Nurses’ attitudes towards patient safety and their relationship to adverse patient events in Oman

Abstract

Background:

Adverse events (AEs) are major causes of mortality. Identification of nurses’ attitudes towards patient safety and their impact on AEs is critical in enhancing safe practices.

Aim:

To assess the relationship between attitudes towards patient safety and AEs as perceived by nurses working in Sultanate of Oman.

Methods:

A descriptive, cross-sectional study was conducted. Data to evaluate nurses’ attitudes towards patient safety was collected using the Safety Attitude Questionnaire. The relationship between attitudes towards patient safety and the perceived incidence of adverse patient events was examined using logistic regression analysis.

Results:

A total of 184 questionnaires were administered from February to April 2022, with a response rate of 96.8%. The results revealed that nurses had a negative attitude towards patient safety. The highest reported adverse event was patient and family complaints. Findings showed a significant relationship between working conditions and patient and family verbal abuse (OR = 0.505, CI (0.283–0.901), p = 0.021). Job satisfaction was a significant predictor of patient fall (OR = 0.57, CI (0.353–0.932), p = 0.025) and medication error (OR = 0.58, CI (0.354–0.949), p = 0.030).

Conclusion:

Nurses’ attitudes towards patient safety are a significant predictor contributing to the occurrence of AEs. This finding provides key insights about patient safety status that key stakeholders could use to improve safety culture, including raising patient safety awareness.

Keywords

adverse patient events nurses safety culture

Introduction

Patient safety is a significant priority for healthcare organisations globally (Bates and Singh, 2018). The vital role patient safety outcomes play reflects the attitude, perception, values and behaviours of individuals, groups and entire organisations in terms of how they prioritise patient care (Malak et al., 2022). The World Health Organization is keen to raise awareness of patient safety among direct caregivers because the emphasis on patient safety produces several benefits (World Health Organization, 2021). A key benefit is that it minimises patient disabilities and injuries and prevents death. In addition, emphasis on patient safety can be used to determine a healthcare organisation’s ability to address and reduce risks to patients (Malak et al., 2022).

Many researchers have recommended building safety culture strategies, such as a blame-free culture, learning from previous errors and encouraging teamwork to reduce adverse clinical events (Labrague et al., 2021). Moreover, research has shown that adverse events (AEs) and medication errors are associated with nurses’ attitudes towards patient safety (Alanazi et al., 2022). Additionally, poor teamwork and lack of communication among nurses directly impact the safety climate in healthcare settings (Zhong et al., 2023). Hence, improving patient safety attitudes is critical to ensure safe practices.

Review of literature

An AE is defined as any untoward event, therapeutic error, iatrogenic injury or other unpleasant error directly linked to care or services delivered within a healthcare setting (Ministry of Health (MOH), 2017). AEs have significant consequences for the patient and organisation, often leading to temporary or permanent disability, and in some cases, death. In a way, the occurrence of AEs can be used to measure patient safety efforts and the overall healthcare service quality in a facility.

There is increasing evidence indicating that nurses who report positive attitudes towards patient safety have less incidence of adverse patient events (APEs; Malak et al., 2022). Nurses’ safety attitudes reflect the organisation’s safety culture and climate, and shape patient safety behaviours among the caregivers.

A recent study took place in 630 U.S. hospitals, using a cross-sectional clustered design. The researchers collected the data from 382,834 healthcare workers. Findings showed that nurses’ attitude towards patient safety has a significant negative relationship with the frequency of reported error events (Azyabi et al., 2022). In another study, Najjar et al. (2015) utilised a retrospective exploratory design in Palestinian territories to find the relationships between patient safety culture and AEs. The results revealed fewer rates of AEs with healthcare providers with a positive patient safety attitude. In a cross-sectional survey carried out among 2295 nurses employed in 32 teaching hospitals in Iran, Kakemam et al. (2021b) similarly found that a higher level of nurses’ perception of patient safety culture is associated with fewer occurrences of AEs. In a baseline assessment of patient safety culture in public hospitals in Kuwait, Ali et al. (2018) found a positive association between reporting patients’ harm and leadership support, which resulted in an overall improvement in patient safety culture.

