Influence of patient safety perception and attitude on inpatients’ willingness to participate in patient safety: An observation study

Abstract

Patient safety (PS) in clinical settings focuses primarily on ensuring active patient participation. However, there is limited understanding of patients’ willingness to participate. This study aimed to investigate the association between PS perception, attitude, and inpatients’ willingness to participate in PS. This cross-sectional study was conducted with 295 inpatients admitted to a tertiary hospital in South Korea between May and July 2023. Structured questionnaires were used to collect the data. The collected data were subjected to various analytical techniques including descriptive statistics, t tests, Pearson correlation analysis, and multiple regression analysis. Willingness to participate in PS of inpatients showed a statistically significant difference in PS education experience (t = −2.69, P = .008). There was a significant positive correlation between PS perception and attitude (r = .54, P < .001). Additionally, willingness to participate in PS had significant positive correlations with PS perception (r = .62, P < .001) and PS attitude (r = .48, P < .001). The factors influencing willingness to participate in PS were PS perception (β = .51, P < .001) and attitude (β = .20, P < .001). Based on these research findings, it is important to provide inpatients with education and campaigns to improve their perceptions and attitudes toward PS. In addition, it is essential to develop programs that encourage and support patient engagement in PS in hospitals. These efforts will promote active implementation of PS activities by inpatients in clinical settings.

1. Introduction

Recent advancements in complex medical systems have increased the likelihood of patient safety (PS) issues, making PS in hospitals a major global concern.^[1] According to previous studies in developed countries, 1 in 10 patients may experience PS issues owing to various complications during hospital treatment, with approximately 50% being preventable.^[2] Annually, low-income and middle-income countries experience approximately 134 million adverse events in hospitals, including PS concerns and errors, resulting in approximately 2.6 million deaths.^[3] In the United States, more than 250,000 deaths are attributed to medical errors annually, ranking it the third leading cause of death.^[4] Systematic literature reviews indicate a PS incidence rate of approximately 9.2% within hospitals in developed countries, such as the United Kingdom, Australia, Canada, and France, with preventable PS issues accounting for approximately 43.5% of cases.^[5] Such PS concerns are critical in the healthcare sector, emphasizing the importance of healthcare institutions strategizing toward enhancing medical service quality and reducing PS issues.

PS entails minimizing harm or error risks for patients and encompasses all activities undertaken to minimize the risks of harm or errors occurring while providing healthcare services.^[1] Numerous studies on PS, primarily centered on healthcare professionals, have focused on preventing errors that occur during the provision of healthcare services.^[6,7] However, recent discourse suggests active patient involvement, including PS activities, as a paramount approach to reducing medical incidents.^[8–10] Strategies aimed at reducing PS issues can lead to fiscal savings and, more importantly, yield better patient outcomes.^[1,2] Thus, recognizing the pivotal role of active patient involvement in reducing the risk of PS issues^[11] is imperative to foster awareness that inpatients can ensure their own safety by participating in accident prevention. Despite the necessity of patient involvement in PS, there is a significant lack of research on inpatient PS perception, attitude, and willingness to participate in PS.

PS perception refers to the extent to which patients perceive themselves as being free from harm in a medical setting.^[12] PS attitude refers to the attitudes that patients must possess to protect themselves from unnecessary risks.^[13] Previous research suggests that PS perception influences the formation of PS attitude^[14] and reports a static correlation between PS attitude and perception.^[15] Additionally, higher PS perception among inpatients correlates with greater willingness to engage in PS.^[16] Factors that have been shown to inhibit willingness to participate in PS include acceptance of new patient roles, lack of medical knowledge, and lack of confidence.^[17] It is necessary to explore the factors that inhibit willingness to participate in PS to improve PS. Thus, it can be inferred that PS perception plays a crucial role in shaping PS attitudes and that both PS perception and attitude influence patients’ willingness to participate in PS.

Most existing research on PS has been conducted among healthcare providers and pre-healthcare workers,^{[6,7,11,13,15]} with more recent studies focusing on patients.^{[8–10,12,14]} In addition, studies have examined the relationship between PS perception and PS attitude,^[14,15] and the relationship between PS perception and willingness to participate in PS^[16] among inpatients. However, no studies have examined the relationship between PS attitude and willingness to participate in PS in an inpatient setting, and no studies have examined whether PS perception and PS attitude influence willingness to participate in PS. Therefore, this study sought to investigate whether inpatient PS perception and attitude influenced their willingness to participate in PS. The study also sought to provide evidence to support the importance of inpatient participation in PS to improve the quality of clinical care.

