired complications
such as catheter-associated infections, it remains
unclear how important changing safety culture is in
reducing catheter-associated infections compared with
the importance of standardising technical components

of care such as standardising procedures. For example,
if educational interventions and training are indeed
successful in standardising the steps of aseptic inser-
tion, maintenance and removal of catheters, how
important are additional interventions focused on
improving safety culture and performing assessments
of safety culture? This question is important to inform
future collaboratives involving catheter-associated
infections to justify the opportunity costs associated
with widespread implementation and facilitation of
safety culture interventions and routinely performing
assessments such as HSOPS. Despite survey tools such
as HSOPS being available as standard tools for collect-
ing baseline and reassessments in different units and
hospitals with limited expertise needed to administer
and analyse the surveys, even these tools have import-
ant limitations such as reporting bias of those who
complete the survey, and the need for busy clinicians
to invest time in completing surveys and collaborative
coaches to invest time in encouraging survey comple-
tion. To further study these issues, we performed an
analysis of HSOPS survey and patient outcome data
from the AHRQ CLABSI and CAUTI collabora-
tives.13 19 We hypothesised that hospital units with
HSOPS results consistent with higher scores for safety
culture measures would be more successful at imple-
menting technical and socioadaptive components of
CLABSI and CAUTI intervention bundles, and would
achieve lower CLABSI and CAUTI rates over time.

METHODS
Design and intervention
This study was a secondary analysis of a subset of
healthcare worker survey and patient outcome data
collected in the AHRQ CLABSI and CAUTI colla-
boratives. Each collaborative was a prospective cohort
study in which participating hospital units implemen-
ted interventions to reduce catheter-associated infec-
tions using principles from the Comprehensive
Unit-based Safety Program (CUSP).19 20 In brief,
CUSP is a multistep programme, designed to promote
safety culture and teamwork, which involves preinter-
vention baseline assessment, strategies to improve
engagement and implementation, and feedback to aid
the implementation of evidence-based interventions
such as checklists for catheter insertion and mainten-
ance care. The HSOPS was employed to assess safety
culture for the CLABSI and CAUTI collaboratives21–23

studied in this analysis.
In the online supplementary material, for interested

readers, we also provide a summary of two other
measures collected in these collaboratives to assess
baseline exposure and experience to interventions to
be prioritised in the collaborative (ie, the Readiness
Assessment,19 20 see online supplementary appendix 2)
and to use input from the team at baseline and serially
in follow-up (ie, the Team Check-up Tool,13 19 20 see

Original research

Meddings J, et al. BMJ Qual Saf 2017;26:226–235. doi:10.1136/bmjqs-2015-005012 227

online supplementary appendix 3) with the goal to
report progress and barriers in implementation.

Study participants and data sources
Analyses included data from participating adult,
acute-care intensive care units (ICUs) and non-ICUs,
including all six cohorts from the CLABSI collabora-
tive with data collected from 2008 to 2011, and
cohorts 1–4 from the CAUTI collaborative with data
collected from 2011 to 2013. CLABSI collaborative
cohorts were 30 months in duration; CAUTI collab-
orative cohorts were 17 months in duration. CAUTI
cohorts 5–6 were excluded because of additional
interventions implemented in the emergency depart-
ment and ICU settings. To be included in the analyses
the unit also had to have (1) non-missing values for all
individual HSOPS measures; (2) hospital characteristic
data from American Hospital Association Annual
Survey 2010 for CLABSI and 2011 for CAUTI (eg,
teaching status, bed size, rurality and critical access);
and (3) at least one valid baseline and one valid post-
baseline outcome reported.

Measures
Patient outcome measures
The conventional National Healthcare Safety Network
infection rate of catheter-associated infections per
1000 catheter-days was collected for both collaborative
projects. Unit-level aggregate infection rates were col-
lected at baseline and monthly postimplementation for
CLABSI. Unit-level aggregate infection rates were col-
lected at baseline and quarterly postimplementation
for CAUTI. Monthly CLABSI results were aggregated
to quarterly numbers for our analyses.

