Nurses’ perception of patient safety culture using the Hospital Survey on Patient Safety Culture tool and its association with nursing-patient outcomes: a systematic review in Iranian hospitals

Abstract

Background

Current systematic review aimed to summarize the evidence that investigated the relationship between nurses’ perception of patient safety culture (PSC), as measured by the Hospital Survey of Patient Safety Culture (HSOPSC), and nursing-sensitive patient outcomes within Iranian hospital contexts.

Methods

This systematic review adhered to the Joanna Briggs Institute guidelines and employed the PRISMA flow diagram to manage the literature screening process. A search of international and local databases, (PubMed, Scopus, Web of Science, Scientific Information Database, IranMedex, and Magiran) was carry out. The Critical Appraisal Skills Program (CASP) checklist was applied to assess the risk of bias within the included studies. A narrative synthesis approach was employed, consisting of three stages: Creating a preliminary synthesis, examining the internal and external relationships of studies, and specifying the overall strength of the synthesized findings.

Results

From an initial pool of 1636 identified studies, 12 of them met the inclusion criteria for this review. These studies encompassed a total of 6001 nurses participating, predominantly working in teaching hospitals. Five studies indicated that positive nurse perceptions of patient safety culture (PSC) were associated with the prevention of adverse events (odds ratio: 0.61 to 2.28). One study reported that there was a significant negative relationship between PSC and barriers to rerror reporting by hospital nurses (r = − 0.42). Significant inverse correlations were observed between overall PSC score and missed nursing care (r = − 0.22), stress level (r = − 0.39 to − 0.46), and medication error (r = − 0.28). Furthermore, PSC demonstrated a positive correlation with social intelligence (r = 0.76) and psychosocial workplace factors (r = 0.88). Finally, PSC among nurses was significantly associated with a reduction in second-victim experience (β = − 0.39) and burnout (β = − 0.24).

Conclusion

This review recommends that hospital managers prioritize enhancing nurses’ perceptions of PSC to improve both nurse and patient outcomes. This can be achieved through interventions such as fostering collaborative and transparent communication within healthcare teams, facilitating the sharing of experiences and lessons learned, incorporating staff feedback, providing external support, cultivating a non-punitive environment, and implementing staff training programs. Further research is warranted to identify and evaluate specific interventions that effectively improve PSC and associated outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-03305-4.

Introduction

Globally, evidence indicates that one in ten patients experiences harm in the settings of healthcenter, which causes more than three million deaths annually due to unsafe care. In low- and middle-income countries, this figure is even more concerning, with as many as four in every 100 patients dying as a consequence of unsafe care [1]. The World Health Organization (WHO) defines patient safety as “a framework of organized activities that creates cultures, procedures, behaviors, technologies, and environments in health care that consistently and substantially lower risks, reduce the occurrence of avoidable harm, make errors less likely, and reduce the impact of harm when it does occur” [2]. A critical part of patient safety initiatives is the foundation and maintenance of a robust patient safety culture (PSC). Currently, PSC is recognized as playing a vital function in boosting the safety and quality of patient care within clinical settings [3].

PSC is specifically defined as the shared beliefs, attitudes, values, norms, and behavioral characteristics of employees regarding patient safety. It is a core element of an organization’s overall culture, specifically oriented towards prioritizing patient safety [4]. Organizations with a strong PSC are positioned to achieve numerous positive outcomes [5]. Nurses are the largest group among hospital-based providers, playing a critical role in safeguarding patient safety and a key part of the overall quality of healthcare [6]. Given their responsibility for providing direct and continuous care, nurses require competency in patient safety practices to ensure the providing of high-quality care [7]. Prior research suggests several factors can influence the state of PSC among nurses, including a punitive work environment, unequal distribution of nurses across units, insufficient supporttive systems, heavy workloads, fatigue, job-related stress, time constraints, and the inherent demands for precision and concentration in roles requiring high levels of accuracy and management of patient safety [8, 9]. In developing countries, the scarcity of effective recording and reporting systems, coupled with limited research data, makes it challenging to accurately assess the status of patient safety and the prevalence of medical errors, although it is generally believed that the rate of such errors is substantial [10].

