Patient safety climate in the hospital cardiology service: instrument for safety management

Clima de seguridad del paciente en la atención hospitalaria de cardiología: instrumento para la gestión de la seguridad

Aline Mirema Ferreira Vitorio Daisy Maria Rizatto Tronchin About the authors

ABSTRACT

Objective:

To assess the safety climate from the perspective of health professionals in the inpatient and intensive care units of a public hospital specialized in cardiology, in the city of Rio de Janeiro.

Methods:

Quantitative, exploratory, descriptive study, using the Safety Attitudes Questionnaire. The findings were analyzed according to descriptive and inferential statistics, with a significance level of 5%.

Results:

The general safety climate had a mean of 66.6; the best score corresponded to the Job satisfaction (80.8) domain and the lowest to Hospital management perception (52.5). The means of the scores were statistically significant regarding the employment relationship, gender and professional category.

Conclusion:

There are weaknesses in the safety climate related to management and having a state job bond, belonging to the male gender and to the nursing team.

Descriptors:
Safety Management; Health Services Assessment; Cardiology Hospital Service; Patient Safety; Organizational Culture

RESUMEN

Objetivo:

Evaluar el clima de seguridad bajo la perspectiva de los profesionales de salud en las unidades de internación y de cuidados intensivos de un hospital público especializado en cardiología, de la ciudad de Río de Janeiro. Métodos: Se trata de un estudio cuantitativo, exploratorio, descriptivo, en el que se utilizó el instrumento "Safety Attitudes Questionnaire" (Cuestionario para Evaluar Comportamientos Seguros e Inseguros). Los hallazgos se analizaron según la estadística descriptiva e inferencial, con nivel de significación del 5%.

Resultados:

El clima de seguridad general obtuvo un promedio del 66,6; la mejor puntuación correspondía al dominio Satisfacción en el trabajo (80,8) y la menor, a la Percepción de gestión del hospital (52,5). Las puntuaciones medias fueron estadísticamente significativas en términos de empleo, género y categoría profesional.

Conclusión:

Existen inconsistencias en el clima de seguridad relacionadas con la gestión y con el vínculo estatutario, en términos de pertenecer al género masculino y al equipo de enfermería.

Descriptores:
Gestión de la Seguridad; Evaluación de los Servicios de Salud; Servicio de Cardiología Hospitalario; Seguridad del Paciente; Cultura Organizacional

RESUMO

Objetivo:

Avaliar o clima de segurança na perspectiva de profissionais de saúde nas unidades de internação e de terapia intensiva de um hospital público especializado em cardiologia, no município do Rio de Janeiro.

Métodos:

Estudo quantitativo, exploratório, descritivo, empregando-se o instrumento Safety Attitudes Questionnaire. Os achados foram analisados conforme a estatística descritiva e inferencial, com nível de significância de 5%.

Resultados:

O clima de segurança geral obteve média de 66,6; o melhor escore correspondeu ao domínio Satisfação no trabalho (80,8) e o menor à Percepção da gerência do hospital (52,5). As médias dos escores foram estatisticamente significantes quanto ao vínculo trabalhista, ao gênero e à categoria profissional.

Conclusão:

Há fragilidades no clima de segurança relativas à gerência e quanto a possuir vínculo estatutário, pertencer ao gênero homem e à equipe de enfermagem.

Descritores:
Gestão da Segurança; Avaliação de Serviços de Saúde; Serviço Hospitalar de Cardiologia; Segurança do Paciente; Cultura Organizacional

INTRODUCTION

Patient safety is necessity for the provision of care in health services. International and national data indicate high rates of adverse events (AE) in this area, with an estimated occurrence between 4% and 16% of all hospitalized patients(11 Organização Mundial da Saúde (OMS). Segundo desafio global para a segurança do paciente: cirurgias seguras salvam vidas (orientações para cirurgia segura da OMS)[Internet]. Brasília 2009[cited 2017 Mar 10]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/seguranca_paciente_cirurgia_salva_manual.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
-22 The Joint Commission. Summary data of sentinel events reviewed by the Joint Commission [Internet]. Oakbrook Terrace; 1951-2017 [cited 2017 Sep 18]. Available from: https://www.jointcommission.org/sentinel_event.aspx
https://www.jointcommission.org/sentinel...
).

Adverse events are related to care and have no association to the underlying disease, resulting in adverse events to patients, such as infections, surgery in the wrong site, incorrect administration of medication, blood and/or blood components, fall during hospitalization, pressure ulcers, among others.

