The association of patient safety culture with patient satisfaction: The role of the pharmacist's performance

Abstract

Background and objective

A cross-sectional research, the questionnaire-based study aimed to investigate the association between patient safety culture and patient satisfaction through pharmacist performance, between patient safety culture and pharmacist performance, between pharmacist performance and patient satisfaction, and between patient safety culture and patient satisfaction.

Methods

Pharmacists and pharmacy technicians working in the community pharmacies evaluated the patient safety culture using an online self-administrated questionnaire filled out by participants. The first research questionnaire was adopted from the agency of healthcare research and quality (AHRQ), which was reliable and valid. Pharmacist performance and patient satisfaction were measured by using an online self-completion questionnaire that patients filled out. To measure performance, a previously validated questionnaire was used. For measuring patient satisfaction, The Patient Satisfaction with Pharmacist Clinical Services Questionnaire the final version (PSPSQ 2.0) was used. A total of 204 pharmacists, pharmacy technicians, and 204 patients constitute the research sample.

Results

The results showed that there is a significant association between the patient safety culture and the pharmacist's performance; an insignificant association between the patient safety culture and patient satisfaction; a significant association between the pharmacist’s performance and patient satisfaction; and a pharmacist’s performance mediates the relationship between patient safety culture and patient satisfaction.

Conclusion

The pharmacy sector may effectively reinforce patient safety culture in community pharmacies and enhance pharmacists’ performance to improve the quality of care and increase patient satisfaction.

Keywords

Patient safety culture pharmacist's performance patient satisfaction Jordan

Introduction

Over the past decades, despite the dramatic improvements in technology in the health system, patients are still harmed when receiving health care. According to the WHO, the probability of being harmed while receiving health care is 1 in 300.¹ Recently, patient safety, which means preventing adverse events during medical care, has become a global issue to improve healthcare quality and reduce errors.² Yearly, at least 43 million injuries result from unsafe medical care.³ Promoting a culture of safety needs a deep understanding of the values, beliefs, norms, attitudes, competencies, roles, and practices regarding health and patient safety within the healthcare providers within an organization.⁴ In addition to dispensing drugs, pharmacists in community pharmacies are also responsible for evaluating patients’ health status, counseling, close monitoring, medication management, and educating patients regarding their medicines. Therefore, pharmacists play a crucial role in preventing errors that could affect patients and leave them unsatisfied. Furthermore, pharmacists help achieve optimal drug therapy outcomes, resulting in lower drug therapy risks. Pharmacists are among the most accessible healthcare professionals without an appointment, especially those working in community pharmacies.^5,6

Pharmacist performance refers to pharmacist activities and behaviors relevant to pharmaceutical care goals. These patient-centered goals focus on optimizing patient health and improving their quality of life. The patient’s perceptions and expectations of pharmaceutical care service depend on pharmacist activities and behaviors. Thus, considered a critical basis for the pharmacist’s performance evaluation, it encourages pharmacists to be more committed to achieving pharmaceutical care goals more effectively and safely.⁷

Patient satisfaction is considered a quality of care measurement, indicating how the patient is happy with the pharmaceutical care. In addition, patient satisfaction is considered a fundamental measure of pharmacist performance and a tool that helps pharmacists recognize their patients’ values and needs. In addition, it helps them to determine the best ways to improve their performance. Additionally, pharmacists look to patient satisfaction as a source of feedback, which gives insights into the effectiveness of the care they provide.⁸

This study was conducted to study the impact of patient safety culture among pharmacists on patient satisfaction through pharmacists’ performance in community pharmacies in Jordan.

Theoretical framework and research hypothesis development

The research framework is built upon three fundamental concepts, patient safety culture, pharmacist performance, and patient satisfaction. The hypothesized research framework examining by the following hypotheses:

There is a significant relationship between patient safety culture and pharmacist performance.

There is a significant relationship between pharmacist performance and patient satisfaction.

There is a significant relationship between patient safety culture and patient satisfaction.

There is a mediating role for pharmacist performance between patient safety culture and patient satisfaction.