HSOPS components
The HSOPS was scored and reported as recom-
mended by the survey tool instructions to the partici-
pating units, without recoding of scores or creation of
composite or climate profiles.23 The measure scores
yielded by this analysis are in the same format pro-
vided to the collaborative members in feedback for
understanding their units and performance.
The HSOPS is a 42-item survey with Likert scale

responses, aligned by 12 dimensions.13 19 20 24 All
staff members were encouraged to complete the
HSOPS survey at baseline and in follow-up approxi-
mately 1 year later.
Of note, the HSOPS tool was employed in these

national collaboratives instead of other measures such
as the Safety Attitudes Questionnaire (SAQ)15 23 25–28

because at the time of these collaboratives’ initiatives,
HSOPS was employed more widely in US hospitals
nationally, and this tool is in the public domain (as a
tool developed by AHRQ) and thus did not require a
fee for hospitals to use. While some studies have
demonstrated improvements in safety culture mea-
sures in response to interventions such as the CUSP,

there is limited evidence linking survey-based safety
culture measures and patient outcomes, particularly
for surveys other then the SAQ.15 23 25–28

Statistical analyses
Multilevel negative binomial models were applied to
adjust for clustering within hospitals and within units
over time and also for overdispersion of the outcome.
Hospital characteristics of bed number, teaching
status, critical access status and rurality were adjusted
for in the models. Separate models were analysed for
ICUs and non-ICUs and culture items were tested
individually because of higher catheter use rates in
ICUs, and because safety culture of ICUs was antici-
pated to differ from non-ICUs due to differences in
team structure and rounding styles. HSOPS measures
were time-varying; models with and without inter-
action with time were tested individually.
Conservative significance testing criteria of p<0.01 was chosen to account for the higher likelihood of random association due to multiple comparisons. Model results for the culture items of interest were depicted using coefficient plots, which plot the coeffi- cient point estimate and the corresponding 99% CI. Analyses were performed using Stata/MP13.1 (StataCorp, College Stations, Texas, USA).

RESULTS
Participant characteristics
Table 1 details characteristics of recruited hospitals
and all participating units for each collaborative
before application of exclusion criteria. A total of
1821 units from 1079 hospitals (CLABSI) and 1576
units from 949 hospitals (CAUTI) were considered for
analysis. Major differences included the CLABSI col-
laborative having a higher proportion of ICUs (75%
vs 41%) and higher proportion of teaching hospitals
(33% vs 7%) compared with the CAUTI collaborative.
The application of inclusion and exclusion criteria for
this analysis is detailed in online supplementary
Appendix Figure 1, yielding 598 units from 436 hos-
pitals (CLABSI) and 675 units from 463 hospitals
(CAUTI) in the analysis.

Table 1 Recruited hospital and unit characteristics by
collaborative

CLABSI CAUTI

Hospitals 1079 949

Critical access hospital, N (%) 82 (8) 190 (20)

Rural hospital, N (%) 259 (24) 355 (37)

Teaching hospital, N (%) 359 (33) 67 (7)

Bed size, mean (SD) 253 (229) 189 (198)

Units 1821 1576

Intensive care units, N (%) 1372 (75) 653 (41)

CAUTI, catheter-associated urinary tract infection; CLABSI, central-line-
associated bloodstream infection.

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228 Meddings J, et al. BMJ Qual Saf 2017;26:226–235. doi:10.1136/bmjqs-2015-005012

Patient outcome measures
Overall, using data available from all participating
units in the collaboratives (prior to application of
exclusion criteria), catheter-associated infection rates
declined over the project periods for the six CLABSI
and four CAUTI cohorts including a 41% decline for
CLABSI and 14.7% decline for CAUTI
(unadjusted).13 29 For the units meeting inclusion cri-
teria for this analysis, catheter-associated infection
rates declined by 47% for CLABSI and 23% for
CAUTI (unadjusted).

HSOPS components
HSOPS response rates were low overall, at 24% for
the CLABSI collaborative and 43% for the CAUTI
collaborative, calculated as the number of units with
HSOPS data divided by the total number of active
units. Summary statistics for the HSOPS dimensions
at baseline, follow-up and change from baseline to
follow-up are detailed in tables 2 and 3 separately for
ICU and non-ICUs. In general, mean changes in
HSOPS scores ranged from −3.4 to +2.9, with vari-
ation in individual hospital units showing both large
improvements and declines.

Association between HSOPS measures and patient
outcomes
Detailed model results for baseline and longitudinal
outcomes for the CLABSI and CAUTI collaboratives
are found in online supplementary appendix 1 tables
1–8 with separate models for ICUs and non-ICUs. In
a few cases, model results are not presented due to
either lack of variation in the response for the culture
item of interest, or too few units responding. Figure 1
illustrates the coefficient plots for the HSOPS models
for ICUs and non-ICUs, for CLABSI (figure 1A) and
CAUTI (figure 1B). Based on the conservative signifi-
cance testing criteria of p<0.01, there were no statis- tically significant associations found between any of the measures selected for testing from each of the selected measures of safety culture and the catheter- associated infection outcomes.

