ABSTRACT
Aims
To examine the associations between patient safety silence, culture, competency, and activities among clinical nurses.
Background
Patient safety ensures harm prevention and quality of care. Factors such as silence, culture, and competency are widely recognized as significantly associated with patient safety activities, but limited research has examined their interrelationships.
Design
Cross‐sectional secondary data analysis.
Methods
This study used data from a study that investigated the patient safety educational needs of 291 nurses from general hospitals located in the Busan, Ulsan, and Gyeongsangnamdo regions of South Korea. To assess patient safety activities, silence, culture, and competency, the study employed the Patient Safety Activities Questionnaire, Patient Safety Silence Scale, Hospital Survey on Patient Safety Culture, and Patient Safety Competency Self‐Evaluation Tool, respectively. The analysis involved descriptive statistics, correlation analysis, and multiple regression using SPSS 27.0.
Results
The factors of silence and receiving patient safety education only once were negatively associated with patient safety activities. Positive associations were found for teamwork within the culture subdomain, skills within the competency subdomain, and hospital size.
Conclusions
These findings provide a basis for educational programs to improve nursing skills and highlight the need to build an open and collaborative organizational culture.
Implications for Nursing
Clinical nurses should develop patient safety skills, report patient safety incidents, and collaborate with team members to foster an open and cooperative organizational culture.
Implications for Nursing Policy
To minimize silence, while strengthening teamwork, organizations actively foster a culture of openness and collaboration. Education should be managed to meet minimum standards, and hospital‐specific policies should be tailored according to each institution's size and characteristics.
Keywords: competency, culture, nurse, patient safety, patient safety activities, silence
1. Introduction
The World Health Organization (WHO) reinforces the principle of healthcare services: “First, do no harm.” This principle emphasizes that medical interventions should not cause harm to anyone. Patient safety involves minimizing preventable harm to individuals receiving medical care and reducing unnecessary risks associated with healthcare to the lowest acceptable level. To ensure patient safety, the WHO is standardizing clinical protocols, improving incident reporting systems, fostering safety‐oriented healthcare cultures, and implementing initiatives such as the Global Patient Safety Action Plan 2021–2030 (WHO 2023).
Despite these efforts, the WHO (2023) recently reported that one in ten patients suffers harm as a result of unsafe care, leading to over three million deaths annually. The Pennsylvania Patient Safety Reporting System reported an 8.7% increase in patient safety incidents from 2022 to 2023, accompanied by an increase in the reporting rate from 28.0 to 30.0 events per 1000 patient days (Kepner et al. 2024). This upward trend indicates persistent safety challenges within hospitals.
In South Korea, following the enactment of the Patient Safety Act in 2015, medical institutions began autonomously reporting patient safety incidents in July 2016. The number of reported incidents has increased, reaching 20,273 in 2023, representing a 36.8% increase from the previous year (Korea Patient Safety Reporting and Learning System [KOPS] 2024). This increase may reflect greater awareness among healthcare providers or improved reporting culture (Kepner et al. 2024). Nevertheless, these incidents present potentially fatal risks, contribute to a deterioration in care quality, and escalate healthcare costs. It underscores the critical necessity for an emphasis on preventive measures (Slawomirski et al. 2017).
Human error is inevitable. It is essential to identify and manage such errors to establish a safety system that anticipates risks and enhances patient safety (Hafezi et al. 2022; Mitchell et al. 2016). As the most numerous healthcare professionals who continuously observe patients throughout the day, nurses are crucial for enhancing patient safety (Han 2018; Tangirala et al. 2008). Proper reporting of patient safety incidents by nurses is important for preventing errors and ultimately enhancing the overall quality of care (Hamed et al. 2022; Han 2018). To prevent nurses’ silence regarding patient safety errors, fostering a positive safety culture and providing professional education to improve competency are required at the organizational level (Hafezi et al. 2022; WHO 2023).
2. Background
Patient safety activities aim to create a safe treatment environment by preventing risks or harm (Aspden et al. 2004). A crucial factor in improving patient safety lies in reporting and learning from errors that have occurred (Aiken et al. 2018). Despite the importance of reporting, nurses often hesitate to report errors because of inefficiencies, unpredictable reactions, a closed organizational culture, and the perception of being ignored (Etchegaray et al. 2020; Hamed et al. 2022). Employee silence leads to negative outcomes, including burnout, stress, and misconduct (Hao et al. 2022; Lee et al. 2024a), with an increasing number of empirical studies examining these negative effects (Han 2018). Nurses' silence regarding patient safety is not solely an individual concern, but rather represents a substantial barrier to promoting safety in nursing practices and advancing healthcare organizations (Lotfi Dehkharghani et al. 2022).