The review of the literature highlights the importance of assessing nurses’ attitudes towards reporting AE to maintain a safety culture. In Western countries, several researchers have evaluated patient safety from different nurses’ perspectives, including exploring demographic key variables associated with the perception of patient safety. However, in Middle Eastern countries, there are limited studies on nurses’ safety perceptions, especially within the Omani healthcare context. Moreover, there is a lack of published data on the types of APEs. This lack of information could be attributed to the increase in APEs in the country. Understanding the factors that influence the reporting of AEs can inform policymakers on the corrective measures that can be put in place to address them in a timely and comprehensive manner for the best outcomes.

Research questions

What is the nurses’ attitude towards patient safety?

What types of clinical AEs are reported by nurses in Oman?

What is the relationship between nurses’ attitude towards patient safety and the occurrence of APEs among nurses working in Oman?

Aim

The aim of the study was to assess the relationship between attitudes towards patient safety and AEs as perceived by nurses working in Sultanate of Oman.

Methods

Study design and setting

The researchers used a descriptive, cross-sectional quantitative research design. They conducted the study in two tertiary-level governmental hospitals in Oman.

Study sample

The researchers utilised a convenience sampling technique to recruit staff nurses employed in inpatient units. They included participants if they had completed at least 3 months of an internship programme, at the time of the survey, to become familiar with the working environment in the various units. Nurses in their units. The researchers excluded nurses who were still under the orientation period in the selected clinical units or who were on leave during the study period.

To obtain the required sample for the study, the researchers used the G-power method based on the following parameters: a confidence level of 95%, α of 0.05, medium effect size (Cohen’s f2 = 0.15), statistical power of 80% and a number of predictors of 18. The acceptable recommended sample was 149 nurses. However, considering a 10% attrition rate, the researchers sampled an additional 15 nurses as well. Hence, the total number of nurses sampled was 164 nurses.

Data collection procedure and ethical considerations

Prior to data collection, the researchers obtained ethical approval from the MOH. Data collection was between February and April 2022. Before administering the paper-based questionnaire, written informed consent was obtained from study participants. The researcher upheld the confidentiality of the data because no personal identification data were collected, and every questionnaire was anonymous. In addition, each survey form was identified using codes, and access to the filled surveys was restricted to the researcher team.

Study instruments

The researchers used the following tools to measure the study variables: demographics sheets, Safety Attitude Questionnaire (SAQ) and APEs Scale.

The researchers developed a demographic sheet and included descriptions of participants’ age, gender, education, clinical working unit and years of work experience. They used the SAQ short form to assess nurses’ attitudes towards patient safety. The questionnaire consists of six domains, comprising 36 items: teamwork climate, safety climate, job satisfaction, stress recognition, management perceptions and working conditions (Sexton et al., 2006). All items were measured on a 5-point Likert scale ranging from (1) ‘Disagree strongly’ to (2) ‘Disagree slightly’, (3) ‘Neutral’, (4) ‘Agree slightly’ and (5) ‘Agree strongly’. Three items – 2, 11 and 36 – were reverse coded. The results were then converted to a 100-point scale. Stress recognition construct was omitted from the overall scale score. A score of 75 or higher indicated a positive attitude. The tool is a valid and reliable tool that achieved a Raykov’s ñ coefficient of 0.9 (Sexton et al., 2006). In the current study, Cronbach’s alpha was 0.92. The tool has been used in several countries, including Oman (Nadabi et al., 2020).

The researchers used the APEs set of five questions to measure nurses’ perceived APEs (Spence Laschinger and Leiter, 2006). Those set of questions were reported by Aiken et al. (2013) as nurse-reported AEs. Nurses were asked to report (1) patient and family complaints, (2) patient and family verbal abuse, (3) patient falls, (4) nosocomial infections and (5) medication errors that occurred over the last year (Spence Laschinger and Leiter, 2006). Nurses were asked to rate the frequency of these events over the past year using a 7-point Likert scale as following: (0) ‘never’, to (1) ‘a few times a year’, (2) ‘at least once a month’, (3) ‘several times a month’, (4) ‘at least once a week’, (5) ‘several times a week and (6) ‘daily’. Responses in each question were dichotomised into ‘happened = 1’ and ‘never happened = 0’ by coding ‘never’ as ‘never happened’ and the rest of the responses as ‘had happened’. This approach was utilised by several scholars (Kakemam et al., 2021a; Wang et al., 2014).

