Study design and setting
A descriptive cross-sectional study was conducted at El-Shatby University Hospital for Gynecology and Obstetrics over a 3-month period from November 2020 to January 2021. The hospital serves four governorates including Alexandria, El-Behira, Matrouh, and Kafr El-Sheikh. It has six departments, one ICU unit, and the eclampsia unit. The hospital has ten operating theatres: four for emergency operations, four for elective surgeries, and two for endoscopic surgeries. It provides both inpatient (254 beds) and outpatient (six outpatient clinics) services. The hospital has a mandatory error reporting system in which the reports received, analyzed, and feedback is provided to the reporter. The providers are held accountable for their mistakes.
Inclusion criteria
A comprehensive sample of all staff members (in charge) during the study period, including assistant lecturers, residents, and head nurses, who were working in the hospital for more than 3 months, were enrolled in the study.
The total number of potential participants who fulfilled the inclusion criteria was 83; the twelve participants who participated in the pilot study were excluded. The total number of participants who agreed to participate in the study was 66 participants (38 residents, 18 assistant lecturers, and 10 head nurses) out of 71 potential participants representing a 92.9% response rate.
Data collection
The questionnaire used to measure the patient safety culture was the adapted form of The Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire [12] and the percentages of the positive responses of health care staff were assessed. The questionnaire was used in English and comprises two parts: the first one includes demographic characteristics, work position and years of working experience. The second part was PSC composites which comprised of 12 safety culture composites and a total number of 42 items. The twelve patient safety culture dimensions include; teamwork within the unit, supervisors expectations and actions to promote patient safety, feedback and communication about error, organizational learning, communication openness, overall perception of patient safety, hands-off and transitions, teamwork across units, frequency of events reported, management support for patient safety, staffing and management support for patient safety. Except for two items that are responded on a five-point frequency scale (never, rarely, sometimes, most of time, and always) the majority of patient safety culture questions are answered on a five-point agreement scale (strongly disagree, disagree, neutral, agree, and strongly agree), with a higher score indicating a more favorable attitude toward patient safety.
A preliminary phase was conducted to assess the validity and reliability of the adapted version of the questionnaire (where some modifications were made to the wording of the questions of the original questionnaire). For the assessment of content validity, three staff members experts in the field of public health were invited to assess the degree to which the items in the questionnaire were relevant and could correctly measure safety culture among the study participants and their remarks were taken into consideration. Test–retest reliability was measured by administering the questionnaire twice. Responses were collected 3 weeks apart. The test–retest reliability coefficient (Cohen’s kappa) was 0.97. Internal consistency was measured using inter-item correlation; Cronbach’s alpha = 0.78, while Cronbach’s alpha of the original questionnaire ranged from 0.63 to 0.84).
Pilot study
A pilot study was conducted before starting the field work. A random sample (n = 12) from the study hospitals’ residents, assistant lecturers, and nurses were asked to answer the self-administered questionnaire and were excluded from the study sample. The results of the pilot study were one question was double negative, so it was re-phrased. The questions were properly understood by participants. The questionnaire took 15–20 min to be completed.
Data was collected at the workplace of the participants (emergency room, outpatient clinics, operation theatre, ultrasonography rooms, and inpatient wards). The self-administered questionnaire was distributed anonymously to the participants. The principle of patient safety culture and the aim of the study were explained to them, and they were asked to fill in the questionnaires. The participants completed the questionnaire while the investigator was available to respond to any issue. The questionnaire was filled in within an average of 15–20 min. Completeness of the questionnaires was checked at the spot.
Statistical analysis
Data were coded, tabulated, and analyzed using (SPSS) version 25 [13]. Categorical data was expressed as numbers and percentages.
Calculation of percent positive scores [14]
Based on HSOPSC user’s database published in 2018 [14], HSOPC’s 42 items had been grouped into twelve domains. Each of the twelve patient safety culture domains is composed of three or four survey items. Composite scores for each domain were calculated by averaging the percent positive response on its items. Out of the twelve domains, nine domains ask respondents to answer using 5-point response categories in terms of agreement (strongly agree, agree, neither, disagree, and strongly disagree). The survey items of the remaining three domains (feedback and communication about error, communication openness, and frequency of events reports) use 5-point response categories in terms of frequency (always, most of the time, sometimes, rarely, and never).
The percent positive response is calculated as follows:
The agreeing with positively worded items takes a score 1 and disagreeing takes the score 0 and vice versa to the negatively worded items. The overall score for each dimension is calculated by adding the percentage of positive responses and then dividing them by the number of items in the dimension. For example, the domain “teamwork within the unit” had three items; people support one another (the positive response = 53.1%), when a lot of work needs to be done quickly, we work together as a team to get the work done (the positive response = 81.8%), and people treat each other with respect (the positive response = 51.5%). The overall score for the dimension = (53.1 + 81.8 + 51.5) divided by 3. So, the overall positive response of that dimension is 62.1%.
For positively worded items, the percent positive response is the combined percentage of respondents who answered “strongly agree” or “agree”/ “always,” or “most of the time”. For negatively worded items, the percent positive response is the combined percentage of respondents who answered “strongly disagree” or “disagree,”/ “never” or “rarely,” because a negative answer on a negatively worded item indicates a positive response.
Strengths and areas for improvement
Consequently, based on HSOPSC user comparative data report (2010) [15], the results are classified based on percent positive response into three categories:
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Areas of strengths: when the percent positive response is more than 75%.
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Areas with the potential for improvement: the percent positive response is 50–75%.
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Areas of weakness: the percent positive response is lower than 50%.