Factors related to the patient safety climate in an emergency hospital*

Objective: to verify the relationship between the socio-demographic and work profile of the nursing professionals and the patient safety climate in a public emergency hospital. Method: a cross-sectional study carried out with 177 nursing professionals from a public emergency hospital. For data collection, the Safety Attitudes Questionnaire - Short Form 2006 was used, validated and cross-culturally adapted to the Portuguese language. To check the factors related to the instrument’s domains, bivariate and multivariate analyses were performed. Results: working in the medical and surgical clinic or emergency room, on a night shift, and having the intention to leave nursing, reduced the general safety climate in the multiple regression analysis. The younger professionals, with less than four years in the institution, and those who worked in the night shift had a lower safety climate related to the perception of the management. On the other hand, having a work contract with a hired worker improved the general safety climate and workplace satisfaction. Conclusion: identifying predictors on patient safety scores is an important management tool that allows diagnosing, planning and executing activities from the domains that need to be improved.


Introduction
Worldwide, 64 million disability-adjusted life years are lost annually due to unsafe care (1) . This means that adverse events, defined as an incident that resulted in harm to the patient (2) are, probably, one of the top ten causes of harm and death (1) .
In Brazil, the bulletin released by the National Health Surveillance Agency (Agência Nacional de Vigilância Sanitária, ANVISA -abbreviation in Portuguese), in 2017 (3) , revealed that most safety incidents (defined as an event or a circumstance that could have resulted in, or resulted in, unnecessary harm to the patient) (2) , reported to the National Health Surveillance System, occurred in hospitals (94%) and in exclusive urgent and emergency services (2.3%). When considering the number of health care-related incidents reported per hospital unit, urgent and emergency services ranked third (7.6%) (3) .
In urgent and emergency services, stress situations related to poor working conditions, inadequate sizing of the nursing team, limited resources, overcrowding, the long waits and the exposure of workers to stress that can impact the quality and safety of care (4) .
In these institutions, the main risks to patient safety are related to the following: clinical management, diagnosis and medication errors (5) , adverse events resulting from insertion, handling and the maintenance of medical devices (such as cannulas, venous catheters, tubes and drains), bronchoaspiration and trauma (6) .
It is also observed that there is a greater number of risk behaviors that impact the mortality rate (7) in a situation of overcrowding. It is important to note that, although urgency and emergency services have a high flow of patients and complex demands, there is no justification for risking patient safety (8) .
Patient safety is considered a priority attribute of the quality of the health systems (9) , a fundamental principle of patient care and a critical component of management (10) . For care to be considered of quality, it is necessary that it is safe, effective, timely, efficient, equitable and patient-centered (11) . In addition, patientcentered care, teamwork and the safety climate are related to better patient outcomes, to the greater number of safety incident notifications and to lower rates of adverse events, death and hospital readmission (12) .
The patient safety climate is also closely related to the safety culture in that it represents people's perceptions and organizational practices that reflect basic assumptions and beliefs based on the culture (13) .
The safety climate plays an important role in reducing safety incidents (14) . For example, medication errors are less frequent, and rates of hospital readmission are lower in units where the health team classifies the safety climate as positive (13) . A positive safety climate improves not only productivity and interpersonal relationships (14) but also the quality of nursing care (15) .
There are several factors that influence the patient safety climate (16)(17)(18) . The following can be mentioned: the perception of the professionals regarding the management, that is, the degree of approval of the teams in relation to the managerial actions; team work that addresses the quality of collaboration among the staff; workplace satisfaction, which is the degree to which people feel positive in their work experience and working conditions, defined by the quality of the work environment and logistical support (19) . In addition, the workload, professional exhaustion and the intention to leave the workplace affect the quality of care provided to patients by the nursing professionals (20) .