Data analysis

The researchers conducted the statistical analysis using the SPSS version 23. A p-value <0.05 was considered statistically significant. In all the statistical analyses, a 95% confidence level was maintained. Descriptive statistics were presented in frequencies, percentages, means and standard deviations. This was used to summarise participants’ demographic characteristics and describe nurses’ attitude towards reporting APEs. The researchers used multivariate logistic regression to examine the relationship between attitudes towards patient safety and perceived APEs, controlling for demographic and work-related variables including participants’ age, sex, educational level, place of work and years of experience. These variables were particularly selected as they have been identified in previous literature to be associated with the outcome variable which is APEs (Kakemam et al., 2021a; Lee et al., 2018). There were no missing data reported and no sensitivity analyses were conducted.

Results

Sample demographics

The study included a total of 184 participants, of whom 42% were 31–40 years old. The sample was predominantly female (92.9%). More than half of the study participants (56.7%) hold a diploma as the highest degree in nursing, whereas only 56 out of 184 (30.4%) have a bachelor’s degree. The sample included nurses working in various units, including medical-surgical (41.3%), critical care units (22.3%), paediatrics (13%), multispecialty units (13%) and maternity (10.3%). The average length of working experience was 11.03 (SD = 5.78) years. On average, nurses cared for seven patients in each shift during a typical day (SD = 4.16); see Table 1.

Table 1.

Participants demographics (N = 184).

Variable	Frequency	%
Age
21–30	59	32.1
31–40	79	42.9
41 and above	46	25
Gender
Female	171	92.9
Male	13	7.1
Educational level
Diploma	106	56.7
Postgraduate diploma	17	9.2
Bachelor’s	56	30.4
Master’s	5	2.7
Clinical unit
Critical care units	41	22.3
Medical and surgical	76	41.3
Paediatric	24	13
Maternity	19	10.3
Multispecialty	24	13
	Mean	SD
Years of work experience	11.03	5.78

Nurses’ attitude towards patient safety

On average, the attitude of nurses towards patient safety was 60.606 (SD = 14.511). The highest reported attitude was related to job satisfaction (M = 71.589, SD = 24.304), followed by perceived teamwork climate (M = 61.154, SD = 18.780), and the lowest response score was towards recognition of stress (M = 52.570, SD = 23.600); see Table 2.

Table 2.

Descriptive statistics of the patient safety attitude score and its subscales.

Scale/Sub-scale	Mean	SD
Patient safety attitude (composite score)	60.606	14.511
Teamwork climate	61.154	18.780
Safety climate	61.869	18.660
Job satisfaction	71.589	24.304
Stress recognition	52.570	23.600
Perceptions of management	56.311	18.489
Working conditions	54.803	18.964

Types of clinical AEs as reported by nurses

The most common AE reported over the previous year was ‘patient and family complaints’ (n = 136, 73.9%), followed by ‘patient and family verbal abuse’ (n = 135, 73.4%), and ‘patient fall’ was the least common AE (n = 100, 54.3%); see Table 3.

Table 3.

Descriptive statistics of the adverse patient events.

Adverse events	Never happenedn (%)	Happenedn (%)
Adverse events	Never happenedn (%)	Few times a year	At least once a month	Several times a month	At least once a week	Several times a week	Daily
Patient and family complaints	48 (26.1%)	48 (26.1%)	24 (13 %)	29 (15.8%)	13 (7.1%)	7 (3.8%)	15 (8.2%)
Patient and family verbal abuse	49 (26.6%)	51 (27.7%)	27 (14.7%)	24 (13%)	19 (10.3%)	8 (4.3%)	6 (3.3%)
Patient fall	102 (55.4%)	50 (27.2%)	19 (10.3%)	9 (4.9%)	2 (1.1%)	1 (0.5%)	1 (0.5%)
Nosocomial infection	49 (26.6%)	47 (25.5%)	36 (19.6%)	31 (16.8%)	14 (7.6%)	5 (2.7%)	2 (1.1%)
Medication errors	84 (45.7%)	55 (29.9%)	30 (16.3%)	10 (5.4%)	4 (2.2%)	0	1 (0.5%)

