The effect of the emergency service work environment on the patient safety attitudes of nurses

Abstract

Background

A safe working environment in the health sector contributes significantly to employee and patient safety and supports positive patient outcomes. Nurses play an important role in improving the healthcare quality related to patient safety practices. This study aimed to investigate the effect of the emergency service work environment on nurses’ patient safety attitudes.

Methods

This cross-sectional study was conducted in the emergency departments of 15 tertiary public hospitals and university hospitals in Izmir, Turkey. 288 nurses who worked 6 months or more in emergency departments were included in the sample. The personal information form, safety attitudes questionnaire, and work environment scale were used in the data collection.

Results

The total mean score for the safety attitudes questionnaire was 136.69 ± 22.14, and the total mean score for Work Environment Scale was 84.51 ± 12.02. A positive correlation was detected between the Safety Attitudes Questionnaire total score and Work Environment Scale total score (r = 0.38, p < 0.001).

Conclusion

The patient safety attitudes of the emergency room nurses were moderately positive, the nurses evaluated the working environment positively, and positive work environments affected patient safety attitudes positively.

Keywords

Patient safety emergency department healthcare environment nursing quality of health care

Introduction

Prevention of medical errors is a significant priority in healthcare organizations around the world, yet increasing complexity of care delivery, the ever-changing healthcare landscape, and newly-adopted technological innovations continue to introduce risks for patient safety.^1–3 Due to their familiarity and proximity to the patient as demanded by their role, nurses are of particular importance in maintaining patient safety^4–6 and nurses are key to improving the quality of care.^7,8

Prevention of medical errors is contingent on the organization's culture of safety. Positive workplace cultures are consistently associated with a wide range of patient outcomes such as reduced mortality rates, falls, hospital-acquired infections, and increased patient satisfaction.⁹ Culture of safety is defined as a set of norms, attitudes and actions taken on general precautions among people working at a specific place and time.¹⁰ Also, this style of behavior is also expressed as the patient safety attitudes of healthcare professionals.¹¹

An organization's culture of safety is largely influenced by the attitudes and beliefs of those working within the organization, and the beliefs of those working within the organization can be influenced by the work environment itself.¹² The delivery of safe patient care is also contingent on healthcare worker safety. The International Council of Nurses (ICN), stated that a safe working environment in the health sector contributes significantly to employee and patient safety and supports positive patient outcomes.⁴ The factors that contribute to a poor work environment, such as excessive workload, long working hours, poor nurse-to-patient ratios, team communication problems, and insufficient physical resources,^13,14 are often disproportionately present in emergency departments compared to other care settings.¹⁵ Because working environments like the emergency room introduce risks to care delivery due to its unpredictable variability in patient needs, the need to diagnose and treat patients urgently, the high number of patients, intensive and stressful working conditions, long working hours, and insufficient personnel and equipment.^15–17 These factors can increase the risk of wrong diagnosis/treatment and contribute to 18 out of every 100 patients who are injured in the emergency department as a result of wrong treatment.^15,18

Research conducted on safety suggests that in the emergency units the probability of occurrence of medical errors and mistakes is higher than that in other units.¹⁰ Thus, evaluating the factors associated with occurrence of these problems in the emergency unit is essential. Because many of the factors that lead to patient harm in emergency departments are associated with the working environment for healthcare professionals, particularly nurses, it is necessary to determine the employee safety risk factors that can influence safety outcomes.¹⁶ While previous research has found that a poor working environment can influence patient safety-related attitudes and behaviors, there is a need to examine the influence of specific attributes of the work environment, particularly in a high-risk environment such as the emergency department. This research aimed to examine the relationship between perceptions of the work environment and the patient safety-related attitudes and beliefs of emergency department nurses.

Methods

Study design

We used a cross-sectional study design to solicit emergency department nurses’ perceptions of their work environment and attitudes toward patient safety.

Participants

This study was carried out in the emergency departments of 15 tertiary public and university hospitals between April and December 2014 in Izmir, Turkey. A convenience sampling method was used to recruit and all nurses working for six months or more in the emergency department and who were willing to participate were included in the study. A total of 288 nurses participated in the study.