The safety culture consists of people's behavior, values, attitudes, norms, beliefs, practices and policies. In its essence, culture is "how we do things around here", with "here" meaning a specific work unit(33 Ministério da Saúde (BR). Portaria n. 529, de 1o de abril de 2013. Institui o Programa Nacional de segurança do Paciente (PNSP) [Internet]. Brasília; 2013 [cited 2017 Nov 02]. Available from: https://www20.anvisa.gov.br/segurancadopaciente/index.php/legislacao/item/portaria-529
https://www20.anvisa.gov.br/segurancadop...
), which has a close relationship with the quality and safety involved in health care.

Thus, the safety culture is not simply about the safety values established by the organization or the individual, but a structural dynamic of the individual and organizational action system. Such dynamics corrects for the understanding and the establishment of effective safety measures, associated by elements such as the leadership commitment, effective and trust-based communication, organizational learning, the non-punitive approach to reported and analyzed AE, the teamwork and the shared belief in the importance of safety(44 Groves PS, Meisenbach R, Scott-Cawiezell J. Keeping patients safe in healthcare organizations: a structuration theory of safety culture. J Adv Nurs. 2011;67(8):1846-55. doi: 10.1111/j.1365-2648.2011.05619.x
https://doi.org/10.1111/j.1365-2648.2011...
-55 Halligan M, Zecevic A. Safety culture in healthcare: a review of concepts, dimensions, measures and progress. 2011. Qual Saf Health Care. 2011;20(4):338-43. doi: 10.1136/bmjqs.2010.040964
https://doi.org/10.1136/bmjqs.2010.04096...
).

From this perspective, the safety culture assessment is a management tool when measuring perception, beliefs and values of individuals about safe care and organizational environment, contributing to the planning and implementation of quality improvement actions and institutional safety(66 Flin R. Measuring safety culture in healthcare: a case for accurate diagnosis. Saf Sci. 2007;45:653-667. doi:10.1016/j.ssci.2007.04.003
https://doi.org/10.1016/j.ssci.2007.04.0...
).

In a literature review, it was found that studies have been used to assess the safety climate through the application of questionnaires and scales, aiming to assess the perception of professionals regarding this construct, whose results show favorability in issues related to job satisfaction in the face of safety climate, differently from the management perception, which denotes weaknesses in the actions in the managerial work process(77 Carvalho REFL, Cassiani SHB. Cross-cultural adaptation of the Safety Attitudes Questionnaire - Short Form 2006 for Brazil. Rev Latino-Am Enfermagem. 2012;20(3):575-82. doi: 10.1590/S0104-11692012000300020.
https://doi.org/10.1590/S0104-1169201200...
-88 Maroco J, Garcia-Marques T. Qual a fiabilidade do alfa de Cronbach? Questões antigas e soluções modernas? Lab Psicol[Internet]. 2006 [cited 2017 Sep 17];4(1):65-90. Available from: http://publicacoes.ispa.pt/index.php/lp/article/viewFile/763/706
http://publicacoes.ispa.pt/index.php/lp/...
).

The health institution, setting for this study, has experienced demands and organizational changes in recent years, with emphasis on the restructuring of the Quality area, the creation of the Patient Safety Center - PSC. Therefore, an environment of safety culture was favored, through the increase of policies, programs, protocols, procedures and practices aimed at monitoring and assessing care quality.

These changes are in line with guiding procedural guides and supporters for the implantation of the Patient Safety Center throughout the national territory, fundamentally designed to promote patient safety, with emphasis on the creation of a safety culture (33 Ministério da Saúde (BR). Portaria n. 529, de 1o de abril de 2013. Institui o Programa Nacional de segurança do Paciente (PNSP) [Internet]. Brasília; 2013 [cited 2017 Nov 02]. Available from: https://www20.anvisa.gov.br/segurancadopaciente/index.php/legislacao/item/portaria-529
https://www20.anvisa.gov.br/segurancadop...
).

Thus, it is essential to investigate the perception of health professionals about the safety climate and the organizational components that make it possible or difficult to promote and consolidate the safety culture, aiming at the implementation of efficient and effective measures to qualify care.

OBJECTIVE

To assess the safety climate from the perspective of health professionals in the inpatient and intensive care units of a public hospital, specialized in cardiology, in the city of Rio de Janeiro.

METHODS

Ethical aspects

This study was submitted and approved by the Research Ethics Committee of the institution, setting for this investigation and conducted according to Resolution 466/12, of the National Health Council, ensuring data confidentiality and anonymity of participants(99 Marinho MM, Radünz V, Barbosa SFF. Avaliação da cultura de segurança pelas equipes de enfermagem de unidades cirúrgicas. Texto Contexto Enferm [Internet]. 2014;23(3):581-590. doi: 10.1590/0104-07072014002640012.
https://doi.org/10.1590/0104-07072014002...
).

