Journal of Sciences, Technology, and Arts Research Vol.2, No.

1, August 2016

Perceived Safety Culture of Healthcare Providers in

Hospitals in the Philippines
Fritz Gerald V. Jabonete1, Leonora R. Concepcion2
1
Assoc. Professor, College of Nursing, National University
2
Dean, College of Nursing, National University

Abstract: Safety culture has been proposed as a means to keep patients safe. Identifying the level of culture and
awareness on patient safety is essential in order to improve the quality of care is crucial. This descriptive, correlation
study determined the perceived safety culture of healthcare providers in selected hospitals in central region in the
Philippines. This study utilized the Manchester Patient Safety Culture Assessment Tool. Generally, healthcare
providers in the public and private hospitals perceived their safety culture at proactive maturity level. Perception in
almost all dimensions of safety culture must be enhanced. Greater emphasis on safety culture dimensions is needed
such as recording and evaluating incidents and communication dimensions of safety culture. Staff education
concerning safety issues and practice has been clearly established. Awareness of the existing safety culture of an
individual or group is the initial step towards improvement of healthcare service through safe and quality care. Age
group is significantly different among healthcare providers who perceived safety culture at reactive (F-5.45),
bureaucratic (F-4.26), and proactive (F-3.66) maturity levels respectively. On the other hand, job position was found
significantly different to those who perceived it at generative (F-3.95) level. However, no significant differences
were found to those who perceived it at reactive, bureaucratic and proactive level respectively. According to area of
assignment, only those who have perceived safety culture at reactive (F-2.26) level have significant differences in
their scores together with length of experience at reactive (F-2.86) level. Interestingly, a significant difference was
found to type of hospital to almost all safety culture level except at bureaucratic level. The findings will guide
hospital leaders to give focus on strategies to improve patient safety. It suggests that group-specific interventions
should be campaigned to improve patient safety.
Keywords: patient safety; safety culture; healthcare providers

I. INTRODUCTION assignment, age and sex, length of experience, and

the type of hospital. However, no relationship was
The key objective of any health system is to established between civil status and the perception of
ensure the safety of the patients. However, it is not healthcare provider’s patient safety culture. It is very
always clear how to establish robust patient safety important to know the relationship between safety
systems across a range of departments and technical culture among healthcare providers in public and
procedures. World Health Organization (2008) private hospitals to build a proof of relationship
recommended that before engaging in interventions which can possibly affect healthcare providers’
designed to achieve a cultural change in an perception to safety culture. A cross-sectional
organization, it is important to assess the current state survey conducted by Al-Ahmadi (2010) in nine
of the safety culture. public hospitals and two private hospitals in Riyadh.
The presence of safety culture is a potentially The key areas that need improvement in public
critical determinant of successes of other activities to hospitals include handoffs and transitions,
improve patient safety (O’Connor, et al., 2007). This communication openness, staffing, and non-
only emphasizes that addressing safety within the punitive response to error. The private hospitals
organization must be prioritized. need an improvement in two aspects; staffing
Listyowardojo et al (2011) determined how and non-punitive response to error. It showed also
different professional groups perceive safety culture. that all types of mistakes were reported more
It showed that there are differences in scores of frequently in private hospitals than in public
organizational and safety cultures across professional hospitals. Interestingly to note that most respondents
groups. Physicians and non-medical workers tended reported “no events" in the twelve months preceding
to rate the dimensions of organizational and safety the survey, with the percentage of not reporting being
culture more positively than did nurses, clinical higher in private sector compared to public hospitals.
workers and laboratory workers. It implied that high percent of "no event" reports
There are other socio-demographic factors that may represent under-reporting in all hospitals.
have showed to influence perception toward safety At the present, there is no known study to
culture. These include job position, area of assess the perception to safety culture between
Journal of Sciences, Technology, and Arts Research Vol.2, No. 1, August 2016

healthcare providers in selected public and private in 2009. ICPS aims to create a classification in which
hospitals in the Philippines. Local literatures patient safety information gathered will be organized
appeared that only few local studies were conducted using a common format to facilitate aggregation,
on patient safety. If there be, most of it would focus analysis and learning across disciplines, borders and
on the medication errors and strategies to cope with time. In 2010, the WHO-ICPS agreed on definitions
it. To fill the gap, the Manchester Patient Safety of 48 concepts related to patient safety. Consensus
Culture Assessment Tool (MaPSCAT) will be was arrived to define patient safety as ‘the reduction
utilized to assess the perception of healthcare in the risk of unnecessary harm associated with
providers of safety culture. healthcare to an acceptable minimum, and risk as the
This study determined the perceived safety probability that the incident will occur’.
culture of healthcare providers in selected public and
private hospitals in Philippines. 1.2 Patient Safety in the Philippines