Data collection

The data were collected by Personal Information Questionnaire, Safety Attitudes Questionnaire, and Work Environment Scale.

Personal information questionnaire

This form was prepared by the researchers to gather sociodemopgraphic information and included 20 items such as age, gender, marital status, education level, institution of employment, position, years of nursing experience, and years of emergency department nursing experience.

Safety attitudes questionnaire (SAQ)

The Safety Attitudes Questionnaire was developed by Sexton and colleagues, and was modified and translated into Turkish by Baykal and colleagues.^19,20 The scale consisted of 46 items in six sub-dimensions including work satisfaction (11 items), teamwork (12 items), safety environment (5 items), management comprehension (7 items), defining stress (5 items), and work conditions (6 items). Responses were captured using a Likert scale from 5 = strongly agree to 1 = strongly disagree, and some items on the scale (numbers 21, 36, 37, 38, 39, 40, 41, 42, 43, and 45) are reverse coded. Cronbach's alpha values for the Turkish version of the SAQ ranged from 0.72–0.93 in the original reliability and validity study for the total scale and its domains. Item total score correlation values of the scale are between 0.35 and 0.58. The minimum possible score was 46 and the maximum possible score was 230. Increases in the total score of the scale indicate that employees’ attitudes toward patient safety are more positive.¹⁹

Work environment scale (WES)

The work environment scale was developed by Blegen and colleagues and was modified and translated into Turkish by Sezgin and colleagues.^21,22 The scale consists of 26 items in five sub-dimensions including quality management, physical resources, professional relationships, personnel fears, and job satisfaction. The Turkish version of the Work Environment Scale Cronbach's alpha coefficient was found to be 0.74, while its reliability coefficients were between 0.62 and 0.77.²¹ Responses were captured using a five-point Likert scale, with higher scores indicating higher levels of satisfaction with the work environment. The minimum possible score was 26 and the maximum possible score was 130. Scores above the mean indicated high satisfaction.²¹

Procedure

Participants were provided with information about the purpose of the study and their rights, including the right to decline participation at any time, before starting the study. After the nurses were informed about the study, the researchers provided the printed survey directly to the volunteer nurses. The participants were asked to respond to the survey questions at a convenient time and completion took approximately 5–10 min. Participants were instructed to leave their surveys in a discrete place in emergency department once completed. Completed surveys were collected at regular intervals by researchers.

Data analysis

The data gathered was entered into SPSS (version 18.0, SPSS Inc, Chicago, Illinois), scrubbed, and analyzed using descriptive statistics, including number, percentage, mean and standard deviation (SD) and non-parametric tests, including Kruskal–Wallis test and Mann–Whitney U test. The relationship between the scales was evaluated by correlation analysis. p < 0.05 was considered statistically significant.

Ethical considerations

The study was examined and approved by the Ege University Faculty of Nursing Scientific Ethics Committee (Ethics Committee No: 2014-80). Permissions to use the instruments were obtained via email from those who developed the instruments. Participants were provided with information about the purpose of the study and their rights, including the right to decline participation at any time, before starting the study.

Results

Descriptive characteristics of nurses

Of the 288 participants, 52.0% were 30 years old or younger, 72.2% were female, 51.7% were single, 81.0% had a undergraduate-level education, 86.1% were staff nurses, 72.9% chose the profession willingly, 52.0% worked in the emergency room for 2 years or less, 53.8% worked for 50 h or more per week, 63.2% cared for 40 or more patients daily, and 75.0% worked in government hospitals. 64.5% of the nurses were satisfied with the working environment (Table 1).

Table 1.

Nurses’descriptive characteristics (n:288).

