Our study showed that the response rate was 84.75%, which was higher than that in Lee’s and Sexton’s studies (69.4 and 67.0%, respectively), this indicated the results could reflect the respondents’ safety attitudes more accurately [24, 34]. Moreover, the psychometric properties of safety attitudes questionnaire was good, which indicated the results were reliable. The Cronbach’s alpha values ranged from 0.751 to 0.938, the results were similar to those in Xi’s and Lee’s studies (scopes of Cronbach’s alpha values were 0.785–0.945 and 0.785–0.912, respectively), indicating the reliability of SAQ was stable [24, 26]. Furthermore, the lowest value of GFI, CFI and TLI was 0.880 and the highest RMSEA value was 0.199, indicating a good model fit in this study. In Xi’s study, the values of GFI and CFI were 0.948 and 0.963, and the values of the validity indices ranged from 0.97–1.00 in Lee’s study [24, 26, 34]. Cumulatively, these studies have shown a stable validity of the SAQ, rendering it is suitable for measuring the health professionals’ safety attitudes in mainland China and Taiwan.
Firstly, the scores of the teamwork climate and safety climate subscales were good; only a few item scores were low. The scores of items 2, 9, 11, and 12 were lower than those of other items, different from the results in Zimmermann’s study, in which items 1, 2, 8, 9, and 11 had higher means than those of other items [19]. The current study, therefore, suggests creating a non-punitive and open culture, establishing simple and expeditious channels, training health professionals to report adverse events, and encouraging health professionals to discuss adverse events and report them in a timely manner. Conversely, this subscale obtained low scores in Raftopouos’ study, implying more attention should be paid to infrastructure and leadership attitudes on handling of errors and learning from adverse events [16].
Secondly, the scores of the job satisfaction subscale items were higher than those in other subscales, which was similar to the results in the studies of Nordenhagg, Patterson, Raftopoulos, Kristensen and Bondevik [11,12,13, 34, 35]. The current study suggests that when hospitals created a climate that allows health professionals to feel family warmth when they worked, a considerable number of health professionals stated loving their work and having high work morale and acknowledged that this would be beneficial to patient safety.
Contrary to previous research, the perception of management subscale items in the current study scored higher than those in other subscales. The international baseline data showed that the means of the items ranged from 38.3 to 55.3 [34]. This subscale score was low in the studies of Nguyen, Relihan and Sexton, scores were 49.4, 48.0 and 38.3, respectively [17, 34, 35]. Indeed, management in the Liaoning province hospitals was good, taking the events that affecting health professionals’ work seriously, particularly errors affecting patient safety, which can improve health professionals’ safety attitudes. It should be noted that serious hierarchical structure can prevent unit staffs from speaking out or discussing safety problems to the management, so it can affect safety attitude [17]. Focusing on prevention, monitoring, learning and improvement on management approach to patient safety, not on blaming and punishing, can benefit patient safety [18]. Moreover, leadership walkrounds applied in studies showed enough power in improving perception of management [35].
It should be noted that the stress recognition subscale obtained the lowest scores of all the subscales, which were similar to those in the studies of Raftopoulos, Xi and Haerkens [10, 26, 36]. However, in contrast previous results, the international benchmark data showed that the means in this subscale for OR-UK was only a score of 54.7, but the means of other samples obtained scores higher than 64 [34]. Moreover, studies of Nguyen and Relihan showed that this subscale obtained mean scores higher than 74 [17, 35]. Results from the current study implies that, when compared to other countries, the safety attitudes of the health professionals in the Liaoning province may be affected by stress more easily, which could affect patient safety. One possible explanation for this difference may be that with China’s rapid economic development, patients’ expectations for a better healthcare service exceed the current capabilities. Moreover, the triage system is not good enough and the existing setup of most primary care clinics cannot meet the patients’ expectations. Therefore, most patients choose tertiary hospitals, overloading the doctor-patient ratio, leading to an increase in health professionals’ workloads. Moreover, subsequent factors including occupational stress, fatigue, burnout, job dissatisfaction and sleep deprivation will jeopardize patient safety [26, 37,38,39,40]. Therefore, adequate staffing levels are necessary to decrease stress [34]. Moreover, there are inherently risks in medical service, the development of medical services often lags behind the development of diseases, if patients were harmed in adverse events, and the relationship between patients and doctors will be tense, inevitably increasing health professionals’ work pressure, and making health professionals perform worse than usual, ultimately, these will affect patient safety.
