bs_bs_banner Nursing Work and Life Nurses’ perceptions of patient safety culture in Jordanian hospitals W.A. Khater1 RN, PhD, L.M. Akhu-Zaheya2 RN, MSN & R. Khater4 MD, CPHQ RN, PhD, S.I. AL-Mahasneh3 1 Assistant Professor, 2 Associate Professor, Jordan University of Science and Technology, 3 Registered Nurse, King Abdullah University Hospital, Irbid, 4 Quality Manager, Prince Hamzah Hospital, Amman, Jordan KHATER W.A., AKHU-ZAHEYA L.M., AL-MAHASNEH S.I. & KHATER R. (2015) Nurses’ perceptions of patient safety culture in Jordanian hospitals. International Nursing Review 62, 82–91 Background: Patients’ safety culture is a key aspect in determining healthcare organizations’ ability to address and reduce risks of patients. Nurses play a major role in patients’ safety because they are accountable for direct and continuous patient care. There is little known information about patients’ safety culture in Jordanian hospitals, particularly from the perspective of healthcare providers. Aim: The study aimed to assess patient safety culture in Jordanian hospitals from nurses’ perspective. Methods: A cross-sectional, descriptive design was utilized. A total number of 658 nurses participated in the current study. Data were collected using an Arabic version of the hospital survey of patients’ safety culture. Findings: Teamwork within unit dimensions had a high positive response, and was perceived by nurses to be the only strong suit in Jordanian hospitals. Areas that required improvement, as perceived by nurses, are as follows: communication openness, staffing, handoff and transition, non-punitive responses to errors, and teamwork across units. Regression analysis revealed factors, from nurses’ perspectives, that influenced patients’ safety culture in Jordanian hospital. Factors included age, total years of experience, working in university hospitals, utilizing evidence-based practice and working in hospitals that consider patient safety to be a priority. Limitations: Participants in this study were limited to nurses. Therefore, there is a need to assess patient safety culture from other healthcare providers’ perspectives. Moreover, the use of a self-reported questionnaire introduced the social desirability biases. Conclusion: The current study provides insight into how nurses perceive patient safety culture. Results of this study have revealed that there is a need to replace the traditional culture of shame/blame with a non-punitive culture. Implications for nursing and health policy: Study results implied that improving patient safety culture requires a fundamental transformation of nurses’ work environment. New policies to improve collaboration between units of hospitals would improve patients’ safety. Keywords: Hospital Survey of Patients’ Safety Culture, Jordan, Nurses’ Perceptions, Patients’ Safety Culture Correspondence address: Wejdan A. Khater, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan; Tel: +962-2-7201000 (Ext. 23715); Fax: 96227095012; E-mail: [email protected] No conflict of interest has been declared by the authors. © 2014 International Council of Nurses 82 Patient safety culture Introduction The Institute of Medicine (1999) report, ‘To Err Is Human’, highlights the need to create a culture of safety within healthcare organizations. According to this report errors that occur in healthcare setting are frequently system related, which implies the need to improve healthcare systems instead of blaming individuals. In accordance with this change in culture, health organizations worldwide are striving to improve the quality of patients’ care and safety through the creation of a patient safety culture. Patient safety culture is defined as ‘values shared among organization members about what is important, their beliefs about how things operate in the organization and the interaction of these with work unit and organizational structures, and systems, which together produce behavioural norms in the organization that promotes safety (Singer et al. 2009, p. 400). Patient safety culture is the product of individual, group or social learning; ways of thinking; and behaviours that are shared to meet the primary objective of patient safety (Mustard 2002, p. 112). Several initiatives had been implemented by many health organizations such as the Accreditations Achievement and Patient Safety Friendly Hospital Initiative, which aimed to improve patient safety culture and to deal with the unsafe healthcare practices in Eastern Mediterranean Regional the Office of the World Health Organization (WHO) (Siddiqi et al. 2012). Despite all initiatives, the adverse events have markedly increased worldwide. The overall reported prevalence of adverse events ranges between 2.9 and 28%, including medication errors, incorrect diagnosis, hospitalacquired infections, bed sores and falls (Hayajneh et al. 2010). Jordan is no exception. Using 75 valid web-based