Characteristics	n	%
Age
30 years or under	150	52.0
30 years or older	138	48.0
Gender
Woman	208	72.2
Male	80	27.8
Marital status
The married	139	48.3
Single	149	51.7
Education level
High school graduate	55	19.0
Undergraduate	233	81.0
Squad status
Staff nurse	248	86.1
Contracted nurse	28	9.7
Choosing the nursing profession
Willingly	210	72.9
Unwillingly	78	27.1
Working year in emergency department
2 years or below	150	52.0
2 years or above	138	48.0
Weekly working hours
40–49 h	133	46.2
50 h or above	155	53.8
Number of shifts per week
5 seizures or below	69	23.9
6 seizures or above	219	76.1
Number of patients giving daily care
40 patients or below	106	36.8
40 patients or over	182	63.2
Hospital employed
Government Hospitals	216	75.0
University Hospitals	72	25.0
Satisfaction with work environment
Satisfied	186	64.5
Not glad	102	35.5
Total	288	100.0

Mean scores and standard deviations for SAQ and SAQ subdimensions

The mean scores and standard deviations for the subdimensions of the safety attitudes questionnaire were 27.54(8.55), 32.94(8.29), 15.86(4.21), 21.51(5.40), 13.61(4.40), and 18.72(3.41) for the work satisfaction, teamwork, safety environment, management comprehension, defining stress, and work conditions subdimensions, respectively. The total mean score and standard deviation were 136.69(22.14) (Table 2).

Table 2.

The overall and sub-dimension mean scores of the safety attitudes questionnaire of nurses (n = 288).

Scale/subscale	Number of items	Minimum score	Maximum score	X ± SD
Work Satisfaction (11–55)	11	11	55	27.54 ± 8.55
Teamwork (12–66)	12	12	66	32.94 ± 8.29
Safety environment (5–25)	5	5	25	15.86 ± 4.21
Management comprehension (7–35)	7	7	35	21.51 ± 5.40
Defining stress (5–25)	5	5	25	13.61 ± 4.40
Work conditions (9–30)	6	9	30	18.72 ± 3.41
Scale total (46–230)	46	74	202	136.69 ± 22.14

SD = standard deviation. Bold values indicate the overall and sub-dimension mean scores of the safety attitudes questionnaire.

Relationship between SAQ scores and descriptive characteristics of participants

Results of the comparison between the Safety Attitudes Questionnaire score and work environment satisfaction, and number of shifts per week were statistically significant at the p < 0.05 level. The safety attitudes questionnaire score was higher for emergency room nurses who were satisfied with the working environment and had 5 or less weekly shifts. There were no significant differences in mean total Safety Attitude Scale scores and age group (z = −1.885, p = 0.059), gender (z = −0.107, p = 0.914), marital status (z = −0.375, p = 0.708), education level (z = −0.124, p = 0.901), emergency department experience (z = −1.100, p = 0.271), weekly working hours (z = −1.713, p = 0.087), number of patients cared for daily (z = 1.559, p = 0.119), position in the emergency department (z = −0.229, p = 0.819), institution of employment (z = −0.447, p = 0.655) (Table 3).

Table 3.

Comparison of the safety attitudes questionnaire score distributions according to nurses’ characteristics (n:288).

Characteristics	n	Median	IQR 25–75%	z	p
Age
30 years or under	150	131.50	33.25	−1.885	0.059
30 years or older	138	136.00
Gender
Woman	208	133.00	31.00	−0.107	0.914
Male	80	134.50	28.25
Marital status
The married	139	133.00	32.00	−0.375	0.708
Single	149	134.00	28.50
Education level
High school graduate	55	133.00	24.00	−.124	0.901
Undergraduate	233	133.00	31.00
Emergency department experience
2 years or below	150	133.00	26.00	−1.100	0.271
2 years or above	138	136.50	36.00
Satisfaction with work environment
Satisfied	184	137.00	29.25	−3.359	0.001
Not glad	102	130.00	25.00
Weekly working hours
40–49 h	133	137.50	32.50	−1.713	.087
50 h or above	155	132.00	24.75
Number of shifts per week
5 seizures or below	69	142.50	31.25	−2626	0.009
6 seizures or above	219	132.00	29.00
Number of patients giving daily care
40 patients or below	106	136.00	28.25	−1.559	0.119
40 patients or over	182	132.00	31.25
Squad status
Staff nurse	248	133.00	31.75	−0.229	0.819
Contracted nurse	40	136.00	25.50
Hospital employed
Government	72	132.50	25.00	−0.447	0.655
University	216	134.00	31.75

IQR = inter quantile range.

