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discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/23685832

Quality and strength of patient safety climate

on medical-surgical units
ARTICLE in HEALTH CARE MANAGEMENT REVIEW JANUARY 2009
Impact Factor: 1.3 DOI: 10.1097/01.HMR.0000342976.07179.3a Source: PubMed

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JanuaryMarch  2009

19

Quality and strength of patient safety

climate on medicalsurgical units
Linda C. Hughes
Yunkyung Chang
Barbara A. Mark
Background: Describing the safety climate in hospitals is an important first step in creating work environments
where safety is a priority. Yet, little is known about the patient safety climate on medicalsurgical units.
Purposes: Study purposes were to describe quality and strength of the patient safety climate on medicalsurgical
units and explore hospital and unit characteristics associated with this climate.
Methodology: Data came from a larger organizational study to investigate hospital and unit characteristics
associated with organizational, nurse, and patient outcomes. The sample for this study was 3,689 RNs on
286 medicalsurgical units in 146 hospitals.
Findings: Nursing workgroup and managerial commitment to safety were the two most strongly positive
attributes of the patient safety climate. However, issues surrounding the balance between job duties and safety
compliance and nurses reluctance to reveal errors continue to be problematic. Nurses in Magnet hospitals were
more likely to communicate about errors and participate in error-related problem solving. Nurses on smaller
units and units with lower work complexity reported greater safety compliance and were more likely to
communicate about and reveal errors. Nurses on smaller units also reported greater commitment to patient
safety and participation in error-related problem solving.
Practice Implications: Nursing workgroup commitment to safety is a valuable resource that can be leveraged
to promote a sense of personal responsibility for and shared ownership of patient safety. Managers can capitalize
on this commitment by promoting a work environment in which control over nursing practice and active
participation in unit decisions are encouraged and by developing channels of communication that increase
staff nurse involvement in identifying patient safety issues, prioritizing unit-level safety goals, and resolving
day-to-day operational problems the have the potential to jeopardize patient safety.

Key words: acute care hopitals, patient safety, safety climate

Linda C. Hughes, PhD, RN, is Associate Professor, Virginia
Commonwealth University, School of Nursing, Richmond.
Yunkyung Chang, PhD, RN, is Social Research Specialist,
University of North Carolina at Chapel Hill, School of Nursing.
Barbara A. Mark, PhD, RN, FAAN, is Sarah Francis Russell
Distinguished Professor, University of North Carolina at Chapel Hill,
School of Nursing.
The parent study was funded by the National Institutes of Health,
National Institute for Nursing Research Grant 5R01NR003149, A
Model of Patient and Nursing Administration Outcomes, to Barbara
Mark, principal investigator. Approval to conduct the study was
provided by the institutional review board of the University of North
Carolina at Chapel Hill and of all participating hospitals.
Health Care Manage Rev, 2009, 34(1), 19-28
Copyright A 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

uring the past two decades, acute care hospitals

have been challenged as never before to develop
and sustain operating systems to ensure patient
safety. In response to this challenge, hospitals have
adopted equipment redesign initiatives that minimize
the role of human fallibility in the causation of unsafe events as well as work reorganization initiatives
that support safe job performance. Along with these
initiatives, substantial attention has been given to
the work environment as a determining factor in
shaping the safety-related attitudes and behaviors of
health care providers. As such, the importance of
promoting safe work practices through an organizational climate in which safety is seen as an essential
institutional priority has been a recurring theme in the
health care literature.

Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

20

Health Care Management REVIEW

Describing the safety climate in acute care hospitals is

an important first step in the development of work
environments where safety is consistently recognized
and enacted as a high priority. Although some studies
have described the safety climate in hospitals, most were
conducted using samples that are too small to permit
valid generalizations (Hellings, Schrooten, Klazinga, &
Vleugeis, 2007; Pronovost et al., 2003; Singer et al.,
2003). Further, safety climate is conceptualized in
many of these studies as a hospital-wide construct
and measured using data from multiple providers
including physicians, nurses, pharmacists, and managers.
Evidence of substantial variability in climate perceptions across both units and professional subgroups in
the same hospital, however, suggests that safety climate
should be viewed as a cluster of profession-specific
subclimates that are best measured at the nursing unit
level (Sexton et al., 2006; Zohar, Livne, Tenne-Gazit,
Admi, & Donchin, 2007). Although some studies have
been conducted at this level, most targeted high-risk
areas such as intensive care units, operating theaters, or
emergency departments (Huang et al., 2007; Makary
et al., 2006). As a result, little is known about the safety
climate on medicalsurgical units where most patients
receive care during hospitalization.
In this study, we address these limitations by describing the climate for patient safety as perceived by
registered nurses (RNs) working as direct caregivers
on medicalsurgical nursing units, selected from a
nationwide sample of acute care hospitals. We focused on RN caregivers because studies indicate that
frontline clinicians are in the best position to provide information about the safety climate on nursing units (Huang et al., 2007; Makary et al., 2006;
Pronovost et al., 2003). Specifically, the purposes of
this study were to describe, using the nursing unit
as the unit of analysis, the quality (positive or negative ratings) and strength (within-unit consensus) of
the patient safety climate on medicalsurgical units
and explore differences in the safety climate according to hospital (size, location, teaching status, and
Magnet status) and unit (size and work complexity)
characteristics.

Conceptual Framework

JanuaryMarch  2009

First, the work environment must facilitate safety

compliance by providing conditions that maximize
consistent adherence to safety-related policies and
procedures (Neal & Griffin, 2002). Second, the work
environment must be conducive to employee participation in safety. Neal and Griffin (2002) argue that safety
participation differs from safety compliance in its
emphasis on voluntary as opposed to required behaviors through which employees make positive contributions to workplace safety. In error-prone organizations
such as hospitals, voluntary employee behaviors include open communication with coworkers about errors
and proactive involvement in error-related problem
solving (Helmreich & Merritt, 2000; Rochlin, 1999).
As such, an optimal safety climate depends on both
employee compliance with safe work practices and
voluntary participation in activities such as discussing errors with coworkers, helping coworkers immediately address errors when they occur, and actively
engaging in a problem-solving approach to error prevention (Tjosvold, Yu, & Hui, 2004; van Dyck, Baer,
Frese, & Sonnentag, 2005). Third, the organizational
response to errors is critical to an optimal safety climate. Employees are more likely to openly discuss
errors when the work environment is characterized by
a nonpunitive atmosphere in which individual blame
and negative employee consequences are minimized
(Tjosvold et al., 2004; Uribe, Schweikhart, Pathak,
Dow, & Marsh, 2002). Fourth, managerial commitment
to safety has been consistently identified as essential
for an optimal safety climate (DeJoy, Schaffer, Wilson,
Vandenberg, & Butts, 2004; Zohar & Luria, 2004). In
particular, managers communicate the importance of
safety in the priorities they establish, the decisions
they make about resource allocation, and the safetyrelated employee feedback they provide. Finally, the
workgroup plays a role in communicating tacit information about behavioral expectations in the workplace.
For this reason, there is emerging recognition that the
importance of safety to the organization is conveyed not
only through managerial actions that demonstrate a
commitment to safety but also through social interactions among workgroup members where organizational norms and values are informally communicated
(Dickson, Resick, & Hanges, 2006; Klein, Conn, Smith,
& Sorra, 2001; Schneider, Salvaggio, & Subirats, 2002;
Zohar & Tenne-Gazit, 2008).

Safety Climate Attributes

Safety climate can be defined as shared perceptions
about the importance of safety to the organization as
communicated through the attitudes and behaviors that
are expected, supported, and rewarded in the work
environment (Schneider, 1990). Several attributes are
recognized as characteristic of an optimal safety climate.