responses, adverse events are determined to be 28% of all admitted cases in the participants’ hospitals (Hayajneh et al. 2010). This figure is considered to be far above average, in comparison with the WHO estimation that it is approximately 10% of all inpatient in Eastern Mediterranean Region (World Health Organization 2007). Nevertheless, there is a compelling need to maximize the concept of patient safety and to build a positive patient safety culture. First step in creating patient safety culture is assessing the existing culture (Mikušová et al. 2012). Assessment of patient safety culture refers to understanding the organization’s beliefs, norms and values, as well as individual’s attitudes and behaviours related to patient safety culture (Sorra et al. 2012). Assessing healthcare providers’ perception of patient safety culture would provide valuable information for both administrators and policy makers. Nurses as healthcare providers © 2014 International Council of Nurses 83 believe that patient safety is primarily a nursing responsibility (Abdou & Saber 2011; Aboshaiqah 2010). It was estimated that more than 90% of potential medication errors were discovered by nurses prior to administration (Ross 2011). Nurses are key to safety improvement in many aspects (Richardson & Storr 2010). However, building on the Institute of Medicine reports a guideline of ‘Keeping Patients Safe: Transforming the Work Environment of Nurses’ illustrated the linkage between patient safety and nurses’ work environment, and demonstrated that nurses play a crucial role in the occurrence of medical errors. The report extrapolates that unclear unit values, fear of punishment, a lack of mistakes analysis, complexity and workload, and lack of team work are the leading causes of patient safety problems related to nurses (National Research Council 2004). The IOM stressed that unclear unit values may lead to adverse events, and a number of nurses neglected the existence of unit values (Institute of Medicine 2004). Nurses, instead, focus on their own values when it comes to decisions related to nursing care (Kalisch & Aebersold 2006). However, literature regarding nursing and patient safety concluded that gaps in nursing patient safety knowledge exist (Richardson & Storr 2010). Thus, understanding nurses’ perception of patient safety culture is vital for policy makers to address patient safety culture from nurses’ staffing policies. Studies disclosed that nurses’ perception of patient safety correlated with the demands of work (Richardson & Storr 2010; Ross 2011). Nurses’ perception of patient safety increased when the work demands decreased, whereas nurses who worked fulltime harboured lower perceptions of patient safety on their unit. Furthermore, the nursing environment such as the arrangement of nursing units, technological equipment, communication, knowledge transfer among staff, inadequate policies, fatigue, stress and an incredible workload are significant factors affecting patient safety and the quality of care (Aboshaiqah & Baker 2013; Keller 2009; Ross 2011; Zakari 2011). In Jordan, since the establishment of the Health Care Accreditation Council (HCAC) in 2007, the awareness of accreditation has improved and there is a policy now implemented throughout Jordanian hospitals (World Health Organization 2013). To date, more than 17 public and private hospitals have been accredited by the Joint Commission International and/or HCAC, in addition to more than 42 primary healthcare centres accredited by the HCAC (World Health Organization 2013). Despite these initiatives to implement patient safety, little is known about patient safety culture in Jordanian hospitals. Therefore, the main purpose of the current study was to assess patient safety culture in Jordanian hospitals from nurses’ perspective. 84 W. A. Khater et al. The study was conducted to answer the following research questions: 1 How do nurses working at Jordanian hospitals perceive patient safety culture? 2 What are the factors influencing patient safety culture in Jordanian Hospitals? Methods Design A quantitative, descriptive–comparative, cross-sectional design employing self-reported questionnaires over 2 months of data collection was utilized so as to assess patient’s safety culture from nurses’ perspective at a Jordanian hospital. Setting The study was conducted in the Middle Region and Northern Region of Jordan. The Middle Region and Northern Region involved eight governorates out of a total of 13 governorates in Jordan. In the current study, we included the smallest and largest governmental hospitals, as well as the largest private hospitals from the selected regions. The largest and smallest hospitals were chosen according to the number of beds in the hospital based on the Jordanian Ministry of Health Statistics. In addition, two university-affiliated hospitals were included. The total