Mean scores and standard deviations for WES and WES subdimensions

The mean scores and standard deviations for the sub dimensions of the work environment scale were 19.84(4.25), 8.85(2.23), 14.28(3.05), 24.16(6.31), and 17.34(4.18) for the quality management, physical resources, professional relationships, personnel fears, job satisfaction subdimensions, respectively. The mean total score and standard deviation were 84.51(12.02) (Table 4).

Table 4.

The overall and sub-dimension mean scores of work environment scale of nurses (n = 288).

Dimension mean scores sub-dimension	Number of items	Minimum score	Maximum score	X ± SD
Quality management (6–30)	6	6	30	19.84 ± 4.25
Physical resources (3–5)	3	3	15	8.85 ± 2.23
Professional relationships (4–20)	4	4	20	14.28 ± 3.05
Personnel fears (7–35)	7	7	35	24.16 ± 6.31
Job satisfaction (6–30)	6	6	28	17.34 ± 4.18
Total score (26–130)	26	42	118	84.51 ± 12.02

SD = standard deviation.

Relationship between SAQ scores and WES scores

There was a significant positive relationship between the work environment scale total score and safety attitudes questionnaire total score (r = 0.380, p < 0.05). As the total score of the work environment scale increased, the total score of the safety attitude questionnaire increased (Table 5).

Table 5.

Correlation between sub-dimensions of the safety attitudes questionnaire and sub-dimensions of the work environment scale.

Work environment scale		Safety attitudes questionnaire
Work environment scale		Work satisfaction	Team work	Safety environment	Management comprehension	Defining stress	Work conditions	Scale total
Quality management	r_s	0.320**	−0.239**	0.384**	0.378**	0.106	0.240**	0.426**
Physical resources	r_s	0.252**	−0.182**	0.254**	0.207**	0.094	0.114	0.259**
Professional relationships	r_s	0.135*	−0.258**	0.296**	0.224**	0.055	0.284**	0.298**
Personnel fears	r_s	−0.019	−0.015	0.000	0.015	−0.180**	−0.008	−0.031
Job satisfaction	r_s	0.272**	−0.134*	0.143*	0.184**	0.201**	0.282**	0.280**
Total score	r_s	0.315**	−0.253**	0.312**	0.318**	0.053	0.273**	0.380**

Bold values indicate the overall and sub-dimension mean scores of the safety attitudes questionnaire. *Correlation is significant at the 0.05 level.

**Correlation is significant at the 0.01 level.

Discussion

Hospital emergency departments are characterized by a number of factors, such as urgency, unpredictability, and high workload, that can contribute to a poor working environment and subsequently negatively impact patient safety.¹⁶ This study is aimed to identify the effect of the emergency department working environment on the patient safety attitudes of nurses.

Results indicated that more than half of the emergency nurses participating in the study were 30 years old or younger and half of them had 6 years or less of professional nursing experience, findings similar to those in previous studies.^23–25 These results may reveal that mostly young nurses are employed in emergency services.

The total mean score and the sub-dimensions score of the Safety Attitude Questionnaire indicated that the patient safety attitudes of the nurses participating in the study were moderately positive, a finding consistent with previous research.^26,27 This demonstrates that nurses attach importance to patient safety and that patient safety attitudes should be developed further.