The theory of planned behavior best describes the relationship between patient safety culture and pharmacist performance. When mapping this theory to this research context, if the pharmacists have safety values and beliefs, they will be reflected in their behavior and then in their performance. In pharmacy practice, literature the theory of planned behavior has been used extensively to explain pharmacist's behavior.^9–11 Patient safety culture was defined previously as the product of shared values, beliefs, norms, attitudes, competencies, roles, and practices that focus on reducing the exposure of the patient to harm or injuries from medical errors that could happen during the provision of health care.¹² According to this definition, patient safety culture is not easy to be measured. So, the intention will use as a substitute for the actual behavior of practicing patient safety culture in the model of the theory of planned behavior.

The theory of planned behavior consists of three significant constructs or domains these domains as follows:

Behavioral attitude: attitude towards patient safety; it represents the pharmacist's perceptions and beliefs in the behaviors that will affect patient safety.

Subjective norms: refer to the pharmacist's belief about whether people agree or disagree with the patient safety behavior. In addition, it refers to the attitude of people around that affects pharmacists’ intention to safety culture behavior.

Perceived behavior control relates to the pharmacist's perception of how easy or difficult it will be to perform patient safety behavior.¹³ According to the fore mentioned information, we suggest the first hypothesis:

H1: Patient safety culture affects job performance.

Primary provider theory suggests that the patient is the only one who judges the quality of care provided; also, it explains that patient satisfaction or dissatisfaction is related to the interaction between the patient and the health provider (physician, pharmacist, nurse, etc.).¹⁴

Furthermore, the expectancy-value theory interprets that patient satisfaction is generated from beliefs and values about the care provided and prior expectations about the care. So, when the pharmaceutical services and pharmacist performance exceed patient expectations, they will be satisfied and happy.⁸ An Australian study revealed that pharmacists’ performance positively influences patient loyalty and trust, especially patients who give high value to their relationship with pharmacists.⁷ Therefore, based on these two theories, we suggest the second hypothesis:

H2: Job performance affects patient satisfaction.

Many pieces of research showed a significant relationship between patient safety culture and patient outcomes, especially after the IOM report in 1998. A cross-sectional survey conducted in Canada showed a positive relationship between safety culture and family satisfaction of non-survivor patients in the ICU.¹⁵ Another study in the United States with 73 participating hospitals found that the staff with more positive perceptions of patient safety culture tends to have more positive assessments of care from the patient.¹⁶ Furthermore, a study in the United States on nursing rounds found a significant reduction in patient falls and increased patient satisfaction when the safety protocol of the nursing round was applied.¹⁷ A study by Wolosin emphasized that hospital safety culture and patient satisfaction are connected; the patient will be satisfied when their needs and expectations are met, mainly when the hospitals provide optimal care without any harm to the patients.¹⁸ Therefore, according to these studies, we suggest the following hypothesis:

H3: Patient safety culture affects patient satisfaction.

According to Patrick Waterson, the safety culture in an organization can enroll the employees in the safety policies and procedures, in particular, an employee that has direct contact with the customers since the safety performance of the employees will be reflected in the customer outcomes and satisfaction. A study showed that the hospital's safety culture affects the performance of physicians in patient care and the probability of making errors, which in turn affects patient satisfaction.¹⁹ Therefore, according to these studies and to the three hypotheses that were mentioned earlier, we suggest the fourth hypothesis:

H4: Patient safety culture affects patient satisfaction through job performance.

Methodology

Research methodology

This was a cross-sectional, questionnaire-based study. This study assessed patient safety culture, pharmacists’ performance, and patient satisfaction. Patient safety culture was evaluated using an online self-completion questionnaire filled by pharmacists and pharmacy technicians working in community pharmacies. While pharmacist performance and patient satisfaction were measured using an online self-completion questionnaire that patients filled out. The researchers got full cooperation and support from each pharmacist who filled out the questionnaire to help us by finding one of the pharmacy patients with whom he works to fill out the patient’s questionnaire after we explained to him all the patient questionnaire dimensions and needs.

Study variables

The primary study variables:

- Independent variable: Patient safety culture (PSC).

- Dependent variable: Patient satisfaction.²⁰

- Mediating variable: Pharmacist performance (P.P.).

Study instrument

In this study, two instruments containing three questionnaires were used. Pharmacists and pharmacy technicians filled the first instrument to measure patient safety culture in community pharmacies, and the second instrument was filled by patients to measure pharmacists’ performance and patient satisfaction.