number of hospitals was 21 hospitals: two are universityaffiliated hospitals, four are private hospitals and 15 are governmental hospitals. Participants The target population included all registered nurses (RNs) who met the inclusion criteria of being able to write and read Arabic, with at least 1 year of experience in the unit to ensure that they are familiar with the unit’s policy and rules. The accessible population included RNs who were working in the hospital’s approached. The RNs who were available at the time of data collection in the approached hospitals and agreed to participate by signing consent were selected. Exclusion criteria included practical nurses with a diploma degree, as their responsibilities were not directly related to patient care in governmental and private hospitals. In addition, RNs with less than a year of experience were excluded to ensure that nurses were involved more in direct patient care. The sample size was determined using power analysis, at a level of significant 0.05 and power 0.80, and linear regression test, whereby the minimum sample size required was 107 participants (Cohen 1992). However, as it is a pioneer study in this © 2014 International Council of Nurses area, more samples approached to gain more understanding of phenomena. The final sample obtained was 658 RNs. Measure The current study utilized the Arabic version of Hospital Survey of Patients’ Safety Culture (HSOPSC), which was translated and utilized by El-Jardali et al. (2011). A formal request and approval to use the measure was acquired. The HSOPSC is a survey that assesses patient safety culture based on the perspectives of health team members. HSOPSC can be used in order to measure patient safety culture dimensions, either for the whole hospital or for its specific units (Sorra et al. 2012). The original HSOPSC included 12 safety culture dimensions, including ten patient safety culture dimensions and two outcome dimensions. The ten patient safety culture dimensions included seven unit-level dimensions and three hospitallevel dimensions. The total number of items are 43 of 5-point Likert scale ranging from 1 = ‘strongly disagree’ to 5 = ‘strongly agree’ (see Table 2). The survey’s score represented the frequency of responses for each survey’s item. The item’s score reflected the hospital’s strength and areas in need of improvement, which was determined by measuring positive responses’ frequency and percentage for each item [(number of positive response/total number of respondent on the item) × 100%]. Areas of strength were identified as those items that about 75% of respondents endorsed positively (by answering strongly agree/agree or always/most of the time), whereas areas requiring improvement were identified as those items scoring 50% or less (Sorra et al. 2012). In addition, the questionnaire included a demographic characteristics part, which included age, gender, marital status, educational level, total years of experience, years of experience in current hospital, years of experience in current unit, total weekly working hours and if participant worked in shifting programme. In addition, it included some situation-related characteristics such as the number of beds in the current hospital, the number of beds in the working unit, the type of hospital, if participant work according to evidence-based practice and if hospital consider patient safety as a top priority. In addition, two open-ended questions, whether or not participant trained for patient safety, and what are the most important three things to improve patient safety were included. Regarding the reliability of instruments, the HSOPSC survey was utilized in numerous countries including the United States, Canada and Belgium, and translated to different languages such as Taiwanese, Turkish and Arabic. The reliability measured by Cronbach’s coefficient alpha of the original English version ranged between 0.63 and 0.84 (Sorra & Dyer 2010; Sorra & Patient safety culture Nieva 2004), whereas for the Arabic version, it ranged between 0.45 and 0.81 (El-Jardali et al. 2010). In the current study, Cronbach’s coefficient alpha values ranged from 0.41 to 0.78. Ethical consideration Formal approval from the institutional review board at the Jordan University of Science and Technology, Ministry of Health, and hospital administrators was attained. Consent forms were obtained from all participants. Full disclosure of the study’s purposes and significance was provided to all. Additionally, participants were assured that participation was voluntary. Furthermore, the acquired data will be kept both anonymous and confidential. In addition, approval to use the instrument was granted. Procedures and data collection Once the IRB’s approval was obtained, a request to collect the data was sent to the Jordanian Ministry of Health (MOH), and the administrator of each private and university