Working hours and perceived workload interfere with the safety culture of primary care

Abstract

bjective  To verify the association between working hours, perceived workload, and safety culture among Primary Care professionals.

Methods  Survey-type research, carried out between January and July 2023, with Primary Care professionals (n = 355) from a capital city in the Central-West of Brazil. The National Aeronautics and Space Administration - Task Load Index was applied to measure workload and the Medical Office Survey on Patient Safety Culture to assess safety culture. The data were subjected to statistical analysis.

Results  The 12 dimensions of the safety culture were evaluated as weak (< 75%), and 73.8% reported a high workload. A significant association was found between a higher prevalence of positive responses regarding the safety culture and a weekly workload of up to 40 hours in the dimensions “Management support for patient safety” and “Issues related to patient safety and quality” (p < 0.001). An association was also observed between a lower perceived workload and a better evaluation of the safety culture in the dimensions “Work process and standardization” (p = 0.01), “Management support for patient safety” (p = 0.03), and in the overall assessment of safety and quality.

Conclusion  Primary care professionals who worked fewer hours and perceived lower workload evaluated it more positively.

Workload; Patient Safety; Primary Health Care; Organizational Culture; Health Personnel; Occupacional Health

Resumo

Objetivo  Analisar a associação entre jornada laboral, carga de trabalho percebida e cultura de segurança em profissionais da Atenção Primária à Saúde.

Métodos  Estudo transversal, com coleta de dados on-line e amostra não probabilística, realizado em 2023, em uma capital do Centro-Oeste do Brasil. Aplicou-se o National Aeronautics and Space Administration - Task Load Index para aferir a carga de trabalho e o Medical Office Survey on Patient Safety Culture para avaliar a cultura de segurança.

Resultados  Participaram 355 trabalhadores, 77,7% do sexo feminino. As 12 dimensões da cultura de segurança foram avaliadas como fracas (< 75%) e 73,8% referiram alta carga de trabalho. Verificou-se associação entre respostas positivas da cultura de segurança e carga semanal até 40h nas dimensões “Apoio dos gestores na segurança do paciente” e “Questões relacionadas à segurança do paciente e qualidade” (p < 0,001). Observou-se associação entre menor carga de trabalho percebida e melhor avaliação da cultura de segurança nas dimensões “Processo de trabalho e padronização” (p = 0,01), “Apoio dos gestores na segurança do paciente” (p = 0,03) e “Avaliação geral de segurança e qualidade”.

Conclusão  Os profissionais que trabalhavam menos horas e percebiam menor carga de trabalho avaliaram mais positivamente a cultura de segurança do paciente.

Carga de Trabalho; Segurança do Paciente; Atenção Primária à Saúde; Cultura Organizacional; Pessoal de Saúde; Saúde do Trabalhador

Introduction

Safety culture can be understood as a set of values and behaviors related to safety and shared by members of an organization. To this end, it must be supported by technologies capable of constantly and sustainably minimizing risks, to prevent avoidable damage and mitigate it when it occurs¹,².

Evaluating safety culture makes it possible to understand how involved health professionals and institutions are in providing safe care². Although the subject is continually addressed in research carried out in the medium and high-complexity spheres, there is a lack of progress when it comes to Primary Health Care (PHC)³. This is an important gap, because this level of care is not exempt from errors and adverse events associated with the provision of care, as already reported by a systematic review that analyzed 33 primary studies⁴. The occurrence of these incidents in PHC is mostly related to failures in team communication⁴, an elementary artifact of the safety culture¹,².

Recognizing that the patient safety culture is still an issue to be discussed in PHC³, it can be inferred that for the National Patient Safety Program (PNSP) to be effective in Brazil, it is necessary to involve the entire care network, especially the Family Health Strategy (ESF), the guiding axis of the Brazilian care model⁵.

Notoriously, the consolidation of the care model and the health system and, consequently, the safety of the care it produces are closely related to labor management, including in PHC⁶. Recent research shows that the context of work management in PHC in different regions of Brazil is marked by problems such as precarious employment relationships⁶, low incentives for continuing education⁷, extensive demands for productivity, and work overload⁸.

That said, among some of the characteristics of PHC, there are numerous risk-generating situations, such as undersizing of human resources, lack of inputs, or insufficient materials, in addition to the need to provide care to a range of users in a short time, multiple and repetitive activities, sometimes without the necessary autonomy, as well as administrative activities⁹,¹⁰, all of which can increase the workload.

Workload can be one-dimensional (e.g. dedicated working time, by contractual regime) or interrelated with other dimensions, as the dynamism of work can lead to more than one type of load¹¹. From the point of view of workers’ health, workload can be classified into groups according to their characteristics: biological, chemical, physical, mechanical, psychological, and physiological¹².

Adding this premise to the characteristics of PHC already mentioned, we have the hypothesis that the workload influences patient safety at this level of care, including in an “indirect” way, such as in the safety culture. Therefore, knowing the workload of PHC professionals can help elucidate their perception of and adaptation to working in this environment, since this is an inherent factor in both the process and the work environment, and is closely linked to workers’ health¹³.

