Cultura de segurança : percepção dos profi ssionais de saúde em um hospital mental Safety culture : perception of health professionals in a mental hospital

Objective: To evaluate the culture of patient safety in a mental health service. Method: Cross-sectional study conducted with health professionals in a mental hospital, by applying the Safety Attitudes Questionnaire (SAQ). Descriptive and inferential analyses were performed. Results: One-hundred and three professionals participated in the study, with female predominance (64.1%) and time of performance equal to or greater than 21 years (32.4%). The nursing professionals of technical level and with statutory work regime were the most participative, 54.4% and 52% respectively. The total score was 69 points. The domain that reached the highest score was Job satisfaction (80 points) and the lowest was Working conditions (57 points). The statutory professionals and those with longer professional experience obtained better scores in the perception of safety culture. Conclusion: The result of safety culture was below the recommended, indicating the need for strengthening this construct in mental health hospitals. Descriptors: Patient Safety; Organizational Culture; Mental Health; Patient Care; Psychiatric Hospitals. RESUMEN Objetivo: Evaluar la cultura de seguridad del paciente en un servicio de salud mental. Método: Estudio transversal realizado con los profesionales de la salud en un hospital mental, aplicándose el Safety Attitudes Questionnaire (SAQ). Fueron realizados análisis descriptivos e inferenciales. Resultados: Participaron del estudio 103 profesionales, con predominancia del sexo femenino (el 64,1%) y el tiempo de actuación igual o superior a 21 años (el 32,4%). Los profesionales de enfermería de nivel técnico y con régimen de trabajo estatutario fueron los más participativos, el 54,4% y el 52% respectivamente. El resultado total fue 69 puntos. El dominio que alcanzó el resultado más grande fue el de Satisfacción en el trabajo (80 puntos) y el más pequeño fue el de Condiciones de trabajo (57 puntos). Los profesionales estatutarios y con tiempo más grande de experiencia profesional


INTRODUCTION
Mental health is understood as a complex field of knowledge and action, plural and intersectoral, which requires the crosssectionality of knowledge and practices.In this context of health care, workers represent important social actors, whose daily life is service is marked by challenges, contradictions and struggles in favor of mental health policies.One of the growing challenges in this field is the discussion about the culture of patient safety, due to its relevance and priority of attention received globally (1) .
Patient safety has been defined as the reduction in the risk of damage, beyond the necessary, during the provision of health care to the minimum possible (2) .Given this, safety culture has been developed in the institutions, being necessary for their safe organization.Thus, it corresponds to the set of values, attitudes, skills and behaviors that determine the commitment to health and safety management, replacing guilt and punishment with the opportunity to learn from failures and improve health care (3) .
Safety culture is developed from five features operationalized by the institution's safety management, including: recognition by all workers of the responsibility for their own safety, as well as their colleagues', patients' and family members'; prioritization of safety over financial and operational goals; encouragement to and rewards for the identification, notification and resolution of safety-related issues; organizational learning from incidents; availability of resources, structure and accountability for the effective maintenance of safety (3) .Among health institutions, the culture of patient safety in mental health hospitals is highlighted in this work.
Although the psychiatric reform movement indicates the deinstitutionalization process, emphasizing the need for the (re)socialization of people in mental distress and other psychosocial network devices, there (still) are operational psychiatric hospitals in the country that need to be studied.These hospitals face many challenges in the context of Brazilian health care, involving difficulties in the management of services, high demand of users and shortage of qualified human resources, corresponding to critical and complex scenarios (4) .
In addition, it is possible to mention the challenges concerning the quality of the human relationships between the multidisciplinary team and the patients themselves, since psychiatric patients can, depending on their clinical history, exhibit psychomotor agitation, practice physical violence, verbal aggression, suicide, destruction of materials, escapes, bouts of crying, homicide, among other psychiatric complications (5) .
The organizational issues resonate in the culture of safety, which is essential for the qualification of the care provided (6) .Medication errors, which are so common in Psychiatry, corroborate this fact, although little attention is paid to them, and due to the magnitude of the consequences resulted from such event, they should be priorities for investigation (7) .
Thus, the importance of researches to assess safety culture in health institutions may be noted, especially in mental health hospitals, seeing as some authors suggest the shortage of studies that address safety-related issues in these environments (6)(7) .
Corroborating this thought, the use of the Safety Attitudes Questionnaire (SAQ) is emphasized, characterized as one of the instruments used to assess safety culture, being able to provide information about the need for implementation of changes in the institution (8) .In this sense, the aim was to evaluate the perception on safety culture of the professionals working in a mental health hospital.