hospital attained approval for the distribution of the questionnaire. An envelope included a self-reported questionnaire, with a cover letter explaining the study purposes, outcomes and instructions were provided to the in-charge nurse by the researcher and her assistant to distribute the envelopes to eligible nurses at different units. Envelopes were given to the in-charge nurses in each unit at the beginning of the ‘A’ shift and returned in a timely manner, in the same day. 85 26 years (M = 7.5 years, SD = 5.377). The mean of nurses’ experience in their current working hospital was 6.37 years (SD = 5.129, R = 1–25), and the mean of nurses’ experience in their current working unit was 4.8 years (SD = 4.321, R = 1–22). Of the participants, 66.6% (n = 438) were working 8 h shift per day, while 33.4% (n = 220) worked more than 8 h per day. In addition, the mean of total weekly working hours was 46.91 h (SD = 3.54, R = 40–58). Participating nurses worked within different hospital sectors including governmental, university and private hospitals with a percentage of 66.9, 23.6 and 9.5%, respectively. For the unit/area of working, a total of 141 nurses (21.3%) worked in intensive care units (ICUs) (general ICU, paediatric ICU, neonatal ICU, cardiac ICU and coronary care unit). Other nurses worked at surgical, medical and emergency units with percentages of 16.6, 13.7 and 11.9%, respectively. Nurses worked in hospitals with less than 100 beds (21.9%, n = 144), between 100 and 300 beds (41%, n = 270) and more than 300 beds (37.1%, n = 244). For the hospital units’ bed, nurses worked in units with less than 20 beds (56.8%; n = 374), between 20 and 40 beds (32.1%; n = 211) and more than 40 beds (11.1%; n = 73). Although 46.7% (n = 307) of the respondents reported that they use evidencebased practice, the remaining 53.3% (n = 351) did not. Most of the nurses in Jordanian hospitals 81% (n = 533) stated that patients’ safety was a priority in their current working hospital. Furthermore, 76.6% (n = 503) of nurses received training on patient safety while 23.4% (n = 154) did not receive any training (see Table 1). Data analysis plan Descriptive statistic, frequencies and percentages according to the level of measurement were used. In addition, multivariate analysis – linear regression – was used to look at the factors that would influence patient safety culture in Jordanian hospitals. Results Participants’ characteristics A total of 797 participants were approached; however, 663 questionnaires were returned with a total response rate of 83.1%. Five questionnaires were excluded, either because they did not meet the inclusion criteria (four filled by practical nurses) or due to missing data. Therefore, the total number of participants was N = 658. Of all participants (N = 658), 59.9% (n = 394) were female RNs and 40.1% (n = 264) were male RNs. Nurses’ mean age was 30 years [standard deviation (SD) = 5.76, R = 22–55]. Most of nurses 87.1% (n = 573) hold a bachelor degree, whereas 8.5% (n = 56) hold a 3-year diploma and 4.4% (n = 29) of nurses hold a master degree. Nurses’ experience ranged between 1 and © 2014 International Council of Nurses How do nurses at Jordanian hospitals perceive patients’ safety culture? Patient safety culture in Jordanian hospitals from nurses’ perspective was appraised by the composite frequency of each dimensions, and by verifying areas of strength and areas necessitating improvement, with respect to patients’ safety issues. The study results revealed that the composite frequencies ranged between 21 and 78.8%. The highest composite frequency of patient safety related to unit-level dimension was 79%, reflecting nurses’ positive perception of team work within the unit, while the lowest composite frequency (21%) means that only 21% of the nurse’s responses reflected positive opinion about the non-punitive response to errors. For hospital-level dimensions of patient safety, the highest composite frequency was related to nurses’ positive opinion of the management support for patients’ safety (53.5%). For the outcome variables, the highest composite frequency related to the frequency of reporting events (69.2%) (see Table 2). From the nurses’ perspective, the major areas needing improvement (percentage of items positive response <50%) 86 W. A. Khater et al. Table 1 Participants demographic and situation-related characteristics Participants characteristics Demographical data Gender – Male – Female Frequency (%) 30.1 (5.757) – Single – Married 215 (32.7) 441 (67.0) – Divorced – Widow 1 (0.2) 1 (0.2) – Bachelor – Master Total years of working experience Years of experience in current hospital Years of experience in current unit Number of weekly work hours Did you work in shifting programme – Yes – No Situation-related characteristics Number of hospital beds Number of unit beds Type of hospital nurses work on – Governmental – University – Private Did you utilize evidence-based practice? – Yes – No Is patient safety a priority in your hospital? – Yes – No Did you receive patient safety training? – Yes – No 56 (8.5) 7.5 (5.38) 6.37 (5.13) 4.8 (4.32) 46.91 (4.52) 1–26 1–25 1–22 40–58 220 (33.4) 438 (66.6) 340.8 (287.5) 21.2 (14.46) 440 (66.9) 155 (23.6) 63 (9.5) 307 (46.7) 351 (53.3) 533 (81.0) 125 (19.0) 154 (23.4) 504 (76.6) 141 (21.3) Surgical Medical Emergency Psychiatric Obstetric Operation Paediatric Orthopaedic Outpatient clinic Others 109 (16.6) 90 (13.7) 78 (11.9) 57 (8.6) 53 (8.1) 50 (7.6) 42 (6.4) 27 (4.1) 7 (1.1) 4 (0.6) © 2014 International Council of Nurses 22–55 573 (87.1) 29 (4.4) Working unit/area Intensive care unit N = 658. SD, standard deviation. Range 264 (40.1) 394 (59.9) Age Marital status Education level – Diploma (3Y) Mean (SD) 30–1100 2–63 with respect to unit-level dimension are related to the staff’s belief that their mistakes are held against them (14.9%), and nurses worried that mistakes made are kept in their personal file (15%). Staff working longer hours than is best for patients’ care (24%) is another area necessitating improvement, with respect to unit level. Regarding hospital-level dimensions, almost all areas regarding patient safety required improvement (item percentage <50%). The three lowest item percentages are related to the exchange of information across hospital units (24.8%), staff’s unwillingness to work with staff from other hospital units (27%) and hospital units’ lack of coordination (32.8%). Areas of strength related to unit level of patient safety in the hospital (item’s positive response >75%) included people support in the unit (85.9%), the frequency of reporting errors (85.3%) and nurses’ work to improve patients safety (83.3%) (see Table 2). What are the factors influencing patients’ safety culture at Jordanian hospitals? A multivariate regression analysis was used to examine the factors of patient safety culture (see Table 3), with regard to participants’ demographic and situational-related characteristics. The total score of patient safety was constructed by summation of all patient safety culture dimensions, without the outcome dimension. The total score was regressed (using linear regression) against participants’ demographics (gender, age, education level) and situational-related characteristics (total years of experience, total years of experience in current hospital, years of experience in current unit, total weekly work hours, shifting work, hospital type, number of hospital beds, number of unit beds, if the patient safety is a priority in current hospital, evidence-based practice and receiving patient safety training). The model explained about 26% (P < 0.05). Regression analysis revealed that the higher the total years of experience, the better the nurses perception of patient safety culture (β = 0.287, P < 0.05); nurses reported using evidencebased practice had a better perception of patient safety than those who did not (β = 0.285, P < 0.001). In addition, nurses who worked at hospitals consider patients’ safety as priority had better perception of patients safety culture compared with other nurses (β = 0.183, P < 0.001). Older respondents had a lower perception of patient safety than younger nurses; however, this difference was not highly significant (β = −0.184, P = 0.048). In addition, nurses who worked more weekly hours had a lower perception of patients’ safety culture compared with nurses who worked less weekly hours (β = −0.145, P < 0.001). Working in a university hospital increased nurses’ perception of patients’ Patient safety culture 87 Table 2 Dimensions’ and items percentage of positive response for patients’ safety culture Sub-dimensions and sub-dimensions items Seven unit-level dimensions (1) Teamwork within units (Cronbach’s α = 0.73) A1. People support one another in this unit A3. When a lot of work needs to be performed quickly, we work together as a team to get the work done A4. In this unit, people treat each other with respect A11. When one area in this unit gets really busy, others help out (2) Supervisor/manager expectations and actions promoting patient safety (Cronbach’s α = 0.54) B1. My supervisor/manager says a good word when he or she sees a job carried our according to established patient safety procedures B2. My supervisor/manager seriously considers staff suggestions for improving patient safety B3. Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking short cuts B4. My supervisor/manager overlooks patient safety problems that happen over and over (3) Organizational learning – continuous improvement (Cronbach’s α = 0.52) A6. We are actively doing things to improve patient safety A9. Mistakes have led to positive changes here A13. After we make changes to improve patient safety, we evaluate their effectiveness (4) Feedback and communication about error (Cronbach’s α = 0.70) C1. We are given feedback about changes put into place based on event reports C3. We are informed about errors that happen in this unit C5. In this unit, we discuss ways to prevent errors from happening again (5) Communication openness (Cronbach’s α = 0.46) C2. Staff will freely speak up if they see something that may negatively affect patient care C4. Staff feel free to question the decisions or actions of those with more authority C6. Staff are afraid to ask questions when something does not seem right (6) Staffing (Cronbach’s α = 0.41) A2. We have enough staff to handle the workload A5. Staff in this unit work longer hours than is best for patient care A7. We use more agency/temporary staff than is best for patient care A14. We work in ‘crisis mode’ trying to do too much, too quickly (7) Non-punitive response to errors (Cronbach’s α = 0.61) A8. Staff feel like their mistakes are held against them A12. When an event is reported, it feels like the person is being written up, not the problem A16. Staff worry that mistakes they make are kept in their personnel file Three hospital-level dimensions (8) Management support for patient safety (Cronbach’s α = 0.60) F1. Hospital management provides a work climate that promotes patient safety F8. The actions of hospital management show that patient safety is a top priority F9. Hospital management seems interested in patient safety only after an adverse event happens (9) Teamwork across units (Cronbach’s α = 0.61) F4. There is good cooperation among hospital units that need to work together F6. It is often unpleasant to work with staff from other hospital units F10. Hospital units work well together to provide the best care for patients F2. Hospital units do not coordinate well with each other (10) Handoffs and transitions (Cronbach’s α = 0.71) F3. Things ‘fall between the cracks’ when transferring patients from one unit to another F5. Important patient care information is often lost during shift changes F7. Problems often occur in the exchange of information across hospital units F11. Shift changes are problematic for patients in this hospital Two outcomes variables (11) Overall perceptions of patient safety (Cronbach’s α = 0.50) A15. Patient safety is never sacrificed to get more work done A18. Our procedures and systems are good at preventing errors from happening A10. It is just by chance that more serious mistakes don’t happen around here A17. We have patient safety problems in this unit (12) Frequency of events reported (Cronbach’s α = 0.78) D1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported? D2. When a mistake is made, but has no potential to harm the patient, how often is this reported? D3. When a mistake is made that could harm the patient, but does not, how often is this reported? D4. When a mistake is made that harm the patient, how often is this reported? © 2014 International Council of Nurses Average percentage of positive response 78.83 85.9 79.0 82.2 68.2 57.95 52.1 54.6 51.4 73.7 68.13 83.3 53.5 67.6 59.53 45.1 68.8 64.7 49.00 55.8 50.8 40.4 34.53 28.9 24.0 60.0 25.2 21.0 14.9 33.1 15.0 53.53 48.5 66.4 45.7 41.73 53.5 27.1 53.5 32.8 41.15 47.7 49.1 24.8 43.0 60.07 80.4 63.7 57.0 39.2 69.15 62.9 57.9 70.5 85.3 88 W. A. Khater et al. Table 3 Factors influencing patients’ safety culture in Jordanian hospitals Variable Β SEM P-value Gender Age Education level Bachelor vs. diploma Bachelor vs. master Total years of experience Years of experience in current hospital Years of experience in current unit Weekly work hours Shifting work Number of beds in current hospital Number of beds in current unit Hospital type Governmental vs. private Governmental vs. university Accreditation Accredited vs. non-accredited Evidence-based practice Is patient safety a priority for hospital? Did nurse receive patient safety training? 0.071 −0.184 1.185 0.250 0.059 0.048* 0.018 0.020 0.287 −0.139 0.041 −0.145 −0.030 −0.058 −0.072 2.090 2.801 0.037 0.313 0.221 0.187 1.283 0.002 0.044 0.634 0.587 0.031* 0.181 0.510 0.000* 0.438 0.185 0.079 −0.015 −0.124 2.021 1.630 0.698 0.006* 0.096 0.285 0.183 0.043 1.929 1.188 1.509 1.406 0.060 0.000* 0.000* 0.260 *P < 0.05. SEM, standard error of the mean. safety culture compared with nurses who worked in government hospitals (β = −0.124, P < 0.05). Discussion This study, to our knowledge, was the first to assess the current state of patient safety culture in Jordan. There were previous efforts by the MOH to assess perception of healthcare professionals on patient safety culture at the accredited hospitals at MOH (Doweire 2012). This survey included only participants from four accredited MOH hospitals, and is yet to be published. In our study, we found that there was only one item, teamwork within unit composite, which was a strong suit in nurses’ perception of patient safety culture, although there were many items (communication