Design, setting of study and period

This is a study with quantitative, exploratory, descriptive approach, conducted in a public teaching and research hospital, specialized in cardiovascular diseases, with a total of 162 beds, located in the city of Rio de Janeiro. This institution involves the sectors that provide inpatient care, with five inpatient units and four intensive care units. Data collection occurred between April and June 2018.

Population/sample: inclusion and exclusion criteria

Of the 718 health professionals working in the inpatient and intensive care units, 474 met the following inclusion criteria: being a nurse, nursing technician/assistant, physician, nutritionist, physiotherapist, occupational therapist, speech therapist, pharmacist, psychologist, social worker; nursing, pharmacy, physiotherapy and medicine residents who had been working in their functions at the institution for at least 6 months. As exclusion, the following criteria were adopted: health professionals on leave, vacation and/or off work activities and working less than 20 hours per week. The employment bond of these professionals is variable, being represented by permanent position, temporary contract for an indefinite period and professional training, respectively described in this study as state bond, contract and residence.

It is worth mentioning that of the 474 eligible professionals, a total of 24 refused to participate, and 450 questionnaires were distributed. Among these, 59 professionals did not return the instrument. The sample was non-probabilistic and intentional.

For data collection, we used the Safety Attitudes Questionnaire in the Short Form 2006 version, adapted, translated and validated for Brazilian hospitals(1010 Luiz RB, Simões AL, Barichello E, Barbosa MH. Factors associated with the patient safety climate at a teaching hospital. Rev Latino-Am Enfermagem. 2015;3(5):880-7. doi: 10.1590/0104-1169.0059.2627.
https://doi.org/10.1590/0104-1169.0059.2...
).

The SAQ - Short Form 2006 has two parts, the first one contains 41 statements: items 24 to 28 are duplicated, since they are answered according to the unit administration and the hospital administration; and numbers 2, 11 and 36 are considered reverse. These statements are answered using a Likert-type scale, containing five degrees: totally disagree, partially disagree, neutral, partially agree and totally agree. There is also the alternative "does not apply".

The questions and the respective domains of the questionnaire are: items 1 to 6 - Teamwork climate; items 7 to 13 - Safety climate; items 15 to 19 - Job satisfaction; items 20 to 23 - Stress perception; items 24 to 29 - Unit management perception; items 14, 24 to 28 - Hospital management perception: approval of hospital management actions; items 30 to 32 - Work conditions; and items 33 to 36, which are not grouped into domains.

To calculate the score of the questions, the reverse items are initially inverted. Then, the statements are grouped by domain and calculated according to a five-degree scale, in which the following values are attributed to the answers: totally disagree (zero points), partially disagree (25 points), neutral (50 points), partially agree (75 points) and totally agree (100 points). Values ≥ to 75 are considered positive(1010 Luiz RB, Simões AL, Barichello E, Barbosa MH. Factors associated with the patient safety climate at a teaching hospital. Rev Latino-Am Enfermagem. 2015;3(5):880-7. doi: 10.1590/0104-1169.0059.2627.
https://doi.org/10.1590/0104-1169.0059.2...
).

Finally, the score for each domain is calculated based on the formula (m-1)x25, where m is the mean of the items in the domain, varying from 0 to 100 points. For the total SAQ item, which corresponds to the general safety climate, the mean scores of each SAQ domain are calculated.

The second part of the instrument includes the following variables: position, gender, main activity (adult, pediatrics or both) and period of experience in the specialty. There is also a question to check whether the individual answered the questionnaire previously. To complement this part, the variables work unit, age, hours worked per week in the unit, time working in the unit (years), period of experience in the specialty (years), type of employment bond and necessary guidelines were added for completing the questionnaire.

The researcher held meetings with the unit managers to show the objectives of the study and the operational procedures for data collection. Then, she asked the heads of services of the units for the list of health professionals to proceed with the selection according to the eligibility criteria. From this stage, the workers were individually approached in their units, during their working days, to explain the purpose of the study and to invite them to participate, respecting their different shifts and availability. To those who expressed interest, the researcher handed a white envelope containing the invitation letter, the questionnaire, colored printed, to be answered and returned on a date and time as agreed between the researcher and the participant, with a ruler, pencil and eraser. In addition, the ICF prepared in two copies was also handed, and after signing them, one remained with the participant and the other one with the researcher.