OBJECTIVE
To evaluate the perception on safety culture of health professionals working in mental health hospitals.

METHOD Ethical aspects
The ethical principles established by Resolution No. 466/2012 of the National Health Council were followed, thus, the study was assessed and approved by the Research Ethics Committee of Maternidade Escola Assis Chateaubriand (MEAC-UFC).The research was part of a broad project developed with funds from the Pesquisa Para o SUS Program (PPSUS), called "Cultura de segurança: percepção dos profissionais de saúde de três hospitais públicos do estado do Ceará."[Safety culture: perception of health professionals of three public hospitals in the state of Ceará] For carrying out data collection, the study's objectives and methodology were explained to the subjects who agreed to participate in the research, the signing of the Informed Consent Form having been requested.It should be noted that free and spontaneous participation in the research was ensured to the subjects, and their anonymity was preserved.

Design, study site and period
Descriptive-exploratory cross-sectional study, with quantitative approach, developed in all sectors of a mental health hospital, considered a reference in Psychiatry in the state of Ceará, located in Fortaleza, Northeast region of Brazil.Data collection took place between January and July 2016.

Population, inclusion and exclusion criteria
Two-hundred and fifty questionnaires were distributed to all health professionals of the institution.The study sample was obtained through random sampling, being composed of 103 health professionals who filled in the instrument and met the following inclusion criteria: workload equal to or over 20 weekly hours and having been performing their activities for at least one month in the respective sectors of data collection.The professionals on holiday or on leave of absence during the period of data collection were excluded, as well as those who did not fill in the questionnaire after contact was attempted.The sample included physicians, residents, nurses, nursing assistants and technicians, psychologists, social workers, occupational therapists and pharmacists.

Collection instrument
The data were collected using the Safety Attitudes Questionnaire (SAQ), translated and validated for the reality of Brazilian hospitals (8) .
The SAQ is divided into two stages: the first contains 41 questions covering the six domains and the second includes the professionals' characterization data, such as position, gender, main performance and time of performance.The six domains are divided as follows: Teamwork climate, Safety climate, Job satisfaction, Stress recognition, Perceptions of management and Working conditions.The answer to each question follows the five-point Likert scale.The final score ranges from 0 to 100 points, in which zero corresponds to the worst perception of safety culture and 100, to the best perception.Positive values are considered when the total score is ≥ 75 (9) .

Analysis of results and statistics
After collection, the data were entered into a database in Excel® and subsequently processed in the Statistical Package for Social Science (SPSS) version 18.0.The categorical variables were expressed as absolute numbers and percentages and the quantitative variables as mean and standard deviation.To compare the means, the Kruskal-Wallis test was applied for the categorical variables, whereas t-test or the Mann-Whitney test was applied for the quantitative variables.The significance level considered was 0.05.