Patient safety incidents arise from individual actions and are deeply rooted in the organizational system. The term “patient safety culture” refers to the extent to which an organizational culture fosters and prioritizes patient safety, encompassing the collective values, beliefs, and standards of healthcare professionals and staff that influence their actions and behaviors (Agency for Healthcare Research and Quality [AHRQ] 2024). A study comparing data from 2005 and 2016 across more than 500 hospitals in the United States found that hospitals with improved workplace culture had better patient safety practices and experiences (Aiken et al. 2018). Improvement in patient safety is most effectively achieved when healthcare organizations implement a culture of safety (Aspden et al. 2004).
Patient safety competency comprises the knowledge, skills, and attitudes required for safe healthcare (Jang 2013). Nurses who possess robust patient safety competency can systematically and continuously evaluate and monitor patients’ health conditions, thereby helping to prevent foreseeable issues (Aspden et al. 2004). Nurses’ patient safety competency is positively associated with engagement in patient safety activities (Kim et al. 2020), with higher competency linked to fewer adverse events and greater proactivity in reporting safety incidents (Hafezi et al. 2022; Kakemam et al. 2024).
Despite the recognition of patient safety silence, culture, and competency as key concepts related to patient safety activities, few studies have thoroughly analyzed their interrelationships or examined their associations. Moreover, given the broad scope of both culture and nurse competency, it is essential to investigate the specific subdomains of each variable. Therefore, this study aimed to analyze the correlations among clinical nurses' patient safety activities, silence, culture, and competency and explore the factors associated with patient safety activities. These findings will serve as a basis for formulating evidence‐based approaches to bolster patient safety activities.
3. Aims
The aim of this study was to investigate the associations of patient safety silence, culture, and competency with patient safety activities among clinical nurses. The detailed objectives are as follows:
To evaluate the level of patient safety activities, silence, culture, and competency among clinical nurses.
To examine differences in patient safety activities levels according to the general characteristics of clinical nurses.
To explore the relationships between patient safety activities, silence, culture, and competency among clinical nurses.
To identify factors associated with patient safety activities among clinical nurses.
4. Methods
4.1. Study Design
This study conducted a secondary data analysis using survey data collected as part of the study by Lee et al. (2025), the Nurses’ Patient Safety Educational Needs Study (NPSENS). The NPSENS aimed to assess how nurses in general hospitals perceive the importance and performance of patient safety care and to explore their educational needs (Lee et al. 2025).
4.2. Participants and Data Collection
The NPSENS data were collected from November 24 to December 7, 2022, through an online survey conducted on SurveyMonkey. The study included nurses with at least six months of experience in general hospitals located in Busan, Ulsan, and Gyeongsangnamdo, South Korea. In the NPSENS, participants were recruited by posting notices on the hospitals' online bulletin boards and through snowball sampling, which involved nurses volunteering to share the survey with their colleagues (Lee et al. 2025). Of the 296 responses gathered, 291 were included in the final analysis after excluding those with missing data.
To assess whether the sample size was sufficient to obtain statistically significant effects in this secondary data analysis, G*Power 3.1.9.4 was utilized to perform a post hoc power analysis. An effect size of f 2 = 0.724, derived from an R 2 value of 0.42, was used in the calculations. With an α level of 0.05, 22 predictors, and a sample size of 291, the statistical power was calculated to be 0.99.
4.3. Measurements
4.3.1. Characteristics of Participants
Demographic characteristics included age, gender, and education level. Work‐related characteristics included the size of the hospital where participants work (number of beds), work unit, total nursing experience, average weekly working hours over the past month, job position, the number of patient safety education sessions received in the past year, experience with patient safety errors in the past year, and the most severe patient safety incidents they have encountered in the past year.
4.3.2. Patient Safety Activities
The patient safety activities tool developed by Ho et al. (2024) adheres to the standards set by the Korea Institute for Healthcare Accreditation. The tool includes 50 items distributed across 11 subdomains: 7 items on patient identification, 5 items on accuracy of communication, 3 items on patient safety before an operation or procedure, 4 items on fall prevention, 4 items on infection control, 4 items on firefighting measures, 4 items on incident reporting, 4 items on bedsore prevention, 5 items on blood transfusion practices, 5 items on use of restraints, and 5 items on medication management. Each question is rated on a 5‐point Likert scale, where higher scores indicate better performance in patient safety activities. Cronbach's α was 0.98 in Ho et al. (2024) and 0.98 in this study.