To measure patient safety culture in community pharmacies, we used The Pharmacy Survey on Patient Safety Culture (PSOPSC) developed by AHRQ. The instrument contained the following sections:

The socio-demographic section includes five questions containing gender, job title, educational level, experience, and working hours per week.

Patient safety culture questionnaire: this section of the survey includes forty items that measure 13 dimensions of patient safety culture; physical space and environment, teamwork, staff training and skills, communication openness, patient counseling, staffing, work pressure and pace, communication about prescriptions across shifts, communication about mistakes, response to mistakes, organizational learning-continuous improvement, and documenting mistakes. This survey was developed by AHRQ, which was previously tested for reliability and validity.

The second instrument for measuring pharmacist performance and patient satisfaction contained the following sections:

The socio-demographic section included six questions on; patient gender, age, income, education level, patient nationality, and resident place.

Pharmacist's performance questionnaire section: this section is adapted from a previously published paper with evidence of validity and reliability. It consists of five questions.⁷

The patient satisfaction part of the final version of The Patient Satisfaction with Pharmacist Clinical Services Questionnaire (PSPSQ 2.0) was used. Researchers have used this questionnaire widely in measuring patient satisfaction, consisting of 16 items.²¹

The demographic data of the study

Pharmacist's demographics

A total of 204 pharmacists and pharmacy technicians participated in the research. The results showed that most of the participants were female with a percentage of 78.9% (161) and 43 participants were males (21.1%). The majority of the participants (84.3%) were bachelor’s degree holders, followed by a master’s degree holder (9.8%). Most participants were pharmacists (86.3%), followed by PharmD and pharmacist assistants (7.3%, 6.4%). Around one-third of the sample had a working experience between 1 and 3 years, while around half of them (52.5%) of the respondents were working in the current pharmacy for 2 and 3 years, while most of the participants (65.2%) have been working more than 48 hours weekly. Table 1 describes participant pharmacists’ demographics in more detail.

Table 1.

Demographic characteristics of pharmacists.

Demographics		N (%)
Gender	Male	43 (21.1%)
Gender	Female	161 (78.9%)
Pharmacy degree	Pharmacist	176 (86.3%)
	PharmD^a	15 (7.3%)
	Pharmacist assistant	13 (6.4%)
The highest degree of education	Diploma	12 (5.9%)
	Bachelor	172 (84.3%)
	Master	20 (9.8%)
	<6 months	43 (21.1%)
	7–12 months	60 (29.4%)
	1–3 years	69 (33.8%)
	4–6 years	17 (8.3%)
	7–12 years	15 (7.4%)
	<6 months	7 (3.4%)
	7–12 months	54 (26.5%)
	2–3 years	107 (52.5%)
	4–6 years	36 (17.6%)
Working hours per week	<24 hours	11 (5.4%)
	24–36 hours	33 (16.2%)
	37–48 hours	27 (13.2%)
	>48 hours	133 (65.2%)
Total		204 (100%)

In Jordan, there is a difference between the pharmacist and the Doctor of Pharmacy regarding the duration of university studies, work tasks, and job descriptions, so the separation between them came during the data collection stage.

Patient's demographics

The results showed most of the participants were female, with a percentage of 59.3% (121), and 83 of the respondents were male, with a percentage of (40.7%). The majority of the respondents held a bachelor's degree, with a percentage of (47.1%), whereas the patient’s age among the sample between 38 and 47 years old was around 27.9% of the sample. Moreover, the income ranged between 500 and 1500 JOD with a percentage of (84.3%). The nationality of the patients was Jordanian, with a percentage of 97.1% followed by Syrian (2.5%). At the same time, most of the patients were living in Irbid city (76.5%), followed by Amman (9.3%). Table 2 describes participant patients’ demographics in more detail.

Table 2.

Demographic characteristics of patients.