It is thought that workload should be considered in view of its possible influence on the safety culture adopted by health services and PHC professionals and, therefore, there is a need to analyze it, as well as the associated factors. Given these facts, the question is: “What are the relationships between safety culture, working hours, and workload as perceived by PHC professionals?”.

In this context, this study aims to analyze the association between working hours, perceived workload, and safety culture in PHC professionals.

Methods

Study design and context

This was a cross-sectional study, with online data collection, carried out in a capital in the Central-West region of Brazil, with a convenience sample of PHC professionals. The study was guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) tool¹⁴.

The municipality where the research was carried out had 897,938 inhabitants at the time¹⁵. The PHC network consisted of 60 Family Health Units (USF), 11 Basic Health Units (UBS), and three Family Clinics (CF), distributed across seven health districts. These units were mixed, with from one to five teams. In addition to these units, there were three dental polyclinics, three Mobile Dental Care Units (Odontomóvel), a Mobile Oral Health Prevention Unit, 16 teams from the Expanded Family Health and Primary Health Care Center (NASF-AP), a Street Clinic Team (eCR), and six Primary Care Teams for the Prison Population (eAPP)¹⁶,¹⁷. Thus, the primary care network in the municipality surveyed had 101 primary care points¹⁷.

Study size

The population corresponded to professionals working in the USF, UBS, and CF teams, and totaled 4,231 workers at the time. Although probabilistic sampling was not used, the size of the study was defined based on a sample calculation, which considered a finite population (n = 4,231), a 95% confidence level, and a 5% margin of error, and obtained a sample size of 353 participants. Data collection was stopped once the sample size had been reached.

Participants

All professionals working in the municipal PHC network were invited to take part. Professionals were included if they had been working in the position for at least three months, regardless of their contractual regime, as it was considered necessary for the professional to be familiar with the routine of their unit, as well as understanding and experiencing the work in the service under investigation.

The professional categories included doctors, nurses, nursing technicians or assistants, dentists, oral health assistants (ASB), social workers, pharmacists, community health agents (ACS), and those working in the unit’s administrative services.

Professionals who, at the time of data collection, were on leave of any kind (maternity, illness, for treatment of personal interest), or on vacation, as well as preceptors and trainees who were not permanent members of the teams, were excluded.

Data collection

This was a closed survey. The data was collected from January to July 2023, initially online via the Google Forms® digital platform, with a link to allow electronic recording. The link was sent weekly to the e-mail addresses of the units, as well as the health districts, and on the WhatsApp® messaging app of the unit managers, with the request to share it in groups, to reinforce the invitation to participate in the survey. To avoid duplicate participation, the platform automatically informed people that the e-mail address used when accessing the survey had already been used, preventing people from answering the forms more than once.

From May to July, to reach the sample, face-to-face visits were made to some randomly selected units. It should be emphasized that, although the approach and invitation were made in person, the collection remained digital throughout the collection period.

There were no losses due to inadequate or incomplete completion.

Instruments

Three instruments were used to collect the research data, namely: I) a sociodemographic, economic, and functional characterization questionnaire developed by the main author; II) the National Aeronautics and Space Administration - Task Load Index (NASA-TLX)¹⁸, translated and validated for the Brazilian context¹², which aims to assess perceived workload; and III) the Medical Office Survey on Patient Safety Culture (MOSPSC) instrument, which assesses patient safety culture in primary care environments, developed by the Agency for Healthcare Research and Quality¹⁹, also adapted to the Brazilian scenario²⁰.

The characterization instrument included questions about professional category, contractual regime, weekly workload, and training.

The NASA-TLX method shows the perceived workload, its score comprising the weighting of the average evaluated by its six dimensions, namely: I) mental demand, II) physical demand, III) time demand, IV) performance, V) level of effort, and VI) level of frustration. The NASA-TLX is analyzed in two phases: scoring and weighting. In scoring, a kind of metric ruler is presented, in which there are 20 intervals with a weight of five points each, totaling 100 points and the interviewee must indicate, in each dimension, which point is considered to be the perceived intensity of their work. Values above 75 are equivalent to a high workload and values below 75 show a low workload index¹²,¹⁸. Since Google Forms® does not allow a metric ruler up to 100, it was adapted from zero to ten. Therefore, for the calculation, values above 7.5 were considered to be high workload and values below 7.5, low workload.

Finally, the MOSPSC instrument is structured by 51 questions distributed in nine sections (A, B, C, D, E, F, G, H, I) that evaluate 12 dimensions, with questions focused on patient safety and the quality of health services, namely: (I) open communication; (II) communication about error; (III) exchange of information with other sectors; (IV) work process and standardization; (V) organizational learning; (VI) general perception of patient safety and quality; (VII) support from managers in patient safety; (VIII) patient care follow-up; (IX) issues related to patient safety and quality; (X) staff training; (XI) teamwork; and (XII) pressure at work and pace²⁰.