It is noteworthy that, in the data collection phase, the researcher had the collaboration of a total of five nursing students who were trained for the activity through a dialogued class, a simulation of completing the instrument, as well as 2 days of training in the area.

Data analysis and statistics

The data were inserted in an electronic spreadsheet and then analyzed using computing resources of a statistical software, whose data analysis was based on descriptive and inferential statistics. For qualitative variables, absolute and relative frequencies were used and, for quantitative ones, measures of central tendency and dispersion. Aiming at a better understanding of the results, the answers were added and grouped in totally disagree ("TD") and partially disagree ("PD") as disagreement, and totally agree ("TA") and partially agree ("PA") as agreement.

The reliability of the questionnaire and its respective domains was checked through Cronbach's α coefficient. This coefficient is an estimator that expresses the degree of reliability of the answers resulting from the evaluated questionnaires, with values above 0.7 considered satisfactory(66 Flin R. Measuring safety culture in healthcare: a case for accurate diagnosis. Saf Sci. 2007;45:653-667. doi:10.1016/j.ssci.2007.04.003
https://doi.org/10.1016/j.ssci.2007.04.0...
).

To compare the domains between the sociodemographic and occupational variables, the Analysis of Variance (ANOVA) Model was used and correlation tests were applied, which are Pearson's correlation coefficient (to compare domains and numerical variables), the Student "t" test and Welch's Correction (to categorical variables) and Games-Howell post hoc tests (to compare groups two by two). The level of significance adopted was 5%.

RESULTS

A total of 391 health professionals participated in the study, which corresponded to a return rate of 86.8%.

Regarding the sociodemographic and occupational characteristics of the professionals, the predominant position was nursing technicians and assistants (123 - 31.4%), followed by nurses (85 - 21.7%;) and physicians (85 - 21.7%). It should be noted that the nursing team, represented by nurses, nursing technicians and assistants, totaled 208 (53.2%) health professionals. The sum of all other professionals corresponded to 183 (46.8%).

Regarding gender, most of them (285 - 75%) were women and had a state bond employment (232 - 64.1%). The respondents' age ranged between 20 and 70 years old, with a mean of 40.89 (SD=10).

Regarding the main activity, most of them (290 - 75.9%) worked with adult patients. The working time in the unit corresponded to an average of 9.77 years (SD=6.98), and the average of the time working in the specialty was 13.76 years (SD=8.71).

Regarding employment bond, the state bond (232 - 64.1%), followed by contract (100 - 27.6%) and resident (30 - 8.3%). Regarding the weekly workload, it varied between 20 and 60 hours, obtaining a mean of 31.27h (SD=9.57).

As for the distribution of professionals among the units studied, 209 (56.2%) participants worked in the four intensive care units and 150 (40.3%) in the inpatient units.

The data in Table 1 point out the statements of the Safety Attitudes Questionnaire (SAQ).

Table 1
Frequency of statements in the Safety Attitudes Questionnaire, according to health professionals, Rio de Janeiro, Brazil, 2018

According to the data in Table 1, the favorability of the safety climate regarding job satisfaction was present in questions 15 and 17. Thus, it can be considered that, from the perspective of the participants, working contributes to their own personal satisfaction, as well as feeling proud of their performance and consider the unit where they operate an adequate place to work.

On the other hand, in questions 24 and 27, there is a negative perception of professionals regarding aspects related to the action of hospital management, with scores below 75.

The data in Table 2 show the findings from the statements regarding the safety climate, according to the SAQ domains and the total SAQ.

Table 2
Means and standard deviation by domain of the Safety Attitudes Questionnaire, Rio de Janeiro, Brazil, 2018

In this study, the instrument general Cronbach's α corresponded to 0.92, varying between 0.7 and 0.8 in the domains, which expresses good reliability(66 Flin R. Measuring safety culture in healthcare: a case for accurate diagnosis. Saf Sci. 2007;45:653-667. doi:10.1016/j.ssci.2007.04.003
https://doi.org/10.1016/j.ssci.2007.04.0...
).

Regarding the total SAQ value, a mean of 66.60 was obtained (SD=15). The job satisfaction domain had the best score, 80.79 (SD=19.6). On the other hand, the worst results were seen in the Management perception domains, both at the hospital and at the unit, 52.5 (SD=22.3) and 60 (SD=27.6), respectively. The Teamwork climate domain, represented by the quality of the relationship and the collaboration among team members, obtained a mean of 73.8 (SD=18.7).