Iran as the second-largest developing country in the Middle East with a population exceeding 80 million, has undergone healthcare system reorganizations to address societal needs [11]. The Iranian Ministry of Health, Treatment, and Medical Education (MoHME), the governing body for healthcare, holds responsibility for promoting patient safety Since 2017, the MoHME has provided relevant indicators to hospitals and implemented a dedicated registration system for reporting medical errors [12]. Despite these efforts, the rate of medical errors in Iran remains high at 50%, necessitating further interventions and research within healthcare facilities, particularly hospitals [13]. The most important factors of medical error occurrence in Iran include physician education levels, inadequate training of healthcare provider, performance of providers, management and executive deficiencies, documentation practices in medical records, insufficient interprofessional collaboration, and overcrowding in hospital wards [14].

Innovative approaches to enhancing care quality have been explored, including initiatives focused on improving PSC within hospitals [15]. Nurses’ attitudes towards patient safety practices in hospital settings can significantly influence patient outcomes [16]. Published evidence supports the impact of PSC on various healthcare outcomes. For example, a study of Jordanian nurses found that increased perceived PSC was associated with a reduction in both intention to leave and personal burnout [17]. Furthermore, a positive PSC is linked to desirable outcomes including improved teamwork and communication among hospital worker, increased job satisfaction, and enhanced well-being [18, 19].

Several tools have been introduced to assess safety culture and/or safety attitudes in healthcare settings, with the Hospital Survey of Patient Safety Culture (HSOPSC) being the most widely applied [20, 21]. The HSOPSC is a validated and reliable instrument, originally developed in the United States and also, translated into several languages [22]. The English version of the HSOPSC was translated and adapted into Persian by Moghri et al. (2012) for use in Iranian hospital settings [23].

The Iranian healthcare system and culture face several challenges in cultivating an effective and positive PSC within hospitals. These challenges include weakness in organizational infrastructure, problems in leadership effectiveness, limited attempts to align with local and global standards, and low levels of teamwork [24]. A meta-analysis has showed that the overall level of PSC in Iran is low and it is essential that healthcare managers and providers pay attention [25]. Furthermore, prior research has demonstrated the negative influence of shift work, burnout, and hospital type on PSC perceptions within the Iranian healthcare system [26].

The documented high rate of medical errors and safety-related issues in Iranian hospitals underscores the need for further research in this area. Synthesizing the available evidence on nurse-patient outcomes associated with PSC can inform healthcare managers and facilitate the development of strategies to improve PSC among Iranian hospital nurses. As far as we know, no comprehensive studies employing a systematic approach have yet examined the relationship between nurses’ PSC and patient outcomes in Iran.

Within hospitals, nurses are pivotal in influencing positive patient outcomes. The established relationship between nurses’ performance and perceptions in clinical settings and patient outcomes further emphasizes their importance. Patient outcomes in nursing primarily refer to the results experienced by patients receiving nursing care. These outcomes are inextricably linked to nursing practice and are therefore considered herein as nursing-patient outcomes. Given the existing body of research conducted across diverse hospital settings in Iran, a comprehensive review is warranted to synthesize and analyze these findings. Current systematic review, therefore, aimed to summarize the evidence examining the relationship between PSC among nurses and nursing-patient outcomes within Iranian hospital settings, specifically using data derived from the HSOPSC instrument.

Methods

Design of study

This study is a systematic review and the Joanna Briggs Institute (JBI) guidelines were used for evidence synthesis [27].

Data source and search strategy

English language databases such as MEDLINE (via PubMed), Web of Science (WoS), and Scopus were searched with relevant keywords. Also, the Persian language databases of the Scientific Information Database, IranMedex, and Magiran were searched to identify published studies. The selected databases have the most number of English and Persian language studies, which were also used in previous reviews. The search strategy was implemented in all databases on titles and abstracts.Additionally, manual searches in Google and Google Scholar were conducted in order to further minimise retrieval bias. During the search in databases, a librarian was consulted to confirm that the search strategy was appropriate. The search in each database was adapted based on keywords and their combinations. These keywords were selected from MeSH (Medical Subject Headings) and published review studies. In designing the search strategy, an effort was made to identify all relevant studies. In online databases, these terms were used for searching: “patient safety” OR “safety culture” OR “safety climate” OR “safety attitude” AND “nurs*” AND “Iran” (Supplementary file 1). Finally, reference lists of selected studies were reviewed to improve the reliability of the study identification and identify additional studies.