The online questionnaires were continuous, made up of eight sections, containing 27 closed questions, all of which were compulsory, and the average time to answer them was 20 minutes.

Variables

The following demographic and work variables were used in the study: skin color (white, brown, black, yellow, indigenous), age (in years, categorized as: 20 to 39, 40 to 59, 60 and over), gender (female, male), marital status (married or in a relationship, without a partner), job title (nurse, ACS or ACE, dentist, administrative/government advisor/municipal civil guard/health services assistant/oral health assistant, physiotherapist/phonoaudiologist/nutritionist/occupational therapist/pharmacist/physical educator/social worker, doctor, manager, nursing technician or assistant), length of time working in primary care (up to five years, five to ten years, over ten years), weekly working hours (up to 40 hours, 48 to 60 hours), on-call duty (yes, no), schooling/academic training (primary/middle school, higher education/postgraduate studies, length of training, up to five years, five to ten years).

For the analysis of the safety culture variable, the percentage of responses was verified and “strengths” were considered when the average obtained by the interviewees was equal to or greater than 75% as “totally agree/agree or often/always” for the questions outlined positively, and “totally disagree/disagree or never/rarely” for those questions outlined negatively; and “weaknesses” when the average was less than 50% as “totally disagree/disagree or never/rarely” for the questions outlined positively, and “totally agree/agree, always/often” for the questions outlined negatively¹⁹,²⁰.

Data analysis

The data was tabulated in a Microsoft Excel spreadsheet^® and subjected to descriptive and inferential statistical analysis using BioEstat 5.3 software. Categorical variables were expressed as relative (%) and absolute (n) frequencies and their associations were analyzed using Fisher’s exact test and those of larger contingencies were analyzed using Pearson’s chi-square test, with Bonferroni correction to identify the difference between proportions in a paired manner.

The multivariable analysis using logistic regression included the variables that were associated with the event studied in the crude analysis with a p-value of< 0.20.

Ethical aspects

All ethical principles were respected, and the research proposal was approved by the Research Ethics Committee (CEP) involving human beings of the Federal University of Mato Grosso do Sul (UFMS), under opinion No. 5.837.387/2022 and registered under CAAE: 66030522.2.0000.0021, on November 29, 2022.

Online consent

All participants had access to the Free and Informed Consent form signed by the main researcher, which was available for download when they opened the link to the questionnaires. If the professional agreed to take part in the study, a second page would open with the start of the questionnaires; if they did not agree to take part, the form would automatically close. In this way, confidentiality and non-obligation in the study were guaranteed.

Results

355 professionals took part in the research, the majority of whom were female (n = 279; 77.75%), aged between 20 and 39 (n = 202; 56.90%), self-declared white (n = 201; 56.62%), living with a partner (n = 191; 53.8%), with higher education or postgraduate degrees (n = 281; 79.20%), and more than ten years’ training (n = 179; 50.40%). Some of the workers worked shifts in addition to their regular shift at the PHC (n = 137; 38.60%), working more than 40 hours a week. In terms of profession, nurses accounted for the largest proportion (n = 112; 31.60%), followed by ACSs or endemic disease control agents (ACE) (n= 63; 17.70%) (Table 1).

Table 1
Characterization of primary health care workers in terms of demographic and work variables. Capital of the Central-West, Brazil, 2023 (n= 355)

	n	%
Skin color
White	201	56.6
Brown	114	32.1
Black	26	7.3
Continue
Continuation
Yellow	11	3.1
Indigenous	2	0.6
Not informed	1	0.3
Age (years)
20 to 39	202	56.9
40 to 59	147	41.4
over 60	6	1.7
Gender
Female	276	77.7
Male	76	21.4
Not informed	3	0.9
Marital status
Married or in a relationship	191	53.8
Without a partner	164	46.2
Position
Nurse	112	31.6
ACS or ACE	63	17.7
Dentist	40	11.3
Administrative officer/governmental advisor/municipal civil guard/health services assistant/oral health assistant	33	9.3
Physiotherapist/speech therapist/nutritionist/occupational therapist/pharmacist/physical educator/social worker	32	9.0
Doctor	31	8.7
Manager	22	6.2
Nursing technician or assistant	22	6.2
Time working in primary care (years)
Up to five	159	44.8
From five to ten	70	19.7
Over ten	126	35.5
Weekly workload (hours)
Up to 40	336	94.6
48 to 60	19	5.4
Continue
Continuation
On duty	137	38.6
Education
Elementary/middle school	74	20.8
Higher education/post-graduate degree	281	79.2
Training time (years)
Up to five	96	27.0
From five to ten	80	22.6
Over ten	179	50.4

• ACS: community health agent; ACE: endemic disease control agent; APS: Primary Health Care; UPA: Emergency Care Unit; CRS: Regional Health Center; CAPS: Psychosocial Care Center.
• Source: Research data, 2023.

