Patient safety attitude among healthcare workers at different levels of healthcare in Sharqia Governorate, Egypt

Background Patient safety (PS) has been identified as a significant healthcare challenge. A good safety attitude helps healthcare workers (HCWs) to decrease medical errors. Aim This study aimed to assess the PS attitude and identify its determinants among HCWs. Setting This study was conducted in Sharqia Governorate at different levels of health care. Methods This was a comparative cross-sectional study that involved240 HCWs selected after using a multistage cluster sampling technique from Sharqia Governorate.In ordertto assess the respondents’ attitudes towards PS, the modified Chinese Safety Attitudes Questionnaire (CSAQ) was used. Results The scale with the highest percentage of positive responses, on average, was safety climate (49.59%). The study found a statistically significant association between the level of health care and mean scores of ‘teamwork climate, perception of management, job satisfaction, working conditions, and stress recognition’ and the overall CSAQ score. In regression analysis, the highest degree of education and job type were significant predictors of PS attitude among the HCWs under study (p = 0.031 and 0.011, respectively). Conclusion According to the study’s findings, PS is low among HCWs in both healthcare units and hospitals, with a significantly higher score among hospital workers than among primary care workers. All PS composites need improvement starting with regular assessment of PS culture along with continuous monitoring.


Introduction
Patient safety (PS) is a worldwide public health topic. According to the World Health Organization, unsafe medical care leads to disabling injuries or deaths in millions of patients. 1 Patient safety is the prevention and avoidance of patient injuries or adverse events caused by delivery processes of healthcare workers (HCWs). 2 The safety culture of the organisation serves as a guide on how employees should perform in the workplace, and their behaviour will be influenced or determined by which behaviours are rewarded and acceptable in the workplace. Organisational positive attitude culture is characterised by trust-based communications, shared perceptions of the importance of safety and faith in the efficacy of preventive measures. 3 Despite the importance of PS in health care, only few organisations have assessed how well their staff culture promotes PS. Assessing the current safety attitudes enables organisations to gain a clear picture of PS issues that require immediate attention, address the strengths and weaknesses of their safety culture, and improve continuous quality management. 4 http://www.phcfm.org Open Access middle-income countries is direr, with approximately 2.6 million deaths occurring because of 134 million adverse events occurring in hospitals each year. 7 In Africa, information is limited about the scope of PS culture. The study in Ethiopia showed a very low-positive PS grade. 8 Patient safety in Kenya remains a challenge, with an increasing number of medical errors being reported in the media. 9 South Africa is among the developing countries that has a higher percentage of PS incidents. 10 Moreover, Eastern Mediterranean and African Study found that unsafe care affects around 10% of patients, most of those incidents were preventable. 11 Patient safety requires knowledge and skills in various areas, including human factors and system management, because most preventable errors, such as medication errors, investigation errors and nosocomial infections, are related to these areas. 12 Patient safety attitude is a significant key influencing factor for improving physician-patient relationship and the quality of service that patients obtain. Reviewing PS attitude regularly enables the organisation management council to realise and monitor the progress of PS within the healthcare processes. In Egypt, different studies highlighted the need for improving the PS culture among healthcare providers. Moreover, relevant research is needed to evaluate the PS attitudes and awareness. This study was designed to assess PS attitude and identify its determinants among HCWs in Sharqia Governorate at various levels of care, including primary health care (PHC) units (primary level) and Zagazig General Hospital (tertiary level). Also, the findings of this study may also be used as an input for the Ministry of Health and population (MOHP) and administrators of the hospitals and healthcare units to make informed decisions regarding PS issues at the study site and in other similar sites in Egypt.

Study population
Healthcare workers include physicians, dentists, pharmacists, nurses and technicians, working in PHC units in Zagazig Health District (primary level) and Zagazig General Hospital (tertiary level) for more than six months.

Inclusion criteria
All HCWs working in the places of the study for more than six months and who were willing to participate in the study were included.

Exclusion criteria
Healthcare workers working in the places of the study for less than six months and who were on annual leave and sick leave during data collection were excluded from the study.

Sample size and sampling
The sample size was calculated using Epi Info™, 13 assuming that the prevalence of positive attitude among HCWs towards teamwork climate is 21.5% at the primary level 14 and 38% at the tertiary level of health care. 3 The total sample was 240 with 95% confidence level, and the study power was 80%. As the ratio was 1:1, 120 HCWs each from the primary and tertiary levels of health care were selected to participate in the study. Sample units in subgroups B and C were divided and selected using the proportional allocation method.
A stratified random sampling technique was used to select the study subjects from the selected units and hospital. During this, primarily, the lists of HCWs were obtained from units and hospital. Then, based on the list obtained, a lottery method was used to select the study participants. Next, the objective of the study was explained to them. Finally, selfadministered questionnaires were distributed for those HCWs who were willing to participate in the study.