Eligibility Criteria

The SPICE (setting, perspective, intervention, comparison, and evaluation) framework was applied to formulate the question of review and guide the search strategy in the present review [28, 29]. Based on the SPICE framework, the setting was hospitals in Iran, the perspective was the nurse’s perception, and the interventions were about PSC. Also, the comparison was PSC in regard to organizational culture, and the assessment was by using the HSOPSC instruments. Studies that met the criteria were selected as follows: Done in the geography of Iran; English or Persian language; publication date between 2000 and 2024; study design was based on a cross-sectional method, hospital setting-based study; use of the HSOPSC questionnaire and inclusion of nurses. The first version of HSOPSC was introduced and developed by the United States Agency for Healthcare Research and Quality in 2004. Since the introduction of this tool in different countries, including Iran, this instrument has been localized and used in several studies.

Therefore, the studies that were performed in Iranian hospitals from 2000 onwards were examined in the present systematic review. We reviewed studies in which PSC was the independent variable and reported outcomes were analyzed as the dependent variable. For the aim of the present systematic review, the term safety attitudes was applied to explain a single safety attitude of nurses, and aggregated scores at the clinical unit of the hospital level referred to as safety culture. Studies that were conducted outside the hospital environment and among other health workers were excluded. Furthermore, studies that were only descriptive of PSC status and did not report clear outcomes were excluded. Studies that had been conducted using other designs, including review, qualitative, intervention, and a pilot study, were also excluded in the present systematic review.

Study selection

The EndNote software (version 21) managed the studies and excluded duplications. Firstly, two authors (A.H. and E.K.) independently screened the remained studies based on titles and abstracts. Subsequently, the progress of the selected studies to the second stage, the full-text review stage, began. The full texts of the remaining studies were retrieved and assessed against predefined inclusion criteria. Any discrepancies arising during any stage of the review process were resolved by consultation with the third author (M.KH.) to achieve consensus.

Data extraction

In order to extract data from selected studies, a form was designed by the authors in Microsoft Word (Version 2021).This information was extracted from the included studies: The name of first author, year, province, design of study, nurse sample size, sampling method, type of hospital, assessment tool used for PSC, mean score or positive response rate (PRR) of PSC, outcomes measured, and key findings relating to the PSC of nurses in hospitals.

Risk of bias assessment

To address the possibility of bias in the included studies, the methodological quality of the studies was assessed by the Critical Appraisal Skills Program (CASP) checklists [30]. This tool enables researchers to systematically assess published studies’ reliability, relevance, and results. We used the CASP tool for assessment of bias in the included studies due to its features such as validity, accuracy, speed, and relevance to the included studies. In this systematic review, all included studies were cross-sectional, which was used to evaluate these studies due to the capability and reliability of the CASP checklist. If a study scored above 70% on the checklist, it was a good study; if it scored between 30 and 70%, it was moderate. Also, a study that scored less than 30% was excluded as a weak study [31].

Data synthesis

Guidelines for synthesis without meta-analysis (SWiM) have been introduced and proposed to guide the data synthesis of systematic review studies, which were used in this systematic review [32]. There was heterogeneity in the way of determining and examining all the outcomes and in the methodological approaches to collecting all the outcome data, which did not allow for meta-analysis. So, the percentage of PRR or means and standard deviations measured with the HSOPSC instrument in selected studies were reported. Also, in the included studies, the correlation coefficient and regression coefficient (β or odds ratio (OR)) were extracted and reported for the studies. The results reported in the selected studies were synthesized and summarized through a narrative method. The three main steps in narrative synthesis include Creating a preliminary synthesis, examining the internal and external relationships of studies, and specifying the overall strength of the synthesized findings [33]. Based on the narrative analysis, the authors of current review reached a consensus on the results and classified data based on the details and qualitatively described and presented the results.