Relationship between patient safety attitudes and AEs

The multivariate logistic regression model predicting the likelihood of AEs occurrence is presented in Table 4. Findings showed a significant relationship between overall SAQ and patient and family verbal abuse (OR = 0.977, CI = 0.951–1.003, p-value = 0.007), patient fall (OR = 0.411, CI = 0.215–0.782, p-value = 0.013) and medication error (OR = 0.461, CI = 0.251–0.847, p-value = 0.018). Specifically, controlling for nurse demographics, nurses working in hospitals with favourable working conditions were 49% less likely to report patient and family verbal abuse (OR = 0.505, CI = 0.283–0.901, p-value = 0.021). In addition, satisfied nurses were 43% less likely to report patient fall (OR = 0.57, CI = 0.353–0.932, p-value = 0.025) and 42% less likely to report medication error (OR = 0.58, CI = 0.354–0.949, p-value = 0.030). There was no significant relationship between patient and family complains, nosocomial infection and nurses’ attitude towards patient safety.

Table 4.

Binary logistic regression on the relationship of SAQ dimensions with adverse events.

Adverse events	Overall SAQ		Teamwork climate		Safety climate		Job satisfaction		Stress recognition		Perceptions of management		Working conditions
	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI
Patient and family complaints	0.973	0.949–0.998	0.728	0.961–1.020	0.753	0.953–1.015	1.170	0.985–1.032	1.456	1.000–1.035	0.682	0.959–1.019	1.015	0.971–1.024
Patient and family verbal abuse	0.977	0.951–1.003*	0.697	0.962–1.020	1.444	0.974–1.036	1.046	0.984–1.028	1.103	0.989–1.022	1.024	0.972–1.031	0.505*	0.283–0.901
Patient fall	0.411	0.215–0.782*	0.995	0.970–1.021	0.997	0.969–1.025	0.573	0.353–0.932*	1.003	0.988–1.018	0.997	0.971–1.023	1.008	0.983–1.034
Nosocomial infection	0.778	0.403–1.502	0.991	0.960–1.022	1.001	0.971–1.033	0.985	0.961–1.009	1.017	0.999–1.035	0.996	0.968–1.026	1.009	0.982–1.037
Medication errors	0.461	0.251–0.847*	0.996	0.971–1.021	0.991	0.964–1.018	0.580	0.354–0.949*	1.008	0.993–1.023	0.990	0.965–1.015	1.021	0.996–1.047

SAQ: Safety Attitude Questionnaire.

p-Value < 0.05.

Discussion

The aim of the current study was to examine nurses’ attitudes towards patient safety and its link to AEs. The findings showed that nurses’ attitudes towards safety were a significant predictor contributing to the occurrence of AEs.

The overall mean score of nurses’ attitudes towards patient safety was below the international benchmark in the six sub-domains of the SAQ (Sexton et al., 2006), indicating a low positive safety culture in the current study. This study’s findings are similar to results from a previous Omani study on the association between the nurses’ nationality and their perception of safety in maternity units (Nadabi et al., 2020). Moreover, several studies from Middle Eastern countries with similar healthcare systems likewise showed comparable results compared to the current research. For example, Mahmoud et al. (2019) conducted a study among nurses working in Egypt to assess their perception towards patient safety culture, reporting a mean perception score of 57.09. Additionally, the findings of our study are closely comparable to an Australian hospital-based study on the improvement of patient safety culture among nurses and midwives after 1 year of the support action plan. In that study, Edgar et al. (2021) reported SAQ scores of 26.6 and 27.9 for 2019 and 2020, respectively, showing improvements in all sub-domain scores after the intervention.

