Patient safety culture in home care service *

2 Universidade Federal de Goiás, Programa de Pós-Graduação em Medicina Tropical e Saúde Pública, Jataí, GO, Brazil. ABSTRACT Objective: Verify perceptions of the health team about patient safety culture in home care in a large city in Brazilian Midwest region. Method: A survey study involving Safety Attitudes Questionnaire and professional profile inventory. Results: From the 37 professionals, most were female (n = 32, 86.5%), lived with their spouse (n = 25, 67.6%), worked in a statutory work regime (n = 29; 78.4%) and have only one job (n = 23; 62.2%). A higher median score for job satisfaction (80.0) and a lower score for management perception (31.8) were found. There was a negative correlation between weekly workload and teamwork (p = 0.02). Safety climate was significantly higher among consolidated (Consolidação das Leis do Trabalho – CLT) professionals in the safety climate (p = 0.001) and overall (p = 0.005) domains. Physicians had a higher perception of the safety climate domain when compared to professionals in other categories (p = 0.005). Age was positively associated to the climate in the safety (p = 0.002), working conditions (p = 0.03) and overall (p = 0.04) domains. Conclusion: Teamwork and job satisfaction were scored as positive and management actions were considered the main weakness of the safety culture.


INTRODUCTION
The culture of an organization consists of sharing its employees' norms, values, behavioral patterns, rituals and traditions (1) . Specifically, safety culture refers to the value an organization places on the safety and health of its workforce through its policies, procedures and practices, as well as a commitment to provide the necessary resources to adequately address the concerns regarding safety (2)(3) . The safety culture in health services recognizes the inevitability of error and the incorporation of a non-punitive system for reporting and analyzing adverse events, replacing guilt and punishment with the opportunity to learn from failures and to improve healthcare (4) . Further, the patient safety culture in care environments is associated with reduced risk of incidents (1,(5)(6) .
An assessment of patient safety culture is the first step towards its implementation (7) in order to improve care (6) and to support service management through its monitoring, thus influencing organizational changes (3) . Such assessment initially only occurred in the hospital environment (1,(8)(9) , but in recent years its use has been increasing in long-term care facilities (8,10) , elderly homes (9) , and primary attention (1) , as it is understood that risks are present in all healthcare spheres (11) .
There is a shortage of studies which address patient safety culture in the area of home care. Only one qualitative study was found in national and international databases (12) .
In an ever-expanding world, including Brazil (13)(14) , home care is part of a complex context, since patients treated in this environment tend to be older, have a greater number of comorbidities and disabilities, as well as several medical prescriptions, which fragment care. Moreover, such a care context requires an increasing use of previously used hospital technologies, which is associated with a higher risk of errors and adverse events (11,13,15) .
In this perspective, the following guiding question is raised: What is the culture of patient safety in home care from the perspective of health professionals? The objective of this study was to verify the perceptions of the health team about the patient safety culture in home care in a large municipality in the Midwest region of Brazil.

Study deSign
A descriptive, cross-sectional, survey study.

Scenario
The study was developed in the Home Care Service (Serviço de Atenção Domiciliar -SAD), which serves users of the Unified Health System (SUS) of a large city in the Midwest of Brazil.
The municipality was qualified in the Ministry of Health's Best at Home Program in 2012, and provides care to patients in need of multiprofessional care, valuing resource rationality and dehospitalization (16) .

PoPulation and SamPle
The population comprises a multiprofessional group of 38 health professionals selected from the following inclusion criteria: health professionals of both genders who work in the SAD of the municipality, with experience in the service for at least 6 months. The following potential subjects were excluded: professionals who were away from work for vacation, leave of absence, health treatment, absence from work or refusal to participate. From the 38 eligible professionals, only one refused to participate. Thus, the sample consisted of 37 professionals working in the SAD under the management of the Municipal Health Secretariat (SMS) of the studied municipality.

data collection
Data collection was performed from December 1, 2017 to March 31, 2018, on the premises of the SAD professionals' capacity unit, and was previously scheduled with the participants without inconvenience to the service. Participants were instructed to respond to the self-administered assessment form which contained the health professional's profile (age, marital status, type of employment bond, workload and on-the-job training) and the Safety Attitudes Questionnaire (SAQ), and they could consult the researcher if they had any questions.
The SAQ instrument is widely used (1,3,5) , and was chosen because it has good psychometric properties and is validated and culturally adapted to the Brazilian reality. The SAQ is composed of questions involving the perception of patient safety and professional data (position held, gender and length of work time). This instrument measures the perception of health professionals through six domains: Teamwork Climate: items 1 to 6; Safety Climate: items 7 to 13; Job Satisfaction: items 15 to 19; Stress Recognition: items 20 to 23; Perception of Management: items 24 to 29; and Working Conditions: items 30 to 33. Items 14 and 34 to 36 are not part of any domain, and are therefore analyzed separately (17) .
The answer to each question follows a five-point Likert scale. The final score of the instrument ranges from zero to 100, where zero corresponds to the worst perception of safety attitudes by health professionals and 100 to the best perception. Total score values equal to or greater than 75 points are considered positive (17) .

