Pilot testing on safety performance among healthcare professionals

Abstract

Background

The study focused on the perception of healthcare professionals on safety performance in the sector.

Objective

The aim of the study is to assess the safety performance among healthcare professionals. This study examines the factors affecting safety performance in Malaysia. The results are expected to provide insights into the provision of a safety management programme for high level of safety performance.

Design

The study uses a quantitative instrument to explore perceptions regarding the healthcare system and health service based on pilot tests conducted.

Respondents: The pilot test respondents were from various departments of two Malaysian private hospitals in Penang and Perak. These medical professionals with representatives from Quality, Pharmacy, Nursing, Rehabilitation, Imaging, Nursing Education, Security, Pharmacy, Nursing, Facility, Dental, and Educational Nursing departments participated across two focus group discussions carried out between July and September 2017.

Results

The most important factors impacting the safety performance were perceived motivation, safety management & process improvement, and safety practices, representing the three dimensions within the safety climate.

Conclusions

This study shows opinion of professionals working in the healthcare sector. Safety performance level in the Malaysian healthcare could be improved by alleviating occupational safety and health programme of the healthcare sector in Malaysia.

Keywords

Emerging market healthcare patient satisfaction quality Malaysia safety climate

Introduction

According to the statistics of the Minister of Human Recourses, there were 41,005 workplace accidents reported in 2016.¹ Out of the number, 7820 cases were occupation-related diseases, such as lung disorders or muscle ailments. The rate of accidents at workplaces in 2016 was 2.88 per 1000 employees.² Based on the Director General of Health, a total of 554 commuting accidents involving healthcare personnel were recorded between 2014 and 2016.³

In addition, healthcare-related infections remain as the most frequent opposing event in any healthcare delivery system and touch millions of people each year, leading to serious illness and even death.⁴ Based on World Health Organization (WHO), three million health workers are exposed to variety of blood infections each year.⁵ Although it is not a single occupational hazard which is to be addressed in the hospital, fire hazard is one of the many occupational hazards to hospital workers and its occupants. Hospital as an institution that is carrying image of providing safe haven to those coming to it, could become hazardous environment if there is lack of focus on safety measures. Based on Ostrom et al.,⁶ safety performance is affected by an organization’s socially transmitted beliefs and attitudes toward safety. The concept of safety culture⁷ was developed which focused attention on the human and organisational elements contributing to the unsafe operation. Zohar’s⁸ study of safety climate used a factor analysis to identify climate dimensions that could discriminate among factors based on their safety climate levels. According to Turner,⁹ safety culture is an organization’s norms, beliefs, roles, attitudes and practices concerned with minimizing exposure of employees to workplace hazards. In other words, there was reported link between organizational culture and performance.

The aim of this study is to assess the healthcare professionals’ knowledge and attitudes of safety management programmes toward safety performance. The four management dimensions discussed in reports concerning safety culture: (a) perceived motivation, (b) quality improvement, (c) satisfaction and (d) safety practices. The objective of the current study was to determine the extent to which these four variables predict safety compliance and its outcomes on safety performance and patient safety.

Literature review

Previous studies show that a large majority of hospitals have expressed an interest in promoting safety management in the healthcare sector. The literature identified a number of important methodological issues concerning the healthcare professionals as pilot test respondents.

Perceived motivation

Employees in healthcare industries are lured by the positive environment which will influence their performance.¹⁰ The motivated environment may be the factor for increasing interest in working for the hospitals. Findings from Shader et al. shown that employee retention was depended on extrinsic motivation and also working environment.¹¹ Though, external contingencies diminished intrinsic motivation of employees.¹² Thus, Barling and Hutchinson¹³ explained that company's control has been motivating the employees to safety compliance as well as on time task completion. Tjosvold¹⁴ gave examples on how the flight cabin crews are motivated to take safety precautions during the case of emergency, and every safety measurement taken are positive when they work as a team. This can be used in hospital environment to motivate a medical practitioner to work as a team so that safety standards can be upheld.