DISCUSSION
Key results
Contrary to our hypothesis, there was no significant
association between safety culture as assessed by the
HSOPS with CLABSI or CAUTI outcomes when
either measured at baseline or in follow-up, in two
national collaboratives that were successful in reducing
these infections. An important implication of this
result is that it is possible to reduce CLABSI and
CAUTI rates without improving safety culture,
through improvements in technical components of
care such as standardising procedures involving cath-
eter insertion, maintenance and removal. This inter-
pretation would prompt reconsideration and
prioritisation of technical and safety culture

components of interventions in future studies, particu-
larly for hospitals or units with limited bandwidth to
implement new interventions given competing prior-
ities or limited resources. Another potential explan-
ation of the findings is that safety culture did improve
in these collaboratives and was instrumental for redu-
cing CLABSI and CAUTI but the HSOPS tool did not
adequately detect or assess important components of
safety culture in the participating units. This could
occur if the HSOPS survey was not designed to
produce a valid measure of safety culture impacting
care at the bedside or if it was completed by respon-
dents who had less influence or understanding of the
safety culture impacting bedside care. Safety culture
can be difficult to assess, particularly given its fluid
nature impacted by changes in staff, resources and
competing priorities that commonly occur in hospital
units in short time frames.30 31

Strengths and limitations
Strengths of this study include the use of data col-
lected from two large national prospective cohort
studies implementing evidence-based interventions
with the support of CUSP strategies for optimising
safety culture. These collaboratives involved a wide
variety of hospital and unit types, and included ana-
lyses specific to ICU and non-ICU designations to
study anticipated differences in the safety culture;
ICUs are often ‘closed’ units with fewer physician
teams and a stronger tradition of multidisciplinary
rounds and more experience in using checklists for
care.
Some important limitations should be noted.

Despite considerable focus during the collaboratives
to encourage the use of HSOPS, survey response rates
were low for both the CLABSI collaborative at 24%
and the CAUTI collaborative at 43%—much lower
than the response rates of >70% in prior studies
using the SAQ to assess safety culture.15 16 Such a low
response rate for HSOPS from two large national col-
laboratives is an important finding of this analysis
given the substantial resources invested in measure
collection. Low culture survey response rates clearly
impacted the available data and which units were
included in the analysis. There are several potential
explanations for the low survey response rate.32 It
could reflect ‘safety culture survey fatigue’ as these
surveys were overlaid on top of periodic safety culture
surveys that many participants may have been asked
to complete on an ongoing basis beyond these colla-
boratives’ tasks. Low response rate could also reflect
participant attitude towards the value of the survey or
the value of the collaborative requesting the survey.
Of note, a low overall response rate does not indicate
that individual units or participants do not find value
in the survey tool as a prompt for discussion and iden-
tification of areas for improvement. However, an asso-
ciation between culture scores and infection rates was

Original research

Meddings J, et al. BMJ Qual Saf 2017;26:226–235. doi:10.1136/bmjqs-2015-005012 229

Table 2 CLABSI HSOPS dimension score summary for analytic sample, mean (SD) (range)

ICUs (n=304) non-ICUs (n=58)