According to the data in Table 3, there is a statistically significant difference (p<0.05) in the comparisons of the variables with another professional category and the domains Teamwork climate, Stress recognition, Unit management perception and Working condition; as for the gender - men in the domains Teamwork climate, Unit management perception and Working condition; and state bond in the domains Teamwork climate, Job satisfaction, Safety climate, Stress recognition, Hospital management perception and Working condition.

Table 3
Means of the domain scores, according to professional category, gender and employment bond, Rio de Janeiro, Brazil, 2018

DISCUSSION

With regard to position and gender, nursing technicians and assistants and women were predominant in the investigation. Among the possible explanations, there is the predominance of the nursing team in the studied sectors. This finding is in line with what was revealed by a research in Brazil, in which the nursing team represents the largest workforce in health services(1111 Ministério da Saúde (BR). Conselho Nacional de Saúde (CNS). Resolução n. 466, de 12 de dezembro de 2012. Dispõe sobre normas regulamentadoras de pesquisas envolvendo seres humanos. Diário Oficial da União: República Federativa do Brasil; 2012. Dez 12, Seção 1: p. 59. (col. 3).).

In the health sector, female participation reaches almost 70% of the total, and the most feminized professional category is nutritionists, in which women corresponds to 95% of them. In addition, there is also the fact that traditionally male professions such as medicine, dentistry and veterinary medicine, have undergone changes with increasing rates of female participation(1212 Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006. 6:44. doi: 10.1186/1472-6963-6-44
https://doi.org/10.1186/1472-6963-6-44...
).

As it is a public institution, the state bond was the main employment status. This result is attributed to the legal nature of the - public, federal and educational - institution, in which the main state bond, followed by the temporary contract.

The favorability of the safety climate regarding job satisfaction was expressed from the perspective of the participants. In the study carried out to identify factors related to job satisfaction/dissatisfaction, in a cardiology unit of a hospital in the state of Sao Paulo, authors showed that one of the contributing factors for job satisfaction was the work itself and in a team(1313 Conselho Federal de Enfermagem (COFEN). Atlas da Enfermagem: profissionais de enfermagem por sexo no Brasil [Internet]. Brasília; 2011 [cited 2018 Aug 01]. Available from: http://www.cofen.gov.br/wp-content/uploads/2012/03/pesquisaprofissionais.pdf.
http://www.cofen.gov.br/wp-content/uploa...
).

Negative perceptions were observed, with domains with an average below 75, in relation to aspects related to the action of hospital management. A study conducted in Santa Catarina (Brazil) with nursing professionals identified weakness in hospital management, and the results found pointed out to the need for support from management regarding patient safety(77 Carvalho REFL, Cassiani SHB. Cross-cultural adaptation of the Safety Attitudes Questionnaire - Short Form 2006 for Brazil. Rev Latino-Am Enfermagem. 2012;20(3):575-82. doi: 10.1590/S0104-11692012000300020.
https://doi.org/10.1590/S0104-1169201200...
).

Regarding the perceptions of collaboration among professionals, it was found that most participants agreed with the propositions, indicating that the nurses' suggestions are well received in this area, having support when they need other members of the team to care for patients, and it is common that professionals working in this area frequently ask questions when they do not understand something.

Findings similar to those mentioned above have been identified in both international and national literature. Thus, in an investigation in the context of an oncology hospital in the United States of America with nurses, residents and hospital physicians and oncologists, it was found that the collaboration of nurses was high in the perception of all professionals(1414 Wermelinger M, Machado MH, Tavares MFL, Eliane dos Santos de Oliveira ES, Moysés NMN. A Força de Trabalho do Setor de Saúde no Brasil: Focalizando a Feminização. Rev Divulg Saúde Debate [Internet]. 2010 [cited 2018 Aug 10];45:54-70. Available from: http://www.ensp.fiocruz.br/observarh/arquivos/A%20Forca%20de%20Trabalho%20do%20Setor%20de%20Saude%20no%20Brasil%20.pdf
http://www.ensp.fiocruz.br/observarh/arq...
). In Ireland, most of the health professionals also had a high perception when evaluating communication and collaboration with nurses, despite having low rates in communication and collaboration with the medical team(1515 Somense CB, Duran ECM. Fatores higiênicos e motivacionais do trabalho do enfermeiro em enfermaria de cardiologia. Rev Gaúcha Enferm [Internet]. 2014 [cited 2018 Oct 13];35(3):82-89. Available from: www.seer.ufrgs.br/revistagauchadeenfermagem
www.seer.ufrgs.br/revistagauchadeenferma...
).