Process improvement or support

To reduce hospital infections, the authorities and hospital infection control departments should pay more attention to staff obedience with the standard safeguards, and reinforce standard precautions training. With learning, the accomplishment of knowledge and skills, and the creation of health beliefs and attitudes, health activity habits can be shaped. Only when individuals are familiar with the gratified and meanings of the standard precautions, with strengthening of the individual's health concepts, can individual practice change so as to improve obedience with safety measures.¹⁵

Satisfaction

Satisfaction among nurses links with the ability to monitor support staff and allow them to concentrate on quality care of patient’s safety.¹⁶ Extension in roles and responsibilities has caused distractions, which contributes to greater medical error.¹⁷ Satisfactions on job for medical professionals are vital, so any expansion in duties may not affect their compliance on safety. Weick and Sutcliffe¹⁸ explained that to create safety culture in healthcare, all they need is work integration besides monitoring and fixing each other’s task regardless of rank only with fullest satisfaction. Johnson and Hudson¹⁹ highlighted some hazards that happened which can lead to dissatisfaction. Furthermore, satisfaction in facilities to provide quality care significantly reduces workplace injuries.²⁰ El-Jardali and Lagace²¹ mentioned that safety healthcare facilities promise patient’s safety.

Safety practices compliance

Based on Rampal et al.,²² majority healthcare workers stated that they were aware about universal precaution guideline and needlestick and sharps injury need to be reported. However, among those who had needlestick and sharps injuries (NSSI), only 30.9% had reported the incident of needlestick and sharps injuries, indicating that there were gaps between knowledge and practice among the healthcare workers. In addition, the knowledge score of nurses was significantly increased and the practice score among the wards was also improved after a series of pharmacist-based interventions.²³ A review of the literature reveals a paucity of well-controlled studies, reflecting the efficacy of workplace safety programmes.

Safety performance

Robust safety climate in hospitals focused on safety performance and incorporates into management level.²⁴ Andriessan²⁵ found that legal has significant relationship with safety performance. Proper synchronization in the departments is mandatory to avoid opportunities for accidents besides promoting the safety performance to rule safety compliance. Yang et al.²⁶ defined safety performance measures as effectiveness of management in managing safety; however, Neal et al.²⁷ described safety performance as behaviour of employees on safety compliance. Healthcare employees have to cope with psychological stress resulting from shift rotations and the frequent need to work overtime. Since hospitals never shut down, and rarely slow down, numerous hazards develop due to fatigue from long hours, stress, rotating shift work and changes in policy. One shift may create a hazard (such as leaving a cart blocking an emergency exit) that is overlooked by subsequent shifts.²⁸ The proper focus of attention to improve a hospital’s quality of service and employee and patient safety is not on the personnel who participate in a flawed process, but the processes that create the flaws. Hospitals that employ quality improvement methods have been found to achieve new levels of efficiency, patient satisfaction, safety, clinical effectiveness and profitability.²⁹ According to Wu et al.,³⁰ safety leadership had main influence on safety climate, and safety performance that focuses on safety management, safety facilities, and accident investigations in the workplace. Nevertheless, due to the health services’ traditional orientation toward sick care rather than health maintenance and hazard prevention and because of the concern for the cost of safety and health management, the implementation might not have been considered a top priority by hospital administration.

Patient safety

Benn et al.³¹ reported that safety climate and capability dimensions are rated as most sensitive to the effects of the patient safety and reliability of care. Particularly, the findings of Bent et al. in United Kingdom revealed that safety climate and capability dimensions found the most sensitive to the effects of the the Health Foundation's Safer Patients initiative (SPI) programme were multi-professional engagement and communication, the degree of routine monitoring of care processes and the capacity to evaluate the impact of changes to clinical work systems. Hospital safety climate scores were significantly correlated with clinical workers’ safety behaviour and patient and worker injury measures, although the effect sizes were smaller for the latter.³² Compliance of safe work practices is expected to improve healthcare quality, i.e. patient safety by minimizing risks. This will reduce chance for healthcare accident, thus achieving overall satisfaction over the effectiveness of the safety climate.

Method

Common factors of core elements in evidence-based interventions is one of the theoretical perspectives-guided intervention development.³³ Another theoretical perspective is self-determination theory which focuses attention on social-contextual factors that influence motivation, self-regulation, mental health and well-being, such as competence, autonomy, and social relatedness. Based on references to past literature, a conceptual model was constructed as a foundation for qualitative work and primary data collection process of this study. This model identifies four antecedents believed to be necessary for Malaysian healthcare professionals to engage in care and adhere to treatment. This study explores the current situation of occupational safety and health in healthcare sector in Malaysia based on self-determinants theory. Based on this theory, it urges individuals to participate without any force or imposed by any party. This study is important as it focuses on the main factors that affect occupational safety and health in the healthcare sector.

