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1- Nurses’ perceptions of patient safety culture in Jordanian hospitals - IMPORTANT---

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.
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
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
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
Patient safety culture
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.
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
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
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
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.
W. A. Khater et al.
The study was conducted to answer the following research
1 How do nurses working at Jordanian hospitals perceive
patient safety culture?
2 What are the factors influencing patient safety culture in Jordanian Hospitals?
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.
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.
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.
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.
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.
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.
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%)
W. A. Khater et al.
Table 1 Participants demographic and situation-related characteristics
Participants characteristics
Demographical data
– Male
– Female
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)
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)
Outpatient clinic
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
573 (87.1)
29 (4.4)
Working unit/area
Intensive care unit
N = 658.
SD, standard deviation.
264 (40.1)
394 (59.9)
Marital status
Education level
– Diploma (3Y)
Mean (SD)
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
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
W. A. Khater et al.
Table 3 Factors influencing patients’ safety culture in Jordanian hospitals
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
Accredited vs. non-accredited
Evidence-based practice
Is patient safety a priority for hospital?
Did nurse receive patient safety training?
*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).
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
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.
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.
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
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-
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.
Manar Saleh, University of Houston, English Literature/Political
Author contributions
WAK participated in the design of the study, participated in
data analysis and prepared the study report. LMA-Z participated in the design of the study, performed the statistical analysis and prepared the final report. SIA-M participated in data
gathering, performed the statistical analysis and prepared the
final report. RK participated in preparing the final report. All
authors read and approved the final manuscript.
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