There was a significant relationship between the total SAQ score and “satisfaction with the work environment,” and “number of shifts per week.” However, age, gender, marital status, education level, weekly working hours, number of patients giving daily care, and years of experience were not significantly associated with the safety attitudes of participants. These factors are important to examine when trying to improve the organization's safety culture.²⁸ There was a significant relationship between willingly choosing the profession and the safety attitude questionnaire subdimensions defining stress and work conditions. This demonstrates that nurses who willingly choose their profession have a better perception of working conditions and can cope better with stress in emergency room conditions. Choosing the profession willingly improves interactions with the institution and their colleagues, job satisfaction, and thus their positive perception of the work environment.²⁹

It was found that 53.8% of the nurses working in emergency departments worked 50 h or more per week. It is well known that nurses who work more than 12 h per day and more than 40 h per week are at a greater risk of making mistakes.³⁰ Similarly, our finding that nurses who work 40–49 h per week experience greater work satisfaction than those who work greater than 50 h per week. Hayashi and colleagues (2020) study suggested a possibility of improving the patient safety culture by managing the working environment of healthcare workers. Proper management of the number of night shifts and days off as well as working hours of healthcare workers might improve patient safety culture.³¹

There was a statistically significant difference in management comprehension (p = 0.044) and nurses with two years or more of emergency department experience (p < 0.05). Professional experience is thought to have developed nurses’ coping methods and positively affected their management approach.³²

In this study, it was found that the work environment scale mean scores of the nurses were high, indicating that the nurses evaluate the working environment positively. In addition, it was found that the total score of the job satisfaction, defining stress, work conditions, and patient safety attitude scale was significantly higher in those who were satisfied with the work environment. It is known that the problems experienced by nurses in the work environment have a negative impact on the nurses physically, mentally, and socially.³³ Therefore, it is thought that positive working environments will increase the quality of the service provided and improve patient safety attitudes.In this study, it was found that as personnel fears increased in the working environment, patient safety attitude decreased. Harlinisari and colleagues (2021) showed a safe working environment is effective in improving the employee's performance.³⁴ Furthermore, Mardani and colleagues (2013) showed there was a positive and significant correlation between patient safety culture and the medical staff's performance.³⁵ Nurses with job satisfaction and high quality of work will have an impact on increasing patient safety culture in the hospital.³³

An examination between the subdimensions of the SAQ and WES revealed that a significant correlation was found between the working conditions subdimension of the SAQ and the institution quality management, professional relations, and job satisfaction subdimensions of the WES. These findings are consistent with previous literature.^36–38 This demonstrates that the specific attributes of the working environment are significantly associated with safety attitudes. Because it is well-known that safety attitudes have a significant impact on safety outcomes, improving the working environment of nurses, particularly in the emergency department, should be of utmost importance.

Strengths and limitations to the study

The aim of patient safety is to provide safety by creating an environment that will positively affect patients and their relatives, hospital staff, physically, and psychologically. The main goal here is to establish a system that will prevent errors during service delivery, protect the patient from possible harm due to errors, and eliminate the possibility of error. The conditions in which people work can be changed and improved.³⁹ It is important to evaluate the factors that may be associated with the emergence of these problems in the emergency department since studies in the field of patient safety show that the probability of occurrence of medical errors in the emergency room is higher than in other units.¹⁰ This study has some limitations. First, the findings have the lack of generalization because the sample size was small and data were collected from a single hospital to control exogenous variables such as the hospital size, patients’ characteristics. Besides, further studies are necessary to expand the including criteria to all emergency units in representative hospitals. Second, the study measured nurses’ patient safety attitudes based on nurses’ self-reporting rather than an objective assessment of parameters, thereby allowing the possibility of measurement errors.

Conclusions

In this study, it was determined that emergency nurses attach importance to patient safety, but patient safety attitudes need to be developed further. In addition, certain characteristics of the work environment were significantly associated with patient safety attitudes. It was determined that as staff fears increased in the working environment, patient safety attitudes decreased. In line with the results obtained from the research, it is recommended to review the working environments in the emergency services, create positive working environments for the employees, and plan initiatives to improve the patient safety attitudes of the employees.

Footnotes

Acknowledgements

The authors would like to thank all the nurses who participated in this study.

Authors’ contributions

This work was carried out in collaboration among all authors. All authors read and approved the final manuscript.

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.

ORCID iD

Esma Ozsaker

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