Investigations carried out in Brazil have shown an
atmosphere of patient safety that is not satisfactory and with fragility in the perception of stress, in the perception of management and in the working conditions. Regarding the positive points observed in the patient safety culture, researchers find workplace satisfaction as a positive dimension (21)(22)(23) .
In another study that aimed to assess the climate of patient safety in a Brazilian urgency and emergency unit, the researchers identified an unfavorable climate, especially with regard to management actions in patient safety management (24) .
Measuring the safety climate can be useful in diagnosing, planning and executing activities based on the domains that need to be improved and the intrinsic and extrinsic factors of the professionals who need attention. Furthermore, it is important to measure the patient safety climate in different units of the same service, because it may differ from the general climate of the institution. This diagnosis will allow for the identification of opportunities for improvement (25) .
Most studies investigated the safety climate in a single unit and focused on locations with high intrinsic risk, such as operating rooms (26) and intensive care units (27)(28) . However, studies aimed at measuring the safety climate in urgent and emergency services are still scarce.
It should also be noted that the safety climate may differ among people working in the same unit and/ or department (29)(30)  examples that can contribute to the adoption of risky behaviors and to the worsening of the safety climate (29) .
However, this relationship has not yet been well established in health institutions, particularly among the nursing professionals (31) .
In this context, identifying the factors that are impacting the patient safety climate is an important tool to improve the quality of care, as it makes it possible to diagnose areas that need improvement within health institutions and among the nursing professionals (32) .
This study aimed to verify the relationship between The participants assign a score to each statement contained in the instrument, based on a 5-point Likert bipolar scale: strongly disagree (0 points), slightly disagree (25 points), neutral (50 points), slightly agree (75 points) and strongly agree (100 points).
Each statement, also, presents the "does not apply" answer option, which is not computed in the calculation of the domain score. Therefore, the scores are counted as follows: first, the reverse items corresponding to questions 2, 11 and 36 of the SAQ. Then, the questions of the instrument are ordered in domains that contain a set of items whose scores are added up. The final result of the sum of the scores is divided by the number of items in the domain. A positive overall climate score is considered to be a general final score greater than or equal to 75 (33)(34) .
To complement socio-demographic and working data, a form constructed by the researchers was applied.
The intention to leave the workplace was measured using the variable in the model (35) . Thus, only variables with p < 0.20 were included in the multiple linear regression models. Finally, multiple linear regression models were performed, using the automatic stepwise method to adjust the variable confusion potentials of the models (36) . The statistical significance of multiple linear regressions was also established by the t test (37) . The results of the regression models were presented as an adjusted regression coefficient (ββ aj ) and respective 95% confidence intervals (95% CI).
In the present study, only the statistically significant variables of the multiple regression models were presented in the tables. Variables with a p-value < 0.05 in the multiple regression analysis were considered statistically significant.

Results
Of the nursing professionals, 177 accepted to participate in the study and met the inclusion criteria, In the regression analysis, it was found that acting in the ER reduced the general safety climate score by 11.30 points (β aj = -11.30) (   (Table 1).   (Table 2).    It was also verified that having a moderate/ high intention to leave nursing reduced the overall climate score by 8.27 points (β aj = -8.27) ( Table 1) and by 9.96 points the management perception score (β aj =-9.96) ( Table 2). The intention to leave the workplace contributed to the reduction of the workplace satisfaction score by 9.50 points (β aj = -9.50) ( Table 4).  (Tables 3 and 4).