These findings corroborate the national investigation that applied the SAQ in a private hospital, located in the state of Minas Gerais (Brazil), including a total of 123 health professionals, in which 74.8% evaluated communication and collaboration with nurses as good, 71.5 % with physicians and 57.7% with pharmacists(1616 Weaver AC, Callaghan M, Cooper AL, Brandman J, O'Leary KJ. Assessing interprofessional teamwork in inpatient medical oncology units. J Oncol Pract. 2015;11(1):19-23. doi: 10.1200/JOP.2014.001536
https://doi.org/10.1200/JOP.2014.001536...
).

Although health professionals act on behalf of the patient, it must be considered that each professional category has its specificity, technical and non-technical knowledge, as well as peculiar behaviors, values and attitudes. Therefore, the level of education and gender are outstanding characteristics, in which the perceptions of these professionals differ(1717 Relihan E, Glynn S, Daly D, Silke B, Ryder S. Measuring and benchmarking safety culture: application of the safety attitudes questionnaire to an acute medical admissions unit. Ir. j. med. sci. 2009. 178(4):433-9. doi: 10.1007/s11845-009-0352-2
https://doi.org/10.1007/s11845-009-0352-...
).

The total SAQ obtained a mean of 66.6 (SD=15), and in the analysis among the domains, Job Satisfaction achieved better favorability, followed by the Teamwork climate and Stress recognition. Thus, the participants showed positive feelings in the experience of developing their activities in the work unit, and satisfaction can be understood as the extent to which workers like their work activity. So, the greater the satisfaction, the greater the commitment to work(1818 Barbosa MH, Floriano DR, Oliveira KF, Nascimento, KG, Ferreira LA. Patient safety climate at a private hospital. Texto Contexto Enferm. 2016;25(3):e1460015. doi: 10.1590/0104-07072016001460015
https://doi.org/10.1590/0104-07072016001...
). This finding is in line with the one found in the literature, which shows better means in the Job satisfaction domain: 80(1818 Barbosa MH, Floriano DR, Oliveira KF, Nascimento, KG, Ferreira LA. Patient safety climate at a private hospital. Texto Contexto Enferm. 2016;25(3):e1460015. doi: 10.1590/0104-07072016001460015
https://doi.org/10.1590/0104-07072016001...
-1919 Gabrani A, Hoxha A, Simaku A, Gabrani J. Application of the Safety Attitudes Questionnaire (SAQ) in Albanian hospitals: a cross-sectional study. BMJ Open. 2015;5:e006528. doi: 10.1136/bmjopen-2014-006528
https://doi.org/10.1136/bmjopen-2014-006...
) and 98(2020 Hora GPR, Ribas Jr R, Souza MA. Estado da arte das medidas em satisfação no trabalho: uma revisão sistemática. Trends Psychol. 2018;26(2):971-86. doi: 10.9788/tp2018.2-16pt
https://doi.org/10.9788/tp2018.2-16pt...
).

Then, the Teamwork climate domain, which expresses the quality of the relationship and collaboration among team members, obtained the second-best mean (73.8), close to the lower limit established (≥75). A study reported in the literature found a similar mean in this domain, reaching a value of 73.9(2121 Oliveira ICL, Cavalcante MLSN, Freitas SA, Freitas RJM, Silva BV, Marinho DMF, et al. Safety culture: perception of health professionals in a mental hospital. Rev Bras Enferm. 2018;71(suppl5):2316-22. doi: 10.1590/0034-7167-2018-0125
https://doi.org/10.1590/0034-7167-2018-0...
).

As for the Stress perception domain, which reflects the extent to which stressors affect the work activities of professionals, an average score of 73.3 (SD=23.8) was obtained. These results are close to those found in a research developed in a cardiovascular institution, in the state of Parana (Brazil), with institutional characteristics similar to the ones of this study, applying the SAQ, which had favorability scores, average of 77.6(2222 Elsous A, Akbarisari A, Rashidian A, Aljeesh Y, Radwan M, Zaydeh HA. Psychometric properties of an Arabic safety attitude questionnaire (short form 2006). Oman Med J. 2017;32(2):115-23. doi: 10.5001/omj.2017.21
https://doi.org/10.5001/omj.2017.21...
). Among the reasons that lead to stress, we can exemplify the fatigue and everyday tensions that compromise the individuals' physical and psychosocial well-being, causing damage to the organization and, also, compromising the patients' safety.