1.1 Patient Safety as a Global Health Issue World Health Assembly (WHA) on Patient
Safety made the challenge to recognize the need to
According to World Health Organization promote patient safety as fundamental principle of all
(WHO), it is alarming to know that healthcare health systems. Along with this global call, former
industry in general is far left behind by other high- Department of Health (DOH) Secretary Francisco T.
risk industries such as aviation, nuclear energy and Duque released a memorandum under Administrative
shipping in terms of addressing issues concerning Order No. 2008-0023 with subject on National Policy
safety. It is estimated that there is one in three for Patient Safety last July 30, 2008. With this, the
hundred (1/300) chance of patient being harmed country commanded to continually reinforce and
while receiving patient care while only there is only institutionalize the establishment of culture where
one in one million (1/1,000,000) chance of being patient safety is highly regarded as one of the key
harmed while in aircraft. To be said in another way, elements of achieving quality care.
the number of deaths in healthcare related-mistakes Institutionalization of patient safety programs and
would be equivalent to the lives lost if a full- mechanisms for monitoring and evaluation were
passenger airplane crashed every day killing all on highlighted. In keeping with AO 2008-0023, various
board. It is very dreadful to discover that most of organizations like Philippine Alliance for Patient
these untoward events in healthcare happen in Safety, Joint Commission International (Center for
developing countries like the Philippines. This was Patient Safety) and the Department of Health (DOH)
confirmed in a study conducted by the World Health corroborated to support patient safety programs.
Professions Alliance Fact (2008) reiterating that Findings showed that patient safety programs were
developing countries like Philippines have higher established in many healthcare institutions. However,
probability that untoward events in healthcare records are not enough to disclose the real score of
industries are frequent to happen than in the country in terms of valuing patient safety.
industrialized countries. This come to happen due to In 2008, the Philippine Alliance on Patient
poor state of infrastructure and equipments, Safety in Surgery was launched to introduce the
unreliable supply of quality medicines, qualified staff culture of safe surgery in the Philippine hospitals.
and personnel to perform healthcare procedures and The launching is aligned to the global call for patient
low motivation of the staff to implement guidelines safety by the WHO’s World Alliance for Patient
intended to prevent adverse events and to promote Safety. This coalition for patient safety was
safety measures at all times. spearheaded composed of the Philippine College of
In some literature, it was mentioned that inability Surgeon, Department of Health (DOH) and the
to address safety in a proper channel is thought to Philippine Health Insurance Corporation (Philhealth).
happen because of lack of uniform classification of Attempts to search on local literature regarding
patient safety concepts. Battles and Lilford (2003) patient safety were made. It appeared that only few
emphasized that the concept and terms used on safety local studies were conducted on patient safety. If
need to be properly and operationally defined to there be, most of it would focus on the medication
organize patient safety activities that may contribute errors and strategies to cope with it.
in achieving patient safety. In respond to this, the 1.3 Difference of Perception of Safety Culture among
WHO Alliance for Patient Safety developed the Healthcare providers
International Classification for Patient Safety (ICPS)
Journal of Sciences, Technology, and Arts Research Vol.2, No. 1, August 2016

It is evident there are differences in the hospitals. Most respondents reported “no events" in
responses of many professionals and their the twelve months preceding the survey, with the
perceptions of the culture of safety (Singer et al., percentage of not reporting being higher in private
2003). This is an important finding as researchers sector compared to public hospitals. It implied that
must be aware of these differences when analyzing high percent of "no event" reports may represent
cultural data from one organization, or even unit under-reporting in all hospitals.
level, with a number of different professions like in
healthcare industries. 1.4 Social and Work-Related Variables
A survey study by Listyowardojo et al (2011) in There are other factors that have showed to
the University Medical Center Groningen (UMCG) influence perception toward safety culture.
in the Netherlands determined how different
professional groups perceive safety culture. It showed 1.4.1 Age
that members of any professional group were Kitch (2005) reviewed of patient safety culture
considered to hold an executive function if they led a survey instruments that measured perception towards
sector, department, unit, sub-unit or clinic and were safety culture among nurses. It was found out that
involved directly in organizational decision making perceived safety culture differs significantly
or policy making. In general, ratings of according to age and level of education. Specifically,
organizational and safety culture were positive. age was significantly correlated with overall
Results showed that there are differences in ratings of organizational climate. This finding is consistent to
organizational and safety cultures were found across the previous studies of Sveiby & Simons(2002) and
professional groups. Physicians and non-medical Forte, CS. & Hansvick, C. L. (1999). Though very
workers tended to rate the dimensions of few researches revealed the same relationship
organizational and safety culture more positively than between age and organizational culture, however, it is
did nurses, clinical workers and laboratory workers. quite evident that older employees express more
For example, physicians gave more positive ratings moderate opinions about actions in organizations as
of “institutional commitment to safety” than did compared to the young workers. As employees' age
nurses, clinical workers and laboratory workers increase, they develop a kind of occupational bond
(mean=3.71 vs. 3.62, 3.61 and 3.58, respectively, p< and become more oriented to their careers. They also
0.01) and non-medical workers gave more positive enjoy seniority, freedom, playfulness and humor,
ratings than did physicians, nurses, clinical workers sharing opposite view point and create a trust and
and laboratory workers to “perceptions towards the openness at workplaces. They also reach a point of
hospital” (mean= 3.69 vs. 3.39, 3.36, 3.49 and 3.47, settling into their respective organizations and close
respectively, p< 0.001). It concluded that other career options because they become limited by
interventions to promote safety culture should be their efforts, promotions and other investments in the
tailored to the target group as attitudes and organizations (Colarelli & Bishop, 1990).
perceptions may differ among groups.
A cross-sectional survey using Hospital Survey 1.4.2 Job Position
on Patient Safety Culture (HSPSC) was carried out in Singer et al. (2003) found that the perceptions on
2008 by Al-Ahmadi. The questionnaire was safety culture varied significantly among individuals
distributed to all hospitals' staff in Riyadh, which with different job position. Similarly, Abdou (2011)
included nine public hospitals and two private found out that job position in general affects the
hospitals. Results showed that organizational perception of nurses on their safety culture among
learning was the safety culture dimension with nurses in twelve (12) inpatient units at Student
the highest positive response (75.9%), while the University Hospital-Egypt. It was cited also that
non-punitive response to error received the lowest nurses in management positions have generally have
positive response (21.1%). The key areas that need more positive perception and recognize more events
improvement in public hospitals include handoffs than frontline staff nurses.
and transitions, communication openness, staffing,
and non-punitive response to error. The private 1.4.3 Area of Assignment
hospitals need an improvement in two aspects; Grant, Donaldson and Larsen (2006) noted that
staffing and non-punitive response to error. The physicians reported a higher perception of teamwork
results show that all types of mistakes were reported than nursing and other staff members in the inpatient
more frequency in private hospitals than in public and operation room (OR) settings than in the
Journal of Sciences, Technology, and Arts Research Vol.2, No. 1, August 2016