In the current study, job satisfaction had the highest score for safety attitude areas, indicating most of the nurses had excellent morale and were satisfied with their jobs. This finding is similar to previous evidence (Durgun and Kaya, 2018). Job satisfaction is an important driver for a safe working environment (Albashayreh et al., 2019). Nurses who feel more satisfied with their work feel more empowered, and accordingly this results in fewer AEs (Liu et al., 2019). In contrast, when nurses feel dissatisfied with working conditions due to high workload, stressful working conditions and inadequate leadership support, the chance of committing patient errors increases (Khatatbeh et al., 2023).

The researchers rated the teamwork climate as the second-highest safety attitude element among the participants. The concept of teamwork refers to the collaboration and open communication among the team members. These findings are comparable to those of a previous study conducted in Oman (Nadabi et al., 2020). Teamwork is a well-recognised modifiable organisational factor that influences the safety of patients (Zaheer et al., 2021). Therefore, health policymakers are encouraged to strengthen teamwork among healthcare professionals to ensure safe practices. Such strategies to enhance teamwork include engaging the healthcare team in simulation-based scenarios to enhance patient safety.

The lowest score was observed in the domain of stress recognition. This finding is consistent with other studies conducted in Oman and Egypt (Al Nadabi et al., 2020; Salih et al., 2021). The similarity may be due to the cultural similarity between the two countries of Oman and Egypt. In the present study, the concept of recognition of stress refers to nurses’ knowledge of the influence of work-related stressors, such as fatigue and emergencies, on their work performance (Falatah and Alhalal, 2022). In interpreting their results, Salih et al. (2021) noted that they might be due to nurses interpreting their internal stressors, which may explain the impact.

The researchers found that the area of working conditions received the second lowest area in terms of the safety attitude. This is similar to a previous study conducted in Oman (Nadabi et al., 2020), and both studies are below the international benchmark. Therefore, an explanation could be that nurses in Oman face several obstacles, such as a shortage of supplies and other staffing issues (Al Sabei et al., 2023), which results in challenging working conditions.

Across the five reported AEs, patient and family complaints were the most frequently reported events. This finding is congruent with other studies based on the same scale and conducted among nurses working in the Philippines (Labrague et al., 2020). Researchers (Nguyen et al., 2015) documented the most common issues that patients and families complained about. These included delayed diagnosis, misdiagnosis, medication errors, inadequate examination and poor-quality nursing care. The increase in patient and family complaints could be due to the increasing workloads. In a study conducted in British Columbia on the association between workload factors, Havaei and MacPhee (2020) found that patient or family complaints and workplace violence at medical and surgical units exacerbated nursing workload and impacted patient satisfaction. Given the importance of addressing patients’ and their families’ concerns, it is important to pursue measures to reduce these particular AEs. Some of the measures are improving teamwork among healthcare professionals and nurses, encouraging patients to participate actively in their care and promoting a positive attitude among healthcare professionals (Al Sabei et al., 2021; Mahmoud et al., 2019).

In the current study, the authors found that the number of patient falls was the lowest reported AE. This might be attributed to the fact that because governmental hospitals in Oman use the fall assessment prevention tool regularly for patient fall prevention, caregivers may proactively identify patients who are at risk of falls during hospitalisation and take preventive measures before actual falls occur, hence the lower rate registered in the current study. These findings were congruent with previous studies that showed a significant positive association between the use of fall assessment tools and low ratings of patient falls in clinical settings in the Jordan and Arab region (Elmontsri et al., 2017).

Findings from the multivariate logistic analysis demonstrated that participants with more positive attitudes towards patient safety culture showed a lower occurrence of patient safety incidents. This finding was similar to a study conducted in Turkey (Yesilyaprak and Demir Korkmaz, 2023). In the current study, satisfied nurses with their working conditions were less likely to report verbal violence and abuse from patients and their families and less likely to report mediation errors and patient falls. Similar findings were reported in other studies (Hu et al., 2024; Labrague, 2024; Liu et al., 2019). Work satisfaction can contribute to a reduction in nurse-reported AEs – including reduced medication errors, fewer incidents of patient falls and less reported verbal abuse – through several mechanisms. Firstly, nurses who are satisfied with their work are more motivated to perform their duties and engaged in their roles (Labrague et al., 2022). An increased sense of motivation may lead to a greater sense of responsibility and a stronger commitment to providing safe and high-quality care (Labrague, 2024). Secondly, nurses who are satisfied with their work are often less stressed and burnout (Al Sabei et al., 2022; White et al., 2020). This improves their ability to focus on patient needs, make informed clinical decisions and ultimately increase patient safety.