Results

Search results

A total of 1636 studies were identified across all databases: 149 from PubMed, 264 from Scopus, 163 from WoS, and 1060 from other sources. Initially, 578 studies were removed due to duplication. 1058 studies were screened based on title and abstract; 1008 studies were removed, and 52 studies were assessed based on eligibility criteria. Full-text review resulted in the exclusion of 40 studies due to inconsistencies with the pre-defined inclusion criteria. Ultimately, 12 studies examining the relationship between patient safety culture (PSC) and nursing-patient outcomes in Iranian hospitals were included in this systematic review. The details of the screening process are shown in Fig. 1.

Fig. 1.

PRISMA flow chart for screening and selection of studies

Characteristics of included studies

The included studies were conducted in different provinces of Iran between 2017 and 2023. All studies employed cross-sectional designs and used the 12-item HSOPSC instrument (Persian version) to collect data from nurses. Each study focused on hospital-based nurses, with their perceived PSC as the independent variable. A total of 6001 nurses participated in the 12 included studies, completing the questionnaire within Iranian hospitals. A variety of sampling methods were employed, resulting in considerable variation in sample sizes, ranging from 130 nurses in a single pediatric hospital study to 2295 nurses in a study conducted across 36 public teaching hospitals. include were single-center studies conducted in teaching hospitals affiliated with the Iranian MoHME (Table 1).

Table 1.

Characteristics of included studies and main results

First authors (year)	Province	Study design	Sample size (Sampling method)	Type of hospital	Findings
					Mean score of PSC (PRR)	Outcomes measured	Key findings
Asefzadeh et al (2017) [34]	Mazandaran	Cross-sectional	350 (Multistage stratified sampling)	20 Teaching hospitals	3.51 out 5 (51.52%)	Level of stress	Dimensions of PSC had a negative relationship with the level of job stress (r = − 0.39 to − .46).
Kakemam and Sheikhy-Chaman (2020) [35]	Tehran	Cross-sectional	260 (Simple Random sampling)	7 Teaching hospitals	3.4 out 5	Occurrence of adverse events (AEs)	Improving the PSC leads to a decrease in the occurrence of of AEs among nurses (OR = 0.59 to 2.28).
Chegini et al (2020) [36]	East Azerbaijan	Cross-sectional	256 (Census sampling)	18 Public and private hospitals	2.9 out 5 (44.8 %)	Intention to report errors	A significant positive relationship between PSC and intention to report errors was observed (β = 0.20).
Habibzadeh et al (2020) [37]	West Azerbaijan	Cross-sectional	298 (Convenient sampling)	5 Teaching hospitals	125 out 210	Burnout and second-victim experience	PSC was negatively associated with second-victim experience (β = − 0.39). and burnout (β = − 0.24).
Gharaee et al (2020) [38]	Hamedan	Cross-sectional	650 (Multistage sampling)	8 Public and private hospitals	3.00 out 5	Occurrence of AEs	PSC had a significant negative relationship with the occurrence of of AEs (OR = 0.31 to 0.43).
Daneshkohan et al (2020) [39]	Tehran	Cross-sectional	420 (Multistage sampling)	Teaching hospitals	3.17 (52.01%)	Barriers to errors reporting	There was a significant negative correlation between PSC and perceived barriers to error reporting (r = − 0.42).
Kakemam et al (2021) [40]	Tehran, Qazvin, Esfahan and Hamedan	Cross-sectional	2295 (Convenient sampling)	32 teaching hospitals in Iran	3.02 (34.1%)	Occurrence of AEs	It found a significant negative correlation between PSC and the occurrence of AEs (OR = 0.67 to 1.49).
Kazemi et al (2021) [41]	Ardabil and Khalkhal	Cross-sectional	300 (Multistage sampling)	5 Teaching hospitals	144.94 out 210	Occurrence of AEs	There was a negative relationship between PSC with the rate of medication error (r = − 0.28).
Ansari et al (2022) [42]	Guilan	Cross-sectional	130 (Convenient sampling)	Pediatric wards of public hospitals	2.76 out 5	Social intelligence and psychosocial factors in the workplace	There was a significant positive relationship between PSC and social intelligence (r = 0.76) and psychosocial factors in the workplace (r = 0.88).
Hafezi et al (2022) [43]	Qom	Cross-sectional	338 (Random sampling)	3 Teaching hospitals	3.08 out 5	Occurrence of AEs	Nurses’ perception of PSC is associated with a reduction in occurrence of AEs (OR = 0.61 to 0.76).
Amiri Amjad et al (2023) [44]	Khuzestan	Cross-sectional	344 (Stratified random sampling)	6 Teaching hospitals	Not reported	Missed nursing care	A significant negative correlation was found between and the score of PSC and missed care (r = − 0.22).
Moosavi et al (2023) [45]	Qazvin	Cross-sectional	360 (Simple random sampling)	6 Teaching hospitals	3.06 out 5	Occurrence of AEs	Dimensions of PSC lead to a decrease in the incidence AEs

