Research Article: Opportunities for improvement in nursing homes: Variance of six patient safety climate factor scores across nursing homes and wards—Assessed by the Safety Attitudes Questionnaire

Date Published: June 19, 2019

Publisher: Public Library of Science

Author(s): Ellen Catharina Tveter Deilkås, Dag Hofoss, Bettina S. Husebo, Gunnar Tschudi Bondevik, Leonidas G Koniaris.


Safety climates are perceptions of safety culture shared by staff in organizational units. Measuring staff perceptions of patient safety culture by using safety climate surveys is a possible way of addressing patient safety. Studies have documented that patient safety climates vary significantly between work sites in hospitals. Across-ward variations in the measurements of safety climate factor scores may indicate ward-specific risk of adverse events related to patient care routines, work environment, staff behaviour, and patient results. Variation in patient safety climates has not yet been explored in nursing homes.

To investigate whether the Norwegian translation of the Safety Attitudes Questionnaire—Ambulatory Version is useful to identify significant variation in the patient safety climate factor scores: Teamwork climate, Safety climate, Job satisfaction, Working conditions, Stress recognition, and Perceptions of management, across wards in nursing homes.

Four hundred and sixty three employees from 34 wards in five nursing homes were invited to participate. Cronbach alphas were computed based on individual respondents’ scores on the six patient safety climate factor scores. Intraclass correlation coefficients were calculated by multilevel analysis to measure patient safety climate variance at ward level.

Two hundred and eighty eight (62.2%) returned the questionnaire. At ward level Intraclass correlation coefficients (ICCs) for the factors were 10.2% or higher for the factors Safety climate, Working conditions and Perceptions of management, 2.4% or lower for Teamwork climate, Job satisfaction, and zero for Stress recognition. ICC for variance at nursing home level was zero or less than one per cent for all factor scores.

Staff perceptions of Safety climate, Working conditions and Perceptions of management varied significantly across wards. These factor scores may, therefore, be used to identify wards in nursing homes with high and low risk of adverse events, and guide improvement resources to where they are most needed.

Partial Text

Patient safety improvement seems to be related to healthcare organizations’ ability to address and improve safety culture [1, 2]. Patient safety climate survey scores may show variation in staff perceptions across organizational units [3]. Such variation may indicate risks related to leadership or other aspects of organization. That offers the opportunity to address patient safety improvement through organizational interventions, e.g. mentoring leaders to conduct patient safety walkrounds, or facilitate improvement board meetings and informal regular meetings where frontline staff may plan and evaluate implementation of improvement efforts [4, 5]. Patient safety culture involves leader and staff interactions, attitudes, routines, awareness, and practices that influence risks of adverse events in patient care [6]. A cultural trait may for example be how leaders facilitate dialogue with staff to uncover negative relationships and behaviour, promote mutual understanding of the causes of adverse events, and establish consensus regarding safety priorities [7].

Of the 463 invited employees working more than 20% in the nursing homes, 288 (62.2%) responded. Response rates varied between 56.9% and 72.2% across the five nursing homes. 30% of respondents were registered nurses, 47% nursing assistants, and 16% health workers. The remaining were kitchen, laundry, secretary, and “other” staff. The average proportion of items with missing values/not applicable was 9.4%. All items of the factor model were answered by 169 respondents. After imputation of missings, 288 health care providers had responses to all items in the factor model. Table 2 shows how respondents were distributed across wards and nursing homes. Details of the respondents’ basic characteristics have been reported elsewhere [26].

Climate score variance across wards was significant for the factors Safety climate, Working conditions, and Perceptions of management. All three factors had noticeable ICCs and sufficient between-ward heterogeneity to be considered organizational climates [19].

Staff perception of the Norwegian SAQ-A factor scores Safety climate, Working conditions and Perceptions of management varied significantly across wards in nursing homes. The results mean that these climate survey scores may probably be used to identify wards in nursing homes with high and low risk of adverse events. Patient safety improvement work in nursing homes should be guided by such measurements so that improvement resources are spent where they are most needed.