The Relationship Between Perceived Quality of Care and the Patient Safety Culture of Turkish Nurses

Introduction

Patient safety is a primary and indispensable condition of qualified healthcare, as it prevents errors during the provision of healthcare, protects the patient from potential damages, and eliminates possible errors (Aktaş, 2015; Rizalar & Topcu, 2017). The organizational culture of hospitals must be based on ensuring patient safety. Hospital management teams that are focused on a patient safety culture should provide an environment for communication based on mutual trust; good information flow; a common perception of the importance of security, management, and leadership; and a noncriminal approach to incident and error reporting (Ege et al., 2019; Sarp, 2018; Wang et al., 2014).

Nurses play a critically important role in ensuring patient safety by monitoring patients for clinical deterioration, detecting errors, and understanding care processes and system weaknesses to ensure that patients receive high-quality care. Nurses' vigilance at the bedside is essential to their ability to ensure patient safety. Improving the safety culture within healthcare is a critical component in preventing/reducing errors and improving overall healthcare quality (Agency for Healthcare Research and Quality, 2019). Concurrently, avoiding medical errors, which is essential for all healthcare professionals, is more important for nurses because related actions have a direct impact on patient care. Medical errors made by nurses may put a patient's life at risk. The most frequently identified causative factors of medication errors include nurses' tiredness (Akgün & Kardaş, 2015; Er & Altuntaş, 2016; Gorgich et al., 2016), distraction or interruption while administering drugs (Petrova et al., 2010), workload and working times (Alemdar & Aktaş, 2013; Er & Altuntaş, 2016; Gorgich et al., 2016), and having an inadequate number of nurses on duty and overburdening nurses with non-job-related responsibilities (Akgün & Kardaş, 2015). Research has shown that inexperience, stress, and insufficient professional knowledge and skills increase the risk of medication errors (Er & Altuntaş, 2016).

In prior studies, nurses' perceptions of patient safety culture have been reported as moderate (Ciğerci et al., 2016; Özşaker & Tehçi, 2016; A. Yilmaz & Duygulu, 2019), whereas their perceptions of nursing care quality are generally positive (Boga et al., 2020; Erol & Turk, 2019; Gül & Dinç, 2018). However, an inadequate number of studies have considered these two concepts together to evaluate the relationship between nurses' care behaviors and patient safety cultures. Because evaluating nurses' perceived quality of care in terms of care behaviors and patient safety culture enables the development of required arrangements in nursing practices and the improvement of nursing service quality, more studies are needed that examine the relationship between nurses' care behaviors and different variables (e.g., training for patient safety practices, medical error-reporting status, the number of patients they care for, working hours per week, shifts).

Thus, this study was conducted to (a) investigate the natures of nurses' perceived quality of care and perceptions of patient safety culture, (b) explore whether sociodemographic characteristics are associated with these factors, and (c) examine the association between these factors.

Methods Study Design, Setting, and Participant Recruitment

This cross-sectional and descriptive correlational study was conducted at a university hospital in Istanbul. The sample consisted of 130 nurses working in the hospital between November and December 2019. The participants were nurses working at outpatient (outpatient clinic, operating room, and emergency room) and inpatient (internal medicine and surgical services and intensive care unit) units. The target sample included all 130 nurses. However, 116 nurses (89%) participated in the study, with the remainder declining to participate because of being on unpaid leave (maternity leave or sick leave) or of current workload. Incomplete questionnaires were not included in the analysis.

Measures

The data were collected using a questionnaire that included the following three surveys: the Nurse Information Questionnaire, Caring Behaviors Inventory-24 (CBI-24), and Patient Safety Culture Scale (PSCS). One researcher was responsible for distributing the questionnaires to participants and collecting the completed questionnaires 1 day later.

Nurse Information Questionnaire

This instrument, prepared by the researchers based on the literature (Celik et al., 2019; Jafree et al., 2017; Karlou et al., 2018), consisted of questions related to variables that were chosen based on previous research. The questions primarily addressed personal and professional variables such as age (Ciğerci et al., 2016; Özşaker & Tehçi, 2016), gender, marital status, educational background (Gül & Dinç, 2018), hospital units, and professional experience (Boga et al., 2020; Erol & Turk, 2019; A. Yilmaz & Duygulu, 2019). The grouping of these variables followed the practice of previous studies conducted in Turkey (Karaca & Arslan, 2014; Rizalar et al., 2016).