Quality assessment of included studies

According to our classification, 9 studies (64%) were of good quality, and the remaining 3 studies (36%) were of moderate quality. Only one study was excluded due to low quality at the quality assessment phase. The details related to the quality assessment of the studies are presented in the supplementary file 2.

Results of synthesis

Figure 2 and Table 1 show the relationship between PSC among nurses and nursing-patient outcomes. The occurrence of adverse events (AEs) was the outcome that has been examined in most included studies regarding its relationship with the PSC among nurses (n = 6 studies).

Fig. 2.

Results of the relationship between nurse’s Patient Safety Culture and nursing-patient outcomes

In general, an AE involves an unintended injury or complication that can cause prolonged hospitalization, disability at discharge time, or death. Incidences related to AEs were inconsistently defined across the included studies, most of which included medication errors, pressure ulcers, falls, and use of physical limitations for more than 8 hours in hospitals. All six studies illustrated that a favorable PSC among nurses was associated with a reduction in the occurrence of AEs, but estimates of the contribution of the dimensions of PSC to the reduction in the occurrence of AEs varied (OR = 0.61 to 2.28) [35, 38, 40, 41, 43, 45]. Furthermore, one study reported a positive PSC was related with a decreased rate of medication errors among nurses (r = − 0.28) [41]. At the present time, AEs are an important global issue and seriously affect patient safety and quality of healthcare in hospitals. The finding of present systematic review prove that these AEs can be reduced by increasing the culture of patient safety among nurses in Iranian hospitals. Among the included studies, most of the statistical samples were related to the study of Kakemam et al. (2021), in which 2295 nurses from hospitals in four provinces of Iran participated [40]. The results of this study illustrated that improving PSC led to a decline in the incidence of AEs among nurses.

Two studies were conducted regarding the relationship between PSC and reporting of errors in hospitals [36, 39]. One study displayed that a significant negative relationship was between PSC and barriers to error reporting among nurses (r = − 0.42) [39]. Similar to this result, another study by Chegini et al. reported that there is a significant positive relationship between dimensions of PSC and the intention to report errors by nurses (β = 0.20) [36]. In the included studies, the score of PSC among nurses in Iranian hospitals is relatively low. In this regard, to facilitate the reporting of errors, it is necessary to raise the PSC so that nurses are more willing to report errors.

Two studies showed that positive dimensions of PSC decrease several factors such as level of stress (r = − 0.39 to − 0.46) and burnout (β = − 0.24) in hospitals [34, 37]. Further, one study found that there was a significant positive relationship between PSC and psychosocial factors in the workplace among the studied nurses (r = 0.88) [42]. A significant inverse correlation (r = − 0.22) was identified between missed nursing care and the total score of PSC in a study conducted in Khuzestan [44]. A study carried out by Ansari et al. (2022) illustrated that PSC has a positive association with social intelligence among the studied nurses (r = 0.76) [42]. Along with these results, it is necessary to consider the limitations of the our systematic review in interpreting the results. Since the included studies are cross-sectional, these studies have less generalizability, and they do not support causal inference. There are also biases in different stages of systematic review, and all these biases were tried to be reduced.