The findings also revealed that none of the SAQ dimensions were significantly associated with the likelihood of reporting patient and family complaints or nosocomial infection. This result can be explained by the fact that other factors, such as safety protocols, the quality of work environment, communications patterns, staffing levels and accountability structures, may influence the link between safety attitude and APEs (Al Sabei et al., 2021; Lee et al., 2018). Future studies exploring the link between those factors and APEs are needed.

Study limitations

As with any research study, the current study had some limitations. Firstly, due to the nature of the cross-sectional study design, the researchers collected data at one point. The problem with this approach is that it can be challenging to derive causal inference because both exposure and outcome are assessed at the same point in time. Secondly, the findings are based on self-administered questionnaires, which might not be accurate because of the possibility of participants giving socially desirable responses. Thirdly, the researchers used a convenience sampling method in both hospitals. This might have caused unforeseeable sample bias, resulting in skewing results in a particular direction unknown to the researcher. However, the study included participants from two large referral hospitals in the country, which may have increased the generalisability of the findings and contributed to the homogeneity of the sample.

Conclusion

Enhancing the safety attitude among healthcare professionals is instrumental in promoting safe practices. Healthcare policymakers are highly recommended to enhance the safety culture among newly graduated nurses during internship and preceptorship programmes as a precursor to developing a positive patient safety culture and inculcating a culture of blame-free reporting of adverse clinical patient events.

Key points for policy, practice and/or research

In order to ensure safe practices, health policymakers are encouraged to promote healthy working conditions, enhance nurses’ job satisfaction and strengthen teamwork among healthcare professionals.

A future large-scale study is needed to examine the impact of intervention-based activities in enhancing nurses’ safety attitude.

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) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

The study was ethically approved by the Ministry of Health Ethics committee (MoH/CSR/21/25359).

ORCID iD

Sulaiman Dawood Al Sabei

Raeda Almanhali is a staff nurse working at Sultan Qaboos Hospital in Sultanate of Oman. She completed her master’s degree in nursing science from Sultan Qaboos University in 2022.

Sulaiman Dawood Al Sabei is an Associate Professor in nursing administration. His research interest is related to exploring the role of the work environment in enhancing patient safety and quality of care.

Gerald Matua Amandu is an Associate Professor at Sultan Qaboos University. His speciality is nursing leadership and management.

References

Al Nadabi

Faisal

Mohammed

(2020) Patient safety culture in Oman: A national study. Journal of Evaluation in Clinical Practice 26: 1406–1415. DOI: 10.1111/JEP.13322.

Al Sabei

AbuAlRub

Labrague

, et al. (2021) The impact of perceived nurses’ work environment, teamness, and staffing levels on nurse-reported adverse patient events in Oman. Nursing Forum 56: 897–904. DOI: 10.1111/nuf.12639.

Al Sabei

Labrague

Al-Rawajfah

, et al. (2022) Relationship between interprofessional teamwork and nurses’ intent to leave work: The mediating role of job satisfaction and burnout. Nursing Forum 57: 568–576. DOI: 10.1111/nuf.12706.

Al Sabei

AbuAlRub

Al Yahyaei

, et al. (2023) The influence of nurse managers’ authentic leadership style and work environment characteristics on job burnout among emergency nurses. International Emergency Nursing 70. DOI: 10.1016/J.IENJ.2023.101321.

Alanazi

Sim

Lapkin

(2022) Systematic review: Nurses’ safety attitudes and their impact on patient outcomes in acute-care hospitals. Nursing Open 9: 30–43. DOI: 10.1002/NOP2.1063.

Albashayreh

Al Sabei

Al-Rawajfah

, et al. (2019) Healthy work environments are critical for nurse job satisfaction: implications for Oman. International Nursing Review, 66: 389–395. DOI: 10.1111/inr.12529.

