Abstract
Background
Patient safety culture plays a vital role in shaping nurses’ professional responsibility, which is essential for delivering high-quality care. Clarifying this relationship and its variations across demographic factors can help healthcare systems implement more effective improvement strategies. This study aimed to examine how patient safety culture influences nurses’ professional responsibility, considering the moderating effects of demographic characteristics.
Methods
This descriptive-analytical cross-sectional study was conducted from January to April 2025 among 301 nurses at Samen al-Hojaj Hospital in Sirjan, southern Iran, using a census sampling method. Data were collected using a demographic questionnaire, the Hospital Survey on Patient Safety Culture (HSOPSC), and Hassaniyan’s Responsibility Questionnaire based on Carroll’s Model. Partial least squares structural equation modeling (PLS-SEM) was used to examine the associations between patient safety culture and nurses’ responsibility.
Results
The mean score of patient safety culture was 2.93 out of 5, with 63.5% of responses categorized as positive, indicating an acceptable safety culture. Nurses’ responsibility averaged 108.3 out of 175, reflecting a good level overall. Pearson’s correlation showed a significant and positive relationship between safety culture and responsibility (r = 0.61, p < 0.001, 95% CI: 0.53–0.68). The SEM analysis confirmed a significant positive effect of patient safety culture on responsibility (β = 0.59, p < 0.001). Age and work experience significantly moderated this relationship, with stronger associations observed among older and more experienced nurses.
Conclusion
This study underscores the association between patient safety culture and nurses’ responsibility, emphasizing its potential influence within healthcare settings. Strengthening dimensions such as hospital management support, non-punitive response to error, and overall perceptions of safety may foster higher levels of responsibility among nurses. Moreover, designing interventions tailored to nurses’ age and experience can further reinforce responsible behavior and the overall quality of care.
Clinical trial number
Not applicable.
Keywords: Patient safety, Safety culture, Nurses’ professional responsibility, Age factors, Work experience, Nurses
Introduction
Patient safety is a key component of healthcare quality, affecting outcomes and institutional trust [1, 2]. One of the key determinants of patient safety is the patient safety culture, which refers to the shared values and behaviors that shape staff commitment to safety [3, 4]. This culture includes elements such as teamwork, open communication, organizational learning, and non-punitive responses to error [5, 6], and plays a major role in preventing medical errors and improving professional collaboration [7].
Alongside organizational factors, nurses’ professional responsibility is pivotal in achieving patient safety [8]. This concept encompasses a nurse’s willingness to be accountable for clinical decisions, actions, and their consequences, shaped by legal, ethical, altruistic, and economic dimensions [9, 10]. In high-risk hospital environments, nurses’ responsibility is vital for protocol adherence, incident reporting, and ethical practice [11, 12].
Despite their importance, only a limited number of recent studies in the nursing field have explicitly examined the link between patient safety culture and nurses’ accountability as a unified construct in hospital settings [13–15]. This gap limits understanding of how safety culture may foster nurses’ responsibility, while addressing it could improve leadership and workforce strategies in healthcare.
Moreover, the strength of this relationship may vary based on demographic factors such as age, gender, education level, marital status, employment status, and work experience. For instance, more experienced nurses may respond differently to safety norms compared to less experienced staff. Studies suggest these variables can moderate how patient safety culture impacts nurses’ responsibility and behavior, especially in complex healthcare settings. For example, research has shown that factors such as age and work experience influence nurses’ perceptions of patient safety culture, which may consequently affect their professional responsibility and behaviors [16, 17]. Other demographic factors such as gender or marital status may indicate broader socio-cultural influences on professional roles in the Iranian healthcare context [2, 18]. Identifying these moderating effects is essential for designing tailored, effective interventions that improve safety and responsibility across diverse workforce groups.
To address these gaps, this study investigates the relationship between patient safety culture and nurses’ professional responsibility using a structural equation modeling (PLS-SEM) approach. The setting is Samen al-Hojaj Hospital in Sirjan, Iran, a site actively seeking to improve safety standards. By exploring how and for whom patient safety culture impacts responsibility, the study offers both theoretical insight and practical implications for policy, education, and clinical leadership.
Theoretical framework
This study draws on Organizational Culture Theory and Responsibility Theory. Schein’s model posits that organizational values and norms shape employee behavior [19]. A culture emphasizing learning, communication, and non-punitive error responses, key aspects of patient safety culture, fosters responsible conduct [13]. Responsibility Theory adds that accountability arises from internal drivers (ethical commitment, personal values) and external expectations (policies, peer behavior) [20, 21]. In supportive cultures, nurses internalize shared safety goals and act responsibly [22, 23].