RESULTS
The study included 103 health professionals, with the majority being female (n = 66; 64.1%) and working in a statutory regime (n = 54; 52%).In relation to the time of professional performance, there was predominance of the period equal to or greater than 21 years (n = 33; 32.4%), followed by the range between 5 to 10 years (n = 23; 22.5%) and, finally, the range between 11 and 20 years (n = 9; 8.8%).As for professional category, most of those who filled the instrument were nursing technicians and assistants (n = 56; 54.4%).
With respect to the descriptive analysis of the SAQ's domains, the mean ranged from 57 to 80 points, with a total score of 69 points.Only three domains, Teamwork climate, Job satisfaction and Stress recognition, reached values ≥ 75 points, regarded as suitable for a positive safety culture (Table 1).
The safety culture of the hospital studied varied according to work regime (statutory or outsourced) and time of performance.In relation to work regime, statutory professionals had an average total score greater than outsourced ones, 71 and 68 points, respectively.When analyzed separately, the averages of statutory professionals were greater than those of outsourced professionals in the Safety climate, Job satisfaction, Perceptions of management and Working conditions domains.Perceptions of management and Working conditions were the domains which corresponded to the lowest values for outsourced professionals, with statistically significant difference for Working conditions (Table 2).
As for time of performance, professionals with less than six months of work achieved the best score in the Job satisfaction (89 points) and Working conditions (72 points) domains, and the worst score in the Safety climate domain (37 points), when compared to other professionals with time of performance greater than six months.It was noted that professionals with 1 to 2 years of experience had the best total score (71 points), followed by professionals with 11 to 20 years of performance (70 points).The Perceptions of management domains were the ones with the lowest averages for all professionals (Table 3).