outpatient department. This finding can be interpreted than public hospitals reported errors and incidents,
that area of assignment where an employee used to still, most of these incidents were not evaluated
work might have influence their perception of safety promptly as it happened especially when no harm
culture. occurred.

1.4.4 Length of Experience The interplay of variables directed the researcher

Older nurses are more committed than younger to answer the following questions.
nurses and this can be manifested by an increase job 1. What is the perceived safety culture of
satisfaction and having obtained better safety healthcare providers (physicians, nurses,
attitudes than younger nurses. This can be inferred pharmacists, medical technicians and
that the longer the length of experience rendered in auxiliary workers) in public and private
an organization by an employee the more he will hospitals according to:
embrace the culture of the organization. The longer 1.1. continuous improvement
employees are with the organization, the more time 1.2. priority given to safety
there is to evaluate the relationship (Buchanan, 1.3. system errors and individual
1974). The later argued that member' perceptions of responsibility
their organizational experiences vary with the length 1.4. recording incidents
of time they have been employed by an organization 1.5. evaluating incidents
(i.e. tenure). As a new employee enters an 1.6. learning and effecting change
organization he or she likely to have some views of 1.7. communication
organizational practices that are different from the 1.8. personnel management
organizational codes (March, 1991).Therefore, the 1.9. staff education
creative climate in general and how it is perceived by 1.10. teamwork?
new employees in particular, influences the
efficiency of labor mobility as a mechanism for idea 2. Is there a significant difference in the
diffusion in organizations. In support, Pant (2010) perception of safety culture among healthcare
concluded that people with longer years in the service providers in public and private hospitals in
in an organization would assess their organizations as the Philippines according to:
more creative. The longer an individual 's tenure or 2.1. age
length of service in an organization, the better is their 2.2. length of work experience
perception about the work environments for 2.3. job position
innovation in terms of generating new ideas for 2.4. area of assignment
actions. However, the finding of Bodur and Filiz 2.5. type of hospital?
(2009) is different. It showed that patient safety
culture scores in primary health services in Turkey 2. METHODOLOGY
decreased as seniority increased. This observation is A descriptive- correlation design was
maybe due to an increase in medical errors done by utilized in the study. A self-administered survey was
the senior staff possibly due to frustration with conducted in two public and two private hospitals in
hospital regulations or increasing staff awareness of central region in the Philippines to physicians
safety problems and thus additional reporting. (consultant, residents and general practitioner),
nurses (supervisors, head nurse and staff) in different
1.4.5 Type of Hospital departments, pharmacists, medical technicians
Al-Ahmadi (2009) compared the perceived (medical technologist, x-ray technicians, CT scan and
safety culture of all medical and administrative staff ultrasound technicians), and auxiliary (dietary,
in all public and private hospitals in Riyadh, Saudi security, utility section).
Arabia. The results showed that all types of mistakes A stratified random sampling was employed. The
were more frequently reported in private than in samples were selected from a population of
public hospitals. A significant difference in the healthcare providers based on the following criteria.
number of events reported between government and
private hospitals was noted. This finding implies that Inclusion Criteria
the type of hospital, either public or private would 1. Registered professional in the
also affect the perception of safety culture. Although Philippines. This applies only to
a high percentage of healthcare providers in private physicians, nurses, pharmacists,
Journal of Sciences, Technology, and Arts Research Vol.2, No. 1, August 2016