None of the dimensions assessed by the MOSPSC instrument obtained percentages of positive responses classified as “strengths” (above 75%) (Table 2).

Table 2
Distribution of the frequencies of positive responses from primary healthcare professionals according to the dimensions of patient safety culture (n = 355). Central-West capital, 2023

MOSPSC dimensions	Positive Answers
	%	n
1. Open communication	49.7	166
2. Communication about the error	45.0	160
3. Exchange of information with other sectors	41.7	148
4. Work process and standardization	43.4	154
5. Organizational learning	55.2	196
6. General perception of patient safety and quality	51.8	184
7. Support from managers in patient safety	26.7	95
8. Patient care follow-up	63.7	226
9. Issues related to patient safety and quality	49.0	174
10. Staff training	34.4	122
11. Teamwork	60.3	214
12. Pressure at work and pace	18.6	66

• *Values expressed in relative frequency. MOSPSC: Medical Office Survey on Patient Safety Culture.
• Source: Research data, 2023.

Regarding the workload, as assessed by the NASA-TLX method, a total of 73.8% (n = 262) of the professionals were classified as having a high workload. A significant and positive association was identified between low workload according to the overall score of the NASA-TLX method and “Excellent/Very good/Good” responses in the five dimensions of the overall assessment of the MOSPSC instrument, corresponding to the best scores related to patient safety culture (p < 0.05) (Table 3).

Table 3
Association between positive responses to the general assessment of patient safety and the quality of health services with the classification of perceived workload (n = 355). Central-West capital, 2023

General Evaluation MOSPSC	NASA-TLX % (n)		p-value
	High 73,8(262)	Low 26,2(93)
Patient-centered
Excellent/Very good/Good	56.9(149)	72.0(67)	0.010*
Fair/Bad	43.1(113)	28.0(26)
Effective
Excellent/Very good/Good	70.2(184)	83.9(78)	0.009*
Fair/Bad	29.8(78)	16.1(15)
Punctual
Excellent/Very good/Good	49.2(129)	62.4(58)	0.030*
Fair/Bad	50.8(133)	37.6(35)
Efficient
Excellent/Very good/Good	58.4(153)	73.1(68)	0.010*
Fair/Bad	41.6(109)	26.9(25)
Impartial
Excellent/Very good/Good	65.3(171)	81.7(76)	0.003*
Fair/Bad	34.7(91)	18.3(17)

• *Significant association by Fisher’s exact test. MOSPSC: Medical Office Survey on Patient Safety Culture; NASA-TLX: National Aeronautics and Space Administration - Task Load Index.
• Source: Research data, 2023.

An association was found between positive responses (totally agree/agree/always/often) and a weekly workload of up to 40 hours in the dimensions described in the MOSPSC instrument: “Exchange of information with other sectors” (p = 0.03), “Support from managers in patient safety” (p< 0.01) and “Issues related to patient safety and quality” (p < 0.01) (Table 4).

Table 4
Association of positive responses in the dimensions of patient safety culture with the weekly workload of professionals (n = 355). Central-West capital, 2023

MOSPSC dimensions	Weekly workload				p-value
	Up to 40 hours (n = 336)		> 40h (n = 19)
	%	(n)	%	(n)
Open communication	46.3	(156)	56.6	(10.8)	0.10
Communication about error	44.9	(151)	44.7	(8.5)	1.00
Continue
Continuation
Exchange of information with other sectors	42.4	(143)	28.9	(5.5)	0.03*
Workprocess and standardization	43.8	(147)	38.2	(7.3)	0.40
Organizational learning	55.3	(186)	54.4	(10.3)	0.89
General perception of patient safety and quality	48.2	(162)	48.7	(9.3)	1.00
Support from managers in patient safety	47.3	(159)	19.7	(3.8)	< 0.01*
Patient care follow-up	63.6	(214)	64.5	(12.3)	1.00
Issues related to patient safety and quality	49.0	(165)	24.7	(4.7)	< 0.01*
Staff training	34.8	(117)	28.1	(5.3)	0.32
Teamwork	60.3	(203)	60.5	(11.5)	1.00
Pressure at work and pace	18.5	(62)	18.4	(3.5)	1.00

• *Significant association by Fisher’s exact test. Positive values expressed in relative and absolute frequency %(n). MOSPSC: Medical Office Survey on Patient Safety Culture.
• Source: Research data, 2023.

The association between high workload and negative safety culture related to “Work process and standardization” and, consequently, low workload and positive perception of safety in this dimension (p = 0.01), as well as the dimension “Support from managers in patient safety” (p = 0.03), also proved to be significant. The other associations were not statistically significant (p ≥ 0.05) (Table 5).