Tool and data collection
The modified Chinese Safety Attitudes Questionnaire (CSAQ), developed by the Taiwan Joint Commission on Hospital Accreditation, was used in this study. 15 This tool consists of seven scales: teamwork climate, safety climate, job satisfaction, stress recognition, perception of management, working conditions and burnout. The tool consisted of 40 statements, with responses rated using a 5-point Likert scale, indicating the participants' level of agreement with the statement (i.e., 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree and 5 = strongly agree). During data analysis, the scores of negatively worded items were reversed so that higher scores in the dataset indicated a more positive assessment of the unit's PS culture. Some demographic characteristics were also collected, including age, sex, marital status, working place, highest degree of education, job title, work shift, years of work experience and previous training on PS.

Content validity and reliability
The questionnaire was translated into Arabic and was translated back to English by language experts. The reliability of the scales was tested through internal consistency measurement. It demonstrated an excellent level of reliability (Cronbach's alpha = 0.915). 16 One month before the start of this study, a pilot study was conducted to demonstrate any data collection difficulties, evaluate the questionnaire validity and reliability after translation, and estimate the time needed for data collection and expected frequency. No changes were employed, so the pilot sample was included in the main sample.

Statistical analysis
The Statistical Package for the Social Sciences, version 25, 17 was used to analyse the data collected. Tables were used to present data as frequencies, proportions, means and standard deviations. Independent samples t-tests and one-way analysis of variance were used, as appropriate, to compare PS attitudes at various levels of health care and assess the relationship between participant characteristics and the total mean score of the PS attitude. To identify predictors, linear regression analyses were performed.

Ethical considerations
After revising the study protocol, the Zagazig University Institutional Review Board (ZU-IRB) granted approval (ZU-IRB #6765). Before the interview, the study's nature and purpose were explained to participants, and verbal consent was obtained. The information provided by all participants was kept private. The study was approved by the Zagazig health directorate. An official permission letter was obtained from the authority and directed to Zagazig General Hospital and the PHC units included in the study.

Results
This study included 240 participants, including 120 primary HCWs (PHCWs) (i.e., 40 physicians, 32 nurses, 28 pharmacists, 12 dentists and 8 technicians) and 120 tertiary HCWs (THCWs) (i.e., 40 physicians, 24 nurses, 32 pharmacists, 8 dentists and 16 technicians). The mean age of the PHCWs was 34.7 ± 6.5 years, and that of the THCWs was 35.7 ± 7.8 years. Most respondents were females, were married, did not attend any PS training courses and had direct contact with patients. More than half of them had morning work shifts and worked in the current place for ≥ 6 years. Almost onethird of the PHCWs had university education and working experience ranging from 5 years to < 10 years. The THCWs had high school education (31.7%) and university education (31.7%) and had working experience ranging from 10 years to < 15 years (Table 1).  Figure 1.
There were significant statistical association between the level of health care and the mean scores of Teamwork climate, Perception of management, Job satisfaction, working condition, Stress recognition and the overall CSAQ score (p = < 0.001, 0.003, < 0.001, 0.002, < 0.001, 0.001, respectively), as the THCWs had a significantly higher mean score (  In the regression analysis, educational degree and job type were significant predictors of PS attitude among the HCWs under study. Non-significant R 2 indicates a good fit model of PS attitude (Table 5).

Discussion
Patient safety is an important aspect of healthcare quality. As healthcare organisations strive to improve, the importance of fostering a safety culture within them is becoming more widely recognised. 18    The levels of staffing in this office are sufficient to handle the number of patients.