medical technicians and dieticians but result of collaboration between researchers in the
not to auxiliary group of workers. United Kingdom and Canada who were interested in
2. Full-time/ part-time and contractual developing a patient safety culture tool that is rooted
healthcare provider who have direct in acute care setting.
contact to patient and to their fellow MaPSCAT helps the organization recognize that
healthcare providers. patient safety is a complex multidimensional concept.
3. Had work commitment to hospital for at It also facilitates reflection on the safety culture of a
least one-year prior administration of given healthcare organization. It shows any
the questionnaire to ensure that they are differences in the perception between staff groups.
familiar with the organization’s culture. Given the framework, summary view of how a more
4. Had consented for the study. mature safety culture looks like helps the
organization visualize what it wants to achieve.
Exclusion Criteria MaPSCAT is designed not to be used to find blame
1. Those who did not completely answer when results show that the organization’s safety
the survey. culture is not sufficiently mature.
2. Those who answer fewer than half of The MaPSCAT advances the research in safety
the items throughout the entire survey culture measurement as it (1) measures ten (10)
3. Those who answer every item the same dimensions of safety culture, (2) examines these
(eg. all “3”s or “4”s). dimensions on the safety culture maturity scales, (3)
aggregates scores to create a safety culture profile,
The sample size was computed using Yamane’s and (4) provides guiding statements on how to
simplified formula for proportions (1967). A 95% improve the safety culture. With the MaPSCAT,
confidence level is assumed. Utilizing Yamane’s decision-makers can examine the level of safety
formula required 238 respondents which include 40 maturity in each dimension and refer back to the
physicians, 76 nurses; 19 pharmacists, 44 medical framework to see what types of statements and
technicians and 59 auxiliary workers) from the public actions are aligned to higher levels of culture. This
hospitals. On the other hand, on the private hospitals unique way of studying and presenting the results
had required 245 respondents which composed of 48 may help provide ideas and direction for moving the
physicians, 80 nurses, 21 pharmacists, 40 medical culture forward.
technicians and 56 auxiliary workers from the private
hospitals. Hence, a total of 483 respondents was 2.2 Dimensions of Safety Culture
desired to be included in the study. Each respondent The ten (10) dimensions of safety culture are 1.)
in each job category was assigned to a number. A Continuous improvement reflects the investment in
computer- generated randomizer was used to allow the quality agenda and the purpose of policies and
the selection of samples. procedures for safety, 2) Priority given to safety
The possibility of non-response bias can reduce reflects about how seriously safety is taken in the
estimated sampling size (Singer et al., 2003; Singer et organization in relation to patient and public
al., 2009a; Singer et al., 2009b).To even out this, an involvement and patient safety practices, 3.) System
oversampling of 10% was considered giving a total errors and individual responsibility reflects how
of 530 samples. reports are received and viewed- as either an
Out of 530 questionnaires distributed, 341 were opportunity to blame or improve, 4) Recording
returned; however, only 335 were completely incidents which relates to the use of reporting
answered. Among the respondents, 177 come from systems and the types of incidents that are reported,
private hospitals and 158 from public hospitals. 5.) Evaluating incidents relates to how the incidents
are being investigated and analyzed and the output of
2.1 Manchester Patient Safety Culture Assessment the output of the investigations, 6.) Learning and
Tool (MaPSCAT) effecting change reflected of what happens after an
Manchester Patient Safety Culture event, what mechanisms are in place to learn from
Assessment Tool (MaPSCAT) was originally the incident and how changes are introduced, 7.)
developed by a group led by Dianne Parker in a Communication reflects systems in place to
collaborative project supported by the National communicate, the quality of information sharing and
Primary Care Research and Development Center, the communications with patient about safety, 8.)
University of Manchester. The MaPSCAT is the Personnel management discusses the way in which
Journal of Sciences, Technology, and Arts Research Vol.2, No. 1, August 2016