Ali

Ibrahem

Al Mudaf

Al Fadalah

, et al. (2018) Baseline assessment of patient safety culture in public hospitals in Kuwait. BMC Health Services Research 18: 158. DOI: 10.1186/S12913-018-2960-X.

Azyabi

Karwowski

Hancock

, et al. (2022) Assessing patient safety culture in United States hospitals. International Journal of Environmental Research and Public Health 19: 2353. DOI: 10.3390/ijerph19042353.

Bates

Singh

(2018) Two decades since to err is human: An assessment of progress and emerging priorities in patient safety. Health Affairs 37: 1736–1743. DOI: 10.1377/hlthaff.2018.0738

10.

Durgun

Kaya

(2018) The attitudes of emergency department nurses towards patient safety. International Emergency Nursing 40: 29–32. DOI: 10.1016/J.IENJ.2017.11.001

11.

Edgar

Middleton

Kalchbauer

, et al. (2021) Safety attitudes build safety culture: Nurse/midwife leaders improving health care using quantitative data. Journal of Nursing Management 29: 2433–2443. DOI: 10.1111/JONM.13444.

12.

Elmontsri

Almashrafi

Banarsee

, et al. (2017) Status of patient safety culture in Arab countries: A systematic review. BMJ Open 7: e013487. DOI: 10.1136/BMJOPEN-2016-013487.

13.

Falatah

Alhalal

(2022) A structural equation model analysis of the association between work-related stress, burnout and job-related affective well-being among nurses in Saudi Arabia during the COVID-19 pandemic. Journal of Nursing Management 30: 892–900. DOI: 10.1111/JONM.13587.

14.

Havaei

Astivia

OLO

MacPhee

. (2020) The impact of workplace violence on medical-surgical nurses’ health outcome: A moderated mediation model of work environment conditions and burnout using secondary data. International journal of nursing studies, 109, 103666. https://doi.org/10.1016/j.ijnurstu.2020.103666

15.

Zhang

Zhai

, et al. (2024) Relationship between workplace violence, job satisfaction, and burnout among healthcare workers in mobile cabin hospitals in China: Effects of perceived stress and work environment. Preventive Medicine Reports 40: 102667. DOI: 10.1016/j.pmedr.2024.102667.

16.

Kakemam

Chegini

Rouhi

, et al. (2021a) Burnout and its relationship to self-reported quality of patient care and adverse events during COVID-19: A cross-sectional online survey among nurses. Journal of Nursing Management 29: 1974–1982. DOI: 10.1111/jonm.13359.

17.

Kakemam

Hajizadeh

Azarmi

, et al. (2021b) Nurses’ perception of teamwork and its relationship with the occurrence and reporting of adverse events: A questionnaire survey in teaching hospitals. Journal of Nursing Management 29: 1189–1198. DOI: 10.1111/jonm.13257.

18.

Khatatbeh

Al-Dwaikat

Alfatafta

, et al. (2023) Burnout, quality of life and perceived patient adverse events among paediatric nurses during the COVID-19 pandemic. Journal of Clinical Nursing 32: 3874–3886. DOI: 10.1111/JOCN.16540.

19.

Labrague

(2024) Relationship between transformational leadership, adverse patient events, and nurse-assessed quality of care in emergency units: The mediating role of work satisfaction. Australasian Emergency Care 27: 49–56. https://doi.org/10.1016/j.auec.2023.08.001

20.

Labrague

Al Sabei

Al Rawajfah

, et al. (2022) Interprofessional collaboration as a mediator in the relationship between nurse work environment, patient safety outcomes and job satisfaction among nurses. Journal of Nursing Management 30: 268–278. DOI: 10.1111/JONM.13491.

21.

Labrague

Al Sabei

AbuAlRub

, et al. (2021) Authentic leadership, nurse-assessed adverse patient events and quality of care: The mediating role of nurses’ safety actions. Journal of Nursing Management 29: 2152–2162. DOI: 10.1111/jonm.13356.

22.

Labrague

De los Santos

JAA

Tsaras

, et al. (2020) The association of nurse caring behaviours on missed nursing care, adverse patient events and perceived quality of care: A cross-sectional study. Journal of Nursing Management 28: 2257–2265. DOI: 10.1111/JONM.12894.