Climate Quality and Strength

Organizational climate is inherently conceptualized as
a group-level construct because it emerges through
social interactions and work experiences that are
shared by members of a well-defined organizational
subgroup (Ashforth, 1985; Schneider & Reichers,

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21

Patient Safety Climate on MedicalSurgical Units

1983). Typically, individual climate ratings are aggregated (averaged) to achieve group-level measurement
when respondents ratings can be at least partially
explained by group membership. This criterion is met
when score dispersion within groups is less than the
dispersion of scores across groups. Once individual
ratings have been aggregated, the climate construct
typically is described in terms of quality or the extent to
which group-level perceptions about a specific facet of
the work environment are favorable. Assuming that
items are scored so that positive ratings represent a more
optimal climate, a group mean closer to the positive end
of the response scale indicates a high quality climate,
whereas the one closer to the negative end of the
response scale indicates a poor quality climate (Lindell
& Brant, 2000).
Although the climate literature emphasizes comparison of score dispersion within and across groups before
data aggregation, less attention has been given to
consensus in climate ratings among members of the
same workgroup. However, organizational researchers
now argue that within-group consensus is an important
dimension of the climate construct because it provides
useful information about climate strength or the extent
to which behavioral expectations in the workplace are
clear and unambiguous (Dickson et al., 2006; Klein
et al., 2001; Zohar & Luria, 2004). Climate strength is
especially relevant because employee behaviors are more
likely to be consistent with workplace expectations
when the climate is strong and, conversely, more likely
to be inconsistent with those expectations when the
climate is weak (Schneider et al., 2002).

Methods
Data Source
This study was conducted as a secondary analysis of data
from the Outcomes Research in Nursing Administration
Project, a large multisite organizational survey study to
investigate relationships among hospital characteristics
and organizational, nurse, and patient outcomes (Mark
et al., 2007, 2008).

Sample
The sample for this study was 286 medicalsurgical units
from 146 Joint Commission-accredited acute care hospitals with at least 99 beds. These hospitals were randomly
selected from the 2002 American Hospital Association
Guide to Hospitals after excluding federal, for-profit,
and psychiatric facilities. These exclusion criteria were
included as part of the parent study to ensure that the
sample was representative of most acute care hospitals in

the United States. On-site study coordinators at each

hospital distributed the safety climate survey to all RNs
who had worked on their unit for at least 3 months and
provided direct patient care no less than 20 hours each
week. In total, 6,360 surveys were distributed, with a
return of 3,689 and thus a response rate of 58%. Overall,
safety climate ratings were obtained from 4% to 100%
of all eligible RNs on each unit.

Variables
Safety climate was measured using four subscales from
Zohars (1980) Safety Climate Scale as revised by
Mueller, DaSilva, Townsend, and Tetrick (1999) and
three subscales from the Error Orientation Scale
(Rybowiak, Garst, Frese, & Batinic, 1999). These
subscales were chosen because they address areas that
are consistent with the conceptual dimensions we
identified from the literature as relevant to an optimal
safety climate. Subscales from the Safety Climate Scale
address safety compliance (three items), safety-related
employee feedback (three items), managerial commitment to safety (three items), and workgroup commitment to safety (three items). Subscales from the Error
Orientation Scale address willingness to reveal errors
(four items), safety participation through open communication about errors (four items), and safety participation through error-related problem solving (five items).
Items from both the Safety Climate and Error Orientation scales were rated using a 5-point summated rating
scale. Items were scored so that higher values indicated a
more positive safety climate. Internal consistency
reliability for the items used in this study was .95.
We examined differences in safety climate according to
three hospital (location, teaching status, and Magnet
certification) and two nursing unit (size and work
complexity) characteristics. These characteristics were
chosen because they have been linked to nurse staffing and
nurses work conditions and thus may have implications
for nurses safety climate perceptions (Mark et al., 2007,
2008). Hospital location was determined using the
Metropolitan Statistical Area (i.e., > 50,000 population),
with hospitals located in a Metropolitan Statistical Area
classified as urban. Teaching status was measured as the
ratio of medical and dental residents to the number of
hospital beds. The term Magnet status was introduced in
the 1980s to describe hospitals that provided a professional
nursing practice environment and thus were successful in
recruiting and retaining nurses (McClure, Poulin, Sovie,
& Wandelt, 1983). Magnet status was measured with
one item that asked if the hospital was currently certified
by the American Nurses Credentialing Center for
Excellence in Nursing. Unit size was measured as the
number of staffed beds. Work complexity was measured
using a seven-item questionnaire that asked nurses to