4.3.3. Patient Safety Silence
Patient safety silence was measured using the tool developed by Tangirala et al. (2008). The tool includes five items rated on a 5‐point Likert scale, with higher scores indicating greater levels of patient safety silence. The tool was translated into Korean by Han (2018), and its validity and reliability were established. Cronbach's α was 0.82 in Han (2018) and 0.88 in this study.
4.3.4. Patient Safety Culture
Patient safety culture was measured using the second version of the Hospital Survey on Patient Safety Culture (HSOPSC), developed by the AHRQ (Sorra et al. 2019). The tool includes 31 items distributed across 10 subdomains: 3 items on teamwork, 3 items on staffing and work pace, 3 items on organizational learning‐continuous improvement, 4 items on response to errors, 3 items on supervisor and management support for patient safety, 3 items on communication about errors, 4 items on communication openness, 2 items on reporting patient safety events, 3 items on hospital management support for patient safety, and 3 items on handoffs and information exchange. Each question is rated on a 5‐point Likert scale, where higher scores indicate a stronger culture of patient safety. This version was translated and adapted by Lee et al. (2021), specifically for use in Korean hospitals. Cronbach's α was 0.61 to 0.83 in Lee et al. (2021) and 0.51 to 0.79 in this study.
4.3.5. Patient Safety Competency
Patient safety competency was assessed using the Patient Safety Competency Self‐Evaluation Tool initially developed by Lee et al. (2012) to assess nursing students. Jang (2013) later modified and validated the tool to make it suitable for use with registered nurses. The tool includes 41 items distributed across 3 subdomains: 14 items on patient safety attitudes, 6 items on patient safety knowledge, and 21 items on patient safety skills. Each item is rated on a 5‐point Likert scale, with higher scores reflecting a higher level of competency. Cronbach's α was 0.95 in Jang (2013) and 0.95 in this study.
4.4. Data Analysis
This study utilized SPSS 27.0 to perform descriptive statistics, correlation analysis, and multiple regression analysis on various variables. General characteristics, along with the levels of patient safety activities, silence, culture, and competency, were examined using descriptive statistics. The Kolmogorov–Smirnov normality test was conducted to assess whether the data followed a normal distribution. Despite the nonnormal distribution of all variables, parametric tests were conducted, given the large sample size (Elliott et al. 2007). Differences in patient safety activities based on participant characteristics were analyzed using independent t tests and one‐way ANOVA. Post hoc verification was conducted using the Scheffé test. The correlations among patient safety activities, silence, culture, and competency were quantified using Pearson correlation coefficients. Factors influencing patient safety activities were analyzed using multiple regression analysis. A p‐value of less than 0.05 was considered statistically significant.
4.5. Ethical Considerations
This study received ethical approval from the Institutional Review Board of Severance Hospital, Yonsei University (approval no. 4‐2022‐1237). Informed consent was obtained from the participants in the original study, where raw data were collected, and the consent form was reviewed. The data were devoid of any identifiable personal information, and access to computerized data was limited to researchers through lockdown settings.
5. Results
5.1. Characteristics of the Participants
The general characteristics of the 291 participants are presented in Table 1. The average age of the participants was 31.97 ± 6.80 years. The majority of them were female (95.9%) and held a bachelor's degree (73.9%). Nurses from hospitals with fewer than 500 beds constituted the largest group (55.3%). Most were employed in general wards (74.9%), and their primary role was general nurse (74.9%). The average total nursing experience was 98.82 ± 78.60 months. The most common range of weekly working hours over the past month was 40–59 hours (67.4%). The most frequently reported frequency of patient safety education sessions in the past year was four or more times (38.5%). Participants reported having experienced patient safety errors in the past year (80.1%). Frequently reported errors were level 1 incidents, which occurred without causing harm to the patient (38.8%).
TABLE 1.