openness, staffing, non-punitive response to errors, teamwork across units and handoff and transition) which were areas for improvement. Teamwork within unit composites indicated that the staff in the same unit supported each other, treated each other with respect and worked together as a team in order to get the work done efficiently, rapidly and safely. This result was congruent with Lebanon, Saudi Arabia, United States, Turkey, Taiwan and Norway’s © 2014 International Council of Nurses survey results, which revealed that teamwork within the unit had the highest percentage of positive response (Sorra et al. 2012). According to Reason’s model of patient safety culture, teamwork is a critical culture dependent on collaboration and cooperation, as well as mutual respect (Sammer et al. 2010). In a supportive and collaborative environment, nurses complied with the safety requirements (Singer et al. 2009). However, teamwork across the unit was an area that required improvement in Jordanian hospitals, whereby staff reported difficulty in working with staff from other units, and there is no coordination between the hospital’s units that could contribute to errors and adverse events. One of the warning results of the current study was related to ‘communication openness’ and ‘hand-off and transition’. Our results indicated that nurses are afraid to ask questions when they were in doubt; given this intriguing information, it was concluded that the majority of patients’ problems occur during the exchange and communication of information across units and during shift exchanges. According to the literature retrieved, communication failure is the primary cause of more than 70% of sentinel events (Sammer et al. 2010). Communication could have been a factor in any adverse event, and could have been affected by hierarchies, power gradients, culture, climate or relationships with the rest of the healthcare team (Dunsford 2009). Consistent with other previous patient safety culture surveys (Alahmadi 2010; El-Jardali et al. 2011, 2014), staffing was an area of patient safety culture that demanded advancement worldwide. In Jordanian hospitals, relatively there was not enough staff to handle the workload. Nurses often attempted to do too much and too quickly and as a result, they operated in what was referred to as ‘crisis mode’. Many studies revealed that the nursing shortage leads to an increase in workload, and this pressure is considered a major cause of errors (Friesdorf et al. 2007; Hayajneh et al. 2010; Keller 2009; Ross 2011). Moreover, in Jordanian hospitals, the system of working shifts was based on 12 h per shift rather than the traditional 8 h per shift. This leads to a decrease in alertness, a decrease in productivity, an increase in staff fatigue and an increase in medical errors (Keller 2009). In our study, the percentage of non-punitive responses to errors composite (21%) was much worse than the U.S. hospitals (44%) (Sorra et al. 2012), but closer to Lebanon’s hospitals (24.3%) (El-Jardali et al. 2011) and Saudi Arabia’s hospital scores (21.1%, 26.8%) (Alahmadi 2010; El-Jardali et al. 2014). The results highlighted the presence of blame and shame culture, and the punitive responses to errors in Jordanian hospitals that prevented the staff from reporting errors. Nurses also feared that their mistakes would have been held against them, or Patient safety culture be kept in their personal file or that they would be written up. Patient safety would be improved in Jordanian hospitals if JUST culture was applied, which means recognizing the errors as flaws in the system, rather than a single individual’s failure, but simultaneously assuring that the individual takes responsibility for their actions (Sammer et al. 2010). Our study results revealed that working based on evidence when providing patient care, and working in a hospital considers patient safety a priority, and are the most significant factors influencing patients’ safety culture. The literature considered evidence-based practice, emphasized research utilization as a major subculture of patients’ safety culture (Sammer et al. 2010). Limitations of study Our results were subjected to several limitations. One limitations of this study resulted from its convenience research sample, a method based on the selection of participants who were accessible at the time of data collection. However, multiple sites were selected to increase the generalizability of current findings and our sample represented most of the hospitals in Jordan. Furthermore, the demographics of the study sample were representative for nurses in Jordan as almost two-thirds of nurses were female and one-third were male nurses. Moreover, the use of a self-reported questionnaire introduced the social desirability biases, which possibly lead to biased research results, as participants may have answered in a manner that would be viewed