Safety culture has been defined as “the product of individual and collective beliefs, values, attitudes, perceptions, competencies, and patterns of behavior of an organization’s commitment to quality and patient safety” Reference Yates, Bernd and Sayles1 by the Joint Commission, 2017. The Coronavirus disease 2019 (COVID-19) which emerged in Wuhan, China, in December 2019, was subsequently declared a global pandemic by the World Health Organization led to unprecedented disruption to health-care systems worldwide. Reference Leite, Lindsay and Kumar2 Shortages in supplies of personal protective equipment, particularly at the beginning of the pandemic have in fact led to health-care workers (HCWs) feeling unsupported and exposed to unnecessary dangers due to supply chain and raw material issues. The International Council of Nurses Reference Kenny3 reported in 2020 that more than 260 nurses worldwide succumbed to COVID-19, raising the crucial issue of HCWs risking their lives to save the lives of others. This study was conducted to determine the potential changes in patient safety culture during the COVID-19 pandemic compared with the prepandemic levels at a tertiary hospital in a middle-income country in Southeast Asia.
Methods
Study Setting and Sample Population
A survey-based study was carried out among HCWs at a 1300-bed teaching hospital in Kuala Lumpur, Malaysia. Eligible participants comprising all HCWs within the teaching hospital were approached in this study with self-administered online questionnaire during the COVID-19 pandemic, with available historical data collected the same way as a baseline in 2018.
Study Instrument
Demographic data with alongside information on vaccination, redeployment, and COVID-19 infection were collected alongside the Safety Attitudes Questionnaire (SAQ) to evaluate patient safety culture. The questionnaire was embedded within the staff portal in both the English and Bahasa Melayu languages as described in the previous study. Reference Krishnasamy, Tan and Zakaria4
The study was approved by the Ethics Committee of University Malaya Medical Centre (ID: 2018921-6702), informed consent was obtained, and participants could leave the study at any stage. Participation in this study was voluntary.
SAQ
The SAQ is a 36-item questionnaire assessing perceptions of safety across 6 domains: safety climate, teamwork, stress recognition, perception of management, working conditions, and job satisfaction. Reference Sexton, Helmreich and Neilands5 Scores of greater than 60% were considered as a satisfactory level of safety culture. The percentage of respondents who “agree slightly” or “agree strongly” for each of the items within a factor are charted as the positive percentage for each SAQ factor. The psychometric properties of the SAQ have been assessed across different countries, contexts, and settings with acceptable Cronbach’s α and internal consistency values. Construct validity had also exhibited a satisfactory model fit. Reference Sexton, Helmreich and Neilands5 The positive percentage responses for each domain were calculated and benchmarked against the 60% positive percentage agreement.
Results
Respondent Characteristics
A total of 3175 responses were obtained during the 2021 survey period, in comparison to 5274 received in 2018. Respondents were mostly of the nursing workforce, while doctors accounted for 440 (13.9%) in 2021. A total of 1485 (46.8%) respondents had to self-quarantined due to exposure with COVID-19; 1679 (52.9%) were tested with nasopharyngeal swabs polymerase chain reaction tests, which were the only tests recognized at the time; 225 (7.1%) had been diagnosed with COVID-19; 1000 (31.5%) were redeployed from general wards to COVID-19 wards or other clinical areas; and 3042 (95.8%) had been vaccinated for COVID-19.
Comparison of Domain Scores by Survey Waves
Percentage agreement scores were highest overall for job satisfaction 72.3% and 71.3%, followed by teamwork, 67.0%, and 66.5% for both 2018 and 2021. Perception of unit management (64.2 vs 64.3%), perception of hospital management (63.9 vs 63.7%), working conditions (62.9 vs 61.2%), and stress recognition (58.4 vs 59.0%) comprised the domains with the lowest domain scores in both 2018 and 2021. Stress recognition consistently scored below the acceptable agreement level of 60% for both survey waves. There was a significant difference in domain scores; shown in Table 1 comparing SAQ scores among professions between prepandemic and intra-pandemic scores.
Table 1. Percentage agreement scores by job category pre-pandemic and intra-pandemic survey waves
Note: 2018, pre-pandemic; 2021, intra-pandemic.
Individuals who had been infected and received treatment for COVID-19 had significantly poorer perceptions of unit management and working condition domain scores. Individuals who were redeployed had higher domain scores. Overall, there were differences in individual domain scores for all participants who had responded to both pre-pandemic (2018) and intra-pandemic (2021) surveys (Table 2).
Table 2. Results from paired comparison and factors that predict change in SAQ dimensions from 2018 to 2021
Abbreviations: HM, perceptions on hospital management; JS, job satisfaction; SC, safety climate; SR, stress recognition; TW, teamwork; UM, perceptions on unit management; WC, working conditions.
Discussion
There were overall changes in patient safety culture evaluated using the SAQ during the COVID-19 pandemic compared with scores obtained from HCWs from the same teaching hospital 2 y before the onset of the COVID-19 pandemic. Redeployment appeared to be associated with improvements across 5 of the 7 SAQ domains.
These unprecedented pressures on hospital staff were expected to affect morale negatively with a high level of burnout reported by numerous sources. Reference Sexton, Helmreich and Neilands5 However, despite these potential challenges faced by HCWs, this study was not able to detect any overall reduction in patient safety attitude. Reference Zakaria, Remeli and Shahamir6 Significant improvements were observed in the SAQ domain scores of the doctors and support staff, while nurses did not record any difference in domain scores between the pre-pandemic and intra-pandemic surveys for overall domains. The rationale underlying the lack of improvement in scores among nurses compared with other HCWs could be attributed to the higher baseline scores among nurses. Reference Krishnasamy, Tan and Zakaria4 However, it was possible that nurses had a lower level of autonomy during the pandemic as redeployment among doctors were carried on a voluntary basis, while nurses were more likely to have been assigned to COVID-19 wards.
With regard to those with COVID-19, initial policies were to admit all those with positive test results regardless of the severity of illness, although during the third wave, hospitals had become too congested and those with no or mild symptoms were allowed to self-quarantine at home if their homes were deemed suitable and they did not fall within the high-risk groups. While negative safety attitudes could have led to an increased risk of becoming close contacts as well as developing COVID-19, negative experiences were also more likely to lead to reduction in morale and poorer mental health, which then adversely affected safety attitudes. 7
Conclusions
Patient safety culture appeared to improve overall among HCWs during the COVID-19 pandemic compared with scores obtained prepandemic, although stress recognition remained unsatisfactory since 2018. Redeployment was associated with improvements in patient safety culture. Future studies should evaluate the use of pandemic simulation training as an intervention to address safety culture.
Acknowledgments
The authors thank the management of the University of Malaya Medical Centre, University of Malaya, and all respondents for providing the necessary support to carry out this research.
Author contributions
K.K., M.I.Z., V.N., N.H. and M.P.T. were responsible for the study conception and design. K.K., M.P.T., and K.C. conducted data analysis. All authors have read and approved the final manuscript.
Funding
None.
Competing interests
The authors report no conflicts of interest.