Differences in patient safety activities according to general characteristics.
| (N = 291) | ||||||
|---|---|---|---|---|---|---|
| Patient safety activities | ||||||
| Variable | Category | Frequency (%) or M ± SD | M ± SD | t, F, or rho |
P (Scheffé) |
|
| Age (y) | 31.97 ± 6.80 | 0.12 | 0.04 | |||
| Gender | Male | 12 | (4.1) | 4.20 ± 1.06 | −0.94 | 0.37 |
| Female | 279 | (95.9) | 4.50 ± 0.48 | |||
| Education level | Diploma | 43 | (14.8) | 4.47 ± 0.49 | 2.26 | 0.11 |
| Bachelor's | 215 | (73.9) | 4.46 ± 0.53 | |||
| ≥Master's | 33 | (11.3) | 4.66 ± 0.41 | |||
| Hospital size (beds) | <500a | 161 | (55.3) | 4.54 ± 0.43 | 5.32 | 0.01 |
| 500–999b | 71 | (24.4) | 4.52 ± 0.45 | (a = b>c) | ||
| ≥1000c | 59 | (20.3) | 4.29 ± 0.72 | |||
| Work unit | General ward | 218 | (74.9) | 4.49 ± 0.52 | 0.94 | 0.42 |
| ICU | 34 | (11.7) | 4.47 ± 0.46 | |||
| ER | 28 | (9.6) | 4.35 ± 0.58 | |||
| Other | 11 | (3.8) | 4.63 ± 0.32 | |||
| Total experience of nursing (months) | 98.82 ± 78.60 | 0.11 | 0.67 | |||
| Weekly working hours for the past 1 month | ≤20 | 5 | (1.7) | 4.57 ± 0.34 | 1.30 | 0.27 |
| 20–39 | 80 | (27.5) | 4.52 ± 0.42 | |||
| 40–59 | 196 | (67.4) | 4.50 ± 0.56 | |||
| ≥60 | 10 | (3.4) | 4.74 ± 0.28 | |||
| Position | General nurse | 218 | (74.9) | 4.48 ± 0.51 | 0.01 | 0.99 |
| Charged nurse | 55 | (18.9) | 4.48 ± 0.53 | |||
| Nurse manager (head nurse) | 18 | (6.2) | 4.50 ± 0.51 | |||
| Number of patient safety education sessions received in the past year | None | 16 | (5.5) | 4.45 ± 0.38 | 2.04 | 0.09 |
| 1 | 72 | (24.7) | 4.39 ± 0.52 | |||
| 2 | 63 | (21.6) | 4.41 ± 0.66 | |||
| 3 | 28 | (9.6) | 4.51 ± 0.50 | |||
| ≥4 | 112 | (38.5) | 4.58 ± 0.42 | |||
| Patient safety error experiences in the past year. | Yes | 233 | (80.1) | 0.46 ± 0.46 | 0.62 | 0.54 |
| No | 58 | (19.9) | 0.69 ± 0.69 | |||
| Most severe patient safety accidents in the past year. | Level 0 | 93 | (32.0) | 4.50 ± 0.61 | 0.78 | 0.54 |
| Level 1 | 113 | (38.8) | 4.47 ± 0.43 | |||
| Level 2 | 54 | (18.6) | 4.42 ± 0.57 | |||
| Level 3 | 20 | (6.9) | 4.49 ± 0.36 | |||
| Level 4 | 11 | (3.8) | 4.70 ± 0.28 | |||
Abbreviations: ER, emergency room; ICU, intensive care unit; M, mean; SD, standard deviation.
5.2. Differences in Patient Safety Activities According to Participants’ General Characteristics
The differences in patient safety activities across general characteristics are shown in Table 1. The general characteristics associated with differences in patient safety activities were age and hospital size. Patient safety activity scores increased with age (r = 0.12, p = 0.04), and hospitals with fewer than 1000 beds reported higher patient safety activity scores than those with 1000 beds or more (F = 5.32, p = 0.01).
5.3. Levels of Patient Safety Activities, Silence, Culture, and Competency
The average total score for patient safety activities among the study participants was 4.48 ± 0.51 out of 5. Patient safety silence was 2.19 ± 0.68 out of 5. Patient safety culture was 3.30 ± 0.43 out of 5, with teamwork scoring the highest (3.84 ± 0.58) and response to error scoring the lowest (2.86 ± 0.70). Patient safety competency was 3.86 ± 0.44 out of 5, with attitudes scoring the highest (4.21 ± 0.47) and knowledge the lowest (3.27 ± 0.67).
5.4. Correlations Among Patient Safety Activities, Silence, Culture, and Competency
The correlations between the variables are presented in Table 2. A negative correlation was identified between patient safety activities and silence. Significant positive correlations were observed between patient safety activities and all subdomains of patient safety culture, except for staffing and work pace, and response to error. Patient safety activities were positively correlated with all subdomains of competency.
TABLE 2.