The specific questions of the study are: first, are there differences in willingness to participate in PS based on the general characteristics of inpatients; second, are there correlations between PS perception, PS attitude, and willingness to participate in PS; and third, do PS perception and attitude influence willingness to participate in PS?

2. Methods

2.1. Research design

This cross-sectional descriptive study aimed to investigate the relationship between PS perception, PS attitude, and willingness to participate in PS among inpatients at a tertiary hospital. Additionally, it sought to identify the factors influencing the willingness to participate in PS.

2.2. Participants

The target population consisted of patients admitted to a tertiary hospital in the Jeolla-do Province, South Korea. Specific selection criteria included: adults aged 20 years; individuals with clear consciousness and communication ability; and those who understood the study’s purpose and agreed to participate. The exclusion criteria were as follows: individuals with a history of stroke, Alzheimer or vascular dementia, memory impairment, or psychiatric disorders; and those with concurrent conditions, such as the use of antidepressants, chronic renal failure, or terminal cancer.

The sample size for the study was determined using G*Power 3.1.9.7 software, with a medium effect size (f²) of 0.11, significance level of.05, power (1 − β) of.95, and 17 independent variables. The minimum required sample size for linear regression analysis was 279 participants. Considering the potential dropout rates, 300 questionnaires were distributed, and 295 completed questionnaires were used for statistical analysis after excluding 5 incomplete or missing responses. Therefore, the minimum number of cases required for statistical analysis was met.

2.3. Questionnaire

The demographic characteristics of the participants included age, sex, educational level, family cohabitation status, and employment status. Disease-related characteristics included PS education experience, hospitalization experience, department of treatment, surgical history, and number of comorbidities (such as hypertension, diabetes, coronary artery disease, stroke, and respiratory diseases).

PS perception was measured using the PS Perception Questionnaire developed by Kim et al,^[12] which was validated for inpatients in South Korea. The questionnaire consists of 24 items categorized into 3 subscales: safety assurance activities (10 items), PS practices (10 items), and trust in the healthcare system (4 items). Each item is rated on a 5-point Likert scale, with scores ranging from 24 to 120. Higher total scores indicate higher PS perception. The questionnaire was developed based on a literature review of PS in inpatient settings, validated by experts for content validity, and assessed for criterion and construct validity.^[12] The reliability coefficient (Cronbach α) reported by Kim et al^[12] was .93, while in this study, Cronbach α was .95.

PS attitude was assessed using the PS Attitude Questionnaire, modified and validated by An et al,^[18] based on the PS Culture Measurement Instrument. This questionnaire consists of 10 items rated on a 5-point scale, covering attitudes toward preventing PS incidents, reporting systems for PS incidents, communication with healthcare professionals, and fall prevention. The scores ranged from 10 to 50, with higher total scores indicating more desirable attitudes toward PS. The questionnaire was developed by reviewing the results of surveys that included PS topics, validated for content validity by a group of experts, and developed to make it easy for patients to answer.^[18] The reliability coefficient reported by An et al^[18] was .71, whereas in this study, Cronbach α was .70.

Willingness to participate in PS was measured using the Patient Participation in PS Questionnaire developed by Lee.^[19] This questionnaire consists of 18 items categorized into 5 subscales: decision-making (1 item), information provision (3 items), asking questions (6 items), double-checking (5 items), and reporting (3 items). Each item is rated on a 4-point Likert scale, with higher total scores indicating greater willingness to participate in PS. The questionnaire was developed based on the “20 Tips to Help Prevent Medical Errors” developed by the Agency for Healthcare Research and Quality (AHRQ), the content of the Joint Commission’s Speak Up campaign, and a literature review, and then validated for content validity by a group of experts.^[19] The reliability coefficient reported by Lee^[19] was .88, whereas in this study, Cronbach α was .94.