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22

JanuaryMarch  2009

Health Care Management REVIEW

estimate the frequency of interruptions or unanticipated

events on their unit (Salyer, 1996). Because items on this
scale are anchored by six response options ranging from
strongly disagree to strongly agree, scores from 7 to 42 were
possible, with higher scores indicative of greater work
complexity. The internal consistency reliability estimate
for this scale was .85. With the exception of work
complexity, data for hospital and nursing unit characteristics were obtained from study coordinators.

Data Analysis
After data aggregation, item-level scores for each unit
were averaged to obtain mean scores for the entire
sample. Justification for data aggregation was based
on values for the intraclass correlation coefficient
Case 1 (ICC1) which compares score variance within
and across groups. ICC1 values supported data aggregation, with 19%32% of the total variance in scores
explained by group membership. Mean rater reliability
of the aggregated data was assessed using the ICC
Case 2 (ICC2) which estimates the extent to which
ratings from members of the same group are comparable
in rank order (although not necessarily the same).
ICC2 values at the item and subscale levels exceeded the minimum criterion of .70, suggesting acceptable mean rater reliability of the aggregated data
(Bleise, 2000).
Inferences about climate quality were based on the
item-level mean scores for the entire sample. Response
options for all safety climate items included strongly
disagree (1), disagree (2), no opinion (3), agree (4), and
strongly agree (5). Because a neutral option was included,
mean scores greater than 3 were interpreted as a highquality climate, whereas those less than 3 were
interpreted as a poor-quality climate. Inferences about
climate strength were based on the item-level response
distribution for the entire sample. This distribution was
obtained by averaging the individual-level response
distributions for each unit to identify the percentage
of respondents who agreed with an item by endorsing
options 4 or 5, disagreed by endorsing options 1 or 2,
or expressed no opinion by endorsing option 3. Although perfect within-group agreement is rare, no
minimum criterion for climate strength has been
identified. However, Kozlowski and Hattrup (1992)
argue that individual ratings are indicative of a weak
climate when they are widely distributed across all
response options or cluster around both end points of
the response scale.
Unit-level scores for each subscale were evaluated
using the t test for independent samples to identify
differences in safety climate according to hospital
location, teaching status, and Magnet certification and
nursing unit size (32 beds or <32 beds) and work

complexity (unit-level mean score 27 or <27). Because

multiple comparisons were performed, the Hommel test
was used to correct for the inflated risk of Type 1 errors
(Hommel & Hoffman, 1987).

Findings
Table 1 reports ICC1 and ICC2 values at the item and
subscale levels, along with item-level mean scores
and response distributions, averaged across all units.
Items addressing workgroup commitment to safety
received the highest ratings for climate quality and
strength, with mean scores ranging from 3.87 to 4.33
and 75% to 89% of respondents in agreement. Similarly,
items addressing managerial commitment to safety had
the second highest ratings, with mean scores ranging
from 3.62 to 3.96 and 67% to 78% of respondents
in agreement.
Safety participation ranked third in quality and
strength. Specifically, climate quality for items from
the open communication about errors and error-related
problem solving subscales was positive, with mean scores
from 3.40 to 3.93 and 3.64 to 3.89, respectively.
Consensus in the ratings of these items was moderately
strong, with 58% to 81% and 62% to 76% of
respondents in agreement, respectively. Although more
than 50% of the respondents agreed in their ratings of
all items from these two subscales, there were several
notable variations in climate strength. Consensus was
substantial for two items from the open communication
about errors subscale, with 77% and 81% of respondents
who agreed that workgroup members communicated
with coworkers as a way to immediately rectify an
error or correct a mistake. In contrast, consensus was
less substantial for the remaining two items from this
subscale focused on communicating with coworkers
about a mistake to identify how it could have been
prevented or how it could be prevented in the future
(64% and 58%, respectively). Finally, consensus was
strong for all but one item from the error-related
problem solving subscale, with 67% to 76% of respondents in agreement. However, climate strength
was minimal for the item, when a mistake occurs,
we analyze it thoroughly, with 62% of the respondents
in agreement.
Climate quality was positive for items addressing
safety feedback, with mean scores from 3.12 to 3.60.
However, evidence supporting climate strength was
limited. Items stating that nurses who ensure patient
safety are more likely to get a positive evaluation and
nurses who ignore patient safety regulations will hear
about it in their evaluation were positively endorsed by
only 57% and 52% of the respondents, respectively. In
contrast, climate perceptions were weak for the