safety issues and staff problems are managed as well 2010) and in a pediatric department in Rockhampton
as the link between safety and recruitment and Hospital in Queensland, Australia (2009). All of
retention practices, 9.) Staff education and training them have utilized the Manchester Patient Safety
reflects training aims, resources and the purpose of Culture Assessment Tool (MaPSCAT).
training in regards to patient safety information, 10.) The English version of the tool was utilized by
Teamwork reflects the structure of the teams, the the professional healthcare providers group
function of the teams and how information is shared (physicians, nurses, pharmacists, medical technicians
across team members. and dieticians), while a translated and validated
Filipino version was used for the auxiliary workers
2.3 Levels of Safety Culture Maturity group (dietary, security, utility section).
Within these 10 dimensions, descriptions were To enhance comprehension of the contents of
developed to reflect five progressive levels of safety the tool by non-professional healthcare providers (eg.
maturity. The levels of maturity of safety culture auxiliary workers) who provide direct patient care, a
range from pathological through reactive, Filipino translated version was made after
bureaucratic, and proactive and, finally to, generative consultation with the language experts from ‘Sentro
(Parker, 2001). Each dimension provides description ng Wikang Filipino’ (SWF) of the University of the
of safety culture that would look like in each of the Philippines Manila. A back translation of the tool
five (5) maturity levels. These maturity levels in was obtained.
increasing order are operationally defined as follow:
1.) Pathological- organizations have a prevailing 2.4 Psychometrics
attitude of ‘why waste our time on safety’, as such, The content validity of the MaPSCAT was
there is little or no investment in improving safety, determined through review by the panel of experts,
2.) Reactive- organizations only think about safety who were asked to comment on whether the
after an incident has occurred, 3.) Bureaucratic- questionnaire adequately sampled healthcare
organizations are very paper-based and safety merely providers safety culture, if the questions and items in
involves ticking boxes to prove to auditors and the questionnaire were accurate, clear and easy to
assessors that they are focused on safety, 4.) understand, if the instructions were clear and
Proactive - the organization place a high value on complete, if any of the questions or statements were
improving safety. It actively invests in continuous likely to discourage the participants from answering
safety improvements and reward staff who raised and whether or not the response options were
safety-related issues, 5.) Generative- the nirvana of adequate for the questions and statements. The
all safety organizations by which safety has become Filipino translated tool was tested to a group of utility
an integral part of everything that they do. In workers from Philippine General Hospital (PGH),
generative organization, safety is truly in the hearts face validity was confirmed. The reliability indices of
and minds of everyone, from senior managers to front the scales were assessed. The cronbach’s alpha for
staff. this study is 0.79, which is considered as adequate
Each dimension provides description of safety value.
culture that would look like in each of the five (5)
maturity levels. The respondent will have to choose 2.5. Data Gathering Procedure
only one maturity level that best describes their Approval of the conduct of study was gained
organization on specific safety culture dimension from UP Manila Review Ethics Board (UPMREB).
(Parker, 2001). The researcher sought permission from the Chief of
On deciding which level to discuss and the hospital and the chief nurses to administer the
highlight in the results and, for the applied aspect, survey in their institution. After hospital approval
where to focus strategies to enhance the patient safety was gained, the researcher with the aid of a research
culture, Fleming and Meakin (2004) emphasized that assistant started to hand down the brown envelopes
the level having the highest number of responses the different unit heads
(expressed in percentage) in a particular dimension
will decide the level of safety culture maturity. The
same method of interpreting the responses was used
in assessing safety culture in a community pharmacy
in Manchester, United Kingdom (Ashcroft et al,
2005), in an acute care setting in Canada (Law et al.,
Journal of Sciences, Technology, and Arts Research Vol.2, No. 1, August 2016

Table 1. Distribution of respondents according to selected researcher and the research assistant returned to
social and work-related characteristics collect the questionnaires. Respondents who did not
answer the questionnaires within the given period of
A self-administered survey was employed. The cover
time were followed up personally.
Type of Hospital
Social and Work- Total 2.6 Data Analysis
related Characteristics N=335
Private Public Data were entered into Microsoft Excel and were
(N=177) (N=158)
verified and transferred to R statistical software for
analysis.
Age (in years) Frequency and percentages were shown to
20-35 98 (55.5) 53 (33.8) 151 (45.1)
36-51 47 (26.8) 78 (49.5) 126 (37.6)
describe the social and work related profile of survey
52-67 32 (17.7) 27 (16.7) 58 (17.3) respondents.
MANOVA was used to test the effects of the
Mean-36.63 Mean-39.56
SD-11.98 SD- 10.51 socio-demographic variables on perceived safety
culture.
Civil Status
All tests were preset at p<0.05 level of
Single 112 (63.2) 47 (29.9) 159 (47.5) significance.
Married 64 (35.9) 108 (68.6) 172 (51.3)
Widow/er 1 (0.9) 3 (1.5) 4 (1.2)

3. RESULTS
Length of Experience
(in years)
1-5 62 (35.1) 54 (34.3) 116 (34.7) 3.1 Demographic
6-10 51 (28.6) 50 (31.4) 101 (29.9) Table 1 shows the distribution of respondents
11-15 38 (21.6) 29 (18.10) 67 (20.0)
16-20 24 (13.4) 18 (11.3) 42 (12.4)
according to selected social and work-related
21-above 2 (1.30) 7 (4.9) 9 (3.0) characteristics. Almost half the total number of
Mean - 8.58 Mean – 8.70
respondents (45.1%) was aged 20-35 with higher
SD-5.48 SD- 5.80 proportion among healthcare providers in private
hospitals (55.5%) than in public hospitals (33.8%).
The mean age for healthcare providers from private
Job Position hospitals is 36.63 years (SD=11.98) while 39.56
Physicians 20 (11.3) 30 (17.7) 50 (14.9)
Nurses 87 (49.1) 84 (53.4) 171 (51.0)
(SD=10.51) years for the public hospitals. Most
Pharmacists 8 (4.6) 5 (3.1) 13 (3.9) respondents from private hospitals were single
Medical 27 (15.3) 15 (9.8) 42 (12.5) (63.2%) while from the public hospitals, most were
Technicians 35 (19.8) 24 (15.2) 55 (17.6)
Auxiliary
married (68.6%). More than one-third of the
healthcare providers both in public and private
Area of Assignment hospitals or 34.7% were employed for 5 years and
Medical-Surgical 64 (35.9) 30 (19.1) 94 (28.1)
Pediatrics 33 (18.6) 33 (20.6) 66 (19.7) below. The mean length of experience in the service
Orthopedics 13 (7.4) 15 (9.8) 28 (8.4) of the healthcare providers in public is 8.70 years
ICU 11 (6.1) 5 (3.4) 16 (4.8) (SD=5.80), which is a little higher than those from
Outpatient Dept. 11 (6.1) 11(6.9) 22 (6.6)
Emergency Room 15 (8.2) 14 (8.8) 29 (8.7) the private hospitals (8.58 years). 171 (51%) of them
Pharmacy 7 (3.9) 5 (3.4) 12 (3.6) were nurses which occupy the biggest proportion of
Laboratory 8 (4.8) 15 (9.8) 23 (6.9)
Auxiliary 9 (5.0) 24 (15.2) 33 (9.9)
healthcare providers in the public and private
Administration 6 (3.5) 6 (2.9) 12 (3.6) hospitals of this study. Most of the healthcare
providers were assigned in medical-surgical
department (28.1%). (Table 1)

