The safety climate in the eleven hospitals evaluated was negative (63.7) because it did not reach the minimum score of 75. The differences among the means of the hospitals (60.9 to 68.2) were significant in general and for all domains, except in management perception. It should be noted that this domain had the second worst performance among the six domains evaluated.
The domains analysis showed that the best overall performance was for work satisfaction, followed by stress perception, while the worst performance was for the working conditions, followed by management perception. The critical performance of the working conditions domain, both in the hospitals and in the total sample, was similar to that found in other studies conducted in several different countries [10—14], where this domain had the worst or second worst performance in comparison to others. Studies conducted in Brazilian hospitals also found similar results [15—18].
The health system is made up of high-risk tasks, yet they are still considered to be of low reliability when one considers the several adverse events that continue to happen daily around the world. In this sense, to make the health system more secure, it is central to invest in infrastructure and work process organization to reach optimal conditions to perform health actions. The results found in the working conditions domain demonstrate the need and importance of these investments in the hospitals evaluated.
Management perception had the second worst performance, and similar results for this domain have been reported in the literature. In a study that evaluated the perception of nurses working in acute care in six Australian hospitals , this domain had the worst performance. A similar result was found in a Taiwanese study , which used the method of Importance and Performance Analysis, in which it was found that this domain was a weakness, as evidenced by the neglect of management’s support for patient safety.
At this point, it is important to emphasize the importance of improving management processes at all levels of leadership—high leadership, tactical and/or intermediary leadership, front-line leadership and/or operational leadership. It seems crucial to reduce the distance between those who command and those who execute to change this scenario in which management is not seen as a strength but as a weakness for the safety culture.
It is noteworthy that another study performed in Taiwan, which used the decision-making trial and evaluation laboratory method , reported management perception as a causal domain in addition to the working climate and stress perception. This result means that improvements directed towards causal domains not only improve the domain itself but also result in better performance of the other domains directly affected by it. Teamwork climate and management perception are the most critical domains because they each have significant influences on four domains .
Teamwork and the security climate had intermediate results and, although all of these domains are equally important in assessing the security climate, studies have shown that favorable results from these domains are correlated with an absence of health care related infections in Neonatal Intensive Care Units . Positive associations between adverse event reporting rates within these domains and another two domains (working conditions and unit management perception) were also found . This result suggests that efforts to improve the perception of these domains can result in improvements in the quality of care with outcomes that directly affect patients.
Work satisfaction and stress perception were the domains that had the best results and were considered positive (75 or more). Work satisfaction was positive in all the hospitals, which was also observed in other studies carried out in Brazil [15—18]. In international studies, although this domain does not always present the best performance, it has been observed that this domain is well evaluated, occupying at least one of the three best positions [10—14, 24]. It should be noted that this result, compared to the worst performance found in this study (working conditions), demonstrates the resilience of professionals who, despite working under questionable conditions, remain positive. This result might also indicate the preservation of the altruistic dimension of work, which is translated by the sense of the social purpose of what is produced. In addition, this result can be explained by the interpersonal relationships established in the work environment with ties of complicity, ways of coordination and cooperation, and implicit rules of mutual help and harmony among workers in situations with poor general conditions .
Stress perception was positive in general and in most hospitals. This domain is fundamental as professionals realize how harmful long working hours can be, often without rest breaks, and professionals leave one job and immediately go to another. This situation is often the case in Brazil, especially among low-paid professions, who need more than one job to maintain their and their families’ living conditions. Research on the Nursing Profile indicated that in Brazil, 25% of the respondents report having two jobs .
The differences between the means of professionals in the domains were significant for all domains except stress perception, which suggests a greater agreement among professionals on this point and emphasizes the good results of this domain. It should be stressed that this domain is a causal domain for work satisfaction , so its strengthening contributes to improving the performance of this domain, which already presents a positive result.
Safety assessments have been conducted more frequently in recent years, which indicates that the attention of researchers and the health system itself have been drawn to the recognition of the safety climate in health services. Several applications are available, ranging from purely safety assessments [15, 16, 19] to safety assessments performed before and after interventions (implementation of work processes and/or assistance protocols) [27—29] as well as combining evaluations to correlate results [22, 30, 31]. The application possibilities are numerous, and the results are very important to verify the scope and efficacy of the implemented improvements.
A study carried out at a children’s hospital in the United States observed significant increases in the safety climate semiannual score of the SAQ across a hospital system, which were also marked by significant reductions in the rates of preventable injury, severe adverse events, and adjusted hospital mortality. These results were obtained after the implementation of programs aimed at improving quality and safety . In this study, the SAQ scores identified low performance levels, which indicated the requirement to conduct formal debriefings and creating a plan of action with a suggested timeline to address at least one problem identified in the most recent SAQ survey. There were marked variations in the scores within the hospital, with underperforming units under the same leadership and administrative management of other units with better performances, suggesting that the causes could be quite specific for the unit . These are some examples of how the SAQ results can be used by the hospital managers involved in this study.
The results of research conducted around the world are useful to identify the point that health services are at in regard to patient safety, as well as to guide actions and promote benchmarking among similar services. However, because it is a security climate assessment, it is not exempt from the local culture itself, which should be considered when analyzing and interpreting the results.
Improving the quality and safety of health care has been a constant concern of health system managers. In Brazil, several strategic government actions have been implemented in recent years, such as the PNSP and its developments, with the aim of training professionals working in the SUS. However, the results of these actions require time to consolidate since cultural changes are required throughout the health system, which includes front-line professionals, managers and users.
It is known that there is no single way to improve safety in health services, but the direction of this change is unique and will lead to the same fate: high reliability.
Convenience sampling is the main limitation of the present study since, due to the outdated information in the CNES database, many of the professionals selected to be invited to participate were no longer working in the hospitals. This situation led to a change of the initially planned strategy from stratified random sampling to stratified sampling for convenience, which prevents the extrapolation of results to the general population.