HSOPS dimension Baseline Follow-up Change Score Baseline Follow-up Change Score

Supervisor expectations and actions promoting safety 75 (12) (33, 100) 78 (14) (24, 100) 3 (16) (−56, 53) 74 (15) (33, 100) 79 (13) (43, 100) 5 (17) (−38, 50)
Organisational learning—continuous improvement 74 (12) (36, 100) 74 (14) (25, 100) 0.4 (14) (−43, 51) 72 (15) (23, 100) 75 (15) (38, 100) 3 (18) (−40, 50)
Teamwork within hospital units 85 (9) (38, 100) 82 (12) (41, 100) −3 (12) (−56, 34) 76 (15) (25, 100) 73 (18) (0, 100) −3 (18) (−63, 43)
Communication openness 63 (12) (30, 100) 63 (16) (8, 100) 0.8 (16) (−50, 54) 55 (15) (24, 84) 61 (15) (29, 100) 5 (18) (−50, 39)
Feedback and communication about error 60 (14) (20, 100) 61 (17) (11, 100) 1 (16) (−59, 71) 61 (16) (20, 100) 58 (15) (7, 85) −3 (17) (−58, 30)
Non-punitive response to error 39 (15) (3, 100) 47 (20) (0, 100) 8 (19) (−44, 72) 39 (16) (7, 100) 55 (20) (13, 100) 16 (27) (−53, 69)
Staffing 58 (14) (18, 100) 59 (15) (13, 100) 1 (15) (−42, 59) 52 (15) (26, 100) 55 (18) (15, 100) 3 (22) (−53, 60)
Management support for patient safety 62 (16) (11, 100) 61 (18) (0, 100) −1 (18) (−77, 59) 65 (15) (29, 100) 66 (17) (0, 100) 0.2 (20) (−52, 29)
Teamwork across hospital units 56 (14) (20, 100) 57 (16) (0, 100) 0.8 (14) (−47, 52) 55 (13) (23, 85) 52 (19) (0, 83) −3 (20) (−52, 29)
Hospital handoffs and transitions 48 (13) (0, 100) 50 (16) (0, 100) 1 (16) (−42, 75) 43 (13) (17, 75) 43 (16) (0, 79) −0.2 (16) (−28, 38)
Frequency of event reporting 57 (14) (0, 100) 56 (17) (0, 100) −0.4 (17) (−75, 56) 60 (14) (29, 90) 51 (20) (0, 100) −10 (23) (−74, 63)
Overall perceptions of safety 60 (14) (22, 92) 56 (19) (0, 100) −4 (18) (−71, 55) 55 (15) (20, 100) 43 (20) (0, 83) −12 (20) (−77, 24)
Patient safety grade 69 (22) (0, 100) 69 (20) (0, 100) 0.2 (20) (−62, 66) 63 (22) (0, 100) 64 (22) (0, 100) 2 (25) (−54, 66)
Baseline and follow-up scores represent the per cent of positive responses for all items in the domain at the baseline and follow-up time points. HSOPS change scores are computed as the change in per cent positive
responses for all items within each dimension from baseline to the follow-up survey period (approximately 11 months later). Values greater than zero represent an increase in per cent positive responses, while values less
than zero represent a decrease in per cent positive responses.
CLABSI, central-line-associated bloodstream infection; HSOPS, Hospital Survey on Patient Safety Culture; ICU, intensive care unit.

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Table 3 CAUTI HSOPS dimension score summary for analytic sample, mean (SD) (range)

ICUs (n=164) Non-ICUs (n=276)

HSOPS dimension Baseline Follow-up Change Score Baseline Follow-up Change Score

Supervisor expectations and actions promoting safety 76 (16) (19, 100) 79 (15) (17, 100) 3 (18) (−58, 81) 79 (12) (40, 100) 80 (13) (8, 100) 1 (14) (−62, 40)
Organisational learning—continuous improvement 73 (15) (29, 100) 74 (16) (20, 100) 0.7 (17) (−54, 71) 76 (12) (41, 100) 77 (14) (33, 100) 1 (12) (−34, 35)
Teamwork within hospital units 86 (9) (64, 100) 87 (10) (38, 100) 0.7 (11) (−38, 33) 79 (13) (0, 100) 80 (13) (32, 100) 1 (13) (−35, 95)
Communication openness 63 (17) (0, 100) 64 (16) (0, 100) 1 (19) (−61, 67) 59 (14) (17, 100) 61 (16) (0, 100) 2 (15) (−66, 44)
Feedback and communication about error 61 (18) (11, 100) 65 (18) (0, 100) 3 (21) (−100, 67) 63 (15) (27, 100) 65 (17) (0, 100) 3 (16) (−100, 67)
Non-punitive response to error 40 (16) (0, 85) 46 (19) (0, 100) 5 (18) (−36, 70) 43 (16) (0, 100) 46 (17) (0, 100) 3 (17) (−100, 58)
Staffing 59 (17) (21, 100) 60 (18) (16, 100) 0.5 (17) (−38, 60) 55 (16) (10, 100) 57 (17) (8, 100) 2 (15) (−45, 63)
Management support for patient safety 63 (21) (0, 100) 65 (19) (4, 100) 2 (20) (−67, 75) 70 (15) (25, 100) 71 (16) (19, 100) 1 (15) (−49, 59)
Teamwork across hospital units 59 (16) (20, 100) 62 (18) (0, 100) 3 (16) (−50, 52) 59 (15) (0, 100) 61 (16) (8, 100) 2 (14) (−45, 72)
Hospital handoffs and transitions 51 (15) (0, 100) 53 (18) (0, 100) 1 (16) (−50, 67) 47 (16) (16, 100) 49 (17) (0, 100) 2 (14) (−50, 66)
Frequency of event reporting 60 (16) (0, 100) 61 (20) (0, 100) 0.6 (16) (−60, 48) 66 (14) (20, 100) 67 (15) (22, 100) 0.6 (15) (−67, 45)
Overall perceptions of safety 60 (18) (0, 100) 62 (18) (0, 100) 2 (18) (−47, 53) 60 (15) (23, 100) 62 (16) (13, 100) 2 (14) (−42, 57)
Patient safety grade 70 (21) (12, 100) 70 (20) (0, 100) −0.4 (26) (−100, 84) 66 (20) (0, 100) 70 (20) (0, 100) 3 (20) (−100, 63)
Baseline and follow-up scores represent the per cent of positive responses for all items in the domain at the baseline and follow-up time points. HSOPS change scores are computed as the change in per cent positive
responses for all items within each dimension from baseline to the follow-up survey period (approximately 11 months later). Values greater than zero represent an increase in per cent positive responses, while values less
than zero represent a decrease in per cent positive responses.
CAUTI, catheter-associated urinary tract infection; HSOPS, Hospital Survey on Patient Safety Culture; ICU, intensive care unit