Discussion

The present study aimed to perform a systematic review of existing research that examined the relationship between the PSC of nurses and nursing-patient outcomes based on the HSOPSC instrument in Iranian hospital settings. The results of present systematic review showed that the nurse’s PSC plays a prominent role in improving nursing-patient outcomes in hospital settings.

The results of included studies showd that raised PSC scores were statistically significantly associated with decreased incidence of AE rates. This is consistent with a previous review that reported a significant negative association between PSC scores and the occurrence of AEs [46]. To mitigate AEs and promote PSC, healthcare managers should prioritize creating supportive environments that encourage AEs reporting and invest in relevant training programs for nurses [45]. Furthermore, this review found that promoting an effective PSC is the effective way to overcome the challenges and barriers of AEs reporting. Timely and reliable reporting of AEs is crucial for organizational learning and the improving more reliable healthcare systems [47]. The results are consistent with previous studies that have showed a positive association between safety culture and incident reporting [47–49].

The association between mental health factors, including job stress and burnout, with PSC seems to be relatively unexplored, as only 2 studies investigated this subject in Iran. The finding of this systematic review proposed that there is a negative relationship between job burnout and stress and PSC, which supported the findings of previous studies [50–52]. For instance, a recent systematic review demonstrated a significant negative relationship between job-related stress in its different factors, PSC, and patient safety [51]. Job-related stress has been considered a challenge and hindrance to improving PSC [52, 53]. However, Keykaleh et al. have found no significant relationship between nurses’ job stress and PSC [54]. That could be due to the differences in working situations in the hospitals where this study was conducted. Regarding burnout, a study conducted by Profit et al. reported a negative association between burnout and measures of PSC [55]. Further study into these relationships could aid to better realize the direction and nature of the relationships.

Regarding missed nursing care, our results showed that a significant correlation was between the total score of PSC and missed nursing care. This meant that by improving PSC, the missed nursing care rate decreased. Nurses provide the most healthcare in the hospital, and missed nursing care undermines standards and reduces patient safety and quality of care [56]. These findings are in alignment with two recent systematic studies that found a significant inverse relationship between PSC and missed nursing care [57, 58]. In addition, according to Hessels et al. [32], enhancing PSC in healthcare organizations reduces missed nursing care [49].

Based on our results, nurses’ perception of PSC can affect other factors as well; for example, there was a significant negative relationship between PSC and second-victim experience in Iran’s pediatric hospital. Nonpunitive PSCs may act as a catalyst for a climate that increases support for those involved in patient safety events, which, in turn, reduces or even prevents second second victim–related trauma. This finding is in agreement with a previous study conducted by Quillivan et al. [59], which showed the PSC dimension nonpunitive response to error was significantly associated with diminishs in the second victim survey dimensions psychological, physical, and professional distress.

As a developing country, Iran Iran’s healthcare system faces challenges that can negatively impact PSC within hospitals. Several studies have identified issues such as low safety culture, insufficient equipment, nursing staff shortages, and high workloads as barriers to maintaining patient safety in Iranian hospitals [25, 60, 61]. In Iran, newly graduated nurses often start their careers in hospitals without an adequate pre-service training period, which compromises the PSC [62]. Also, differences in culture, language, and other factors in Iranian hospitals also affect PSC. In this regard, some issues, such as the patient’s advanced age, cognitive problems, and cultural and linguistic discrepancies between the patient and the nurse, also exacerbate the lack of close communication between the nurse and the patient. These issues somewhat reduce patients’ trust in nurses and their failure to follow nurses’ recommendations, which is dangerous for patient safety [63, 64].