Both theories, however, may oversimplify complex hospital realities. Organizational Culture Theory assumes uniform value transmission, which may not apply in hierarchical settings, while Responsibility Theory may underplay systemic constraints such as workload or burnout. Yet, they intersect in their focus on value-driven behavior: culture provides context, and individuals respond with responsibility, explaining how norms shape accountability in hospitals.
Empirical studies support this framework. For example, a systematic review found that nursing competence correlates with patient safety culture scores [22]. Moreover, a recent correlational study of 753 nurses in Turkey found that better perceptions of patient safety culture were significantly associated with greater “voice behavior” (speaking up), a dimension of responsibility [24]. Similarly, Abu-El-Noor et al. (2019) reported that stronger safety culture scores correlated with higher engagement in responsible, patient-centered care [25]. Recent work also highlights safety culture as dynamic and context-dependent [26, 27] and shaped by workforce diversity and demographics [28], underscoring the value of demographic moderators in this model.
Despite these findings, many existing studies rely on self-reported data, limiting the generalizability of results. Moreover, few studies integrate multi-level or longitudinal designs to capture how these theoretical constructs operate over time or across organizational levels. These limitations underscore the need for empirical approaches, such as structural equation modeling, to test these relationships more rigorously.
Hypothesis development
Based on the literature and theoretical framework, while acknowledging the theoretical assumptions and their practical limitations, the following hypotheses are proposed:
H1
Patient safety culture has a positive and significant effect on nurses’ responsibility.
H2
Demographic factors moderate the relationship between patient safety culture and nurses’ responsibility.
H2a
Age moderate the relationship between patient safety culture and nurses’ responsibility.
H2b
Gender moderate the relationship between patient safety culture and nurses’ responsibility.
H2c
Education level moderate the relationship between patient safety culture and nurses’ responsibility.
H2d
Marital status moderate the relationship between patient safety culture and nurses’ responsibility.
H2e
Employment status moderate the relationship between patient safety culture and nurses’ responsibility.
H2f
Work experience moderate the relationship between patient safety culture and nurses’ responsibility.
Conceptual model
To visually illustrate the hypothesized relationships, the following conceptual model integrates the independent (patient safety culture), dependent (nurses’ responsibility), and moderating variables (Demographic factors; age, gender, education level, marital status, employment status, work experience) based on both theory and prior empirical evidence. The conceptual model of the study is illustrated in Fig. 1.
Fig. 1.
Conceptual model of the study
Methods
Study design and setting
This descriptive-analytical cross-sectional study was conducted between January and April 2025 among nurses working at Samen al-Hojaj Hospital in Sirjan, southern Iran. This hospital is affiliated with Sirjan School of Medical Sciences and serves as a primary clinical training center for nursing and medical students.
Participants and sampling
The study population included all clinical nurses at the hospital (N = 306). A total of 301 nurses completed the survey (response rate 98.4%). The sample size was considered adequate for partial least squares structural equation modeling (PLS-SEM) based on a priori power analysis using G*Power 3.1, assuming an alpha level of 0.05, statistical power of 0.80, and a medium effect size (f² = 0.15). Non-response analysis showed no significant demographic differences between respondents and non-respondents.
Inclusion and exclusion criteria
Inclusion criteria were clinical nurses who voluntarily participated in the study. Exclusion criteria included nurses working exclusively in administrative or non-clinical roles, those on leave during the data collection period, and nurses who declined to participate or did not complete the questionnaire.
Measures
Data were collected using a structured questionnaire in three parts. The first part captured demographic characteristics including age, gender, marital status, education level, employment status, and work experience.
The second part of the questionnaire was the Hospital Survey on Patient Safety Culture (HSOPSC), a standardized instrument developed by the Agency for Healthcare Research and Quality (2004) to assess hospital staff perceptions of patient safety culture [29]. The Persian version, previously validated and used in Iranian studies, includes 42 items across 12 dimensions. Responses were rated on a five-point Likert scale ranging from strongly disagree to strongly agree. Positively worded items were scored from 1 to 5, while negatively worded items were reverse-scored. Scores were classified as favorable (positive response > 75%), acceptable (50–75%), and poor (< 50%) [30]. This questionnaire section was previously validated in Iran by Moghbri et al. (2012) through confirmatory factor analysis, reliability testing, and content validation [31]. The Persian version used in this study was obtained from these validated sources and applied with proper citation [30, 31]. The original instrument is publicly accessible through the AHRQ website and can be used for academic purposes under standard conditions [32]. A summary of the dimensions, items, and Cronbach’s alpha is presented in Table 1.