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not detected even among the units who completed
the culture surveys, despite overall having moderate
(23% CAUTI decline, unadjusted) to large (47%

CLABSI decline, unadjusted) improvements in
catheter-associated infection rates. Therefore, having a
higher response rate would not be anticipated to

Figure 1 (A) Central-line-associated bloodstream infection (CLABSI) coefficient plots, Hospital Survey on Patient Safety Culture
(HSOPS) models. (B) Catheter-associated urinary tract infection (CAUTI) coefficient plots, HSOPS models. Incidence rate ratios (IRRs)
and their 99% confidence intervals (CIs) are given for the HSOPS domains. CIs that cross the vertical line at the value of 1 indicate
non-significant findings. Models also adjusted for hospital characteristics including bed size, teaching and critical access hospital
status and rurality. For detailed model results, see online supplementary appendix. ICU, intensive care unit.

Original research

232 Meddings J, et al. BMJ Qual Saf 2017;26:226–235. doi:10.1136/bmjqs-2015-005012

better detect changes in safety culture. The low
response rate is also an important outcome as empir-
ical evidence of the difficulty in using these survey
tools in busy inpatient units, particularly in collabora-
tives such as these with a strong focus on measure-
ment and improvement of safety culture. The validity
of HSOPS in the AHRQ CLABSI and CAUTI colla-
boratives for detecting true changes in safety culture is
also unclear, particularly when assessed periodically,
at the unit level, with low response rates, from a
limited number of clinicians per unit, from multiple
hospitals. Indeed, this study did not assess other safety
culture tools collected in other collaboratives such as
the SAQ, a validated and reliable survey tool that has
been found to be responsive to interventions including
CUSP.15 16 26

It is also important to note that there are differences
of opinion in whether HSOPS results should be ana-
lysed and interpreted using individual survey dimen-
sions or items as opposed to generating and comparing
‘climate profiles’, as described by Weaver and collea-
gues using a k-means cluster analysis to study the asso-
ciation between the HSOPS baseline data and baseline
CLABSI outcomes in the AHRQ CLABSI collaborative
ICUs.23 In contrast to our study, which demonstrated
no statistically significant associations between the indi-
vidual dimensions (in HSOPS) and CLABSI outcomes,
Weaver et al report that certain climate profiles
described as ‘conflicting’ or ‘non-punitive’ climates
generated from baseline HSOPS dimensions are signifi-
cantly associated with higher baseline CLABSI rates
compared with a climate profile described as ‘genera-
tive leadership’.23 It is acknowledged that profiles of
survey measures can provide additional insight into the
combination of factors that yield a unit-based culture.
However, generating and interpreting climate profiles
is resource intensive, and climate profiles are not avail-
able in real time currently to hospital units that are
implementing and feeding back results of these survey
tools to clinicians. It remains concerning that of the
multiple measures selected for analysis by content and
coaching experts as most likely to be associated with
success in device-associated infection prevention, not a
single positive association was demonstrated and some
associations appeared to be in the opposite direction of
what was expected.