letter addressed the purpose of the study and the 3.2 Perceived Safety Culture of Healthcare Providers
direction for completing the survey. After two weeks in Private and Public Hospitals
that survey questionnaires were distributed, the
Journal of Sciences, Technology, and Arts Research Vol.2, No. 1, August 2016

There are 10 safety culture dimensions in significant difference was found to type of hospital to
Manchester Safety framework that were considered almost all safety culture level except at bureaucratic
in the study: 1) continuous improvement, 2) priority level.
given to safety, 3) system errors and individual
responsibility, 4) recording incidents, 5) evaluating 100%
incidents, 6) learning and effecting change, 7) 37
90% 64 77
91 80 101 84
communication, 8) personnel management, 9) staff 80% 124
144
education and training, and 10) teamwork. 70% 181
Figure 1 showed the percentage distribution of 60% 147 181
perceived safety culture among healthcare providers 161 134
50% 157
across the ten dimensions of safety culture. As can 221 Generative
40%
be seen, majority of the healthcare providers 0 0 204 231
30% 181 0 Proactive
perceived safety culture is at proactive level in all 0 151
dimensions specifically to personnel management 20% 124 117 110 Bureaucratic
87 97
(231, 69%), system errors and individual 10% 0
34 Reactive
0% 0
10 0
7 0
3 0
3 7
responsibility (221, 66%), learning and effecting
Pathological
change (201, 61%), continuous improvement
(181,54%), evaluating incidents (181, 54%),
communication (161, 48%), priority given to safety
(157,47%), recording incidents(147, 44%), and
teamwork (134, 40%). It is interesting to note that
respondents perceived staff education and training at
generative level (181, 54%). Bureaucratic maturity
level was only observed to teamwork at 110 (33%).
Some respondents showed safety culture perception
at reactive maturity levels were observed to Figure 1. Percentage distribution of perceived
dimensions recording (124, 37%) and evaluating safety culture among healthcare providers
(117, 35%) incidents and communication (97, 29%).
None of the respondents answered in any of the
safety culture dimension at pathologic maturity level. 4. DISCUSSION
Generally respondents perceived safety culture at Majority of the responses from the healthcare
proactive to generative maturity level except to providers in public and private hospitals are at
recording and evaluating incidents and proactive level. This suggests that they feel that
communication healthcare providers’ organization has a genuine
Using MANOVA, differences in the perception desire and enthusiasm for continuous safety
of safety culture among healthcare providers in improvement. This perception is further validated by
public and private hospitals according to age, job the comments made by a hospital administrator, “We
position, area of assignment and type of hospital were are happy that you have conducted this study in us.
tested (Table 2). It can be observed that age group is We are eager to know the result of your study. It is a
significantly different among healthcare providers big help for us”. This finding is supported by Al-
who perceived safety culture at reactive (F-5.45), Ahmadi (2010) in which nurses (61%), pharmacist
bureaucratic (F-4.26), and proactive (F-3.66) (9%) and auxiliary workers (6%) in a tertiary hospital
maturity levels respectively. In terms of job position, are likely to express a positive perception to
a significant difference in safety culture was found to continuous improvement. However, Law (2010)
those who perceived at generative (F-3.95) level. found that pharmacists, nurses and support staff feel
However, no significant differences were found to that continuous improvement in their organization is
those who perceived it at reactive, bureaucratic and at a bureaucratic level. She also found out that
proactive level respectively. According to area of nurses, medical technicians and support group in
assignment, it can be seen that only those who have general in a health facility perceived that they are
perceived safety culture at reactive (F-2.26) level was proactive in giving priority to safety. In the present
to have significant differences in their scores. The study, an increase number of the healthcare providers
same finding was observed to length of experience at who perceived recording and evaluating incident and
reactive (F-2.86) maturity level. Interestingly, a communication at reactive level. This may be
Journal of Sciences, Technology, and Arts Research Vol.2, No. 1, August 2016