The lowest average scores were verified in the hospital and unit management perception domains. Such findings are analogous to those reported in the literature(1818 Barbosa MH, Floriano DR, Oliveira KF, Nascimento, KG, Ferreira LA. Patient safety climate at a private hospital. Texto Contexto Enferm. 2016;25(3):e1460015. doi: 10.1590/0104-07072016001460015
https://doi.org/10.1590/0104-07072016001...
,2323 Barbosa MH, Sousa EM, Felix MMS, Oliveira KF, Barichello E. Patient safety climate in a hospital specialized in oncology. Rev Eletrôn Enferm. 2015;17(4):1-9. doi: 10.5216/ree.v17i4.xxx
https://doi.org/10.5216/ree.v17i4.xxx...
). It is worth pointing out that several factors can contribute to the results in relation to management in the study context, such as: different forms of relationship, diversified contractual workload, among others, in a single space of local management of the health system.

In a setting like this, it is difficult to find a counterpoint to promote acceptance of such diverse led people groups. Thus, the support and encouragement of hospital managers are important steps to provide better patient safety(2424 Misiak M, Radünz V, Dal Sasso GTM, Tourinho FSV. Atitudes para cultura de segurança do paciente em uma instituição cardiovascular. Rev Varia Sci [Internet]. 2016 [cited 2018 Sep 03];2(2):102-14. Available from: http://e-revista.unioeste.br/index.php/variasaude/article/view/15453/10777
http://e-revista.unioeste.br/index.php/v...
).

The comparison of means among the domains of SAQ and the variables professional category, gender and employment relationship of health professionals pointed out that other workers obtained better scores in the domain Teamwork climate, Stress recognition, unit management perception and Work conditions with statistically significant differences when compared to the nursing team. Similar data were found in studies developed in teaching hospitals(1717 Relihan E, Glynn S, Daly D, Silke B, Ryder S. Measuring and benchmarking safety culture: application of the safety attitudes questionnaire to an acute medical admissions unit. Ir. j. med. sci. 2009. 178(4):433-9. doi: 10.1007/s11845-009-0352-2
https://doi.org/10.1007/s11845-009-0352-...
-1818 Barbosa MH, Floriano DR, Oliveira KF, Nascimento, KG, Ferreira LA. Patient safety climate at a private hospital. Texto Contexto Enferm. 2016;25(3):e1460015. doi: 10.1590/0104-07072016001460015
https://doi.org/10.1590/0104-07072016001...
). Although health professionals act on behalf of the patient, it must be considered that each professional category has its specificity, technical and non-technical knowledge, as well as its own sociodemographic characteristics.

Therefore, we can say that, due to direct contact with the patient, the nursing team experiences care uninterruptedly, which is close to the risks associated with patient safety, having a critical perception of reality. In the United States of America, a hospital specialized in oncology showed that nurses rated the Teamwork climate with lower averages compared to physicians and residents(1414 Wermelinger M, Machado MH, Tavares MFL, Eliane dos Santos de Oliveira ES, Moysés NMN. A Força de Trabalho do Setor de Saúde no Brasil: Focalizando a Feminização. Rev Divulg Saúde Debate [Internet]. 2010 [cited 2018 Aug 10];45:54-70. Available from: http://www.ensp.fiocruz.br/observarh/arquivos/A%20Forca%20de%20Trabalho%20do%20Setor%20de%20Saude%20no%20Brasil%20.pdf
http://www.ensp.fiocruz.br/observarh/arq...
).

The male gender had higher mean scores of SAQ when compared to the female in the domains Teamwork climate, Unit management perception and Work conditions, with a statistically significant difference. It is important to emphasize that, in the work context, men and women have different attitudes and perceptions, in which women are more critical, they value social relationships, wishing to obtain verbal recognition from superiors and status corresponding to their achievements, while men understand that interpersonal relationships at work are more linked to obtaining career-related benefits(2525 Matiello RDC, Lima EFA, Coelho MCR, Oliveira ERA, Leite FMC, Primo CC. Patient safety culture from the perspective of nurses. Cogitare Enferm. 2016;21(esp):1-9. doi: 10.1590/S0080-623420150000200013
https://doi.org/10.1590/S0080-6234201500...
).

Thus, another relevant point refers to the imperative need women have to reconcile the activities of their public and private life: "[...] this double working day affects women in the Third World more intensely, where working and living conditions for this group are visibly worse"(1212 Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006. 6:44. doi: 10.1186/1472-6963-6-44
https://doi.org/10.1186/1472-6963-6-44...
).