Conclusions
Analyses from two large national collaboratives
involving the prevention of CLABSI and CAUTI
demonstrated no association between safety culture
measures collected from the HSOPS and patient out-
comes of CLABSI and CAUTI. These unexpected
results do not support the hypothesis that hospital
units with improvements in safety culture measures
would be more successful in prevention of CLABSI
and CAUTI. These results have two important

potential interpretations. First, it may simply be true
that these collaboratives successfully reduced CLABSI
and CAUTI by means other than improving safety
culture, such as a strong emphasis on standardising
technical components of care such as aseptic insertion,
maintenance and removal. Changing safety culture
may not be critical in the setting of improvements in
standardised practices. A second interpretation is that
the safety culture did improve and was instrumental in
improving outcomes, but was inadequately measured
by the HSOPS tool. Assessment of safety culture is
complicated, dynamic and may simply not be captured
adequately by survey tools. Considering the training,
time and financial resources needed to conduct and
analyse these types of surveys in busy clinical units,
these results showing a lack of association between
HSOPS and CLABSI and CAUTI outcomes do suggest
the need to reassess and potentially reprioritise com-
ponents of intervention bundles and collaborative
tools that focus on improving and monitoring tech-
nical aspects of care with respect to the need to
collect measures of safety culture such as HSOPS as a
routinely recommended tool.

Author affiliations
1Department of Internal Medicine, University of Michigan
Medical School, Ann Arbor, Michigan, USA
2Department of Medicine, Ann Arbor Veterans Affairs Medical
Center, Ann Arbor, Michigan, USA
3VA Center for Clinical Management Research, Ann Arbor
Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
4Department of Internal Medicine, University of Wisconsin
School of Medicine and Public Health, Madison, Wisconsin,
USA
5Department of Medicine, William S. Middleton Memorial
Veterans Affairs Hospital, Madison, Wisconsin, USA
6Infection Prevention and Control, Trinity Health, Livonia,
Michigan, USA
7Michigan Health & Hospital Association, Keystone Center for
Patient Safety & Quality, Okemos, Michigan, USA
8Health Research and Educational Trust (HRET), Chicago,
Illinois, USA

Acknowledgements The authors thank Helen McGuirk MPH
and Jason Mann MSA for assistance with references and
manuscript editing.

Funding National Institute of Health-National Institute on
Aging (Probiotics for improving outcomes of C. difficile),
Agency for Healthcare Research and Quality
(HHSA290201000025I/HHSA29032001T) and (K08
HS19767) and (VA MERIT grant (Probiotics for reducing
carriage by S. aureus)).

Competing interests JM has reported receiving honoraria for
lectures and teaching related to prevention and value-based
purchasing policies involving catheter-associated urinary tract
infection and hospital-acquired pressure ulcers. SS has received
numerous honoraria and speaking fees from academic medical
centres, hospitals, specialty societies, state-based hospital
associations, group purchasing organisations and non-profit
foundations (eg, Michigan Health and Hospital Association,
Institute for Healthcare Improvement) for lectures about
healthcare-associated infection prevention. He is on the medical
advisory board of Doximity and Jvion. RO served as an
external faculty for HRET’s On the CUSP: stop CAUTI project,
serves on a Speaker’s Bureau sponsored by Ethicon, and is a
member of Premier Safety Institute.

Original research

Meddings J, et al. BMJ Qual Saf 2017;26:226–235. doi:10.1136/bmjqs-2015-005012 233

Provenance and peer review Not commissioned; externally
peer reviewed.

Data sharing statement Permission to share data can only be
requested to and given only by the Agency for Healthcare
Research and Quality (AHRQ).

Open Access This is an Open Access article distributed in
accordance with the Creative Commons Attribution Non
Commercial (CC BY-NC 4.0) license, which permits others to
distribute, remix, adapt, build upon this work non-
commercially, and license their derivative works on different
terms, provided the original work is properly cited and the use
is non-commercial. See: http://creativecommons.org/licenses/by-
nc/4.0/

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http://dx.doi.org/10.1016/S0196-6553(00)90015-4

http://www.cdc.gov/hai/pdfs/hai/scott_costpaper

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http://dx.doi.org/10.1186/1472-6963-6-44

http://dx.doi.org/10.1136/qshc.2005.015180

http://www.utpatientsafety.org

http://ofid.oxfordjournals.org/content/1/suppl_1/S44.1.full?sid=26e19ee0-5cc3-4c6e-a41c-2524ab723d3e

http://dx.doi.org/10.1136/bmjqs-2013-002757

http://dx.doi.org/10.1136/bmjqs-2015-004403

http://dx.doi.org/10.1177/109442810141001

qhc-26-226_2583

Evaluation of the association between Hospital Survey on Patient Safety Culture (HSOPS) measures and catheter-associated infections: results of two national collaboratives
Abstract
Introduction
Methods
Design and intervention
Study participants and data sources
Measures
Patient outcome measures
HSOPS components
Statistical analyses
Results
Participant characteristics
Patient outcome measures
HSOPS components
Association between HSOPS measures and patient outcomes
Discussion
Key results
Strengths and limitations
Conclusions
References

NR449 Evidence-Based Practice

RUA: Analyzing Published Research Guidelines

NR449_RUA_Analyzing_Published_Research_Guidelines_Sept20_v2

Purpose
The purpose of this paper is to interpret the two articles identified as most important to the group topic.

