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

e20190549 http://dx.doi.org/10.1590/0034-7167-2019-0549 8 of 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.


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 (1)(2) .
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 (3) , 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 (4)(5) .
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 (6) .
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 (7)(8) .
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 (3) .
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.

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 (9) .

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 (10) .
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  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 (10) .
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 (6) .
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 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).
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).
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.
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 (6) .
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.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.

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 (11) .
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 (12) .
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 (13) .
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 (7) .
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 (14) .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 (15) .
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 (16) .
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 (17) .
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 (18) .This finding is in line with the one found in the literature, which shows better means in the Job satisfaction domain: 80 (18)(19) and 98 (20) .
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 (21) .
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 (22) .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 (18,23) .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 (24) .
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 (17)(18) .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 (14) .
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 (25) .
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" (12) .
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 (26) .
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 (27) .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 (28) .
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 (29) .
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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Table 1 -
Frequency of statements in the Safety Attitudes Questionnaire, according to health professionals, Rio de Janeiro, Brazil, 2018

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

Patient safety climate in the cardiology hospital service: instrument for safety management
Vitorio AMF, Tronchin DMR.

Table 3 -
Means of the domain scores, according to professional category, gender and employment bond, Rio de Janeiro, Brazil, 2018 of Patient safety climate in the cardiology hospital service: instrument for safety management Vitorio AMF, Tronchin DMR.