Demographics		Frequency (N)	Percentage (%)
Patient gender	Male	83	40.7
Patient gender	Female	121	59.3
Patient age	<18 years old	6	2.9
	18–27 years old	43	21.1
	28–37 years old	44	21.6
	38–47 years old	57	27.9
	>47 years old	54	26.5
Patient income	<500 JD	148	5.9
	500–1000 JD	40	84.3
	1000–1500 JD	10	9.8
	>1500 JD	6	2.9
Education level	Secondary	55	27.0
	Diploma	33	16.2
	Bachelor	96	47.1
	Graduates	20	9.8
Patient nationality	Jordan	198	97.1
	Syria	5	2.5
	Palestine	1	0.5
Resident place	Irbid	156	76.5
	Amman	19	9.3
	Mafraq	11	5.4
	Jerash	2	1.0
	Ajloun	3	1.5
	Others	13	6.4
Total			204

Data analysis protocol

All completed questionnaires were coded in Microsoft Excel, reviewed for accuracy, and imported into IBM© SPSS© statistics version 21. The descriptive data, such as participants’ demographic characteristics, was expressed in percentages. Five-point Likert scale responses of the conceptual model items were computed as mean scores and standard deviations for each statement. In this study, the frequency analysis has been performed of all variables to check the missing data. The results of the pharmacist’s responses show that two responses need to be skipped from further analysis. In contrast, the patient’s responses had no missing values among the data sets.

This study used exploratory factor analysis.²² The factors were rotated (Varimax rotation) for a better understanding of the results, and they could be easier to interpret. The study involved many different measurements that have sorted based on the items to ensure more significant factor loadings. Generally, the item has loaded from every factor, but in this analysis, a request from the analysis is to include only the factor loadings greater than 0.50.

The current study used confirmatory factor analysis (CFA) to determine the constructs’ reliability and different types of validity, which is required for performing structural equation modeling (SEM). The types of validity used:

The average variance extracted (AVE) was used to assess the convergent validity.

The discriminant validity index is used to validate the discriminant validity.

Also, this study used composite reliability (C.R.) to evaluate the reliability of the constructs. This study used the SEM technique to propose the conceptual model constructs and to investigate the association between patient safety culture and patient satisfaction and pharmacist performance. For testing the direct hypotheses regression path was used. The hypothesis was accepted if the P-value ≤ 0.05. To confirm the results, the study used the method of maximum likelihood estimator (MLE) and bootstrapping approach with a 95% confidence interval. The Social Package of Social Sciences SPSS-AMOS Version 21 software for developing SEM was used.

Statistical analysis results

Factor analysis results

The factor analysis of the independent variable (i.e. patient safety culture) provided 6 items/components. Factor analysis of the mediator variable (i.e. job performance) provided 5 items/components. Finally, factor analysis of the dependent variable (i.e. patient satisfaction) provided 14 components, as shown in Table 3.

Table 3.

Factor analysis results.

Construct	Components number	Components name	Items numbers	Reliability (>0.7)
Patient safety culture	1	Documenting mistakes	4	0.942
	2	Communication about mistakes	6	0.890
	3	Teamwork	4	0.883
	4	Organization learning	4	0.781
	5	Patient counseling	3	0.843
	6	Communication about prescriptions	5	0.705
Job performance	1	Job performance	5	0.901
Patient satisfaction	1	Patient satisfaction	14	0.957

Confirmatory factor analysis (CFA) for validating patient safety culture

CFA and SEM are used to analyze the data of the current study and examine the validity of the structural model. CFA was initially conducted to validate each construct in the study. Three fit indices, namely parsimonious fit, incremental fit, and absolute fit, were used to measure the shared values and validity of the constructs. Only one fitness index from each group is needed. The AVE and C.R. values for the patient safety culture construct and its associated sub-constructs were calculated using simple Microsoft Excel equations and are provided in Table 4.

Table 4.

AVE and C.R. of patient safety culture.

Construct	Item	Factor loading	CR (>0.6)	AVE (>0.5)
Patient safety culture	Documenting mistakes	0.80	0.905	0.614
	Communication about mistakes	0.78
	Teamwork	0.78
	Organization learning	0.81
	Patient counseling	0.75
	Communication about prescriptions	0.78

CFA for validating job performance

The AVE and C.R. values for the job performance were calculated and provided in Table 5. To achieve convergent validity, these values should be more than the agreed value of 0.5 and 0.6. C.R.'s value was 0.907, and the AVE value was 0.661, which indicates that job performance constructs achieved convergent validity.

Table 5.