The selection of pilot test participants was random, keeping in mind the departmental diversity of participants. From each department of hospital, one representative was invited. It is because all departments are concerned with safety practices in their respective departments. All the participants were given general questions and also specific relative questions to their departments. For the pilot test, statistical analyses were conducted in SPSS version 16. Simple frequency distribution methods were used to analyse the survey. The follow-up survey was analysed with non-parametric Spearman’s correlation coefficient tests for means comparisons. Spearman’s correlation coefficient is a statistical measure of the strength of a monotonic relationship between paired data. The interpretation of Spearman's correlation coefficient (r) is that the closer r is to 1 or -1, the stronger the monotonic relationship.

Results

Pilot tests were held between July and September 2017. Among the respondents, 66.7% were female, 33.3% were male. The main age group of the respondent was 35–44 years (50%). Majority of the participants were bachelor graduates (50%), 58.3% of the participants are managers, and 41.7% are healthcare front liners; 58.3% of the respondents have been working for 15–24 years in hospitals.

Table 1 presents the means of the variables used in the survey. As for safety performance and healthcare quality, the means are 4.4333 and 4.4333, respectively. The table also shows that the most reflected safety climate is safety management (mean = 4.4375), followed by safety practices (mean = 4.1481), perceived motivation (mean = 3.8472), and the lowest mean of satisfaction (mean = 3.5500). An overall descriptive analysis revealed the means for each of the constructs based on the averages of each of their respective measures.

Table 1.

Descriptive statistics of safety climate.

Variables	Mean
Safety management	4.4375
Safety performance	4.4333
Patient outcomes (healthcare quality)	4.3056
Safety practices	4.1481
Perceived motivation	3.8472
Satisfaction	3.5500

Post hoc tests were performed to determine whether there were possible alternate explanations for the results (Table 2). Since the type of gender was categorical (female, male), a nonparametric (independent sample Mann–Whitney) test was performed (p = 0.384); gender made no difference in the safety performance.

Table 2.

Safety performance by gender (ranks).

Gender	N	Mean rank	Sum of ranks
SPE4
Male	4	7.63	30.50
Female	8	5.94	47.50
Total	12

A Mann–Whitney test was also performed to determine if the job title of the person (managers, front liners-nurses, etc.) who performed the risk-management function had any impact on safety performance (Table 3). No difference was found (p = 0.229).

Table 3.

Safety performance by position (ranks).

Position	N	Mean rank	Sum of ranks
SPE4
Frontliners	5	5.20	26.00
Managers	7	7.43	52.00
Total	12

A Spearman's correlation was run to determine the relationship between safety performance and its antecedents (Table 4). There was a strong, positive monotonic correlation between Safety Performance and its antecedents SMPI5 (ϒѕ = 0.751, p < 0.01), SMPI6 (ϒѕ = 0.781, p < 0.01), SP1 (ϒѕ = 0.731, p < 0.01), SP7 (ϒѕ = 0.681, p < 0.05), PM1 (ϒѕ = 0.680, p < 0.05), PM2 (ϒѕ = 0.700, p < 0.05).

Table 4.

Spearman's rho rank correlation of safety performance with its antecedents.

Items	Correlation coefficient (ϒѕ)	Sig. (two-tailed)
Safety management and process improvement
SMPI1: Provision of personal protective equipment	0.450	0.142
SMPI2: Provision of safety training	0.220	0.492
SMPI3: Emphasis safety goals and procedures	0.443	0.160
SMPI4: Safety decision by qualified personnel	0.342	0.277
SMPI5: Risk assessment	0.751	0.005**
SMPI6: Risk management	0.781	0.003**
SMPI7: Review of safety training goals	0.244	0.445
SMPI8: Support of teamwork	0.264	0.407
Safety practices
SP1: Use of personal protective equipment	0.731	0.007**
SP2: Corrections of violations	0.525	0.079
SP3: Safety incident reporting	0.363	0.246
SP4: Violation disclosure	0.220	0.492
SP5: Violation information	0.329	0.296
SP6: Violation reporting	0.229	0.475
SP7: Recognition of safety achievement	0.681	0.015*
SP8: Safety communication	0.150	0.642
SP9: Unsafe acts	−0.310	0.327
Perceived motivation
PM1: Safety climate	0.610	0.035*
PM2: Safety suggestions	0.700	0.011*
PM3: Reward for violation identification	0.492	0.104
PM4: Learning from other’s mistake	0.008	0.979
PM5: Effective when not fatigued	−0.082	0.799
PM6: Violation disciplinary actions	0.217	0.497
Employee satisfaction
S1: No personal problems affecting performance	−0.406	0.190
S2: Pleasant work with other staff	0.573	0.051
S3: Satisfaction to resources	−0.045	0.889
S4: Peers encourage patient care	−0.564	0.056
S5: Not Fatigued	0.342	0.276