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23

Patient Safety Climate on MedicalSurgical Units

Table 1

Quality and strength of the unit-level climate for patient safety

Average percentages

Subscales and items

ICC1

ICC2

Average
means

Workgroup commitment to safety

The best nurses on this unit expect
other nurses to ensure patient safety.
The best nurses on this unit care
about patient safety.
Nurses on this unit remind each other
of the need to ensure patient safety.
Managerial commitment to safety
The nurse manager on this unit makes
every effort to ensure that nurses
have the equipment/resources they
need to ensure patient safety.
The nurse manager on this unit views
violations of patient safety practices
very seriously even when they do not
result in apparent harm.
The nurse manager on this unit
emphasizes patient safety.
Safety participation: error communication
On this unit, if nurses cannot rectify
an error by themselves, they turn to
other nurses on the unit for help.
On this unit, if nurses cannot figure
out how to correct a mistake, they
can rely on other nurses on the unit
for help.
On this unit, when nurses make a
mistake, they ask others about how
they could have prevented it.
On this unit, when a nurse makes a
mistake, they tell others about it so
that the same mistake is not made
in the future.
Safety participation: error problem solving
On this unit, if something goes wrong,
we think about it carefully.
After a mistake happens on this unit,
we think long and hard about how
to correct it.
On this unit, when a mistake occurs,
we analyze it thoroughly.
On this unit, nurses think about
how they could have prevented
mistakes that occur.
On this unit, after a nurse makes a
mistake, we think about how it
came about and how to prevent
it in the future.
Safety feedback
Nurses on this unit who ensure
patient safety are more likely to
get a positive performance
evaluation.

.18
.19

.74
.76

4.02

79

.23

.79

4.33

.22

.79

3.87

.20
.32

.77
.86

.22

Quality

Agree

Disagree

Neutral

Strength

13

89

75

16

3.62

67

18

14

.79

3.79

69

23

.26

.82

3.96

78

15

.21
.26

.77
.82

3.93

77

17

.25

.81

3.40

81

13

.31

.85

3.62

64

15

21

.27

.83

3.49

58

18

24

.20
.30

.77
.85

3.86

75

17

.27

.83

3.71

67

13

20

.28

.83

3.64

62

15

23

.27

.83

3.89

76

17

.29

.84

3.84

74

17

.16
.23

.71
.80

3.60

57

14

29

(continues)

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24

JanuaryMarch  2009

Health Care Management REVIEW

Table 1

Continued
Average percentages

Subscales and items

ICC1

ICC2

Average
means

When a nurse violates patient safety

practices, it will show up on his or
her evaluation, although no harm
was done.
Nurses on this unit who ignore
patient safety regulations will
hear about it in their evaluation.
Willingness to reveal errors
On this unit, it is best to keep my
mistakes to myself. (R)
On this unit, it is a bad idea to
openly admit ones mistakes. (R)
Nurses on this unit admit mistakes
even when they would go unnoticed.
It is advantageous on this unit to
openly discuss ones mistakes.
Safety compliance
Job duties often prevent nurses from
acting as safely as they would like. (R)
Job duties often interfere with nurses
ability to comply with patient safety
practices. (R)
Job duties often interfere with nurses
ability to ensure adequate levels of
patient safety. (R)