Various strategies can be used to strengthen the culture of patient safety in Iranian hospitals. For example, one of the important strategies in providing quality and safe services in hospitals, as an important concern of managers and policymakers of the Iranian health system, is patient participation [65]. Other strategies gaining traction in many Iranian hospitals include the establishment of a hospital safety committee, development of effective training programs, promotion of interprofessional teamwork, and implementation of upgraded, computerized service delivery systems [66]. Furthermore, the use of critical thinking skills, through creating evidence-based practices, leads to positive outcomes in patient safety [67]. Accreditation programs and other similar programs in Iran offer valuable opportunities to promote a culture of patient safety, not only among nurses but across all hospital staff.

According to global experiences,measures are needed to improve patient safety and prevent future incidents. The most important of these measures include training of staff, effective communication, medication safety, control of infection, and emergency preparedness [68]. Also, as in international successful experiences, there was some evidence to support that leadership walk-rounds and multi-faceted unit-based programs may have a positive effect on PSC [69]. Likewise, decreasing errors needs systemic interventions that address the interrelated processes of PSC in a balanced way [70].

Recommendations for future research

This review suggests updating previous meta-analyses to examine nurses’ perceptions of PSC, particularly in the context of the COVID-19 pandemic within Iranian hospitals. Future study should more examine the relationship between PSC and outcomes such as burnout, fatigue, intention to leave, job satisfaction, and stress. Additionally, the impact of nurses’ PSC on hospital-level outcomes, including patient satisfaction, discharge rates, interprofessional conflict, and perceived service quality, warrants investigation. Based on the present findings, researchers are encouraged to employ alternative study designs, such as longitudinal and interventional studies, to further explore the effects of PSC in hospitals. Comparative research across different countries and hospital settings, utilizing diverse methodologies, is needed to facilitate broader analysis and understanding of PSC outcomes.

Limitations of study

This systematic review has several limitations. First, the cross-sectional design of all included studies precludes causal inferences, highlighting the need for future research employing longitudinal and interventional designs. Second, the majority of included studies were conducted within single locations or units of single Iranian teaching hospitals with small sample sizes, limiting the generalizability of the findings. Third, despite a comprehensive search strategy, it is possible that some relevant evidence was not identified and therefore not included in the review. While systematic reviews are valuable for synthesizing existing evidence, they are susceptible to various biases, and this review is no exception. These potential biases include publication bias (the non-publication of certain studies), selection bias, bias in data extraction and analysis, and bias in the reporting and interpretation of results. In this review, these biases were mitigated through adherence to the JBI protocol, collaboration among authors, peer review at all stages of the process, the absence of conflicts of interest, unbiased reporting, and meticulousness throughout the review process. Finally, we were unable to conduct a reliable meta-analysis because the included studies applied a variety of conceptual definitions to measure outcomes and heterogeneity in administrative data and populations.

Conclusion

This systematic review revealed that a positive PSC among Iranian nurses is associated with favorable outcomes for both patients and nurses. Therefore, enhancing PSC within hospital settings can be a strategic way to improve nursing-patient outcomes. Nurses and hospital managers should prioritise fostering a safety-oriented culture by targeted interventions, continuous education, and supportive policies to improve patient care outcomes. Hospitals can implement targeted interventions such as encouraging collaboration and open communication among healthcare teams, exchanging experiences and learnings, integrating staff perceptions, external facilitation, creating a ‘‘no blame” culture, and staff training.

Electronic supplementary material

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List of abbreviations

WHO

World Health Organization

PSC

Patient Safety Culture

MoHME

Ministry of Health and Medical Education

HSOPSC

Hospital Survey of Patient Safety Culture

JBI

Joanna Briggs Institute

SPICE

Setting, Perspective, Intervention, Comparison, and Evaluation

CASP

Critical Appraisal Skills Program

PRR

Positive Response Rate

SWiM

Synthesis Without Meta-analysis

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

COVID-19

Corona Virus Disease 2019

Author contributions

All authors contributed to the design of this study. AH and JS developed the search strategy and screened the studies. AH, BAK, SS, and MK were participated in the study selection, data extraction, quality assessment, and data synthesis. AH, EK, and JS crafted the first draft of the manuscript. Also, the manuscript was revised by SS. The final draft of the manuscript was read and approved by all authors.

Funding

No financial support was provided for this systematic review.

Data availability

Datasets are available through the corresponding author upon request.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.