A highlight of this investigation was the difference in the perception of the safety climate between statutory and contracted professionals. It was found that contracted workers had higher mean scores compared to statutory ones in six domains (except for Stress recognition). On the other hand, the statutory bond occupies more than half of the team, which may infer that workers with this type of contract have a realistic perception of the institutional context, with knowledge, beliefs and values acquired over the time of work.

Findings in line with the results of this study were reported in a national survey, in which it was found that hired workers had higher averages than statutory professionals in the Working Conditions and Unit management perception domains. The authors reported that these results may be associated with the fact that the hired/outsourced professional does not have stability and responds favorably to the statements for fear of reprisals in the work environment(2626 Huang CH, Wu HH, Lee YC. The perceptions of patient safety culture: a difference between physicians and nurses in Taiwan. Appl Nurs Res. 2018;40:39-44. doi: 10.1016/j.apnr.2017.12.010
https://doi.org/10.1016/j.apnr.2017.12.0...
).

A study also conducted in the national context, aiming to evaluate the culture of patient safety in three hospitals showed that the type of hospital management, the service unit, the position and the amount of notification of adverse events were associated with the patients' safety climate, and the contracted employment relationship obtained better results(2727 Magalhães MO, Macambira MO. Estilos interpessoais e vínculos com a organização: diferenças de gênero. Psico (Porto Alegre) [Internet]. 2013 [cited 2018 Feb 27];44(1):99-102. Available from: http://revistaseletronicas.pucrs.br/ojs/index.php/revistapsico/article/view/10660/8852
http://revistaseletronicas.pucrs.br/ojs/...
). However, the authors emphasized that the professionals' instability due to the type of relationship could inhibit exposure about the hospital negative points, although the Informed Consent Form provided the respondents' anonymity and the confidentiality of the answers.

However, the opposite was found in a study carried out to evaluate the patient safety culture in a mental health service in the state of Ceara (Brazil), applying the SAQ to a total of 103 health professionals, whose results showed that statutory professionals had better scores in the perception of safety culture compared to outsourced workers(2828 Carvalho REFL, Arruda LP, Nascimento NKP, Sampaio RL, Cavalcante MLSN, Costa ACP. Assessment of the culture of safety in public hospitals in Brazil. 2017. Rev Latino-Am Enfermagem. 2017;25:e2849. doi: 10.1590/1518-8345.1600.2849
https://doi.org/10.1590/1518-8345.1600.2...
).

So, the literature presents a study with the objective of identifying suffering at work in public services among workers with contract and state bond employment, showing that both had the condition of suffering, each one in its own way. Another finding pointed out that the hired professionals considered the suffering inherent to work, adopting the adaptive type of behavior(2929 Andrade LEL, Lopes JM, Souza Filho MCM, Vieira Jr RF, Farias LPC, Santos CCM, et al. Cultura de segurança do paciente em três hospitais brasileiros com diferentes tipos de gestão. Ciênc Saúde Coletiva. 2018.;23(1):167-72. doi: 10.1590/1413-81232018231.24392015
https://doi.org/10.1590/1413-81232018231...
).

Thus, it is possible to infer that hired professionals perceive the work environment and its repercussions better when compared to state bond, which can be influenced by the instability of the labor market and the possibilities of employability. On the other hand, the professional with a state bond, for having guaranteed job stability, assumes greater freedom of expression and a critical view of the institutional work environment.

Limitation of the study

The limitations of this study are related to the fact that it was conducted in a tertiary hospital specialized in cardiology, resulting in restrictions for its generalization, and having a reduced participation of professionals from other health areas, although they agreed to participate.

Contributions to the Health Area

This study contributes towards ratifying the complexity of the elements that contribute to patient safety, and understanding and strengthening the safety climate in the organization is essential to qualify care and provide worker safety.

CONCLUSION

The data analysis of this study about the safety climate found that most of the participating professionals were female, represented by the nursing team, in the adult phase of life, with sufficient time in the profession and in the unit to apprehend the elements of the organizational culture and patient safety.

The safety climate has weaknesses, especially in matters involving the hospital and unit management. The type of employment bond significantly influenced the patients' safety climate, followed by gender and the professionals who are members of the nursing team.

These aspects need to be seen and understood as propellers of measures aimed at strengthening the safety culture and safe care, both at the institutional level and in support for new studies. Furthermore, we recommend these studies to be conducted in a qualitative approach in order to understand and elucidate the managerial components of the institutional micro and macro environment.

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Publication Dates

  • Publication in this collection
    30 Sept 2020
  • Date of issue
    2020

History

  • Received
    03 Oct 2019
  • Accepted
    29 June 2020
Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
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