2.4. Procedure and ethical considerations

This study was approved by the Institutional Review Board (IRB) of W University Hospital in April, 2023. Data collection was conducted at a tertiary hospital, and permission for research purposes and data collection procedures was obtained from the nursing department. Data were collected from May to July 2023. To collect data, we trained research assistants during the research process. Initially, participants who voluntarily applied for the research were selected after posting recruitment posters on a ward bulletin board. Subsequently, the researchers reviewed whether the patients who agreed to participate in the study met the selection criteria, explained the research purpose and methods to them face-to-face, and obtained written informed consent. Written consent included information about the research purpose, data collection content, and confidentiality of the personal information. The participants could withdraw from the study at any time during hospitalization, without any disadvantages. The research assistants administered the survey in the ward consultation room to patients who voluntarily provided written consent to participate. The average time taken to complete the survey was 10 to 15 minutes. Participants who completed the survey were provided with a token of appreciation.

2.5. Data analysis

The collected data were analyzed using International Business Machines (IBM) SPSS/WIN 26.0. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to analyze the general and disease-related characteristics of the subjects. Differences in the willingness to participate in PS according to the general and disease-related characteristics of the participants were analyzed using t tests and 1-way analysis of variance (ANOVA). The means and standard deviations of PS perception, attitude, and willingness to participate in PS were calculated, and the correlations between these variables were analyzed using Pearson correlation coefficient. Normality tests for PS perception, attitude, and willingness to participate in PS were conducted using skewness and kurtosis. As a basic assumption of the regression analysis, the absence of autocorrelation or independence was confirmed using the Durbin–Watson value, and multicollinearity issues were confirmed using the variance inflation factor (VIF). Hierarchical multiple regression analysis was conducted with variables showing significant differences in willingness to participate in PS among the general characteristics of the participants, variables correlated with willingness to participate in PS as independent variables, and willingness to participate. There were no missing data from 295 participants. Statistical than.05 were considered at significant.

3. Results

3.1. Differences in willingness to participate in PS according to general and disease-related characteristics

Table 1 presents participants’ general and disease-related characteristics. The mean age of inpatients was 66.95 years (±10.74), with 42 individuals (14.2%) aged under 40, 103 (34.9%) aged 40 to 64, and 150 (50.8%) aged 65 or older. This study included 165 males (55.9%) and 130 females (44.1%). Education levels were: 120 patients (40.7%) had completed middle school or lower, 101 (34.2%) graduated from high school, and 74 (25.1%) graduated from college. Most patients, 239 (78.9%) resided with their families, while 178 (60.35%) were currently unemployed. Regarding PS education, 153 patients (51.9%) reported having received it and 262 (88.8%) had previous hospitalization experience. The most common department of treatment was internal medicine, with 150 (50.8 %) and 201 (68.1 %) patients undergoing surgery. The number of comorbidities was “none” for 85 individuals (28.8%) and “one” for 84 individuals (28.5%).

Table 1.

Differences in willingness to participate in patient safety according to demographic and clinical characteristics (N = 295).

Characteristics	Categories	Total	Willingness to participate in PS	t or F	P
		n (%)	M ± SD
Age (yr)	≤39	42 (14.2)	62.90 ± 7.63	2.61	.075
	40 to 64	103 (34.9)	60.16 ± 7.79
	≥65	150 (50.8)	59.47 ± 9.39
Gender	Male	165 (55.9)	59.39 ± 8.99	−1.79	.073
	Female	130 (44.1)	61.22 ± 8.17
Education level	Middle school	120 (40.7)	59.58 ± 9.59	0.67	.514
	High school	101 (34.2)	60.32 ± 7.70
	College	74 (25.1)	61.04 ± 8.38
Family cohabitation	Alone	56 (19.0)	60.46 ± 10.16	0.26	.798
	With family	239 (81.0)	60.13 ± 8.31
Employment	No	178 (60.3)	60.02 ± 9.09	−0.44	.661
	Yes	117 (39.7)	60.47 ± 8.01
PS education	No	142 (48.1)	58.80 ± 8.97	−2.69	.008
	Yes	153 (51.9)	61.49 ± 8.20
Hospitalization	No	33 (11.2)	61.85 ± 7.98	1.16	.246
	Yes	262 (88.8)	59.99 ± 8.75
Department	Medicine	150 (50.8)	59.89 ± 9.25	0.43	.652
	Surgery	79 (26.8)	60.05 ± 8.28
	Others	66 (22.4)	61.06 ± 7.79
Surgical history	No	94 (31.9)	60.54 ± 9.30	0.47	.640
	Yes	201 (68.1)	60.03 ± 8.38
Number of comorbidities	0	85 (28.8)	60.71 ± 8.27	0.99	.395
	1	84 (28.5)	60.69 ± 8.13
	2	70 (23.7)	60.41 ± 7.88
	≥3	56 (19.0)	58.41 ± 10.75

PS = patient safety, SD = standard deviation.