AVE and C.R. of job performance.

Construct	Item	Factor loading	CR (>0.6)	AVE (>0.5)
Job performance	JP1	0.85	0.907	0.661
	JP2	0.84
	JP3	0.78
	JP4	0.75
	JP5	0.84

CFA for validating patient satisfaction

The AVE and C.R. values for the job performance were calculated and provided in Table 6. These values should be more than the agreed value of 0.5 and 0.6, respectively, to achieve convergent validity. C.R.'s value was 0.947, and the AVE value was 0.603, which indicates that the job performance constructs achieved convergent validity.

Table 6.

AVE and C.R. of patient satisfaction.

Construct	Item	Factor loading	CR (>0.6)	AVE (>0.5)
Patient satisfaction	PS1	0.78	0.947	0.603
	PS2	0.51
	PS3	0.82
	PS4	0.83
	PS5	0.84
	PS6	0.82
	PS7	0.75
	PS8	0.75
	PS9	0.75
	PS10	0.77
	PS11	0.81
	PS12	0.83
	PS13	0.82
	PS14	0.81

The pooled CFA for all measurement models of constructs

Additionally, the study has evaluated other methods of CFA procedure, namely pooled CFA, which includes all study constructs in one model instead of evaluating them individually. Since the model is not too complex, two latent constructs included in this analysis are first order and only one-second order and have six sub-constructs; thus, the researchers have decided to calculate and estimate the CFA procedure by pooling all constructs at once for quick results. In this step, the researchers need to show the fitness indexes for all variables to evaluate another type of validity called discriminant validity between these variables.

The results of this pooled CFA model have provided the required fitness indexes and the factor loading for each item and dimension; Table 7 shows the fitness indexes for all constructs; in addition, the correlation between the constructs. Therefore, the study model achieved fitness indexes, and the correlation coefficient between the two constructs also met the threshold, which means that the correlation did not exceed the value of 0.85.²³ None of the correlation values at the double-headed arrows were more significant than 0.85; thus, the multi-collinearity problem in this model did not exist.

Table 7.

Fitness indexes for all constructs.

Name of index	Level of acceptance	Fitness indexes of all constructs
P-Value	P ≤ 0.05	0.000
RMSEA	RMSEA < 0.08	0.075
CFI	CFI > 0.90	0.933
TLI	TLI > 0.90	0.924
Chisq/df	Chi-square/pdf < 3.0	2.136

Structural model and structural equation modeling

According to the direction of the study hypotheses, the researchers connect the exogenous construct (independent variable) with the endogenous construct (dependent variable) through the mediator variable. In addition, Table 8 shows the fitness indexes of the model.

Table 8.

Fitness indexes for the SEM.

Name of index	Level of acceptance	Fitness indexes of SEM
P-Value	P ≤ 0.05	0.000
RMSEA	RMSEA < 0.08	0.076
GFI	GFI > 0.90	0.828
CFI	CFI > 0.90	0.930
TLI	TLI > 0.90	0.922
Chisq/df	Chi-square/pdf < 3.0	2.172

The causal effect of the independent variable was toward the dependent variable. The current structural model consists of only one independent variable, so there is no need for a double-headed arrow that uses two or more exogenous constructs to estimate the correlational effect between them to check the multi-collinearity in the model. The outputs provided are the standardized regression weights, R², and factor loading of the structural model. The value of R², or called the coefficient of determination, explains the patient safety culture perceived by the sample explains about 94% of the job performance, and both patient safety culture and job performance explain 94% of the patient satisfaction.

Testing the direct hypotheses

The regression coefficient findings of the model are also presented in Table 9. According to the P-value, the effect of the exogenous patient safety culture on the endogenous construct of patient satisfaction was insignificant, the effect of the exogenous patient safety culture on the mediating variable job performance is significant, and the effect of mediating variable job performance on the endogenous patient satisfaction is significant.

Table 9.

Regression path and significance.

Endogenous	Path	Exogenous	Estimate	C.R.	P-Value	Result
Patient satisfaction	←	Patient safety culture	0.107	0.429	0.668	Reject
Job performance	←	Patient safety culture	0.968	14.766	0.000	Accept
Patient satisfaction	←	Job performance	0.867	3.395	0.000	Accept

Testing mediation hypothesis

The present study also has a mediator that requires examining this effect in the determined model, and this examination is conducted alone. The study implemented an approach performed in many studies that are interested in examining this effect. Based on the outputs, the study summarizes the findings as follows:

Indirect effect 1 = 0.86 (significant).