Correlations among patient safety activities, silence, culture, and competency.
| (N = 291) | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | |||
| r (p) | r (p) | r (p) | r (p) | ||||||||||||||
| Patient safety silence | 1 | 1 | |||||||||||||||
| Patient safety culture | Teamwork | 2 |
−0.16** (0.007) |
1 | |||||||||||||
| Staffing and work pace | 3 |
−0.21** (<0.001) |
0.33** (<0.001) |
1 | |||||||||||||
| Organizational learning‐continuous improvement | 4 |
−0.14* (0.016) |
0.34** (<0.001) |
0.26** (<0.001) |
1 | ||||||||||||
| Response to error | 5 | −0.29** (<0.001) |
0.47** (<0.001) |
0.43** (<0.001) |
0.49** (<0.001) |
1 | |||||||||||
| Supervisor, manager, or clinical leader support for patient safety | 6 |
−0.27** (<0.001) |
0.47** (<0.001) |
0.21** (<0.001) |
0.42** (<0.001) |
0.41** (<0.001) |
1 | ||||||||||
| Communication about error | 7 |
−0.14* (0.015) |
0.26** (<0.001) |
0.04 (0.522) |
0.16** (0.006) |
0.15* (0.012) |
0.30** (<0.001) |
1 | |||||||||
| Communication openness | 8 |
−0.40** (<0.001) |
0.34** (<0.001) |
0.19** (<0.001) |
0.39** (<0.001) |
0.45** (<0.001) |
0.54** (<0.001) |
0.43** (<0.001) |
1 | ||||||||
| Reporting patient safety events | 9 |
−0.10 (0.109) |
−0.01 (0.845) |
−0.08 (0.169) |
0.15* (0.011) |
0.09 (0.119) |
0.11 (0.065) |
0.22** (<0.001) |
0.24** (<0.001) |
1 | |||||||
| Hospital management support for patient safety | 10 |
−0.20** (<0.001) |
0.24** (<0.001) |
0.33** (<0.001) |
0.49** (<0.001) |
0.49** (<0.001) |
0.39** (<0.001) |
0.15** (0.009) |
0.41** (<0.001) |
0.17** (<0.001) |
1 | ||||||
| Handoffs and information exchange | 11 |
−0.33** (<0.001) |
0.38** (<0.001) |
0.32** (<0.001) |
0.37** (<0.001) |
0.41** (<0.001) |
0.39** (<0.001) |
0.07 (0.227) |
0.31** (<0.001) |
−0.01 (0.906) |
0.40** (<0.001) |
1 | |||||
| Patient safety competency | Attitudes | 12 |
−0.36** (<0.001) |
0.18** (0.002) |
−0.05 (0.366) |
0.12* (0.036) |
0.04 (0.485) |
0.34** (<0.001) |
0.27** (<0.001) |
0.22** (<0.001) |
0.18** 0.002 |
0.15* (0.012) |
0.23** (<0.001) |
1 | |||
| Skills | 13 |
−0.32** (<0.001) |
0.18** (0.002) |
0.01 (0.847) |
0.04 (0.466) |
−0.02 (0.793) |
0.18** (0.003) |
0.30** (<0.001) |
0.15** (0.009) |
0.14* (0.015) |
0.07 (0.272) |
0.17** (0.005) |
0.54** (<0.001) |
1 | |||
| Knowledge | 14 |
−0.32** (<0.001) |
0.15** (0.010) |
0.19** (0.002) |
0.24** (<0.001) |
0.12* (0.050) |
0.23** (<0.001) |
0.24** (<0.001) |
0.33** (<0.001) |
0.12* (0.047) |
0.23** (<0.001) |
0.21** (<0.001) |
0.33** (<0.001) |
0.55** (<0.001) |
1 | ||
| Patient safety activities | 15 |
−0.35** (<0.001) |
0.25** (<0.001) |
0.06 (0.293) |
0.21** (<0.001) |
0.09 (0.118) |
0.28** (<0.001) |
0.28** (<0.001) |
0.27** (<0.001) |
0.19** (0.002) |
0.20** (0.001) |
0.17** (0.004) |
0.42** (<0.001) |
0.50** (<0.001) |
0.41** (<0.001) |
1 | |
Note: * p < 0.05, ** p < 0.01.
5.5. Factors Associated With Patient Safety Activities
The results of the multiple regression analysis are shown in Table 3. The independent variables for the regression analysis included age and hospital size (beds), which showed significant differences. The number of patient safety education sessions, education level, and total nursing experience, which have been identified as significant in previous studies, were also included (Im et al. 2018; Kim et al. 2020). Furthermore, the subdomains of patient safety silence, culture, and competency that showed significant relationships in the correlation analysis were included.