Note: ** and * indicate significance at 1% and 5% level, respectively.

A Spearman's correlation was run to determine the relationship between Healthcare Quality and Safety Performance, see Table 5. There was a very strong, positive monotonic correlation between Safety Performance and SPE2 (ϒѕ = 0.863, p < 0.01) as well as SPE4 (ϒѕ = 1.000, p < 0.01). In addition, there was a strong, positive monotonic correlation between Safety Performance and its antecedents SMPI5 (ϒѕ = 0.698, p < 0.05).

Table 5.

Spearman's rho rank correlation of healthcare quality with its antecedents.

Items	Correlation coefficient (ϒѕ)	Sig. (two-tailed)
Safety performance
SPE1: Safety policy	0.553	0.062
SPE2: Not suffer any injuries	0.863	0.000**
SPE3: Effective safety policy	0.380	0.224
SPE4: Improved patient safety	1.000	0.000**
SPE5: Rules and regulations	0.698	0.012*

Note: ** and * indicate significance at 1% and 5% level, respectively.

Discussion

Based on the pilot study, the results show that gender and job title made no difference in the safety performance. In other words, the achievement of Safety Performance is similar regardless of female or male healthcare professionals by both front liners and managers. In general, safety management has the highest mean among the variables. This implies that safety climate of the hospitals is good especially when safety management is in place and implemented accordingly. On the other hand, perceived motivation and satisfaction are found to be relatively less important in safety climate as there are lower mean values. Some of the most effective component of Safety Management to Safety Performance according to the pilot data were SMPI5 (Risk Assessment) and SMPI6 (Risk Management). It can be said that Risk Assessment and Management were more important than Teamwork or Safety Decision, Goals, Reviews, Training, and Equipment. Based on the results of the pilot study, it was found that when considering safety performance in relation to employees' perceived motivation, of which PM1 (Safety Climate) and PM2 (Safety Suggestions) were found to be a strong correlation with safety performance, but not elements of Violation Identification, Disciplinary Actions, Mistake Learning, and Not Fatigued. Some of the most effective safety practices that hospitals can implement are violation reporting and safety communication. This pilot study also demonstrated that these were not adequate; hospitals must verify that the safety practices taught in the classes are being implemented in the work areas by ensuring SP1 (Use of Personal Protective Equipment) and SP7 (Recognition of Safety Achievement). Furthermore, since safety behaviour is often tied to hospital quality, it is probable that an added benefit of better safety performance to protect their employees, the hospital derives a financial benefit in improved healthcare quality. For Healthcare Quality, there was a very strong, positive monotonic correlation between Safety Performance and SPE2 (Not suffer any injuries) as well as SPE4 (Improved Patient Safety). Within Healthcare Quality, there was a strong, positive monotonic correlation between Safety Performance and SPE5 (Rules and Regulations). While many literature have typically discussed safety practices as general goals, this study systematically examined the specific elements of these safety practices that predict healthcare quality. The data collected in this pilot study are somewhat low due to the difficulty in recruiting hospitals. Since this was the pilot study, an extension of this work is recommended. A recommended follow-up study is to select more comparable hospitals, preferably within the same system. An assessment could be conducted to establish a measure of the safety performance. The results of this study can be used to determine which factors to emphasize when performing an organizational development change in safety culture. The total of the data will be used to identify gaps in the current measure on healthcare professionals.