Table 5
Association of responses related to patient safety culture with perceived workload (n = 355). Central-West capital, 2023

MOSPSC dimensions	Perceived Workload (NASA-TLX)				p-value
	High (n = 262)		Low (n = 93)
	Positive	Negative	Positive	Negative
Open communication	44.5(117)	55.4(145)	53.2(50)	46.8(44)	0.18
Communication about error	43.0(113)	57.0(149)	50.3(47)	49.7(46)	0.23
Exchange of information with other sectors	42.8(112)	57.2(150)	38.4(36)	61.6(57)	0.54
Work process and standardization	39.3(103)	60.7(159)	55.1(51)	44.9(42)	0.01*
Organizational learning	53.8(141)	46.2(121)	59.1(55)	40.9(38)	0.40
General perception of patient safety and quality	49.0(128)	51.0(134)	59.7(56)	40.3(38)	0.09
Support from managers in patient safety	23.6(62)	76.4(200)	35.2(33)	64.8(60)	0.03*
Patient care follow-up	63.5(166)	36.5(96)	64.2(60)	35.8(33)	0.90
Continue
Continuation
Issues related to patient safety and quality	49.0(128)	51.0(134)	49.4(46)	50.6(47)	1.00
Staff training	32.4(85)	67.6(177)	40.1(37)	59.9(56)	0.21
Teamwork	58.1(152)	41.9(110)	66.7(62)	33.3(31)	0.17
Pressure at work and pace	16.3(43)	83.7(219)	24.5(23)	75.5(70)	0.09

• *Significant association by Fisher’s exact test. Values expressed in relative and absolute frequency %(n). MOSPSC: Medical Office Survey on Patient Safety Culture; NASA-TLX: National Aeronautics and Space Administration - Task Load Index.
• Source: Research data, 2023.

Discussion

This study showed that none of the 12 dimensions of safety culture had a percentage of positive responses classified as strengths (above 75.0%) and most professionals reported a high workload (73.8%). There was an association between high workload and a worse perception of patient safety culture among PHC professionals, which corroborates the results of other studies that did not show strong dimensions of safety culture²¹-²³.

This reveals the fragility of establishing a safety culture in the PHC environment, and it is inferred that strengthening this culture also involves mitigating the workload of professionals. In addition to the need for human resources, there is also a need for constant evaluation of the work process, to generate input for planning actions and the definition of roles among team members.

The dimension of safety culture most highly rated in this study was “Patient care follow-up”, with almost two-thirds of professionals suggesting that the network tries to follow recommended programs. This result may be influenced by the various follow-up and health care programs that take place in PHC, such as HIPERDIA (hypertension and diabetes control), immunization, oral health, Rede Cegonha (low-risk prenatal and puerperium follow-up), tuberculosis and leprosy²⁴, among others. Thus, since the bond is a main characteristic of the care provided in the health unit, it is expected that follow-up will be a concern of the professionals.

There was a significant association between a higher frequency of low workload and a higher prevalence of “Excellent/Very good/Good” responses in the five dimensions of the general assessment of patient safety and health service quality, which classifies the service as patient-centered, effective, punctual, efficient, and impartial (in terms of ethnicity, gender, and socioeconomic status), showing that the highest scores related to patient safety culture are associated with a higher prevalence of low workload (p < 0.05). This finding corroborates the hypothesis that lower workloads result in safer care in the perception of professionals. This is because, for effective and/or efficient patient care to take place, there is a need for health workforce management and resources in the work environment²⁵, which allow for professional qualification.

Patient-centered care favors actions to promote and protect health²⁶, enabling the co-production of care between professionals, service users, and families, based on respect and overcoming barriers to promote quality care²⁷. Within the scope of PHC, health care is not restricted to the structural walls of the units, as the professionals working there offer actions and care in homes, schools, permanent institutions, among others²³,²⁴,²⁸.

A study has shown that high workloads have a direct influence on workers’ ability to pay attention, making self-care more difficult and thus increasing the risk of patient care¹⁰. When the dimensions of the safety culture were compared with the weekly working hours, the dimension “Exchange of information with other sectors” (41.7%) was evaluated as a weakness by the workers and was associated with working over 40 hours a week. The literature review pointed out that long working hours lead to situations of patient insecurity²⁹.

The exchange of information between units through referrals and counter-referrals is essential between health teams²⁴, an important activity for PHC, as it is the organizer of care in networks. This attribution can be jeopardized by a stressful workday, since PHC workers are inserted in a context of work overload and stressful working conditions³⁰due to the various care and administrative activities⁹,¹⁰, inadequate physical structure of the units, lack of maintenance, lack of basic supplies such as medication and beds, which can increase the workload of professionals.

There was an association between a higher prevalence of positive responses and weekly working hours of up to 40 hours in the dimensions “Support from managers in patient safety” (p < 0, 01) and “Issues related to patient safety and quality” (p < 0, 01). Similar results were found in a study carried out in the south of the country²³, which raises questions about the exhaustion perceived by professionals, given that management support is essential for PHC workers²⁹,³¹, as the programs and protocols developed are often complex.