23.

Lee

Vincent

Dahinten

, et al. (2018) Effects of individual nurse and hospital characteristics on patient adverse events and quality of care: a multilevel analysis. Journal of Nursing Scholarship 50: 432–440. DOI: 10.1111/jnu.12396.

24.

Liu

Zheng

Liu

, et al. (2019) Workplace violence against nurses, job satisfaction, burnout, and patient safety in Chinese hospitals. Nursing Outlook 67: 558–566. DOI: 10.1016/J.OUTLOOK.2019.04.006.

25.

Mahmoud

Khalifa

Farghally

(2019) Nurses’ perception of safety culture, medication errors occurrence and reporting. Journal of Nursing and Health Science 8: 8–15. DOI: 10.9790/1959-0803010815.

26.

Malak

Salouk

Al-Shawawreh

, et al. (2022) Perceptions of patient safety culture among emergency room nurses in Jordanian accredited hospitals. Journal of Nursing Management 30: 3131–3138. DOI: 10.1111/JONM.13729.

27.

Ministry of Health (2017) Policy and Procedure of Incident Reporting. Available at: https://moh.gov.om/en/web/directorate-quality-assurance-center/policy-and-procedure

28.

Nadabi

Faisal

Mohammed

(2020) Association between the nationality of nurses and safety culture in maternity units of Oman. Eastern Mediterranean Health Journal 26: 517–524. DOI: 10.26719/2020.26.5.517.

29.

Najjar

Nafouri

Vanhaecht

, et al. (2015) The relationship between patient safety culture and adverse events: A study in palestinian hospitals. Safety in Health 1: 1–9. DOI: 10.1186/s40886-015-0008-z.

30.

Nguyen

Gambashidze

Ilyas

, et al. (2015) Validation of the safety attitudes questionnaire (short form 2006) in Italian in hospitals in the northeast of Italy. BMC Health Services Research 15: 284. DOI: 10.1186/S12913-015-0951-8.

31.

Salih

Abdelkader Reshia

Bashir

WAH

, et al. (2021) Patient safety attitude and associated factors among nurses at Mansoura University Hospital: A cross sectional study. International Journal of Africa Nursing Sciences 14: 100287. DOI: 10.1016/J.IJANS.2021.100287.

32.

Sexton

Helmreich

Neilands

, et al. (2006) The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Services Research 6: 44. DOI: 10.1186/1472-6963-6-44.

33.

Spence Laschinger

Leiter

M. P

. (2006) The impact of nursing work environments on patient safety outcomes: The mediating role of burnout/engagement. The Journal of Nursing Administration 36: 259–267. DOI: 10.1097/00005110-200605000-00019.

34.

Wang

Liu

You

L ming

, et al. (2014) The relationship between patient safety culture and adverse events: A questionnaire survey. International Journal of Nursing Studies 51: 1114–1122. DOI: 10.1016/J.IJNURSTU.2013.12.007.

35.

White

Aiken

Sloane

, et al. (2020) Nursing home work environment, care quality, registered nurse burnout and job dissatisfaction. Geriatric Nursing 41: 158–164. DOI: 10.1016/j.gerinurse.2019.08.007.

36.

World Health Organization (2021) Global Patient Safety Action Plan 2021 – 2023. Available at: https://www.who.int/teams/integrated-health-services/patient-safety/policy/global-patient-safety-action-plan

37.

Yesilyaprak

Demir Korkmaz

(2023) The relationship between surgical intensive care unit nurses’ patient safety culture and adverse events. Nursing in Critical Care 28: 63–71. DOI: 10.1111/NICC.12611.

38.

Zaheer

Ginsburg

Wong

, et al. (2021) Acute care nurses’ perceptions of leadership, teamwork, turnover intention and patient safety – a mixed methods study. BMC Nursing 20: 134. DOI: 10.1186/S12912-021-00652-W.

39.

Zhong

Simpson

Spetz

, et al. (2023) Linking patient safety climate with missed nursing care in labor and delivery units: Findings from the LaborRNs survey. Journal of Patient Safety 19: 166–172. DOI: 10.1097/PTS.0000000000001106.