data analySiS and treatment
Data were analyzed using Stata software, version 14.0 (StataCorp, 2015). Descriptive statistics were used to describe the numerical and nominal variables. P-values < 0.05 were considered statistically significant. Cronbach's alpha coefficient was used for internal consistency analysis, with values > 0.7 representing good reliability (18) .
A bivariate analysis was performed to verify the association between demographic and labor variables and the SAQ domains, which was confirmed by the multiple analysis. Pearson's correlation tested the relationship between climate scores and numerical variables. Student's t-test or analysis of variance (ANOVA) for independent samples verified the differences between mean scores of nominal variables. Linear regression analysis examined factors associated with the SAQ domain scores, and variable regression models with a p-value < 0.05 were included in the bivariate analysis of gender and age to fit the models.

ethical aSPectS
The study was approved by the Research Ethics Committee of the Universidade Federal de Goiás, under

RESULTS
A total of 37 questionnaires were answered, thereby comprising 97.4% of the study population. Sociodemographic characteristics showed a mean age of professionals of 38.92 years (SD = 9.89), ranging from 25 to 65 years; five (13.5%) were male and 32 (86.5%) were female. Regarding marital status, 25 participants (67.6%) lived with their spouse and 12 (32.4%) did not have a spouse.
Regarding the professional profile, nine (24.3%) were nursing technicians, eight (21.6%) physicians, six (16.2%) nurses, five (13.5%) physiotherapists, four (10.8%) social workers, two (5.4%) speech therapists, two (5.4%) nutritionists, and one psychologist (2.7%). The employment bond of most professionals was statutory (n = 29; 78.4%), only eight were contracted (21.6%), and 23 (62.2%) had only one job, while the others (n = 14; 37.8%) had two jobs. Regarding working time in such specialty, it was observed that 14 (37.9%) professionals had worked in their respective area for less than 5 years, 12 (32.4%) had worked 5 to 10 years, and 11 (29.7 %) for more than 10 years. The average weekly workload was 44.9 hours (SD = 11.2), ranging from 30 to 70 hours. No professional in the study had patient safety and safety care training. Table 1 details the frequencies of SAQ questions by scale items, with the highest satisfaction percentages in the job satisfaction domain questions (example: 91.9% [n = 34] said they like their work), and lower percentages in the management perception (example: 13.5% [n = 5] responded that management is doing a good job).   2 shows a higher median score for job satisfaction (80.0) and a lower score for management perception (31.8). Regarding Cronbach's alpha values, the following domains showed good reliability: job satisfaction (0.88); overall (0.80), perception of the unit/Municipal Healthy Secretariat management (0.79), and stress recognition (0.71). The comparison between the safety climate domains and the investigated variables (gender, work regime, employment and workload) showed a statistically significant difference between: safety climate and work regime (p = 0.001); safety climate and workload (p = 0.005); overall domain and work regime (p = 0.05). The safety climate was significantly higher among CLT professionals in the safety and overall climate domains. Physicians had a higher perception of the safety climate domain when compared to professionals in other categories (Table 3).  Table 4 shows the correlation between the safety climate and age domains, weekly workload and time in the specialty.
A negative correlation was observed between the weekly workload and teamwork domain (p = 0.02).  Table 5 presents the linear regression analysis of factors associated with safety climate domains obtained in the regression models. The variables with p-value < 0.20 in the bivariate analysis and the gender and age variables were included in the respective domain models for adjustment.
Weekly workload was associated with teamwork climate (p = 0.025). Age was positively associated with safety climate (p = 0.002), working conditions (p = 0.03) and overall (p = 0.04). The work regime showed a statistically significant association with the safety climate (p <0.001) and the overall domain (p = 0.004). The position was positively associated with the overall domain (p = 0.007). Age and gender showed no statistically significant association with job satisfaction (p = 0.64; p = 0.18, respectively), stress recognition (p = 0.67, p = 0.56, respectively), and management perception (p = 0.62; p = 0.92, respectively). The workload and work regime also did not present a statistically significant association with the perception of management (p = 0.30 for the medical team and others; p = 0.09, respectively).