The results showed most items in the work conditions subscale obtained favorable scores, but item 29 obtained a lower score, which was similar to those in Xi’s study [26]. Conversely, the results in Samsuri’s study showed that this subscale score was 54.8, lower than other subscales [16]. Studies implied that training and supervising newcomers and maintaining diagnostic and therapeutic information would be beneficial to patient safety. Moreover, to build a better working condition, we should keep adequate staffing, training and supervising new comers, availability of information for therapeutic decision [16], [41]. Subscale means and standard deviations in other empirical researches that were compared with this study were shown in Table 6.
Table 6 Subscale means and standard deviations in empirical researches The scores of the items not in subscales showed that strengthening the communication of health professionals, encouraging health professionals to report adverse events, and making safety training a priority would be beneficial to patient safety. Items 38 obtained a high score, suggesting that safety training received enough attention. Item 36 obtained a low score, but was reverse worded and may have been misunderstood. We therefore suggest that future studies should positively word this item to decrease respondents’ misunderstanding. The current study obtained results of the scores of items not in subscales similar to those previously reported by Xi and Lee [24, 26], except for item 37, which was rated low, contrary to Lee’s study. These results suggest that managers should encourage reporting adverse events. If adverse events are to be resolved, the first step is to report them, however, when reporting adverse events, the reputation of individuals and hospitals may be affected. Moreover, if the adverse events are discovered by patients and their families, health professionals may experience unnecessary disputes and lawsuits. Therefore, managers should improve the mechanism of medical disputes and strengthen the sharing mechanism of medical risks to allow health professionals to safely and promptly report adverse events [24, 26].
This study explored the impacts of demographic factors on safety attitudes. Sex, age, degree, occupational function, technical title, years in hospital, and participation in training all significantly affected safety attitudes. Further analyses were conducted to determine the direction of the influences of these factors on safety attitudes. Females achieved higher scores than males in most subscales, possibly due to the fact that females are more careful when they do things. Our results was similar to those in Kristensen’s study [20]. Additionally, scores tended to decrease with increasing age, perhaps because older individuals had more work experience and therefore experienced more patient risks. Moreover, the results in Raftopoulos’ study showed younger nurses felt more powerful to cope with stressors [10]. The higher the degree earned, the lower the teamwork climate and stress recognition scores, potentially because highly educated health professionals have a wide ranger of ideas and think more about the problems, which may lead to more pressure, thereby affecting teamwork climate. General staff generally obtained lower scores in the job satisfaction and stress recognition subscales as well as on the total scale when compared to deans and head nurses, plausibly because general staffs have longer contacting time with patients, leading to the potential of more medical risks. Our results were similar to those in Relihan’s study, it implies the higher scores obtained by the head nurses may be explained by a sense of unit ownership and responsibility [35]. Additionally, health professionals with more years in the unit scored higher on stress recognition, which, due to reverse scoring, suggests that being familiar with units may decrease stress. However, the more years worked in the hospital the lower the safety attitudes score, possibly because of an increased knowledge about the defects in the work climate and conditions. Similarly, as weekly work time increased, health professionals had lower scores, suggesting that extending the time worked during the week may not improve patient safety. In all subscales, health professionals who participated in patient safety training obtained higher scores than those who did not participate in training, which demonstrated that training is an effective method to improve patient safety. This study suggests that increased attention should be paid to men, older individuals, those with an advanced degree, those with general staff positions, and staff who have worked in hospitals for a long time. Moreover, managers should ensure proper promotions, arrange workload reasonably, especially arrange multidisciplinary team to share responsibility [18], and promote safety training. These methods will improve patient safety.
Strengthens and limitations
First, the selected hospitals in this study are representatives of the three-level hospitals in Liaoning Province, selected departments (including wards, outpatients, medical and technical departments) and respondents (including doctors, nurses and technicians) can represent the safety attitudes of health professionals in Liaoning Province. Second, the response rate is high, so the results can reflect the safety attitudes of the respondents accurately. Third, this study provides the influences of demography factors on safety attitudes, and provides reference for future intervention studies.
In spite of the many strengths, the current study also has some limitations. For example, there was no continuous assessment of safety attitudes and adverse event reports over time. In addition, there was no intervention to improve patient safety in this study; therefore, we suggest that a prospective study should include interventional methods to improve patient safety.