Discussion
The fact that most of the nursing professionals are female and young adult converges with other national studies carried out with the nursing teams (38)(39)(40) .
The reality of human resources with different work regimes, statutory and hired workers, was also found in another investigation (40) and can be explained due to the movement of adoption of the management of public health services by social organizations, so that there are, within the same hospital, workers with different employment relationships and, consequently, with unequal rights and wage conditions (41) .
It was evident that almost all the nurses stated that they had some complementary training such as graduation, training and refresher courses.
The participation of Nursing in permanent education programs results in changes in the work process and generates positive impacts on the care provided (42) and, consequently, on patient safety.
The number of patients per professionals was close to double for nurses when compared to nursing technicians and assistants. In Brazil, the number of patients ranged from 9 to 27 per nurse and from 3 to 7 per assistant/technician, according to the inpatient units (43) . The increase in the workload is related to the occurrence of failures and health incidents (43) .
Four factors related to the general safety climate were identified: working in the ER or in the medical and surgical clinic, having the intention to leave the workplace or nursing, working in the night shift and having a working time greater than or equal to five years in the institution.
Working in the ER decreased the general patient safety climate, the atmosphere related to teamwork and the safety climate, in addition to decreasing workplace satisfaction, the atmosphere related to the perception of management and the climate associated with the working conditions. In an emergency service in a Brazilian hospital, the safety climate was negative, with a mean SAQ score below 75. The participants' perceptions about the safety climate were negative, regardless of gender, length of service and position (24) .
The ER is characterized by being a unit with high patient turnover, which results in an increase in the workload and may justify the lower safety climate among these professionals. In addition, factors such as the severity and complexity of the patients can interfere with the safety climate of this sector. The manifestations of stress, tiredness, suffering, mental exhaustion and work overload of the nursing professionals who work in emergency units (4) are also frequent.
An investigation into the influences on satisfaction, involvement at work, emotional exhaustion, the intention to leave work and psychosomatic suffering in nurses from emergency services showed that almost 20% of the respondents left work in less than 18 months.
It also showed that work overload and high emotional demands can lead to a state of exhaustion. The authors concluded that high turnover is an important issue in the emergency services and that investments in collaborative and empathic leadership of supervisors are necessary, as well as the creation of a favorable working climate and opportunities for the professional growth of emergency nurses with the objective of stimulating their permanence at work (44) .
Urgency and emergency care units may present peculiar stressors such as meeting spontaneous demands, coping with unexpected situations, and work overload, in addition to problems related to work processes, infrastructure, and human and material resources (4) .
The Nurses working in the night shift showed an increase in the symptoms related to chronic and psychological fatigue, in addition to a greater intention to quit their workplace when compared to the others (45) .
Managers and leaders need to adopt strategies that enable the engagement, appreciation and participation of the collaborators in making organizational decisions. Researchers have demonstrated the relationship between reduced workplace satisfaction, increased stressors, and night shift work (46)(47) . However, in this study, daytime professionals had less workplace satisfaction. This data may be related to a greater volume of activities planned for the day, such as scheduled exams and surgeries, hospital discharge, and patient transfer.
The greater workload attributed to these professionals can result in decreased workplace satisfaction.
Having the intention to leave nursing contributed to the reduction of the general patient safety climate and the climate associated with the management's perception. The intention to leave the workplace also reduced workplace satisfaction. The leadership styles and the lack of employer support among team members are very common reasons for the professionals to leave the workplace (47) or to have the intention to leave the profession (48) .
Diverse research studies carried out with both nurses and nursing technicians and assistants demonstrated the direct correlation between the professional practice environment, the levels of emotional exhaustion, the perception of the quality of care, workplace satisfaction, and the intention to leave the workplace in the next 12 months.
All of this can be influenced by the level of complexity and the management method of the institution (15,49) . In another study, the professionals with the intention to leave nursing had less perception of management and less workplace satisfaction (50) . Stress and lack of workplace satisfaction contribute to an increase in the turnover rate and to the intention to leave the profession (48) .
The nurses with the worst relations with doctors, with little autonomy and with low control over the environment, had a higher level of emotional exhaustion.
This can negatively influence their perception of the quality of care, their satisfaction with work and their intention to leave the workplace (15) .
The hired professionals rated the safety climate better and had better workplace satisfaction. In another investigation, being statutory was negatively related (p < 0.05) to the perception of the management of the unit and of the hospital. The authors suggested that the professionals without workplace stability may present more positive responses, regarding the safety culture, because they fear retaliation in the workplace (17) . However, the study carried out in three public Brazilian urgency and emergency hospitals suggested that workplace stability can be a motivating strategy to guarantee the permanence of the professionals working in emergencies (51) .
The urgency and emergency units may have adverse working conditions that, negatively, affect the patient safety climate. For this reason, it is necessary to implement strategies to reduce stress, improve teamwork, and promote a safety culture for these workers.
The limitation of this work refers to its performance only with nursing professionals, which may limit the extrapolation of data to other scenarios and other professional categories. It is suggested to continue research in other health institutions, involving multiprofessional health teams to survey factors that predict the patient safety climate.

Conclusion
In the multiple regression analysis, working in the On the other hand, having a work contract with a hired worker improved the general safety climate (β aj = 7.00) and workplace satisfaction (and β aj = 17.38).
Understanding the factors related to the patient safety climate in nursing is of paramount importance, since these professionals are in a strategic situation to act in the prevention of the occurrence of adverse events and, when they occur, they must act accordingly in order to institute conducts to minimize the damage caused to the patient.
Considering the context of urgency and emergency units, the proper performance of the nursing professionals becomes vital for the promotion of patient safety.
The evidence from this research may assist health managers in planning actions aimed at three aspects: investing in the valorization of the workers, stimulating dialog and promoting organizational learning based on mistakes. They can also contribute to the education of the nursing professionals, in order to promote reflection on organizational and personal issues that interfere in the provision of safe care. The findings of this study may also support future investigations aimed at assessing the patient safety climate in the health institutions.
These efforts contribute to the improvement of the clinical practice in nursing and, consequently, to the dissemination and strengthening of the culture of patient safety in the country.