Standardization in the health service is essential for dealing with care and management issues³², facilitating the organization and flow of the service²⁵. That said, “Work process and standardization” was mostly negative (n = 159, 60.7%) for those professionals exposed to a high workload. Standardization is essential when it comes to health services, since by organizing protocols, standard operating procedures, and life cycle care flows, it is possible to apply new technologies, making care more robust, based on the principles of the Unified Health System³¹and strengthening the safety culture.

Another dimension that resulted in an association between high workload and a negative safety culture was “Support from managers in patient safety” (p = 0.03). The lack of support from managers was also found in other studies that assessed patient safety culture in primary care in the South²³,³³ and North³⁴ of the country. In this way, we can see that this need is not exclusive to the Central-West region investigated, but perhaps nationwide, and requires a change in the attitude of health managers. From this perspective, it can be inferred that a just culture involves open communication and the reporting of incidents in the search for improved care, which can be achieved with the support of managers and permanent and continuing education actions.

This study is subject to selection bias due to non-probability sampling. In addition, the sample size was insufficient to reach a minimum size in subgroups defined by professional categories and employment relationships, for example, which prevented stratified analyses from being carried out. Despite this, the findings of this study can contribute to discussions about workload in PHC, to reflect the factors that trigger workload and strengthen the safety culture in this area of the care network.

Conclusion

The conclusion is that, although the patient safety culture was fragile overall in the PHC setting investigated, there is evidence that professionals with shorter working weeks and a lower perceived workload evaluate the safety culture better, since they are more rested and, consequently, more attentive and willing to continue providing care and services.

And, to achieve both a safety culture and safe patient care, it is necessary to analyze the workforce management process and the resources used in health. Thus, we need to reflect on how overloaded primary care professionals are, given that PHC is the basis of the single public health system and takes up a large part of the health workforce.

In this way, it can be inferred that a better-balanced workload can result in a more consolidated patient safety culture among professionals, as they are less overburdened and tend to provide care with more propriety and confidence.