because of fear of reprisal attached from reporting of communicate with their immediate staff only.
incidents. Van Geest & Cummins (2003) reported Furthermore, because of high volume of patients in
that many errors in healthcare go unreported for public hospitals, there might have been instances that
many reasons including fear, humiliation, the error incidents that had happened were left
presence of a punitive response to error, and the fact unattended and unresolved. Law et al (2010)
that reporting will not usually result in actual change. revealed that most healthcare providers in a certain
Thus, it discourages many health professionals, health facility perceived personnel management on a
specifically nurses to report events because of the reactive level. This may be due to the lack of support
presence of a punitive environment when it comes on for most healthcare providers under personnel
reporting of these incidents. Naturally, people are management and the destructive effect of blame
afraid to be blamed, thus they tend to hide incident culture. An integral part of creating a culture of
making the situation more crucial in achieving patient safety is providing education and training. This
safety. Law (2010) believed that healthcare providers present study showed that healthcare providers
have gone through to such effort in terms of making perceived generative maturity level on staff
policies and procedures in reporting of incidents. education. Education has positive effect on
However, she reiterated that further strategies are improvement of managers’ attitudes towards safety
needed to enhance the implementation of safety culture and it can act as a motivating proof to
practices. Further improvements shall be pushed on the health centers to provide safety culture
proper toleration and secretion of events reported courses in their respective hospitals (Azimi L, 2012).
especially by immediate superiors (Acuin, 2011). In This clearly indicates that training is clearly an
contrast, Law (2010) reported that most of the health important aspect of safety improvement (Reason JT,
staff in Hamilton Science Center perceived that their 1995) as this was observed in the present study.
organizations are taking it seriously when it comes to The importance of teamwork in healthcare has
evaluating incidents. Although it was found that most been shown in many different studies (Baker et al.
healthcare providers have a positive regard on 2006). Good teamwork can help reduce patient safety
evaluating these incidents, it seems that learning a problems and it can improve team members’ morale
lesson from an incident will be obscured because of and well being, as well as team viability - the degree
lack of feedback (Evans et al, 2006). Al-Ahmadi et al to which a team will function over time (Cannon-
(2010) found out that organizational learning was one Bowers et al, 1997). In this study, most healthcare
of the dimensions of safety culture that has positive providers in public and private hospitals perceived
response (75.9%) among nurses. However, some teamwork at a proactive level. This suggests that
medical technicians from a private hospital in this many healthcare providers understand that
study have told that no actions were done after an cohesiveness to perform safety activities is of great
incident. They just file it in for recording purposes. concern. Furthermore, El- Jardali (2011) revealed
Proper communication within and across healthcare that higher scores on teamwork across hospital units
teams is essential to remove any threats to safety of increase the frequency of events reported. This
patients. Communication problems have been indicates that having a high ‘team spirit’ plays a vital
identified as major contributing factors to adverse part in achieving improvements in patient safety.
events according to Cook et al (2007). An analysis of In terms of test of difference between selected
2,455 sentinel events reported to the Joint public and private hospitals and each dimensions of
Commission on the Accreditation of Healthcare safety culture, healthcare providers at different age
Organizations showed that 70% of the cases were a groups varies their perception on their existing safety
result of failure in communication (Leonard et al, culture either they perceived safety culture at
2004). The present study revealed that there is an different maturity level. Kitch (2005) identified that
significant number of healthcare providers who age differs significantly on his review of patient
perceived this at reactive level. The same finding also safety culture among nurses. This tells that as nurses'
was found by Aboshaiqah (2010) to nurses in Saudi age increase, they develop a kind of occupational
Arabia hospitals. Similarly, Singer et al (2003) noted bond and become more oriented to their careers.
that nurses were found to be inattentive to the However, present finding contrasted previous study.
“possible occurrence” of medical error, and a lack of As can be observed, age group does not correspond
open communication was reported. This can be due to increasing level of safety maturity. This may be
to the high volume of patients that are catered in due to differences in distribution of age of the
public hospitals, thus, they may be busy enough to respondents. Singer et al. (2003) found out that the
Journal of Sciences, Technology, and Arts Research Vol.2, No. 1, August 2016