Conclusion

Results show that Safety Management, Perceived Motivation, Safety Practices and Employee Satisfaction are factors influencing safety performance. Furthermore, the pilot study provides insights pertaining to safety performance among healthcare professionals in Malaysia, although only Safety Management, Perceived Motivation and Safety Practices were factors found to be correlated to Safety Performance. Safety Management elements of Risk Assessment and Management were more corrected to Safety Performance. In addition, healthcare professionals perceived that the Safety Climate and Safety Suggestions were motivations strongly correlated to safety performance, and Use of Personal Protective Equipment (SP1) and Recognition of Safety Achievement (SP7) were important elements of Safety Practices contributing to Safety Performance. The strength of this study is its provision of an insight into safety performance of healthcare professionals. In addition, this study reveals the safety performance elements affecting healthcare quality. These results will be used for compiling a new questionnaire. The measures of the questionnaire instrument should be modified covering all items important for healthcare professionals.

Respondent backgrounds were diverse in age and ethnic. The study has several limitations, suggesting that the results should be interpreted with some caution. The primary limitation is that the pilot study was small and limiting statistical power, designed only to test for feasibility and acceptability; it was not powered to test any outcomes. Second, this pilot study took place in Penang and Perak hospitals willing to volunteer for this project; but more objective measures were not feasible in this pilot; as such, small samples and convenience sampling may limit the generalizability of findings. In future research, it will be important to conduct a larger study to confirm these results and to fully understand determinants of support for safety performance. In conclusion, hospital managers need to be mindful of the importance of these safety performance antecedents, to be incorporated in the instituting of superior quality of healthcare services and delivery. Malaysian hospitals need to make a continual effort to examine the ever varied needs of safety performance and ensure the quality of healthcare services provided to the patients.

Precis

Based on the pilot study, safety management programme in the healthcare sector involving enhancement in perceived motivation, process improvement and safety practices are more effective than satisfaction in improving safety performance hence quality of patient healthcare.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Universiti Tunku Abdul Rahman Research Fund (UTARRF) under Grant No. 6200/A33.

Author biographies

HN AuYong achieved her Bachelor of Science (Hons.) at Universiti Putra Malaysia, MA, at University of Tsukuba and Ph.D. at Universiti Sains Malaysia. She is an Assistant Professor and Dean of the Faculty of Business and Finance, Universiti Tunku Abdul Rahman. She was certified safety and health officer and a Member of the Malaysian Institute of Management. She is author of more than 70 peer-reviewed conference and indexed journal papers. She has received research grants to the amount of US$30,000 between 2015 and 2017. Her research topics include environment, occupational, safety and health.

K Usmonov is a Master of Philosophy student from Uzbekistan.

Charles Ramendran SPR is an Assistant Professor from Department of Business under the Faculty of Business & Finance, Universiti Tunku Abdul Rahman (UTAR). He obtained his PhD from Universiti Sains Malaysia (USM) in Human Resource Management. He also obtained his Train the Trainer certificate awarded by Human Resource Development Fund (Ministry of Human Resource) and engaging in training people on conflict management, occupational safety and industrial relations.

GG Yeoh is an experienced founding partner with a demonstrated history of working in the Information Technology and Education industry; skilled in Healthcare Information Systems (HIS) Integration, Management, Requirements Analysis, and Implementation Management, with strong entrepreneurship professional and lecturing with a Master of Science (MSc) major in E-Business from The University of Bolton, UK.

L Surienty has been a faculty member of School of Management, Universiti Sains Malaysia since 2005. Her research works focused on finding a sustainable safety management practices for SMEs and this includes researching about gender responsive OSH. She has international collaborations with Canadian, Norwegian and British researchers. She has graduated ten (10) full research students and has published both locally and internationally. She has been an invited speaker for the Department of Occupational Safety and Health (DOSH), the Federation of Malaysian Manufacturers (FMM) and Safe Work Australia at the recent XXI World Congress for Health and Safety at Work. Her expertise has been regularly consulted by the private sectors including the Local Government projects to encourage women participation in the economy.

References

Msar

Strategic cooperation important to reduce workplace accidents, says Human Resources Minister. New Straits Times, 17 November 2017, https://www.nst.com.my.

Jay

BN.

40,000 M'sians hurt in workplace accidents in 2016: Human Resource Ministry. New Straits Times, 7 September 2017, https://www.nst.com.my.

High number of accidents among healthcare personnel a cause for concern. New Straits Times, 31 May 2017.

Zingg

Holmes

Dettenkofer

et al . Hospital organisation, management, and structure for prevention of health-care-associated infection: a systematic review and expert consensus. Lancet Infect Dis 2015; 5: 212–224.