The primary purpose of providing quality care and ensuring patient safety is to prevent errors during care that may harm the patient. The related risks may be reduced by implementing certain measures. Nurses' sociodemographic and occupational characteristics may influence the establishment of patient safety culture and the effectiveness with which qualified nursing care is provided. Quality of care and patient safety may be affected by individual factors such as perception, attitudes, beliefs, culture, values, and personality traits. It is also possible that factors such as work environment, working conditions, team cohesion, organizational behavior, and corporate policies may influence both quality of care and patient safety culture.

Factors related to the sociodemographic and professional characteristics of nurses may also influence quality of care and patient safety culture. For example, older age and professional experience may relate positively to knowledge and skills, and longer experience working in the unit may relate positively to treatment and care practice competencies and reduce the risk of error. Moreover, the educational level of nurses relates positively with their professional knowledge and enables them to practice more comprehensively in clinical settings. Conversely, marital status may increase the responsibility burden of nurses, which may negatively affect care by introducing familial problems into the workplace. Furthermore, specialized units such as operating rooms and emergency and intensive care units may be associated with higher patient safety risks.

Caring Behaviors Inventory-24

The CBI-24 was designed to evaluate the nursing care process/quality. Wolf initially developed this scale with 75 items (1981) and later revised it as a 42-item scale in 1994 (Wolf et al., 1994). The 42-item scale, which is suitable for bidirectional diagnosis use by patients and nurses, was reduced to 24 items by Wu et al. (2006) and reorganized into four subdimensions. A validity and reliability study of the Turkish version of the CBI-24 was conducted by Kurşun and Kanan (2012). The CBI-24 consists of four subdimensions, including assurance, knowledge and skills, respect, and connectedness, and is scored using a 6-point Likert scale (1 = never, 2 = rarely, 3 = sometimes, 4 = usually, 5 = often, and 6 = always), with higher scores indicating higher perceived quality of care. In the original study, the Cronbach's alpha coefficient of the CBI-24 in nurses was found to be .94 for the assurance subdimension, .81 for the knowledge and skills subdimension, .90 for the respect subdimension, .85 for the connectedness subdimension, and .96 for the total scale (Kurşun & Kanan, 2012). In this study, the Cronbach's alpha coefficients of the subdimensions were .90, .87, .84, and .86, respectively, and the total scale reliability coefficient was .96.

Patient Safety Culture Scale

This scale was developed by Türkmen et al. (2011) to evaluate nurses' perceptions of patient safety culture. The PSCS consists of five subdimensions and 51 items. The subdimensions include management and leadership, employee behavior, unexpected event and error reporting, employee education, and care environment. The effectiveness of patient safety practices is rated from 1 to 4 (1 = totally disagree, 2 = disagree, 3 = agree, and 4 = totally agree), with higher mean scale scores indicating a more positive patient safety culture and lower mean scale scores indicating a more negative patient safety culture. Türkmen et al. found the Cronbach's alpha reliability coefficient of the PSCS and its subdimensions to be .97 and .83–.92, respectively. In calculating the scale score, the total score of the items is divided by the number of items. The average score for each subdimension is thus a number between 1 and 4. The means of the five subdimensions were then summed, and the total score was then divided by 5 to obtain a total score, which also ranged between 1 and 4. In this study, the Cronbach's alpha coefficients of the subdimensions were .95 for management and leadership, .95 for employee behavior, .84 for unexpected event and error reporting, .92 for employee education, and .93 for care environment. The scale's total reliability coefficient was .98.

Ethical Considerations

Ethical approval was obtained from the Biruni University Clinical Research Ethics Committee (number: 2019/34-10, date: November 7, 2019). Written informed consent was obtained from the hospital management and from the researchers who had developed the scales used in this study. The participants were instructed not to write their name on the questionnaire. Written consent was obtained from the participants after explaining to them the research purpose and methodology and that the data would remain confidential and not be used or made available in any context beyond this study.