Course outcomes: This assignment enables the student to meet the following course outcomes.

CO 2: Apply research principles to the interpretation of the content of published research studies.

(POs 4 and 8)

CO 4: Evaluate published nursing research for credibility and clinical significance related to evidence-based practice.

(POs 4 and 8)

Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to
this assignment.

Total points possible: 200 points

Preparing the assignment
1. Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions.
2. Please make sure you do not duplicate articles within your group.
3. The paper will include the following:

a. Clinical Question (30 points/15%)
1. Describe the problem: What is the focus of your group’s work?
2. Significance of problem: What health outcomes result from your problem? Or what statistics document this

is a problem? You may find support on websites for government or professional organizations.
3. Purpose of the paper: What will your paper do or describe?
***Please note that although most of these questions are the same as you addressed in paper 1, the purpose of
this paper is different. You can use your paper 1 for items 1 & 2 above, including any faculty suggestions for
improvement provided as feedback.

b. Evidence Matrix Table: Data Summary (Appendix A) – (60 points/30%)
Categorize items in the Matrix Table, including proper intext citations and reference list entries for each article.
1. References (recent publication within the last 5 years)
2. Purpose/Hypothesis/

Study Question(s)

3. Variables: Independent (I) and Dependent (D)
4. Study Design
5. Sample Size and

Selection

6. Data Collection Methods
7. Major Findings (Evidence)

c. Description of Findings (60 points/30%)
Describe the data in the Matrix Table, including proper intext citations and reference list entries for each article.
1. Compare and contrast variables within each study.
2. What are the study design and procedures used in each study; qualitative, quantitative, or mixed method

study, levels of confidence in each study, etc.?

3. Participant demographics and information.

4. Instruments used, including reliability and validity.
5. How do the research findings provide evidence to support your clinical problem, or what further evidence

is needed to answer your question?
6. Next steps: Identify two questions that can help guide the group’s work.

d. Conclusion (20 points/10%)
Review major findings in a summary paragraph.
1. Evidence to address your clinical problem.
2. Make a connection back to all the included sections.

NR449 Evidence-Based Practice
RUA: Analyzing Published Research Guidelines

NR449_RUA_Analyzing_Published_Research_Guidelines_Sept20_v2 2

3. Wrap up the assignment and give the reader something to think

about.

e. Format (30 points/15%)
1. Correct grammar and spelling
2. Include a title and reference page
3. Use of headings for each section:

o Problem
o Synthesis of the Literature

− Variables

− Methods

− Participants

− Instruments

− Implications for Future Work
4. Conclusion
5. Adheres to current APA formatting and guidelines
6. Include at least two (2) scholarly, current (within 5 years) primary sources other than the textbook
7. 3-4 pages in length, excluding appendices, title and reference pages

For writing assistance (APA, formatting, or grammar) visit the APA Citation and Writing page in the online library.

Please note that your instructor may provide you with additional assessments in any form to determine that you fully
understand the concepts learned.

https://library.chamberlain.edu/APA

NR449 Evidence-Based Practice
RUA: Analyzing Published Research Guidelines

NR449_RUA_Analyzing_Published_Research_Guidelines_Sept20_v2 3

Grading Rubric Criteria are met when the student’s application of knowledge demonstrates achievement of the outcomes for this assignment.

Assignment Section and
Required Criteria

(Points possible/% of total points available)

Highest Level of

Performance

High Level of
Performance

Satisfactory
Level of

Performance

Unsatisfactory
Level of

Performance

Section not
present in

paper

Clinical Question
(30 points/15%)

30 points 26 points 24 points 11 points 0 points

Required criteria
1. Describe the problem: What is the focus of your group’s work?
2. Significance of problem: What health outcomes result from your

problem? Or what statistics document this is a problem? You may
find support on websites for government or professional
organizations.

3. Purpose of the paper: What will your paper do or describe?

Includes 3
requirements for
section.