Job satisfaction
This health unit/hospital is a good place to work.  between the results of this study and those of other studies is a lack of PS culture awareness, training programmes for HCWs and institutional performance improvement strategies.
In this study, the safety climate score was higher than those of other domains, implying that creating a non-punitive culture, developing prompt networks, providing training and motivating HCWs to discuss and report adverse events and timely. However, this scale scored low, indicating the need for more attention to infrastructure and leadership attitudes towards dealing with errors and learning from adverse events.
The job satisfaction score was the second highest; the higher response rate was related to the statement, 'I like my job', suggesting that when the workplace facilitates HCWs to feel family warmth, several HCWs will love their work and behave well, which would be beneficial to PS.
The perception of management and working conditions domains were rated lower than other domains, implying that supervising and training new workers and the preservation of diagnostic and therapeutic data would be valuable to PS. Furthermore, to foster a better working environment, we must train and supervise new employees, and ensure that therapeutic information is readily available. 23 In this study, a significant difference in the mean score of PS attitude was observed between PHCWs and THCWs in terms of teamwork climate, perception of management, job satisfaction, working conditions and stress recognition. Furthermore, the overall score in the seven PS scales of the CSAQ was higher at the tertiary level than that at the primary level. This finding conforms to that of a study conducted in Turkey, which found that the average overall score of PS culture in PHC units is lower than that of hospitals. 24 This finding explained why healthcare units do not handle severe clinical cases that can only be handled by intensive care units, emergency departments or hospitals. Because most dangerous medical interventions are performed in hospitals, hospital workers may receive additional training and specialisation in safetyrelated issues. 25 This result is expected because PS topics have largely been identified at the hospital level, with less emphasis placed to the primary care level, where adverse outcomes are less common, and the greatest volume of care is delivered with infrastructure restrictions and guidelines and criteria for safe practices. 26 This study showed that older age groups had higher attitude scores; this may be explained by higher working experiences, which lead to an increase in tolerance to changes in working conditions. Furthermore, it is expected that the increasing age of HCWs will make them more appreciative of their jobs and push them to improve their performance. 27 Moreover, new workers may be less sensitive to safety issues, according    14,24,28 This study showed that male participants had higher attitude scores than females. This can be explained by difference in specialties and responsibility distribution and duration of work between them.
In this study, a link was observed between previous PS training courses and caregivers' perceived influence on PS. This result is suspected and related to the fact that education about PS impacts the attitude of healthcare worker which determines how they act and behave. This finding conforms to that stated by Asem et al., 2 Zhao et al., 29 and Biresaw et al. 30 in Ethiopia, which reported that nurses who received information on PS were 4.39 times more likely to have good knowledge and attitude as compared with those who had not.
Regarding job type, this study showed that staff holding master's degree had higher attitude scores than those with lower educational levels, and regression analysis revealed that educational level is a significant predictor, which explained by highly educated health professionals having a broader range of ideas and thinking more about the problems, which may lead to more pressure, negatively affecting teamwork climate. 29 Another predictor revealed by regression analysis was that nurses had a more positive attitude towards PS than physicians. This finding is as a result of the nurses being the first point of contact with clients for most basic benefit packages and services. 31 Furthermore, because most nurses were younger and received more information about safety culture, they may be more resilient and could handle stressful working conditions. 32 The findings conform to those of the studies by Abu-El-Noo and El Shafei and Zayed, who reported relatively high mean scores among nurses, particularly in the stress recognition domain, working in PHC centres. In contrast, various studies have revealed that physicians outperformed nurses. 28,33,34

Strengths and limitations of the study
The strength of our study was based on the comparison of PS between different levels of care in contrast to other studies. The limitation was that the data collected depended on selfreports from the participants. The accuracy of the questionnaire may have been affected by the fear of punishments. Moreover, we wanted to assess PS culture from the perceptions of other healthcare givers, for example, nursing students, clerks, managers and patients. Furthermore, the cross-sectional nature of the study design does not confirm definitive cause and effect relationship.

Conclusion
The current study showed that the PS score is low among HCWs at both healthcare units and hospitals, and no domain had a score higher than 75. Moreover, hospital HCWs had significantly higher scores in most PS domains and overall score than PHCWs. Personnel with master's degree and nurses were predictors of good PS attitude.
All PS domains necessitate improvement beginning with continuous PS culture assessment along with regular monitoring and increasing the awareness of PS culture. Other studies are required in different regions and healthcare settings to generalise the results to other units and hospitals in Egypt.
Training and learning by providing skills for healthcare professionals is a key for optimising quality and PS. Thus, hospitals and healthcare units' management should be prepared to all new staff and they should be given a general orientation programme and training to outline the policies, procedures, and their role and responsibilities in order to improve quality of patient care. Also, it is necessary to create an open and non-punitive culture to encourage and train health professionals to report adverse events. Moreover, it is necessary to establish scientific and reasonable hierarchical diagnosis and treatment system, arrange health professionals' workload reasonably, increase the number of health professionals reasonably and reduce the stress of health professionals.
Further research is recommended to include staffing and the work environment factors to predict the outcomes of care.