.19

.75

3.12

31

26

43

.23

.80

3.51

52

16

32

.21
.21

.78
.77

3.61

14

66

20

.26

.82

3.48

17

57

26

.24

.81

3.30

48

23

29

.26

.82

3.19

46

39

24

.25
.27

.81
.82

2.81

48

40

12

.29

.84

2.98

42

46

12

.31

.85

2.80

49

40

11

Quality

Agree

Disagree

Neutral

Strength

Note. ICC = intraclass correlation coefficient; H = high; L = low; R = reverse scored item; S = strong; W = weak.

statement that patient safety violations will show up on

an evaluation even though no harm was done, with
ratings distributed across all response options.
Climate quality was positive for the willingness to
reveal errors subscale, with most respondents agreeing
with the two positively worded items from this subscale
and disagreeing with the two negatively worded items
(mean scores from 3.19 to 3.61). However, item-level
response distributions provided limited support for
climate strength. Although 66% of the respondents
disagreed that it is best to keep my mistakes to myself,
only 57% disagreed that it is a bad idea to openly admit
ones mistakes. Further, climate perceptions were weak,
with ratings distributed across all response options for
the statements that nurses admit mistakes even when
they would go unnoticed and that it is advantageous
to openly discuss ones mistakes.
Finally, safety compliance was the only subscale in
which these respondents rated climate quality as poor,
with mean scores from 2.80 to 2.98. Despite negative
ratings for these items, however, no agreement was
found. In fact, respondents, on average, were almost

equally divided in their perceptions that job duties have

an adverse effect on safety compliance.
Differences in the patient safety climate according
to hospital and unit characteristics are reported in
Table 2. Nurses working on units in urban and Magnet
hospitals participated in error-related problem solving
to a greater extent than did nurses in rural or nonMagnet hospitals. Nursing workgroups in Magnet
hospitals also were more likely to communicate about
errors and reported greater managerial commitment to
safety. No differences were found in scores for safety
compliance, willingness to reveal errors, safety feedback,
and workgroup commitment to safety according to these
hospital characteristics.
Differences in the patient safety climate were
identified for unit size and work complexity. RNs on
smaller units and units with lower work complexity
described their workgroup as more compliant with safe
work practices, more likely to communicate about
errors, and more willing to reveal errors when compared
with RNs on larger units or units with higher work
complexity. Nurses on smaller units also described their

Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

25

Patient Safety Climate on MedicalSurgical Units

Table 2

Hospital and nursing unit characteristics associated with the unit-level climate for patient safety
Commitment
Hospital
characteristics

Location
Urban
241
Rural
44
Teaching status
Teaching
140
Nonteaching
143
Magnet
Yes
140
No
143
Unit characteristics
Size
<32 beds
137
>
_ 32 beds
148
Work complexity
M <27
141
M>
_ 27
144

Safety participation

Error
Error problem Safety
Reveal
Workgroup Managerial communication solving
feedback errors

Safety
compliance

12.32
12.34

11.52
11.19

15.31
14.91

19.23**
18.53

10.34
10.36

13.76
13.41

8.67
8.62

12.32
12.32

11.55
11.38

15.28
15.20

19.18
19.05

10.35
10.33

13.80
13.61

8.84
8.47

12.39
12.32

11.81*
11.42

15.75*
15.17

19.24*
18.84

10.39
10.33

13.97
13.67

9.12
8.59

12.43*
12.24

11.52
11.42

15.49**
15.02

19.38*
18.89

10.30
10.38

13.98** 8.96**
13.46
8.38

12.40
12.26

11.57
11.37

15.45**
15.04

19.30
18.95

10.43
10.25

13.94** 9.19**
13.49
8.14

*p < 0.05; **p < 0.01.

workgroup as more committed to patient safety and

more likely to participate in a problem-solving approach
to error management. No differences were found in
scores for safety feedback and managerial commitment
to safety according to these unit characteristics.