TABLE 3.
Factors associated with patient safety activities.
| B | SE | β | t | p | ||
|---|---|---|---|---|---|---|
| (Constant) | 1.92 | 0.43 | 4.42 | 0.000 | ||
| Age | 0.01 | 0.01 | 0.15 | 1.46 | 0.146 | |
| Education level (ref: > master's) | Diploma | −0.13 | 0.10 | −0.10 | −1.29 | 0.200 |
| Bachelor's | −0.11 | 0.08 | −0.10 | −1.32 | 0.189 | |
| Hospital size (beds) (ref: >1000) | <500 | 0.16 | 0.07 | 0.16 | 2.37 | 0.019 |
| 500–999 | 0.13 | 0.07 | 0.11 | 1.73 | 0.085 | |
| Total experience of nursing | 0.00 | 0.00 | −0.19 | −1.77 | 0.077 | |
| Number of patient safety education sessions received in the past year (ref: 4 times or more) | None | −0.01 | 0.11 | −0.01 | −0.11 | 0.909 |
| 1 time | −0.13 | 0.07 | −0.11 | −1.98 | 0.049 | |
| 2 times | −0.07 | 0.07 | −0.05 | −1.03 | 0.305 | |
| 3 times | −0.15 | 0.09 | −0.09 | −1.66 | 0.097 | |
| Patient safety silence | −0.11 | 0.04 | −0.15 | −2.58 | 0.010 | |
| Patient safety culture | Teamwork | 0.13 | 0.05 | 0.15 | 2.59 | 0.010 |
| Organizational learning‐ continuous improvement | 0.06 | 0.05 | 0.08 | 1.28 | 0.201 | |
| Supervisor, manager, or clinical leader support for patient safety | −0.03 | 0.05 | −0.04 | −0.56 | 0.579 | |
| Communication about error | 0.05 | 0.04 | 0.08 | 1.41 | 0.160 | |
| Communication openness | −0.01 | 0.05 | −0.01 | −0.13 | 0.896 | |
| Reporting patient safety events | 0.01 | 0.04 | 0.02 | 0.32 | 0.750 | |
| Hospital management support for patient safety | 0.04 | 0.03 | 0.07 | 1.27 | 0.205 | |
| Handoffs and information exchange | −0.05 | 0.04 | −0.07 | −1.14 | 0.255 | |
| Patient safety competency | Attitudes | 0.06 | 0.07 | 0.06 | 0.92 | 0.359 |
| Skills | 0.35 | 0.07 | 0.36 | 5.27 | 0.000 | |
| Knowledge | 0.08 | 0.05 | 0.10 | 1.66 | 0.098 | |
| R 2 = 0.42, adjusted R 2 = 0.37, F = 8.71, p < 0.001 | ||||||
The verification of the independence of residuals for multiple regression analysis revealed a Durbin–Watson value of 2.01, indicating the absence of autocorrelation. Multicollinearity was assessed using tolerance limits, all of which were above 0.1, and variance inflation factor values, none of which exceeded 10, suggesting no multicollinearity among the variables. Case diagnostics showed that the residuals followed a normal distribution, as all standardized residuals fell within ±3, thereby confirming the normality of the residual distribution and the appropriateness of the regression model. Multiple regression analysis demonstrated that the model achieved statistical significance (F = 8.71, p < 0.001) with an explanatory power of 37.0%.
6. Discussion
This study indicates that improving teamwork culture, reducing silence regarding patient safety incidents, and strengthening skills are key factors in enhancing patient safety activities among nurses.
The patient safety activities score was relatively high at 4.48 ± 0.51, which is notably higher than the scores of patient safety silence, culture, and competency variables that ranged between 2 and 3 points. Findings are consistent with previous studies conducted in South Korea, where patient safety activity scores were also higher than those for job stress, awareness of patient safety culture, and the critical thinking tendency (Ho et al. 2024; Kim et al. 2021). This suggests that nurses recognize the importance of patient safety activities. These outcomes may reflect heightened attention to patient safety following the enactment of the Patient Safety Act in 2016 in South Korea. Since then, subsequent enhancements have been included in healthcare institution accreditation evaluations.