References

• ¹ Guldenmund FW. The nature of safety culture: a review of theory and research.Saf Sci. 2000 Feb;34(1-3):215-57. https://doi.org/10.1016/S0925-7535 (00)00014-X
  » https://doi.org/10.1016/S0925-7535 (00)00014-X
• ² World Health Organization. Patient Safety. Global patient safety action plan 2021-2030: towards eliminating avoidable harm in health care .Geneve: World Health Organization; 2021.
• ³ Junges JR, Schaefer R, Lopes PPS, Altissimo FC, Coral GP, Salvador, RF, et al. A segurança do paciente na atenção primária à saúde: uma revisão de escopo. Rev Cient RECISATEC. 2022;2(5):1-31. https://doi.org/10.53612/recisatec.v2i5.124
  » https://doi.org/10.53612/recisatec.v2i5.124
• ⁴ Marchon SG, Mendes WV Jr. Patient safety in primary health care: a systematic review. Cad Saude Publica. 2014 Sep;30(9):1815-35. https://doi.org/10.1590/0102-311X00114113
  » https://doi.org/10.1590/0102-311X00114113
• ⁵ Matos MEC, Bowes ECS. Aspectos metodológicos para priorização de municípios: a experiência da diretoria da atenção básica. Rev Baiana Saúde Pública. 2021;45(esp_3):53-64. https://doi.org/10.22278/2318-2660.2021.v45.nEspecial_3.a3541
  » https://doi.org/10.22278/2318-2660.2021.v45.nEspecial_3.a3541
• ⁶ Lopes WP, Carvalho BG, Santini SML, Mendonça FF, Martins CP. Contexto sociopolítico e a organização da força de trabalho e oferta de serviços da Atenção Básica. Trab Educ Saude. 2023;21: e02005221. https://doi.org/10.1590/1981-7746-ojs02005
  » https://doi.org/10.1590/1981-7746-ojs02005
• ⁷ Gleriano JS, Fabro GC, Tomaz WB, Forster AC, Chaves LD. Gestão do trabalho de equipes da saúde da família. Esc Anna Nery. 2021;25(1):e20200093. https://doi.org/10.1590/2177-9465-ean-2020-0093
  » https://doi.org/10.1590/2177-9465-ean-2020-0093
• ⁸ Santos RPO, Chinelli F, Fonseca, AF. Novos modelos de gestão na atenção primária à saúde e as penosidades do trabalho. Caderno CRH. 2022;35:e022037. https://doi.org/10.9771/ccrh.v35i0.43776
  » https://doi.org/10.9771/ccrh.v35i0.43776
• ⁹ Biff D, Pires DE, Forte EC, Trindade LL, Machado RR, Amadigi FR, et al. Cargas de trabalho de enfermeiros: luzes e sombras na Estratégia Saúde da Família. Cien Saude Colet. 2020 Jan;25(1):147-58. https://doi.org/10.1590/1413-81232020251.28622019
  » https://doi.org/10.1590/1413-81232020251.28622019
• ¹⁰ Gomes MR, Araújo TM, Soares JF, Sousa CC, Lua I. Estressores ocupacionais e acidentes de trabalho entre trabalhadores da saúde. Rev Saude Publica. 2021;55:98. https://doi.org/10.11606/s1518-8787.2021055002938
  » https://doi.org/10.11606/s1518-8787.2021055002938
• ¹¹ Mendes M, Trindade LL, Pires DEP, Biff D, Martins MMFPS, Vendruscolo C. Cargas de trabalho na Estratégia Saúde da Família: interfaces com o desgaste dos profissionais de enfermagem. Rev Esc Enferm USP. 2020;54:e03622. https://doi.org/10.1590/S1980-220X2019005003622
  » https://doi.org/10.1590/S1980-220X2019005003622
• ¹² Ciofi-Silva CL, Cordeiro L, Oliveira NA, Mainardi GM, Levin AS, Almeida RM, et al. Avaliação da carga de trabalho: adaptação transcultural, validade de conteúdo e confiabilidade de instrumento. Rev Bras Enferm. 2023;76(3):e20220556. https://doi.org/10.1590/0034-7167-2022-0556pt
  » https://doi.org/10.1590/0034-7167-2022-0556pt
• ¹³ Coelho AP, Beck CL, Silva RM, Vedootto DO, Prestes FC. Cargas de trabalho de catadoras de materiais recicláveis: proposta para o cuidado de enfermagem [Internet]. Rev Gaucha Enferm. 2018;39:e2018-0006. https://doi.org/10.1590/1983-1447.2018.2018-0006
  » https://doi.org/10.1590/1983-1447.2018.2018-0006
• ¹⁴ Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies [Internet]. J Clin Epidemiol. 2008 Apr;61(4):344-9. https://doi.org/10.1016/j.jclinepi.2007.11.008
  » https://doi.org/10.1016/j.jclinepi.2007.11.008
• ¹⁵ Instituto Brasileiro de Geografia Estatística. Cidades e Estados. Brasília, DF: Instituto Brasileiro de Geografia Estatística; 2023. em: https://www.ibge.gov.br/cidades-e-estados/ms/campo-grande.html Acesso em: 3 jan. 2023.
  » https://www.ibge.gov.br/cidades-e-estados/ms/campo-grande.html
• ¹⁶ Campo Grande. Prefeitura. Coordenadoria de Atenção Básica. Carteira de Serviços. Relação de serviços prestados na Atenção Primária à Saúde. Campo Grande: Prefeitura Municipal de Campo Grande; 2023.
• ¹⁷ Ministério da Saúde (BR).e-Gestor Atenção Básica. Departamento de Atenção Básica. Núcleo de Tecnologia da Informação [Internet]. Disponível em: https://acesso-egestoraps.saude.gov.br/ Acesso em: 03 jan. 2023.
  » https://acesso-egestoraps.saude.gov.br/
• ¹⁸ Hart SG, Staveland LE. Development of NASA-TLX (task load index): results of empirical and theoretical research. Adv Psycho. 1988;52:139-83. https://doi.org/10.1016/S0166-4115 (08)62386-9
  » https://doi.org/10.1016/S0166-4115 (08)62386-9
• ¹⁹ Agency for Healthcare Research and Quality. Surveys on Patient Safety Culture. 2007. Rockville: Agency for Healthcare Research and Quality; 2022 [citado 03 Ago. 2022]. Disponível em: https://www.ahrq.gov/sops/surveys/medical-office/index.html
  » https://www.ahrq.gov/sops/surveys/medical-office/index.html
• ²⁰ Timm M, Rodrigues MC. Adaptação transcultural de instrumento de cultura de segurança para a Atenção Primária. Acta Paul Enferm [Internet]. 2016;29(1):26-37. https://doi.org/10.1590/1982-0194201600005