Discussion
Workgroup and Managerial Commitment
to Safety
We found that commitment to safety among the nursing
workgroup was the most strongly positive attribute of
the safety climate on these units. Hospital nurses work
most closely with other nurses on their unit, thus
making the workgroup a powerful mechanism for
communicating normative expectations about acceptable workplace behaviors. Our findings in terms of
workgroup commitment to safety stand in contrast to
much of the climate literature in which managers have
been identified as the primary force in creating an
optimal safety climate by articulating and enforcing
behavioral expectations in the workplace (Clarke &
Ward, 2006; Katz-Navon, Naveh, & Stern, 2005).
Although managerial commitment to safety was also
identified as a strongly positive safety climate attribute
on these units, our findings suggest that the nursing
workgroup may play a more central role in creating and

sustaining a climate for patient safety than has been

previously described.

Error-Related Safety Participation and

Willingness to Reveal Errors
Although climate quality was positive for all items
addressing safety participation through error-related
communication and problem solving, climate strength
was mixed. Perceptions were strongest for items addressing open communication aimed at correcting or
rectifying ones own mistake compared with perceptions
for items addressing prevention of that mistake from
happening again. Yet, we found strongly positive
endorsement for all but one item addressing participation in a problem-solving approach to error prevention.
Items from the open communication about errors
subscale specifically address communication initiated
by a nurse in response to a mistake he or she has just
made. In contrast, items from the error-related problem
solving subscale focus on group problem solving as a way
to prevent errors in general. As such, our findings
suggest that nurses motivation to discuss their mistakes
with coworkers may stem more from concerns about the
immediate consequences to a patient rather than from
concerns about preventing errors in the future. Further,
our findings suggest that nursing workgroups may be
more likely to participate in identifying error prevention
strategies when the focus is on errors in general rather

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JanuaryMarch  2009

Health Care Management REVIEW

than on a specific error that can be linked to the

identity of a coworker. This interpretation is consistent
with the work of other researchers who have found
that health care providers are reluctant to discuss their
own mistakes solely to help others learn how to avoid
making the same mistake (Edmondson, 1999; Uribe
et al., 2002).
In contrast to their counterparts, RN workgroups
in Magnet hospitals were significantly more likely to
communicate about errors and participate in errorrelated problem solving. One of the defining attributes
of Magnet hospitals is that they provide a professional
practice environment in which nursing autonomy and
participation in decision making are supported. It is
possible that nurses in Magnet hospitals have more
opportunities to develop effective patterns of communication and supportive relationships, thus providing
a foundation for active participation in solving potentially sensitive error-related issues. This explanation is
consistent with studies that have linked employee
communication quality and autonomy to workplace
safety (Barling & Hutchinson, 2000; Parker, Axtell, &
Turner, 2001).
Similarly, nursing workgroups on smaller units
communicated about errors to a greater extent than
did those on larger units, whereas workgroups on smaller
units and units with lower work complexity participated
more in error management through open communication and problem solving. Further, we found that
workgroups on smaller units and units with lower work
complexity were more willing to reveal errors. These
findings again suggest that, depending on the size and
work complexity of the unit, some nursing workgroups
may be better able to develop a strong network of peer
relationships that serves to reduce threats to coworkers
self-esteem, sense of professional competence, and social
standing, reasons often identified by nurses for not
discussing their mistakes with coworkers (Edmondson,
1999; Zhao, 2006).
Although climate quality was positive for willingness
to reveal errors, climate strength was limited. Lack of
strong consensus for these items suggests that, although
nurses recognize the value of reporting errors, they are
also keenly aware of penalties that can be imposed when
an error is admitted. Despite substantial literature
focused on creating a nonpunitive atmosphere in which
individual blame for errors is minimized, fear of blame
and disciplinary action continue to be two of the most
frequently identified reasons nurses give for not reporting errors (Antonow, Smith, & Silver, 2000; Jeffe et al.,
2004; Uribe et al., 2002). As such, our findings reinforce
the work of other researchers who argue that progress in
error reporting is unlikely to occur in the absence of an
anonymous or, at least, confidential reporting mechanism that protects the identity of individual providers

(Antonow et al., 2000; Grant & Larsen, 2007; Webster

& Anderson, 2002).