Data Collection

A researcher visited the clinics and distributed the study questionnaire to the nurses who had agreed to participate. The next day, the same researcher revisited the clinics and collected the completed questionnaires. Questionnaires were not collected from nurses who were on annual, maternal, illness, or unpaid leave. Two completed questionnaires were excluded because of missing information.

Data Analysis

Data were analyzed using IBM SPSS Statistics 21.0 (IBM Inc., Armonk, NY, USA) for Windows. The mean and standard deviation (SD) were used as descriptive statistics of the data. Skewness and kurtosis values and variance coefficients were obtained using the Shapiro–Wilk test, which was performed to determine whether the scale scores were distributed normally. If the data indicated a normal distribution, an independent t test and a one-way analysis of variance (F) were used to test the associations of sociodemographic characteristics with nurses' perceived quality of care and perceptions of patient safety culture. If the data indicated a nonnormal distribution, nonparametric Mann–Whitney U (z) and Kruskal–Wallis H tests were used to test these associations. Spearman's rank correlation (rs) analysis was used to examine the association between nurses' perceived quality of care and perceptions of patient safety culture. Cronbach's alpha was used to calculate the internal consistency coefficient of the scales. Post hoc power analysis was also performed.

Results Descriptive Findings

The power of the study sample was 83% for a type I error rate of α = .05. With regard to the sample, the mean age was 25.95 (SD = 6.72) years, the mean duration of professional experience was 6.37 (SD = 6.05) years, and the mean duration of experience at the current unit was 1.66 (SD = 1.41) years. The participants were mostly women (72.4%), graduates of vocational high schools (52.6%), and working in the neonatal intensive care unit (37.9%) or the intensive care unit (37.1%; Table 1).

Table 1. - Sociodemographic and Professional Characteristics of the Participants (N = 116) Variable Mean SD Age (years) 25.95 6.72 Duration of professional experience (years) 6.37 6.05 Duration of experience in the unit (years) 1.66 1.41 n % Gender  Female 84 72.4  Male 32 27.6 Marital status  Married 30 25.9  Single 86 74.1 Education  Vocational high school 61 52.6  Associate degree 34 29.3  Undergraduate 18 15.5  Graduate 3 2.6 Unit  Internal medicine 9 7.8  Surgery 16 13.8  Emergency 10 8.6  Intensive care unit 44 37.9  Operating room 10 8.6  Outpatient clinic 10 8.6  Other 17 14.6 Professional position  Nurses working at wards 38 32.8  Intensive care nurse 43 37.1  Manager 8 6.9  Others 27 23.3
Caring Behaviors Inventory-24 and Patient Safety Culture Scale Scores

The mean scores were 5.70 (SD = 0.42) for the CBI-24 and 3.48 (SD = 0.46) for the PSCS. The lowest CBI-24 subdimension mean score was obtained for the connectedness subdimension (mean = 5.63, SD = 0.52), and the highest mean score was obtained for the knowledge and skills subdimension (mean = 5.78, SD = 0.4; Table 2). The PSCS subdimensions are presented in Table 2, with the lowest PSCS subdimension mean score obtained for the employee behavior subdimension (mean = 3.41, SD = 0.53) and the highest mean score obtained for the unexpected event and error reporting subdimension (mean = 3.55, SD = 0.48).

Table 2. - Means of Scales' and Subdimensions' Scores of Nurses (N = 116) Scale and Subdimension Mean SD Minimum Maximum Caring Behaviors Inventory-24 5.70 0.42 3.67 6.00  Assurance (eight items) 5.70 0.46 3.75 6.00  Knowledge and skills (five items) 5.78 0.43 3.20 6.00  Respect (six items) 5.69 0.45 3.83 6.00  Connectedness (five items) 5.63 0.52 3.80 6.00 Patient Safety Culture Scale 3.48 0.46 2.25 4.00  Management and leadership (18 items) 3.49 0.50 2.12 4.00  Employee behavior (15 items) 3.41 0.53 1.93 4.00  Unexpected event and error reporting (five items) 3.55 0.48 2.40 4.00  Employee education (seven items) 3.46 0.59 2.00 4.00  Care environment (eight items) 3.49 0.50 2.12 4.00

The PSCS scores were normally distributed. However, the CBI-24 scores did not meet the normal distribution condition, with the kurtosis value of the CBI-24 scores exceeding the threshold range of −2 to +2 based on the results of the Shapiro–Wilk test.