perception to safety culture among nurses varies determine the whole healthcare delivery system of
significantly with different job position. The present the organization. Thus, generalizability cannot be
study found significant difference in the perceived assumed. It focused basically on the safety as this
safety culture at generative level. Similarly, Abdou could possibly affect the delivery of a quality health
(2011) emphasized that job position in general affects services.
the perception of nurses on their safety culture. This
predominant to nurses who handles managerial 5. CONCLUSIONS
positions than frontline staff nurses. Thomas et al. Generally, healthcare providers in the public
(2005) reported higher levels of teamwork with and private hospitals perceived their safety culture at
surgeons than anesthesiologists, surgical nurses and proactive maturity level. Perception in almost all
surgical anesthetist in Utah and Colorado. This dimensions of safety culture must be enhanced.
implies that the team cohesiveness portrayed among Greater emphasis on safety culture dimensions is
healthcare team members differ even they are needed such as recording and evaluating incidents
working in the same unit. This indicates that maybe and communication dimensions of safety culture.
the complexity of nature of job that exists among Staff education concerning safety issues and practice
healthcare providers has an effect on their perception has been clearly established. Recording and
on teamwork. Grant, Donaldson and Larsen (2006) evaluating incidents and communication must be
noted that physicians reported a higher perception of given greater emphasis in creating a positive safety
teamwork than nursing and other staff members in culture. Age and type of hospital of the healthcare
the inpatient and operation room (OR) settings than provider must be taken into consideration in
in the outpatient department. This can be interpreted determining the safety culture of any organization.
that area of assignment might have influence their The study finding indicates that awareness of the
perception of healthcare provider on their safety existing safety culture of an individual or group is the
culture. A significant difference was found at initial step towards improvement of healthcare
reactive level in terms of the length of experience. service through safe and quality care.
This supported Pant (2010) who has concluded that Given the findings, it is recommended that a
people with longer years in the service in an regular and multi- professional assessment of safety
organization would assess their organizations as more culture be done to reflect the status of the institution
creative. The longer an individual’s tenure (length of in terms of prioritizing patient safety. The hospital
service) in an organization, the better is their management should assess and redesign their current
perception about the work environments for patient safety system including governance and
innovation in terms of generating new ideas for reporting structures. The hospital administration
actions. Safety culture mean scores as to type of must reduce the fear of blame culture and create
hospital between private and public hospitals at a climate of open communication and continuous
reactive, proactive and generative maturity level learning. Error-reporting should not be viewed as
showed a significant difference. This further an end in itself, but rather as a means of learning
supported Al-Ahmadi (2010) that all types of from mistakes and the first step towards
mistakes were more frequently reported in private elimination of harm and improvement of patient
than in public hospitals. Moreover, the former safety. To ensure safety, patient safety issues and
concluded that there is a significant difference in the concerns should be included and emphasized in the
number of events reported between government and orientation of the new staff. Re-evaluation/ revisiting
private hospitals. It was further reiterated that there existing guidelines on safety to give direction to
is a high percentage of healthcare providers in private strategic planning and program development must be
than public hospitals reported errors and incidents. prioritized. For future studies, the need to explore
This finding implies that the type of hospital would some other factors that could affect the perception of
also affect the perception of safety culture. However, healthcare providers on the dimensions of safety
still, most of these incidents were not evaluated culture specifically to the emotional and
promptly as it happened especially when no harm psychological aspects of the respondents must be
occurred. This explicitly show that safety culture emphasized.
among healthcare providers is not yet fully
established.
The study is limited to a geographic region
in which it was conducted. It did not attempt to
Journal of Sciences, Technology, and Arts Research Vol.2, No. 1, August 2016

Table 2. Test of Difference in the Perception ofSafety Culture according to selected socio-demographic factors

Variable Level Group Mean F-value p-value

Score
Age Reactive young 0.53 5.45** 0.00
middle 0.59
old 0.87
Bureaucratic young 4.39 4.26** 0.01
middle 4.97
old 4.59
Proactive young 3.22 3.66** 0.03
middle 2.92
old 2.80
Generative young 1.87 2.18 0.11
middle 1.52
old 1.74
Job Position Reactive Nurses 0.59 1.70 0.15
Physicians 0.81
Pharmacists 0.78
Medtechs 1.00
Auxiliary 0.64
Bureaucratic Nurses 4.52 1.62 0.17
Physicians 4.81
Pharmacists 4.17
Medtechs 4.57
Auxiliary 4.30

Proactive Nurses 3.12 2.25 0.06

Physicians 2.81
Pharmacists 2.22
Medtechs 3.23
Auxiliary 2.86
Generative Nurses 1.78 3.95** 0.00
Physicians 1.58
Pharmacists 1.83
Medtechs 1.20
Auxiliary 2.20
Area of Reactive MS 0.42 2.26** 0.02
Assignment Lab 0.94
Admin 0.64
Auxiliary 1.02
Pharmacy 0.75
ER 0.81
Pedia 0.62
OPD 0.96
ICU 0.38
Ortho 0.70
Bureaucratic MS 4.39 1.14 0.33
Lab 4.26
Admin 4.93
Auxiliary 4.50
Pharmacy 4.19
Journal of Sciences, Technology, and Arts Research Vol.2, No. 1, August 2016

Variable Level Group Mean F-value p-value

Score
cont. Area of ER 4.76
Assignment Pedia 4.89
OPD 4.39
ICU 4.76
Ortho 4.54
Proactive MS 3.14 0.86 0.56
Lab 3.25
Admin 3.21
Auxiliary 2.75
Pharmacy 3.38
ER 2.68
Pedia 2.91
OPD 2.96
ICU 2.86
Ortho 3.08
Generative MS 2.05 1.60 0.11
Lab 1.45
Admin 1.21
Auxiliary 1.73
Pharmacy 1.69
ER 1.76
Pedia 1.58
OPD 1.68
ICU 2.00
Ortho 1.68
Length of Reactive 1-5 years 0.71 2.86** 0.02
Experience 6-10 years 0.72
11-15 years 0.55
16-20 years 0.43
>20 above 1.38
Bureaucratic 1-5 years 4.61 0.36 0.84
6-10 years 4.45
11-15 years 4.54
16-20 years 4.69
>20 above 4.77
Proactive 1-5 years 3.04 0.67 0.61
6-10 years 2.99
11-15 years 2.91
16-20 years 3.24
>20 above 2.62
Generative 1-5 years 1.64 0.97 0.10
6-10 years 1.83
11-15 years 2.00
16-20 years 1.65
>20 above 1.23
Type of Hospital Reactive Private 0.01 398.87** 0.00
Public 1.42
Bureaucratic Private 4.55 0.18 0.87
Public 4.57
Proactive Private 3.33 23.49** 0.00
Public 2.65
Generative Private 2.11 43.80** 0.00
Public 1.36
Journal of Sciences, Technology, and Arts Research Vol.2, No. 1, August 2016

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