Safety Compliance
Maintaining a balance between productivity and safety
has been consistently identified as an important
factor in the formation of an optimal safety climate.
Yet, we found that climate perceptions in the area of
balancing job duties with safety compliance were
negative. This result is comparable with that of other
researchers who have found that job duties can interfere
with consistent adherence to safe work practices
(Elfering, Semmer, & Grebner, 2005; Flin, Mearns,
OConnor, & Bryden, 2000; Hellings et al., 2007).
In particular, employees who feel pressured to complete work assignments may be more likely to take
shortcuts that can result in unsafe events (Salminen,
1995). However, we also found no consensus in
RN perceptions about the adverse effect of job
duties on safety compliance, with an almost equal
distribution of positive and negative ratings. This
lack of consensus may reflect an intermittent yet
recurring inability to balance work demands with
safety compliance due to frequent and unpredictable
fluctuations in staffing, admissions, and workload,
sources of volatility that are typical on most nursing
units. It is also possible that weak consensus in the
area of safety compliance can be traced to differences
among the nursing units in our sample. Specifically, we
found that nursing workgroups on smaller units and
units with lower work complexity were more likely to
comply with safe work practices. As such, our findings
suggest that nursing units may differ in ways that have
important implications for creating an optimal safety
climate. In fact, it is possible that success in the
development of an optimal patient safety climate on
nursing units will depend on the use of strategies that
are individually tailored to specific characteristics of
each unit.

Practice Implications
Our findings have several implications for practice.
Although climate researchers emphasize managerial
behaviors that show a commitment to safety as essential
for an optimal safety climate, we found that nursing
workgroup commitment to safety was the most strongly
positive attribute of the safety climate on these units.
Such commitment is a valuable resource that can
be leveraged to promote a strong sense of personal
responsibility for and shared ownership of patient
safety among the nursing staff. Managers can capitalize on this commitment to safety by developing
channels of communication that increase staff nurse

Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

27

Patient Safety Climate on MedicalSurgical Units

involvement in identifying patient safety issues, prioritizing unit-level safety goals, and resolving day-to-day
work system problems that have the potential to
jeopardize patient safety. Managers can also cultivate
greater workgroup ownership of patient safety by
promoting a work environment in which control over
nursing practice and active participation of nurses in
unit decisions are encouraged. In particular, managers
can foster shared ownership of patient safety by
routinely providing nurses with feedback about unitlevel progress in the attainment of safety goals and
proactively responding to recommendations from
nurses for modifications to the work environment that
enhance patient safety. Finally, nurses who are recognized as informal leaders on their unit can be
designated as patient safety advocates who, because of
their close proximity to and constant interactions
with coworkers, can model safe work behaviors and
also serve as a patient safety resource for coworkers
(Rapala, 2005).
We also found that balancing job duties with safety
compliance was the only area in which climate quality
was poor. Although it can be argued that conflicts
between job duties and safety compliance are inevitable
on most nursing units, we also found greater safety
compliance on units with fewer work interruptions
and unanticipated events. As such, there may be aspects
of nurses job duties that are amenable to change
through managerial intervention. Studies suggest that
the work interruptions encountered most often on
nursing units stem from routine operational failures that
result in a breakdown in the availability of materials,
information, and equipment needed to provide patient
care (Tucker, 2004; Tucker & Spear, 2006). Consistent
communication with frontline providers along with
direct observation of daily unit activities can provide
managers with the information they need to work
with other hospital departments to reduce operational
failures that have the potential to impede efficient
and safe job performance (Tucker, Singer, Hayes, &
Falwell, 2008).
In summary, the findings from this study provide
useful information about the quality and strength of
the patient safety climate on medicalsurgical units.
In particular, our results suggest that nursing workgroup
and managerial commitment to safety are the two
most strongly positive attributes of the patient safety
climate on these units. However, issues surrounding
the balance between job duties and safety compliance
along with nurses reluctance to reveal errors continue
to be problematic. Future investigation of the patient
safety climate on nursing units is needed to clarify
relationships among climate quality and strength,
employee work behaviors, and patient safety outcomes.
In particular, studies to investigate possible quality

strength interactions and the effect of those interactions

on patient safety outcomes are warranted.
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