Indirect effect 2 = 0.57 (significant).

Total indirect effect 1 × 2 = (0.86)*(0.57) = 0.490

Direct effect 3 = 0.40 (significant).

Thus, the mediation exists since both indirect effect one and indirect effect 2 are significant.

The type of mediation is partial since the direct effect three is also significant even after entering the mediator into the model. Further, a bootstrapping approach was used to confirm this result after analyzing the mediation effect and determining the type of mediation. The study used the MLE method in this analysis and ran 1000 bootstrap samples with a 95% confidence interval. The results of the analysis are given in Table 10, as job performance acts as a mediator in the relationship between patient safety culture and patient satisfaction. Based on these results, the study concluded that bootstrapping confirms the mediation results.

Table 10.

Bootstrapping results of the mediator.

		Indirect effect	Direct effect
Bootstrapping values	Lower bounds	0.399	0.305
	Upper bounds	0.565	0.495
	Two-tailed significance	0.003	0.002
Results		Significant	Significant
Type of mediation	Mediation exists since both indirect effects are significant. The type of mediation is partial since the direct effect remains significant.

Hypotheses discussion

H1: Patient safety culture is associated with pharmacist’s performance.

The results confirmed the first hypothesis; patient safety culture is associated with job performance; patient safety culture has a significant positive association with job performance, indicating safety culture will positively influence pharmacist performance. When pharmacists have safety values, beliefs, and norms, it will reflect on their attitudes and practices. In line with the theory of planned behavior, which interprets people's behaviors are related to their intentions and beliefs.¹³ Pharmacists’ beliefs and perceptions about the importance of safety are shaped by the safety culture of the pharmacy (the place they work in), which then affects their behaviors and attitudes toward safety. To date, there have been limited studies about the relationship between patient safety culture and pharmacist performance, but a study conducted in Taiwan supports our research finding.²⁴ Taiwanese study aimed to improve and develop better strategies regarding patient safety in healthcare organizations by applying the importance-performance analysis technique to identify the significant strengths and weaknesses of the safety culture. The study found that low performance is a significant weakness related to poor safety culture, and it suggested enrolling the new personnel in training programs to enhance safety culture and thus improve job performance.²⁵ Better safety culture means better performance, more productivity, and more profitability.²⁶

H2: Pharmacist’s performance is associated with patient satisfaction.

The finding of this current research supported the second hypothesis. The results were in accordance with the primary provider theory; this theory suggests that patient satisfaction or dissatisfaction primarily happens at the nexus of patient expectations and the influence of the healthcare provider.²⁷ Furthermore, the results show that patient satisfaction is influenced by the degree to which a pharmacist’s performance rises to the patient’s expectations. When the patient visits the pharmacy, it comes with an image of the pharmacist’s role; and how the performance should be. This image represents the societal definition of the pharmacist’s role as well as the ideas generated by the patient from experiences or by hearing about other people’s experiences.

Moreover, patients share emotional, sensitive, and personal information with the pharmacist and expect an empathetic response and expert advice. Therefore, patients are going to re-visit the same pharmacy if they find the pharmacist is trustworthy and can depend on his experience. This result is consistent with the findings of a study that Australian pharmacists’ performance positively influenced patient loyalty and trust.⁷

Moreover, these results build on the existing evidence on the direct relationship between patient satisfaction and hospital performance and physician practice.^28,29 Also, the results are in line with the findings of many studies outside the medical field, which found an association between employee performance and customer satisfaction.^30,31

According to this result, pharmacists have to continuously improve their performance to gain patient satisfaction; by improving their skills in problem-solving, upgrading their medical knowledge, and developing their communication skills to be more empathic during the interaction with the patient.

H3: Patient safety culture is associated with patient satisfaction.