DISCUSSION
According to the results, a predominance of females was observed, as well as greater participation of nursing professionals as respondents of the research.This finding corroborates those of national (10)(11) and international (12)(13) studies conducted in recent years.
The female presence in healthcare, particularly among the nursing staff, is still a reality of the profession.However, the uneven proportion between male and female nurses has been modified, which has been confirmed by the last national census conducted with nursing professionals (14)(15) .
It was found that a time of professional performance equal to or greater than 21 years and statutory work regime were the most prevalent.The data show that individuals with this type of employment relationship remain for longer in the institutions, leading to lower rates of staff turnover.Institutions with lower turnover rates tend to have a lower number of patient falls and lower occurrence of adverse events involving drugs (16) .
Safety climate varied according to each domain, time of performance and work regime.The descriptive analysis of the SAQ's domains showed that the mean ranged from 57 to 76 points, with a total score of 69 points, which is a result below the satisfactory limit.A study highlights that the lower the score achieved in the scale, the more fragile the unit's safety culture is (8) .
A survey conducted in hospitals in the west of Lithuania pointed out that professionals working in psychiatric units had inferior safety culture when compared to professionals working in other units.The authors suggest that this finding may be related to specific characteristics of the environment, since the professionals of this area can be subjected to physical or psychological violence by patients.The need to control the suffering of another person can lead to increased levels of interpersonal stress, and impact the ability to meet the needs of patients, if the team is not prepared to deal effectively with this population (17) .
Similarly, a study conducted in the United States highlighted the importance of promoting a culture of safety in these scenarios, something that can only occur with the involvement of patients, their family and management, since the mental health environment has specific needs that need to be recognized by the latter (18) .
When carrying out the analysis by domains, only three reached positive values (≥ 75 points).This result is consistent with other surveys conducted in different contexts, which also showed positive scores for Job satisfaction, Stress recognition and Teamwork climate (11,(19)(20)(21) .
The Job satisfaction domain obtained the best result when compared to the other domains.This positive perception of professionals is a favorable factor, since the quality of care and, consequently, patient safety are directly related to satisfaction.
Work in mental health has several specificities, which require from professionals that they have the skills needed to deal with human beings, considering their daily contact with the psychological suffering of patients.To act in the field of mental health, it is necessary to be able to see beyond the disease -care must be integral and extended to the family.New knowledge must be constructed to be used in practice.Social inclusion should occur, so patients with mental disorders may be reinserted in society and in their family sphere.These specificities require each time more skills from mental health workers (22) .Thus, they are more exposed to situations which can influence their work satisfaction.Factors that are intrinsic (such as personal motivation, well-being) or extrinsic (interpersonal relationships, compensation) to the working environment are related to satisfaction and have direct consequences on the worker's life, being reflected in the stance they assume while performing their work (11,(19)(20) .
Despite the difficulties encountered in mental health services, the professionals are satisfied with the work they perform, despite it being considered a scenario that is still impregnated with biased beliefs.This result goes against the stigma that is still attributed to mental hospitals and helps ensure the safety of patients (23) .
In this discussion, it may be seized that the satisfaction the professionals claimed to have in relation to their work has direct influence on the quality of the care offered, because satisfied professionals tend to remain in the institution for longer, increasing the opportunities for creation of a bond with the organization, as they become acquainted with its protocols and approach management (24) .
Stress recognition was the second domain to achieve a positive score, i.e., the professionals recognize that stress triggers, whether excessive workload, exhaustion, tense or hostile situations, directly influence the execution of their work.
Contrary to the results found, a research conducted in five Intensive Care Units in regional public hospitals of a city in Greece indicated stress recognition as the domain with the lowest score, i.e., the general result indicated that the Greek professionals did not agree that they are less effective when tired (25) .However, the literature indicates work overload as one of the main sources of stress, as well as intense interpersonal contact, which is characteristic of work in health, and more specific in the field of mental health, due to the professionals' daily contact with users who have emotional difficulties, whose needs require their attention and care (26) .
In this way, workers exposed to these situations in psychiatric hospitals should be careful so this overload of emotions and feelings does not affect the maintenance of their physical and psychosocial health, contributing to the occurrence of work accidents and safety deficits in their decisions and actions, which reflects directly on the quality of the service offered (26) .
Another domain with positive results was Teamwork climate, which refers to the quality of the relationship and collaboration between team members.This result is crucial so that safe and adequate care may be provided, since teamwork and communication, its key point, when carried out ineffectively, can negatively affect organizational culture (27) .
A research conducted in Jordan corroborates the findings of this study, showing that nurses from four hospitals in the country had positive Teamwork climate scores.The professionals indicated respect, mutual support and working together as essential in the provision of efficient and safe care, contributing to a culture of safety (28) .
Safety climate, Working conditions and Perceptions of management obtained negative values in the evaluation of general domains.A similar result was found in a study conducted in surgical units of a university hospital in Florianópolis, Santa Catarina (29) .
Safety culture: perception of health professionals in a mental hospital Oliveira ICL, Cavalcante MLSN, Freitas SA, Freitas RJM, Silva BV, Marinho DMF, et al.
Safety climate encompasses the commitment of the institution with patient safety from the professionals' point of view.In this way, negative scores suggest the need for joint actions aimed at the patients' safety, being related to the work performed by management and to the promotion of the participation of patients and families.
A research conducted in Iran ratifies this finding, demonstrating that the Safety climate domain corresponded to the lowest scores of the study (30) .In Slovenia, researchers elucidated that the perception about Safety climate can fluctuate according to professional category or to the professionals' time of performance at the institution (31) .
In this regard, the importance of investing in strategies to improve patient safety in the mental health scenario may be noted, as it is an environment that is often overlooked.For this, it is important to consider the different points of views of the professionals who are part of the institution, listing priority actions.
In relation to the Working conditions domain, which refers to the perception of the quality of the work environment, national studies (11,19) indicate that it was also evaluated negatively, when compared to the results obtained in a research conducted in Iran, in which the average was 72 points (30) .The relevance of investing in an environment that is favorable to the development of professional activities is emphasized, since this factor heavily interferes in the care provided (32) .
The Perceptions of management domain, which encompasses the approval of the management's actions in relation to safety issues, was the domain with the second lowest average when compared to the others, corroborating national (19,21,33) and international (34) studies.The negative perception of the professionals can be indicative of managerial issues, revealing the distance between the health staff and its managers.So the safety of care is ensured, it is necessary that a strong bond is formed between professionals and managers, leading to the development of a motivating work climate for professionals, and to the improvement in the quality of services provided to patients (35) .
The identification of a negative perception regarding the hospital's management draws attention to the need for the management's support in relation to patient safety, requiring actions to promote a culture of safety and the quality of care.In addition, for mental health care to become focused on the person in distress, new forms of management are needed.This requires thinking of management as a political action, which has a methodology that contemplates plurality and interdisciplinarity, the interrelationships between subjectivity, management of work processes and clinic (22) .
In this context, it is essential that managers of mental health services treat safety culture as priority, because they are able to propose and implement strategies that promote a safe environment, ensuring respect and dignity to human life.
By analyzing Table 2, with the domains' scores in relation to work regime, it is observed that statutory professionals achieved the best values, though still below the ideal average, compared to outsourced ones.This result corroborates a study conducted in three hospitals in the Northeast of Brazil (11) .
In Table 3, analyzing the values separately, it is possible to note that Stress recognition varied from 81 points for professionals with up to 6 months, to 73 points for professionals with 21 years or more of work.Thus, Stress recognition was more significant in professionals with longer time of performance.
Similarly, the Working conditions domain went from 72 to 54 points when professionals with up to 6 months and those with 21 years or more of work were analyzed.
When correlating the Job satisfaction domain with time of performance, the professionals with less than 6 months of work were more satisfied.This demonstrates that when professionals initiate their work in a new service, due to internal motivations and expectations, they perceive the institution positively (11) .
In contrast, Safety climate, which corresponded to 37 points for professionals with up to 6 months, increased to 65 points for professionals with 21 years or more of work.These results emphasize that Safety climate is connected to the professionals' relationship with the institution.Thus, professionals who have been for longer in the organization can understand this domain better.
These findings corroborate those from studies conducted in hospitals of China (36) and Lithuania (17) , which showed the effects of a more positive perception of Safety climate among more experienced professionals, offering them a broader view of the patient's safety issues.