The willingness to participate in PS according to the general and disease-related characteristics of inpatients showed a statistically significant difference in PS education experience (t = −2.69, P = .008), as shown in Table 1.

3.2. Correlations between PS perception, attitude, and willingness to participate in PS

The skewness values were all less than 3 in absolute terms, and the kurtosis values were all less than 8, indicating that the univariate normality assumption of the sample was satisfied. The mean scores for PS perception, PS attitude, and willingness to participate in PS were 101.08 (±14.33), 40.15 (±4.91), and 60.20 (±8.67), respectively. There was a statistically significant positive correlation between PS perception and attitude (r = .54, P < .001). Additionally, willingness to participate in PS was found to have a statistically significant positive correlation with PS perception (r = .62, P < .001) and PS attitude (r = .48, P < .001), as shown in Table 2.

Table 2.

Descriptive statistics and correlations among the variables (N = 295).

Variables	Min	Max	Mean ± SD	Skewness	Kurtosis	PS perception	PS attitudes
						r (P)	r (P)
PS perception	24	120	101.08 ± 14.33	−0.94	2.42
PS attitude	26	50	40.15 ± 4.91	−0.23	−0.49	.54 (<.001)
WPPS	18	72	60.20 ± 8.67	−0.63	1.13	.62 (<.001)	.48 (<.001)

PS = patient safety, SD = standard deviation, WPPS = willingness to participate in patient safety.

3.3. Factors influencing the willingness to participate in PS

Hierarchical multiple regression analysis was conducted to identify the factors influencing inpatients’ willingness to participate in PS. First, the assumptions of regression analysis were verified. The Durbin–Watson value was 1.82, which was close to 2, indicating no autocorrelation or independence among the variables. Moreover, the VIF was below 10 for all variables, indicating no multicollinearity issues.

In Step I of the regression model, PS education experience, which showed a significant difference in willingness to participate in PS, was included as a dummy variable. Steps II and III included PS perception and PS attitude, respectively. The results of the regression analysis indicated that Model I was statistically significant (F = 7.23, P = .008), and PS education experience (β = .16, P = .008) explained 2.1% of the variance in willingness to participate in PS. Model II was also statistically significant (F = 92.70, P < .001), with PS attitude significantly influencing willingness to participate (β = .61, P < .001), accounting for 38.4% of the variance. Model III was statistically significant (F = 69.16, P < .001), where PS perception (β = .51, P < .001) and PS attitude (β = .20, P < .001) explained 41.0% of the variance in willingness to participate in PS (Table 3).

Table 3.

Hierarchical linear regression analysis predicting willingness to participate in patient safety (N = 295).

Predictors	Step Ⅰ				Step Ⅱ				Step Ⅲ
	B	β	t	P	B	β	t	P	B	β	t	P	VIF
PS education (1 = yes)	2.69	.16	2.69	.008	0.90	.05	1.12	.263	.74	.04	0.94	.349	1.03
PS perception					0.37	.61	13.19	<.001	.31	.51	9.46	<.001	1.43
PS attitude									.35	.20	3.73	<.001	1.42
F (P)	7.23 (.008)				92.70 (<.001)				69.16 (<.001)
Adjusted R²	.021				.384				.410

PS = patient safety, B = unstandardized estimates, β = standardized estimates.

4. Discussion

This study revealed that PS perception and attitude among inpatients significantly influenced their willingness to participate in PS. These results show that inpatients who score higher on perception and attitude toward PS are also more likely to be engaged in PS. This supports previous research that reported that inpatients feel safer and perceive greater interest from healthcare providers when they have the opportunity to participate in their care process.^[20] Additionally, previous studies have identified factors influencing PS participation, such as disease severity, experience of PS incidents, relationships with healthcare providers,^[21] PS education experience,^[16] and health literacy.^[22] Given that efforts from healthcare institutions and providers alone may not be sufficient to defend against and prevent all the factors threatening PS,^[23] the active participation of patients is paramount.