Includes 2
requirements for
section.

Includes 1
requirement for
section.

Present, yet
includes no
required criteria.

No requirements
for this section
presented.

Evidence Matrix Table: Data Summary (Appendix A)

(60 points/30%)
60 points 56 points 47 points 25 points 0 points

Required criteria
Categorize items in the Matrix Table, including proper intext citations and
reference list entries for each article.
1. References (recent publication within the last 5 years)
2. Purpose/Hypothesis/Study Question(s)
3. Variables: Independent (I) and Dependent (D)
4. Study Design
5. Sample Size and Selection

6. Data Collection Methods
7. Major Findings (Evidence)

Includes 7
requirements for
section.

Includes 6
requirements for
section.

Includes 5
requirements for
section.

Includes 4 or less
requirements for
section.

No requirements
for this section
presented.

Description of Findings

(60 points/30%)
60 points 53 points 47 points 23 points 0 points

Required criteria
Describe the data in the Matrix Table, including proper intext citations
and reference list entries for each article.
1. Compare and contrast variables within each study.
2. What are the study design and procedures used in each study;

qualitative, quantitative, or mixed method study, levels of confidence
in each study, etc.?

3. Participant demographics and information.
Includes 6
requirements for
section.
Includes 5
requirements for
section.

Includes 4
requirements for
section.

Includes 3 or less
requirements for
section.

No requirements
for this section
presented.

NR449 Evidence-Based Practice
RUA: Analyzing Published Research Guidelines

NR449_RUA_Analyzing_Published_Research_Guidelines_Sept20_v2 4

Assignment Section and
Required Criteria
(Points possible/% of total points available)

Highest Level of
Performance

High Level of
Performance
Satisfactory
Level of
Performance
Unsatisfactory
Level of
Performance
Section not
present in
paper

4. Instruments used, including reliability and validity.
5. How do the research findings provide evidence to support your

clinical problem, or what further evidence is needed to answer your
question?

6. Next steps: Identify two questions that can help guide the group’s

work.

Conclusion
(20 points/10%)

20 points 18 points 15 points 8 points 0 points

Required criteria
Review major findings in a summary paragraph.
1. Evidence to address your clinical problem.
2. Make a connection back to all the included sections.
3. Wrap up the assignment and give the reader something to think

about.
Includes 3
requirements for
section.
Includes 2
requirements for
section.
Includes 1
requirement for
section.
Present, yet
includes no
required criteria.
No requirements
for this section
presented.

Format
(30 points/15%)

30 points 26 points 23 points 11 points 0 points

Required criteria
1. Correct grammar and spelling
2. Include a title and reference page
3. Use of headings for each section:

o Problem
o Synthesis of the Literature

▪ Variables
▪ Methods
▪ Participants
▪ Instruments
▪ Implications for Future Work

4. Conclusion
5. Adheres to current APA formatting and guidelines
6. Includes at least two (2) scholarly, current (within 5 years) primary

sources other than the textbook
7. 3-4 pages in length excluding appendices, title and reference pages

Includes 8
requirements for
section.

Includes 7
requirements for
section.
Includes 6
requirements for
section.

Includes 5 or less
requirements for
section.

No requirements
for this section
presented.

Total Points Possible = 200 points

NR449 Evidence-Based Practice
RUA: Analyzing Published Research Guidelines

NR449_RUA_Analyzing_Published_Research_Guidelines_Sept20_v2 5

Appendix A

EVIDENCE MATRIX TABLE

Article

References

Purpose
Hypothesis

Study Question(s)

Variables
Independent(I)
Dependent(D)

Study Design
Sample
Size &

Selection

Data
Collection
Methods

Major Finding(s)

1
(SAMPLE
ARTICLE)

Smith, L. (2013). What
should I eat? A focus for
those living with diabetes.
Journal of Nursing
Education, 1(4), 111-112.

How do educational support
groups effect dietary modifications
in patients with diabetes?

D-Dietary
modifications
I-Education

Quantitative N- 18
Convenience
sample-selected
from local support
group in Pittsburgh,
PA

Focus Groups Support and education
improved compliance with
dietary modifications.

1
2
3
4
5

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We write your papers in a standardized way. We complete your work in such a way that it turns out to be a perfect description of your guidelines.

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Areas of Expertise

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

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See How We Helped 9000+ Students Achieve Success

We Analyze Your Problem and Offer Customized Writing

We Mirror Your Guidelines to Deliver Quality Services

We Handle Your Writing Tasks to Ensure Excellent Grades