  » https://doi.org/10.1590/1982-0194201600005
• ²¹ Bohrer JK, Vasconcelos AC, Bezerra AL, Teixeira CC, Andrade J, Santos PH, et al. Patient safety culture in Primary Health Care. Rev Rene. 2021 Aug;220:e70874. https://doi.org/10.15253/2175-6783.20212270874
  » https://doi.org/10.15253/2175-6783.20212270874
• ²² Araújo GL, Amorim FF, Miranda RC, Amorim FF, Santana LA, Göttems LB. Patient safety culture in primary health care: medical office survey on patient safety culture in a Brazilian family health strategy setting [Internet]. PLoS One. 2022 Jul;17(7):e0271158. https://doi.org/10.1371/journal.pone.0271158
  » https://doi.org/10.1371/journal.pone.0271158
• ²³ Mocelin FM, Alvarez AG, Reckziegel JC. Cultura de segurança do paciente na atenção primária à saúde na perspectiva dos enfermeiros. RSC. 2024;3(1):69-88. https://revistasaudecomportamento.emnuvens.com.br/rsc/article/view/43/54
  » https://revistasaudecomportamento.emnuvens.com.br/rsc/article/view/43/54
• ²⁴ Brasil. Portaria de Consolidação nº 1, de 2 de junho de 2021. Consolidação das normas sobre Atenção Primária à Saúde. Diário Oficial União. 8 jun 2021.
• ²⁵ Dias NT, Costa AM, Martinez MR. A humanização como estratégia de gestão de pessoas para os profissionais da enfermagem: ensaio teórico reflexivo. Braz J Dev. 2020;6(2):7762-75. https://doi.org/10.34117/bjdv6n2-180
  » https://doi.org/10.34117/bjdv6n2-180
• ²⁶ Costa KC, Gaban RDM, Lourenço MCS, Secco LC, Creazzo KD, Ferrante SK, Gemignani EYMY, Sousa LVA. Relação entre os serviços fornecidos pela atenção primária e o cuidado integral da população: uma revisão integrativa. RESP. 2023;1(1):1-18. https://doi.org/10.59788/resp.v1i1.11
  » https://doi.org/10.59788/resp.v1i1.11
• ²⁷ Costa DG, de Moura GM, Canever BP, Weimer LE, Kassick F, da Costa FG, et al. Experiência do paciente: caminhos percorridos e a percorrer na coprodução do cuidado centrado no paciente. Research Soc Dev. 2022 Jan;11(1):e32911124899-e32911124899. https://doi.org/10.33448/rsd-v11i1.24899
  » https://doi.org/10.33448/rsd-v11i1.24899
• ²⁸ Fullman N, Yearwood J, Abay SM, Abbafati C, Abd-Allah F, Abdela J, et al. Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016. Lancet. 2018 Jun;391(10136):2236-71. https://doi.org/10.1016/S0140-6736 (18)30994-2
  » https://doi.org/10.1016/S0140-6736 (18)30994-2
• ²⁹ Campos BM, Mendes DF, Martins GE. Relação da sobrecarga de trabalho da equipe de enfermagem na segurança dos pacientes. Contemporanea. 2023 Oct;3(10):19327-49. https://doi.org/10.56083/RCV3N10-145
  » https://doi.org/10.56083/RCV3N10-145
• ³⁰ Santos POR, Nunes JA, Dias NG, Lisboa AS, Antunes VH, Pereira EJ, et al. Condições de trabalho na atenção primária à saúde na pandemia de COVID-19: um panorama sobre Brasil e Portugal. Ciencia & Saude Coletiva. 2023 Oct 1;28(10):2979-92. https://doi.org/10.1590/1413-812320232810.10002023
  » https://doi.org/10.1590/1413-812320232810.10002023
• ³¹ Diaz PS, Barth PO, Silva MP, Ferreira DS, Brehmer LCF, Brito MJM, et al. Gestão e ambientes de trabalho na atenção primária à saúde: revisão de escopo. REME - Rev Min Enferm. 2022 Dec;26:e-1489. https://doi.org/10.35699/2316-9389.2022.40472
  » https://doi.org/10.35699/2316-9389.2022.40472
• ³² Pantoja CSM, Carmo WLN, Pureza NS, Costa DF, Santos DN, Tavora JA. A importância do apoio institucional na implementação de protocolos e fluxos assistenciais na atenção primária em saúde de municípios do estado do Amapá: relato de experiência. Braz J Dev. 2022;8(5):39387-408. https://doi.org/10.34117/bjdv8n5-434
  » https://doi.org/10.34117/bjdv8n5-434
• ³³ Sandoval LG, Blatt CR, Daudt CG, Bergmann J, Bruschi LP. Cultura de segurança do paciente na Atenção Primária à Saúde. Revista APS. 2022 abr-jun;25(3):494-517.
• ³⁴ Santos FB, Hang AT, Pinheiro AS, Pereira PP, Pontes DO, Júnior EF, et al. A cultura de segurança do paciente da Atenção Primária à Saúde no Norte no Brasil. Saude Colet (Barueri). 2025;15(92):13772-8. https://doi.org/10.36489/saudecoletiva.2024v14i92p13772-13785
  » https://doi.org/10.36489/saudecoletiva.2024v14i92p13772-13785

• Information about academic work:
  The authors inform that the work was based on the master’s thesis by Cynthia Fernanda Teles Machado, entitled “Cultura de segurança e carga de trabalho de profissionais da Atenção Primária à Saúde” (Safety culture and workload of Primary Health Care professionals), presented in 2023 to the Postgraduate Program in Nursing at the Federal University of Mato Grosso do Sul.
• Data availability:
  The entire data set supporting the results of this study is available on request from the corresponding author.
• Presentation at a scientific event:
  The authors declare that the study has not been presented at a scientific event.
• Funding:
  The authors declare that the study was not funded.

Edited by

• Editor-in-Chief:
  Leila Posenato Garcia

Data availability

The entire data set supporting the results of this study is available on request from the corresponding author.

Publication Dates

• Publication in this collection
  22 Aug 2025
• Date of issue
  2025

History

• Received
  16 Sept 2024
• Reviewed
  29 Apr 2025
• Accepted
  05 May 2025