The third hypothesis is confirmed by the results; patient safety culture has an insignificant positive effect on patient satisfaction. Therefore, the current research was unable to accept this third hypothesis. This means that patient safety culture is made up of psychosocial variables, which pharmacists should adopt and the place they work to ensure the aim of patient safety culture, which is reducing errors to the absolute minimum, irrespective of patient satisfaction.³²

At the end of the process of pharmaceutical care service, patients do not matter if the pharmacists have the values, beliefs, norms, and attitudes about reducing errors. Patients do not matter if there is good teamwork between pharmacists, if pharmacists communicate well, or if they discuss mistakes. Ultimately, all patients need to take their proper medications and know when to take their medications, answer their questions, and receive the care they need without being exposed to any harm.

There are no studies on the relationship between patient safety culture and patient satisfaction in community pharmacies. However, many hospital settings studies showed a relationship between patient safety culture and patient satisfaction.15 –18 There is a high difference between the hospital setting and community pharmacy setting and the time the patient spends in the hospital versus community pharmacy, which limits the generalization of the findings from the hospital on community pharmacies and vice versa. Additionally, most of the previous studies were about the impact of patient safety culture among nurses and physicians on patient satisfaction, so there is a need to do a further study that includes pharmacists in hospital settings.

H4: Patient safety culture is associated with patient satisfaction through pharmacist's performance.

The results confirmed the fourth hypothesis; job performance mediates the relationship between patient safety culture and patient satisfaction. According to the knowledge of the researchers, no studies have been conducted to investigate the association between patient safety culture and patient satisfaction through pharmacist performance. This novel finding is considered one of the most important contributions to this research.

This finding provides healthcare policymakers with appropriate information and evidence that are crucial for guiding them to make informed decisions and better improvements toward enhancing patient safety culture in community pharmacies.

Therefore, for patient satisfaction to reach the desired levels, pharmacy owners/managers have to spend energy on increasing safety culture and improving pharmacist performance and reducing errors that could happen in community pharmacies.

Managerial implication

This study suggests that pharmacy managers should pay more attention to employee performance.

Jordanian pharmacy schools must promote patient safety culture by updating their curricula to include more subjects that enhance patient safety culture.

The decision-maker in the Jordanian Pharmacists Association and the Ministry of Health must put their power into ameliorating patient safety culture and make shifting from a blame and shame culture to non-punitive culture, encourage pharmacists to discuss their mistakes, focus on the importance of documenting mistakes, and encourage pharmacists to continue learning to improve patient safety culture and thus their performance.

Pharmacists should continuously join different workshops to improve their knowledge and skills in patient counseling to improve patient understanding of the medical information and the pharmacist’s instructions, reducing the potential of errors and achieving better patient outcomes.

Managers and owners of pharmacies should take patient safety culture into account to improve job performance by encouraging pharmacists to communicate with each other and exchange the important prescription information they face. Also, encourage pharmacists to discuss their mistakes with each other, why these mistakes happened, and how to prevent them from happening again.

Conclusion

This is the first study in Jordan investigating the association between patient safety culture and patient satisfaction through the pharmacist in a community pharmacy. The results showed a significant effect of patient safety culture on pharmacist’s performance, an insignificant effect of patient safety culture on patient satisfaction, a significant effect of pharmacist performance on patient satisfaction. That pharmacist performance mediates the relationship between patient safety culture and patient satisfaction.

This study highlights the need to conduct more studies about this topic in pharmacy and other settings in the medical field. In addition, this study helps the decision-makers know where and how to improve community pharmacies regarding reducing medication errors, achieving better patient outcomes, and gaining patient satisfaction. This study and its results are supportive of community pharmacies, and taking these results will have a positive impact on pharmacists and patients. Attention to the culture of patient safety, pharmacist performance, and patient satisfaction is one of the vital issues in managing community pharmacies.

Footnotes

Key messages

This study is the first study in Jordan about patient safety culture in community pharmacies. The findings of this study provide healthcare policymakers with appropriate information and evidence that are crucial in guiding them to make informed decisions and better more efficient improvements.

Ethical approval

The study's protocol was approved by the Institutional Review Board (IRB) at Jordan University of Science and Technology (reference number: 12/134/2020) dated 27-8-2020. Verbal and written Arabic Language Informed Consent has obtained from participants before administrating the questionnaire about the purpose of the study.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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 iDs

Main Naser Alolayyan

Raneen Atef Jalaileh

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