Study limitations
The limitations of this study were related to two factors: the shortage of studies addressing the cross-sectionality of the themes of mental health and patient safety, in particular the evaluation of safety culture, thereby limiting a more comprehensive discussion that would provide a comparison between the results; and the fact of this study being unicentric, therefore, other institutions may find different or convergent results in relation to the outcomes achieved in this research.

Contributions to the fields of nursing, health or public policies
As contribution of this study, the possibility of promoting reflections about patient safety in the area of mental health is emphasized, it being characterized as a research that offers innovative information by pointing out the weaknesses in the safety culture of these institutions, which need to be addressed.These results may support future interventions, so that mental health hospitals become increasingly safer.

CONCLUSION
The health professionals' safety culture result was below the recommended, indicating the need for strengthening this construct in mental health hospitals.Although the Job satisfaction, Stress recognition, and Teamwork climate domains stood out positively, the professionals' evaluation in relation to Perceptions of management and Working conditions was unfavorable.These results reflect the fragility of management, exposing the need for support regarding patient safety, and demanding actions that promote the quality of care.
The importance of further studies on the evaluation of safety culture is emphasized, considering the scarcity of researches that address this topic in mental health hospitals.The score below satisfactory levels in the hospital studied reflects the need for professionals and management, through permanent education in health, to work together to address the main patient safety issues in the institution, discussing the domains that had negative scores and thereby improving the health service provided.
Safety culture: perception of health professionals in a mental hospital Oliveira ICL, Cavalcante MLSN, Freitas SA, Freitas RJM, Silva BV, Marinho DMF, et al.

Table 1 -
Distribution by domains of the Safety Attitudes Questionnaire (SAQ) of the means of a mental health hospital, Fortaleza, Ceará, Brazil, 2016 Note: SAQ -Safety Attitudes Questionnaire; SD = standard deviation.

Table 2 -
Distribution of the average scores for work regime by domain of the Safety Attitudes Questionnaire (SAQ), Fortaleza, Ceará, Brazil, 2016 Note: (*) p< 0.05 t test; SAQ -Safety Attitudes Questionnaire; SD = standard deviation.

Table 3 -
Distribution of the average scores for time of performance by domain of the Safety Attitudes Questionnaire (SAQ), Fortaleza, Ceará, Brazil, 2016 Note: (*) p< 0.05 Kruskal-Wallis test; SAQ -Safety Attitudes Questionnaire.Safety culture: perception of health professionals in a mental hospital Oliveira ICL, Cavalcante MLSN, Freitas SA, Freitas RJM, Silva BV,Marinho DMF, et al.