The patient safety silence score was reported as 2.19 ± 0.68, falling below the median, indicating that the level of nurses' silence regarding patient safety incidents is low. This result is consistent with a study conducted among South Korean nurses (Lee et al. 2024a). In contrast, a higher score was reported in a study involving nurses and nursing assistants in Greece (Kritsotakis et al. 2022). Silence occurs in various forms and is associated with multiple factors (Lotfi Dehkharghani et al. 2022). These include personal factors such as attitudes, experience, and knowledge, as well as organizational and cultural factors that encourage maintaining silence on patient safety issues (Han 2018; Tangirala et al. 2008). Comprehensive research is needed to examine these personal, organizational, and cultural variables to better understand and address the root causes of this silence.
Nurses' awareness of patient safety culture had a score of 3.30 ± 0.43, indicating a moderately high level, with “teamwork” recording the highest score and “response to error” the lowest. These findings align with earlier studies conducted in the United States, Brazil, Malaysia, and South Korea, where teamwork was reported as either the highest (Reis et al. 2023; Sorra et al. 2019) or the second‐highest subdomain (Ho et al. 2024; Lee et al. 2021b). In contrast, “response to error” had the lowest scores. Even for the lowest‐rated items, positive responses exceeded 60% in studies conducted in the United States and Brazil (Reis et al. 2023; Sorra et al. 2019), whereas the rates were below 40% in studies conducted in Malaysia and South Korea (Ho et al. 2024; Lee et al. 2021b). Given South Korea's collectivistic and hierarchical organizational culture (Buja 2016), culturally tailored strategies are needed to improve the safety culture within nursing environments. Enhancing teamwork and promoting nonpunitive responses to errors is an essential strategy for improving patient safety activities.
Patient safety competency was relatively high at 3.86 ± 0.44, with attitudes scoring the highest and knowledge the lowest. The finding that the knowledge domain scored the lowest is consistent with the results of studies conducted in Iran, Egypt, and South Korea (Atalla et al. 2025; Kakemam et al. 2024; Yoon et al. 2020). These results support the findings of a systematic review indicating insufficient knowledge of patient safety among healthcare professionals (Brasaite et al. 2015). Knowledge serves as a fundamental basis (Aspden et al. 2004; Atalla et al. 2025), and nurses with higher levels of knowledge show significantly lower error rates (Kakemam et al. 2024). Establishing systematic education and support programs is necessary to enhance nurses’ knowledge of patient safety, as these efforts are key to strengthening overall competencies and preventing errors.
A multiple regression analysis was conducted to identify the factors associated with patient safety activities. Among the factors, skills showed the strongest association with patient safety activities. Skills are a vital component for effectively translating nurses' knowledge into practice (Atalla et al. 2025). Patient safety skills include both technical aspects (i.e., fundamental nursing care techniques) and nontechnical aspects (i.e., teamwork, leadership, communication, and decision‐making) (Brasaitė et al., 2016). Beyond these, they also encompass broader attributes like conscientiousness and humility (Brasaitė et al., 2016). Nurses’ patient safety skills contribute to a reduction in patient safety incidents (Zaitoun et al. 2023), and nurses with higher skill levels are 2.84 times more likely to report incidents (Kakemam et al. 2024). Although patient safety skills are an essential capability that nurses should develop, most studies have reported a moderate level (Kim et al. 2020; Yoon et al. 2020), while fewer studies have focused on skills than on attitudes or knowledge (Brasaite et al. 2015). It is necessary to continue focusing on patient safety skills and to develop educational programs to enhance both technical and nontechnical aspects.
As a subdomain of patient safety culture, teamwork has been recognized as a key factor associated with patient safety activities. Collaborative teamwork in the clinical setting is an essential part of delivering safe and efficacious patient care while reducing errors (Hafezi et al. 2022; Soyer Er et al. 2024). Effective teamwork, facilitated by efficient communication among team members and a conducive organizational environment, enables proactive mutual support and information exchange, ultimately enhancing the quality of care (Atalla et al. 2025; Soyer Er et al. 2024). Fostering teamwork requires organizational support, structured educational programs, and ongoing training to enhance communication and collaboration, ensuring a culture of teamwork and safety.
Another factor associated with nurses' patient safety activities was silence. The reasons for nurses maintaining silence have been shown to be highly varied (Etchegaray et al. 2020; Han 2018). Previous research has described various types of silence, such as individual and organizational silence (Lotfi Dehkharghani et al. 2022), highlighting the need for more specific research on this topic. Silence was measured using a tool without subdomains, which makes it difficult to capture the detailed aspects. Further research is necessary to elucidate the various forms of silence prevalent in healthcare environments and to comprehensively analyze and address the underlying factors contributing to the perpetuation of such silence.