To prevent potential medical errors in healthcare institutions, the active involvement of patients directly affected by PS incidents is crucial.^[11] In this study, the average score for willingness to participate in PS for inpatients was 60.20 out of 72 points. This aligns with the results of previous studies involving inpatients.^[10] PS participation enhances PS by increasing diagnostic accuracy and treatment effectiveness and identifying side effects and errors by monitoring the treatment process.^[24,25] To enhance patient involvement in PS within healthcare institutions, healthcare professionals must adopt patient-centered approaches to encourage inpatient participation in PS.^[26] Furthermore, patients and their caregivers should actively engage in PS activities as active participants who fulfill patients’ rights and responsibilities, rather than passively receiving healthcare services. To achieve this, national policies supporting healthcare providers in PS management and development, as well as the provision of specialized personnel, are required.

In this study, the PS perception of inpatients was found to have the greatest impact on their willingness to participate in PS. This is consistent with previous studies, which have also shown that higher PS perception among inpatients correlates with greater willingness to participate in PS.^[16] In this study, the inpatient PS perception score was an average of 101.08/120 points. This result is similar to that of previous studies involving inpatients.^[10] To enhance their perceptions of PS, patients must show interest in PS activities conducted by healthcare providers and trust the healthcare system.^[12] Healthcare institutions should focus on raising awareness of the importance of PS practices by promoting campaigns and initiatives tailored to patients, perspectives, and encouraging active participation in PS activities.^[27] Given the significance of patient communication with healthcare providers and direct participation in PS activities, it is essential to develop intervention programs aimed at improving PS perception. Such programs can help to increase the number of patients.

In this study, PS attitude emerged as a significant factor influencing the willingness to participate in PS. The average score for inpatient PS attitude was 40.15 out of 50 points. This result was higher than that reported in a previous study^[14] involving inpatients who used the same instrument. This indicates that, in this study, repeated hospitalization experiences may have influenced the participants’ PS attitude. Moreover, in our study, inpatients’ perceptions of PS were significantly correlated with their attitudes toward PS. This finding aligns with previous research that demonstrated a correlation between PS perception and attitude.^[14,15] Previous studies have highlighted that inpatients who receive PS education tend to have more positive attitudes toward PS, emphasizing the importance of fostering desirable attitudes toward PS to improve PS practices.^[28,29] Given that patients undergo repeated hospitalizations and visits to various healthcare institutions, standardized education on PS is necessary. Therefore, developing standardized guidelines for PS education and creating patient-tailored educational materials that consider inpatients’ knowledge and comprehension levels is essential.

The following suggestions were proposed based on the limitations of this study. First, as this study employed a cross-sectional design and used convenience sampling of patients admitted to a single tertiary hospital, caution should be exercised when generalizing the research findings. Therefore, to increase the generalizability of our findings and continue exploring PS research, we propose a repetitive study that extends to different regions and types of healthcare facilities using a larger sample size. Second, because self-reported measures were used, there was potential for recall bias, which may have led to both overestimation and underestimation of the research results. Therefore, it is necessary to ensure objectivity in the data collection process to prevent bias in the process of selecting measurement tools and creating questionnaires. Research on the development of reliable and valid instruments to measure PS topics should be continued. Third, the study was limited in that it did not consider various factors that may affect willingness to participate in PS; therefore, future research should include longitudinal and mixed methods studies to gain insights into PS topics. Furthermore, research is needed to develop intervention programs that promote PS engagement activities.

5. Conclusions

In this study, a significant positive correlation was found between PS perception, attitude, and willingness to participate in PS among inpatients at a tertiary hospital. It was confirmed that both PS perception and attitude significantly influenced willingness to participate in PS. The findings of this study are expected to serve as foundational data for the development of intervention programs aimed at enhancing inpatients’ willingness to participate in PS activities and improving PS practices.

Acknowledgments

Thank you to all the patients who participated in this study.

Author contributions

Conceptualization: Mi Hwa Won, Sun-Hwa Shin.

Data curation: Mi Hwa Won.

Formal analysis: Mi Hwa Won, Sun-Hwa Shin.

Funding acquisition: Mi Hwa Won.

Methodology: Mi Hwa Won, In Suk Hwang, Sun-Hwa Shin.

Project administration: Mi Hwa Won, In Suk Hwang.

Supervision: Mi Hwa Won.

Writing – original draft: Mi Hwa Won, Sun-Hwa Shin.

Writing – review & editing: Mi Hwa Won, Sun-Hwa Shin.

Investigation: In Suk Hwang.

Validation: Sun-Hwa Shin.

Visualization: Sun-Hwa Shin.