World Health Organisation (WHO). Health care worker safety, www.who.int/injection_safety/toolbox/en/AM_HCW_Safety_EN.pdf (2014, accessed 2 May 2018).

Ostrom

Wilhelmsen

Kaplan

Assessing safety culture. Nuclear Safety 1993; 65: 163–172.

Pidgeon

Safety culture: transferring theory and evidence from the major hazards industries.

J Cross Cultural Psychol 1991; 22: 129–140.

Zohar

Safety climate in industrial organisations: theoretical and applied implications.

J Appl Psychol 1980; 65: 96–102.

Turner

BA.

The development of a safety culture. Chem Ind 1991; 4: 241–243.

10.

Natan

Berker

Israelis' perceived motivation for choosing a nursing career.

Nurse Educ Today 2010; 10: 308–313.

11.

Shader

Broome

et al . Factors influencing satisfaction and anticipated turnover for nurses in an academic medical center. J Nurs Admin 2001; 31: 210–216.

12.

Deci EL and Ryan RM. Intrinsic motivation and selfdetermination in human behavior. New York: Plenum Press, p. 64.

13.

Barling

Hutchinson

Commitment vs. control-based safety practices, safety reputation and perceived safety climate.

Can J Admin Sci 2000; 17: 76–84.

14.

Tjosvold

Flight crew collaboration to manage safety risks.

Group Organiz Manage 1990; 15: 177–191.

15.

Yang

Guo-Ping

Jijan-Wei

et al . Factors impacting compliance with standard precautions in nursing, China. Int J Infect Dis 2010; 14: 1106–1114.

16.

Gershon

Stone

Bakken

et al . Measurement of organizational culture and climate in healthcare. J Nurs Admin 2004; 34: 33–40.

17.

Porto

Lauve

Disruptive clinician behavior: a persistent threat to patient safety. Patient Saf Qual Healthc 2006; 3: 16–24.

18.

Weick

Sutcliffe

KM.

Managing the unexpected. Assuring high performance in an age of complexity. San Francisco: Jossey-Bass, 2001.

19.

Johnson

Hudson

MA.

Keeping patients safe: an analysis of organizational culture and caregiver training.

J Healthc Manage 2004; 49: 171–79.

20.

Yassi

Hancock

Patient safety – worker safety: building a culture of safety to improve healthcare worker and patient well-being.

Healthc Q 2005; 8: 32–38.

21.

El-Jardali

Lagacé

Making hospital care safer and better: the structure-process connection leading to adverse events.

Healthc Q 2005; 8: 40–48.

22.

Rampal

Zakaria

Leong

et al . Needle stick and sharps injuries and factors associated among health care workers in a Malaysian hospital. Eur J Soc Sci 2010; 13: 354–362.

23.

Chan

Sooaid

Cheng

et al . Improving safety-related knowledge, attitude and practices of nurses handling cytotoxic anticancer drug: pharmacists’ experience in a general hospital, Malaysia. Asian Pacific J Cancer Prev 2013; 14: 69–73.

24.

Singer

Lin

Falwell

et al . Relationship of safety climate and safety performance in hospitals. Health Serv Res 2009; 44: 399–421.

25.

Andriessan

Safe behavior and safe motivation.

J Occup Accid 1978; 1: 363–376.

26.

Yang

Wang

Chang

et al . A study on the leadership behavior, safety culture, and safety performance of the healthcare industry. World Acad Sci Eng Technol 2009; 53: 1148–1155.

27.

Neal

Griffin

Hart

The impact of organizational climate on safety climate and individual behavior.

Safety Sci 2000; 34: 99–109.

28.

Johnson

Safety in ward 3. Occup Health Saf 1997; 66: 37–41.

29.

Berwick

Godfrey

Roessner

Curing health care. San Francisco, CA: Jossey Bass, 1990.

30.

Chen

CC.

A correlation among safety leadership, safety culture and safety performance.

J Loss Prevent Process Ind 2008; 21: 307–318.

31.

Benn

Burnett

Parand

et al . Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK Safer Patients Initiative. J Eval Clin Pract 2009; 15: 524–540.

32.

Agnew

Flin

Mearns

Patient safety climate and worker safety behaviours in acute hospitals in Scotland.

J Saf Res 2013; 45: 95–101.

33.

Rotheram-Borus

Swendeman

Flannery

et al . Common factors in effective HIV prevention programmes. AIDS Behav 2009; 13: 399.