Key factors associated with patient safety activities included general characteristics such as hospital size (number of beds) and frequency of education. Age showed a statistically significant relationship with patient safety activities, but it was not identified as a significant predictor. Given that age is typically associated with accumulated clinical experience and professional competence, the observed correlation may reflect the influence of these underlying attributes rather than the numerical age itself. Hospital size was significantly correlated with patient safety activities, with higher levels of safety activities observed in hospitals with fewer than 500 beds. According to South Korea's 2023 patient safety reporting data, despite the lower number of hospitals with more than 500 beds compared to those with fewer than 500 beds, they reported the highest number of patient safety incidents (KOPS 2024). Similarly, data from Australia show different rates of hospital‐acquired complications depending on hospital type, with public hospitals reporting 2.0 cases per 100 admissions and private hospitals reporting 0.8 cases during 2022–2023 (Australian Institute of Health and Welfare, 2023). This suggests a variation in patient safety incidents based on hospital size. Comprehensive research should analyze the types and frequencies of patient safety incidents in relation to hospital size. Future studies should support the development of targeted nursing education programs that address these specific challenges.
Participants who received patient safety nursing education only once a year demonstrated lower engagement in patient safety activities than those who received it four or more times a year. This aligns with previous research conducted in South Korea (Im et al. 2018), which found that nurses with experience in patient safety education tend to demonstrate higher levels of patient safety activities than those without such training. Continuing education helps nurses adapt to rapidly changing clinical environments, improves their knowledge and skills, and is essential for ensuring the quality of nursing activities (Jackson et al. 2019). Education is recognized as a key component in improving patient safety activities, highlighting the necessity of continuous and repeated training at the organizational level.
6.1. Implications for Nursing and Health Policy
In an increasingly complex healthcare environment, fostering a culture of collaboration and empowering nurses to voice safety concerns without fear can significantly reduce errors and improve care quality. Furthermore, the integration of technical and nontechnical skills ensures that nurses are better equipped to meet evolving patient needs. Additionally, this study demonstrated that nurses' patient safety activities are associated with hospital size and education, highlighting the need for tailored policy development. Continuous education and organizational support can enhance patient safety activities, making healthcare systems more adaptable to future challenges.
6.2. Limitations
Although this study provides valuable insights, it had several limitations. First, it employed a convenience sample of nurses from selected general hospitals within specific regions, which could restrict the broader applicability of the results. The cross‐sectional nature of data collection restricts the capacity to determine causal relationships between the variables. Finally, the measurement tools employed were self‐reported questionnaires, which may not accurately reflect the actual level of nursing activities. The scarcity of previous research restricts the ability to compare the results. Further studies are necessary to validate these findings through repeated research.
7. Conclusion
To enhance nurses' patient safety activities, comprehensive and ongoing education aimed at improving both technical and nontechnical skills is essential for developing the competencies required for patient safety. Organizational efforts are necessary to establish an open and transparent culture to enhance effective teamwork. This culture encourages nurses to report patient safety incidents without fear of retribution. It is crucial to examine the differences in nurses' patient safety activities in relation to hospital size, with an emphasis on delivering continuous and effective education at the organizational level.
Author Contributions
Conceptualization: JL, YL, and DL. Methodology: JL, YL, and DL. Investigation: DL, KN, and YS. Formal analysis: YL and DL. Validation: KN and YS. Writing—original draft: DL. Writing—review and editing: JL, KN, YS, and YL. Project administration: JL, and YL. All authors read and approved the final manuscript.
Funding
This research was supported by Yonsei ‘Eokkaedongmu Project’ through the 4th BK21 Graduate School Innovation Support Project funded by the Ministry of Education (2022‐22‐0274). The author Deokhyun Lee received a scholarship from the Brain Korea 21 FOUR Project funded by the National Research Foundation (NRF) of Korea, Yonsei University College of Nursing.
Conflicts of Interest
The authors declare no conflicts of interest.
Lee, J. , Nam K., Suh Y., Lee Y., and Lee D.. 2025. “Factors Associated With Patient Safety Activities of Clinical Nurses: A Cross‐Sectional Secondary Data Analysis.” International Nursing Review 72, no. 4: e70127. 10.1111/inr.70127
Contributor Information
Yoonju Lee, Email: lyj@pusan.ac.kr.
Deokhyun Lee, Email: leedeokhyun@gmail.com.
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