Variables Associated With Caring Behaviors Inventory-24 and Patient Safety Culture Scale Scores

In terms of the association between the sociodemographic and professional characteristics (age, gender, marital status, educational level, unit, professional position, professional experience, and experience at the current unit) and CBI-24 score, no statistically significant differences were found between the groups (p > .05; Table 3).

Table 3. - Comparison of Caring Behaviors Inventory-24 Scores, by Participants' Personal and Professional Characteristics (N = 116) Caring Behaviors Inventory-24 (CBI-24) Assurance Knowledge and Skills Respect Connectedness CBI-24 Variable n Mean SD Mean SD Mean SD Mean SD Mean SD Age group (years)  ≤ 30 98 5.67 0.48 5.76 0.45 5.67 0.46 5.62 0.52 5.68 0.44  ≥ 31 18 5.84 0.28 5.92 0.24 5.78 0.37 5.66 0.53 5.80 0.32   z (p) 1.511 .13 1.819 .07 1.094 .27 0.691 .53 1.424 .15 Gender  Female 84 5.71 0.45 5.78 0.43 5.70 0.42 5.65 0.47 5.71 0.40  Male 32 5.66 0.48 5.78 0.44 5.64 0.51 5.56 0.64 5.66 0.48   z (p) 0.445 .66 0.540 .59 0.097 .92 0.056 .96 0.199 .84 Marital status  Married 30 5.75 0.34 5.83 0.35 5.70 0.40 5.63 0.46 5.73 0.36  Single 86 5.68 0.49 5.77 0.45 5.68 0.47 5.62 0.54 5.69 0.45   z (p) 0.210 .83 0.905 .37 0.301 .76 0.535 .59 0.097 .92 Educational level  High school to associate degree 95 5.71 0.45 5.80 0.38 5.70 0.44 5.64 0.51 5.71 0.40  Undergraduate and higher 21 5.65 0.51 5.70 0.62 5.63 0.51 5.57 0.56 5.64 0.51   z (p) 0.732 .46 1.050 .29 0.749 .45 0.972 .33 0.855 .39 Unit  Clinic unit (internal medicine and surgery) 25 5.76 0.32 5.89 0.23 5.77 0.32 5.74 0.36 5.78 0.25  Special unit (intensive care units, operating  room, emergency room) 64 5.67 0.46 5.75 0.43 5.66 0.47 5.61 0.56 5.67 0.45  Other (outpatient clinics, etc.) 27 5.57 0.76 5.61 0.76 5.60 0.66 5.41 0.74 5.55 0.68  KW (p) 0.221 .90 2.426 .30 0.073 .96 2.016 .37 0.224 .89 Professional position  Nurse 81 5.69 0.46 5.79 0.38 5.71 0.42 5.66 0.49 5.71 0.39  Managers and others 35 5.72 0.48 5.78 0.54 5.63 0.52 5.54 0.59 5.67 0.50   z (p) 0.514 .61 0.767 .44 0.521 .60 0.976 .33 0.292 .77 Professional experience  ≤ 5 years 10 5.60 0.70 5.58 0.87 5.63 0.68 5.56 0.66 5.60 0.71  ≥ 6 years 106 5.70 0.43 5.80 0.36 5.69 0.43 5.63 0.51 5.71 0.39   z (p) 0.132 .90 0.883 .38 0.304 .76 0.415 .68 0.302 .76 Experience at the current unit  ≤ 5 years 33 5.73 0.45 5.80 0.52 5.75 0.42 5.70 0.46 5.74 0.43  ≥ 6 years 83 5.68 0.47 5.78 0.39 5.66 0.46 5.60 0.54 5.68 0.42   z (p) 0.348 .73 0.730 .47 0.583 .56 0.810 .42 0.254

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