favourably by others. In addition, the participants in this study were nurses; therefore, the results reflected only the perception of nurses, there is a need to assess patient safety culture from other healthcare providers’ perspectives such as physicians, technicians, etc., and even from clients’ perspective. Implications Positive patient safety culture was essential for each hospital in order to provide a safe patient care and prevent patient harm, which is the core of patient safety. The implication of the current study could be at the level of practice, policy making, administration, research and curriculum. Implications for practice In terms of practice, implementation of positive patient safety culture can result in improving the quality of care, decreased adverse events, and increases in patients’ and nurses’ satisfaction, decreases in nurses’ burnout related to shame and blame from error occurrence, and increases in nurses’ awareness in patient safety measures. Bedside nurses have a crucial responsibility to transform their individual workplaces, asserting lead- © 2014 International Council of Nurses 89 ership at the unit level and hospital level as well to help identify issues that could affect patient safety. New strategies and policies are compulsory so as to improve patients’ safety in Jordanian hospitals. Identifying strong and weak areas of patients’ safety culture helped in concentrating on the areas requiring improvement. More specifically as study results have indicated that communication ‘openness’ and ‘hand-off’ and transition were weak areas that needed improvement, thus team training that could create an open communication atmosphere for reporting errors spontaneously. Team training was found to be an effective strategy in improving safety culture (Jones et al. 2013; Weaver et al. 2013). Furthermore, our results indicated that nurses are afraid to ask questions when they were in doubt, which implied that there was a need for nurses’ empowerment. Nursing empowerment and leadership development supported nurses’ influential role in the safety movement (Richardson & Storr 2010). Finally, policy makers and administrators reinforced the strength areas, such as team work within the units. Implications for policy maker Improving patient safety culture requires a fundamental transformation of nurses’ work environment. Feng et al. (2011) suggested that improving safety culture could be achieved through establishment of a clearly written safety policy that should be communicated to everyone in the organization. Study results implied that staffing policies were needed where there should be a limit to the number of patients that nurses can tend to. Policy makers and administrators needed to create a culture where the traditional culture of shame/blame should be replaced by non-punitive and JUST culture. New policies to improve coordination and collaboration between units of hospitals would improve patients’ safety. Development of a structural communication for hand-off and transition of patients, improvement of communication between managers and staff and placement of patients’ safety were at the top of the priority list of hospitals that would help in improving patients’ safety. Encouragement of evidence-based practices in hospitals by providing accessible recourses such as databases to ensure that it was easy for nurses to get up-to-date information, so as to develop new policies and standardized guidelines based on last evidence and publicized it to the staff. Finally, as indicated by the results of this study, staffing was an area that needs improvement so strategies ensured adequate staffing and were necessary to improve patients’ safety culture. Implications for research In regard to research, this study is the first study in Jordan that concerned patients’ safety culture, and at the moment, numer- 90 W. A. Khater et al. ous countries worldwide have not started this initiative, as of yet. However, because patient safety is a global concern, patient safety culture should be implemented worldwide. Furthermore, studies in this field are required to examine the composites of patient safety culture and other outcomes composites, and examine the effect of implementation of new strategies and training programmes in patient safety culture. Implications for education Patient safety culture should be integrated in the nursing curriculum as well in order to increase the awareness of patients’ safety. Nursing schools/faculties around the world need to integrate safety competencies and quality into nursing school curricula at the undergraduate and graduate levels. Acknowledgement Manar Saleh, University of Houston, English Literature/Political Science. Author contributions WAK participated in the design of the study, participated in data analysis and prepared the study report. 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