DISCUSSION
The internal reliability of the instrument demonstrated that the job satisfaction, stress recognition, perception of management and overall domains presented Cronbach alpha values higher than 0.70 (18) , confirming the robustness to measure the safety culture in home care.
Knowing the opinion of health professionals is essential to understand the issues related to loss of patient safety, as they are directly linked to care management (6) . The participation of 65% to 85% of the population is considered adequate to evaluate the safety culture (19) . Therefore, the values presented in this study express the perceptions and attitudes about the patient safety culture in the evaluated service.
Regarding the sociodemographic profile of professionals, feminization among health professionals is confirmed as a growing trend (20)(21) . The nursing category is predominant among respondents because it is the majority of professionals in health institutions, as recommended in the SUS home care regulations (16) .
The results obtained in this study indicated that the teamwork climate and stress recognition domains were considered positive for patient safety attitudes. In the teamwork domain, it was found that there was a large percentage of respondents who stated that it was difficult to speak openly when they noticed a problem in patient care. There is a need to improve discussion among team members and openness to error discussion (3,22) .
Studies have examined the barriers that professionals encounter when perceiving problems related to patient care. Power dynamics, feelings of resignation, negative past experiences or ineffectiveness of reported episodes, fear of impairing relationships with colleagues or superiors, and lack of psychological security were identified as the main reasons for a professional's difficulty in expressing themselves. It is concluded that the "organizational climate" is an explicit motivator for a professional's silence on safety issues, and therefore encouragement, reinforcement and development of the team's ability to listen and respond appropriately to the concerns expressed are fundamental (22)(23) .
The safety climate regarding service management showed the worst means of the domains. It is mentioned the strategy to take a proactive and transparent approach to addressing safety issues so that health professionals see that their opinions are valued and followed without a threat of retaliation (23) . Another indication is the need to develop a strong safety climate or share employee perceptions that safety is rewarded, supported, valued and prioritized over other organizational goals (24) .

RESUMEN
Objetivo: Verificar las percepciones del equipo de salud sobre la cultura de seguridad del paciente en la atención domiciliar en un municipio de grande porte en la región Centro-Oeste del Brasil. Método: Estudio tipo Survey, con aplicación del Cuestionario de working conditions with training programs for new staff and hiring a sufficient number of staff (26) .
The lower scores in the perception of management domain suggest low approval of management actions on safety issues, corroborating other studies (25,27) .
A British study revealed that teamwork and positive perceptions by professionals regarding managers were associated with significant gains in patient safety through decreased complications and mortality (7) . Leaders should play a key role in supporting a robust learning system, serve as guardians of the learning system, apply improvement and reliability concepts, and encourage transparency at all levels of the organization (2) , in addition to providing a quality work environment for the workers (5) .
A study based on hospital data suggests that management should focus on implementing combined initiatives to improve continuous quality and safety climate in order to achieve gains in quality and safety outcomes (28) . Knowing the relationships between SAQ domains and how each domains interacts with others is essential for management to have parameters in the decision and to evaluate the cause-effect relationship (29) . Therefore, teamwork and management in support of patient safety are two critical domains for enhancing the safety culture, as they have direct impacts on all other domains except stress recognition (5,29) .
The present study also made it possible to understand the relationship between SAQ domains and the variables of age, time since graduation, experience time in the specialty and type of employment relationship.
Older age is associated with significantly increased scores for safety climate and working conditions, which may be explained by increased attachment to work and a sense of confidence among older people. Another possible explanation would be the better perception of factors which affect patient safety among younger people due to a more recent academic education focused on the patient safety theme (8) . This finding is demonstrated among primary care healthcare professionals in the Netherlands (1) .
Better perception of the work safety climate was observed among medical professionals, who coincidentally are those who have a temporary contract as a work bond. This better perception can be explained by the fact that the precarious bond and lack of stability tend to affect more positive responses due to fear of retaliation (25) . However, it is believed that this is not the main reason for such perception, and the result is attributed to the physicians professional training being more focused on safety culture due to the invasiveness of the procedures they perform.
The results showed that the higher the workload, the worse the perception of the safety climate, which is worrying because workload is associated with a higher risk of errors in care (6) . Damage caused by indignities and inequities in health services is understood to be as preventable and as unacceptable as incorrect surgery and medication errors. Ensuring patient safety is ensuring everyone's right to a free care experience which includes being treated fairly and with dignity (2) .
The peculiarities of home care with the presence of the caregiver and family members who share the patient care with the team and the unique hospital environment demand a safety culture from health professionals who should support, stimulate and train caregivers, requiring a reflection regarding autonomy and safety (11) .
The small sample size was the main limitation of this study, associated with the evaluation of a single service, which limits generalizing the results to other services. The scarcity of home care studies leads to comparisons being constrained by differences in work environments, service levels and safety issues.
In this sense, one emphasizes the importance of the findings in this work environment. Future studies should focus on comparing SAQ with other home care services, especially longitudinal studies, and correlate the outcomes of safety behaviors and attitudes and the magnitude of care incidents. It is also suggested to include the perception of the other actors involved, i.e. management and support services. From the care and managerial point of view, the results of the present study may help to implement strategies to consolidate a safety culture in the service.

CONCLUSION
Teamwork climate and job satisfaction were scored as positive; managerial actions are considered the main weaknesses of the patient's safety culture, representing a warning sign that needs to be improved in the service.