This research is the first comprehensive study to examine the relationship between factors affecting the patient's safety culture in private and public hospitals with different health care workers in Iran.
In this study, two highly common tools were used to evaluate patient safety culture and occupational burnout.
Medical personnel as a subset of a human society who are involved with occupational burnout and stress and high occupational burden in comparison with other groups of the population are more exposed to physical and emotional problems than the ordinary society. This issue is highly important since the problems of this group directly affect the erosion of medical errors and consequently the health of people in the community, it has a double impact. Reducing medical errors is not possible by directly increasing the observance of the safety culture by medical personnel. Therefore, this study aimed to investigate the burnout and demographic factors affecting the level of patient safety culture. The results of this study showed a negative effect of burnout on patient safety culture. There was also a significant difference in patient safety culture in different types of hospitals, in which the patient safety culture was better in public than in private hospitals.
Today, in order to provide a desirable and standard health care services, a notable emphasis is placed on the physical and mental health of health care personnel. Occupational burnout is a very crucial topic because of the dramatic changes that bring to personal, family, and general and professional health [18].
The first hypothesis, which was the better patient safety culture in private hospitals, was rejected according to the results of the study. The patient safety culture score in public hospitals was higher than private ones, which indicates that health care in public hospitals is better than private hospitals. This could be the result of a greater investment of the Ministry of Health in its hospitals compared with private hospitals regarding patient service quality and safety. In a study by Walston et al., they studied the safety of the patient in private and public hospitals in Saudi Arabia. The results of this study showed that the quality of patient safety in a public hospital is better than private hospitals, which is consistent with the results of this study [18].
The results confirmed the second hypothesis, which stated that the patient's safety culture is at lower levels in shift workers. The patient safety culture score for shift workers was lower than those who weren’t, which actually means shift working has a negative impact on the safety culture of the patient. In this regard, the negative impact of shift work on the reduction of observance of the patient's safety culture can be explained by the double fatigue resulting from shift work [19]. Griffiths et al. showed that shift work and night work would reduce the quality of the patient's safety and, consequently, increase medical errors [20].
There was no significant difference between the patient safety culture score and the age group, work experience, sex, education, and unit of service (P-value>0.05). However, this difference was significant in the type of hospital and shift work (P-value <0.05).
Based on the results of the 12 dimensions of patient safety culture, two dimensions of organizational learning/continuous improvement, and non-punitive responses to errors and mistakes were identified as the strengths of safety culture in public and private hospitals. Additionally, the overall perceptions of patient safety in public hospitals and the teamwork within hospital units have also been recognized as a strong point in the safety culture in private hospitals.
In the study of El-Jardali et al., which determined the patient safety culture score in 68 hospitals in Lebanon, as in this study, organizational learning/continuous improvement was the highest score, but unlike the results of the present study, the non-punitive response to errors and mistakes had the lowest score [21].
In a study by Noord et al., in which the patient safety culture was evaluated in the emergency departments of 33 non-academic hospitals in the Netherlands, the subjects chose teamwork within the emergency department and open communications as the best patient safety dimensions [22].
In the study of Alahmadi et al., which was carried out to assess the safety culture of 16 public and private hospitals in Saudi Arabia, organizational learning/continuous improvement and feedback & communication about error were indicated as strengths and frequency of events reported, non-punitive responses to errors and mistakes, staffing, and teamwork within units were reported as weaknesses [23].
Based on the results of this study, the dimensions required for improvement in both public and private hospitals were three dimensions of supervisor/manager expectations & actions promoting patient safety, feedback & communication about errors and the frequency of unwanted errors reported.
In the study of Noord et al., dimensions with the lowest score were the frequency of events reported, teamwork between units, and management support [22].
In the study of El-Jardali et al., the dimensions with the lowest score were handoffs & transitions of patient information between the department and the shift, the staffing and the non-punitive response to errors and mistakes [21].
In the context of the weakness of management support for patient safety, in terms of manager's expectations and actions to improve patient safety, it is worth noting that the promotion of the hospital's safety culture is a major development and requires the change in the values, beliefs, and behavior of the organization staff in line with the values of the safety culture; and such a change requires the support of senior executives, leaders, and supervisors [21, 22].
Given the fact that the hospitals are weak in terms of feedback and informing others about the errors and frequencies of unwanted errors reporting, they will not have the opportunity to take lessons and to improve safety culture from errors and mistakes by exploring the reasons of this errors and the way of handling them [22, 24].
In this regard, the establishment of a systematic and comprehensive system for reporting errors and incidents seems vital because it leads to the identification of types, the nature, and cause of errors, and to design processes and adopts measures to reduce or eliminate similar errors and occurrences, which diffidently will be very effective [24].
In this study, 24% of healthcare personnel of public hospitals gave as perfect score, 39% as very good, 13% as acceptable, 13% as poor and finally 11% as failed to the safety of their working unit and in private hospitals 18% scored for a perfect score, 30% for very good, 15% for acceptable, 19% for poor, 18% for failed. This finding suggests that the development of different dimensions of safety culture in hospitals, especially private ones, needs improvement, and confirms the studies by Chen et al. [15] and Khater et al. [7]. In the study of Alahmadi et al., 60% of the subjects rated hospital safety as excellent and very good, 33% acceptable and 7% poor [23].
The results of the study are consistent with the third hypothesis, which indicates that burnout has a direct negative effect on the patient's safety culture so that when the burnout increases, the patient's safety culture decreases. The results of this study are consistent with the results of studies by Halbesleben et al. [25] and Hall et al. [26].
In other words, it can be claimed that since in this study burnout is known as an independent variable affecting the observance of patient safety culture, planning to reduce burnout and consequently increasing the observance of the patient safety culture that follows reducing hospital accidents can be considered as a concern for managers.
There was no significant difference between occupational burnout score and age group, work history, sex, education, and place of service (P-value> 0.05) but this difference was significant in hospital type and shift work (P-value <0.05).
Occupational burnout score was lower among public hospitals health care staff than private hospitals. One reason for this can be that the ultimate goal in private hospitals is to reduce costs in order to increase profits and benefits, leading to a reduction in workforce and an increase in workload, which will result in an increase in the burnout of health care personnel. The results of this study are consistent with the results of the study by Hansen et al. [27].
Burnout score was higher among shift workers than non-shift workers. In concluding this result of the study, it can be said that constant changing in sleep and awakening cycles causes psychological stress and family and personal problems. As working hours are longer, responsibilities are heavier, and the family and social support are lower, the amount of burnout is increased. The results of this study are consistent with the study by Wisetborisut et al. [28].
Existence of high levels of emotional exhaustion and depersonalization and lack of sense of personal accomplishment can trigger an alarm for the managers because, in the absence of appropriate planning to control it, it can lead to extensive damage to the health system [28].
Generally speaking, when people work in areas where there is lack of proper encouragement, induced sense of effectiveness, and insight, and the tasks are not well understood, the duties and policies are not well explained, the new and diverse approaches do not come up, the work environment is not pleasant and desirable, the situation does not have the conditions for mental comfort, people not only get occupational burnout but also they lose their attitudes toward the patient care.
Limitations
This survey was a cross-sectional study, and causation cannot be investigated. The number of participants in the study was large in comparison to the existing studies, so the extended research team was needed. The results of this survey may not be generalized for other countries because of different patient safety culture structure.