Table 1.
Summary of HSOPSC dimensions and psychometrics (Persian Version)
| Dimension | Number of Items |
|---|---|
| Overall perceptions of safety | 4 |
| Supervisor/manager expectations and actions promoting safety | 4 |
| Organizational learning | 3 |
| Teamwork within units | 4 |
| Communication openness | 3 |
| Feedback and communication about error | 3 |
| Non-punitive response to error | 3 |
| Staffing | 4 |
| Hospital management support for patient safety | 3 |
| Teamwork across hospital units | 4 |
| Handoffs and transitions | 4 |
| Frequency of event reporting | 3 |
| Tool’s validity and reliability (Iranian validation) * | GFI = 0.96 |
| AGFI = 0.98 | |
| Cronbach’s alpha = 0.82 |
* Reference: [31]
The third part of the questionnaire was Hassanian’s Responsibility Questionnaire, developed based on Carroll’s model. It contains 35 items across four dimensions: legal responsibility (7 items), economic responsibility (7 items), ethical responsibility (9 items), and altruistic responsibility (12 items) [10]. Items were rated on a 5-point Likert scale from strongly disagree to strongly agree. Total scores (35–175) were classified as low (35–70), moderate (71–105), good (106–140), and excellent (141–175) [10]. The Persian version was formally validated by Hassanian et al. (2017) using expert panel review, exploratory factor analysis, and reliability testing in an Iranian nursing population, demonstrating good psychometric properties including a Cronbach’s alpha of 0.86 [10]. Verbal permission to use the Persian version was obtained from the corresponding author, and proper citation was provided.
Data collection
Data collection was coordinated with hospital administration and conducted ethically. A trained researcher distributed and collected questionnaires across all shifts, explained the study, obtained written informed consent, and assured participants that their information would remain confidential and anonymous. Questionnaires were collected the same day and securely stored to minimize loss and bias.
Statistical analysis
Data were analyzed using SPSS version 26 and SmartPLS version 4. Although PLS-SEM is non-parametric, skewness and kurtosis were assessed to ensure data suitability for descriptive statistics and Pearson correlation. Skewness and kurtosis values for all variables were within the acceptable range of ± 2. Multicollinearity was ruled out as all VIF values were below 5.
Descriptive statistics including frequency, mean, and standard deviation were calculated for all variables. Measurement model evaluation included internal consistency reliability using Cronbach’s alpha and composite reliability (threshold ≥ 0.70) [33]. Convergent validity was confirmed by average variance extracted (AVE > 0.50), and discriminant validity was assessed using the Fornell–Larcker criterion and Heterotrait–Monotrait ratio (HTMT < 0.85) [34].
Pearson correlation was used to preliminarily examine the linear relationship between patient safety culture and nurses’ responsibility. This helped to confirm the presence of a statistically significant association before proceeding with the more complex structural modeling.
The structural model was assessed using Partial Least Squares Structural Equation Modeling (PLS-SEM) to examine the direct effects of patient safety culture on nurses’ responsibility. Demographic moderators were assessed using multi-group analysis (MGA) and interaction terms. Model fit was evaluated with the Standardized Root Mean Square Residual (SRMR < 0.08), the Normed Fit Index (NFI > 0.90), and the coefficient of determination (R²>0.26). Predictive relevance was assessed using the Q² statistic (Q²>0) [35]. The significance level for all analyses was set at p < 0.05.
Given the cross-sectional design, causal relationships between patient safety culture and nurses’ responsibility cannot be inferred. The observed associations reflect correlations at a single point in time. Although census sampling was used, the final sample of 301 nurses was sufficient for PLS-SEM, exceeding the recommended minimum of 100–200 and considered very good for robust estimation [36].
Results
Out of a total sample of 306 individuals, 301 participated in the study, resulting in a response rate of 98.4%. The average participant age was 32.74 years (SD = 5.21) with a mean work experience of 7.35 years (SD = 5.46). A total of 46.18% of the participants were permanently employed, and a majority were female (86.38%), married (68.77%), and held a bachelor’s degree (97.67%). The demographic characteristics indicate a predominantly young, female, and experienced nursing workforce in the hospital. Table 2 summarizes the demographic characteristics.
Table 2.
Frequency distribution of nurses under investigation (n = 301)
| Variable | Category | Frequency (n) | Percentage (%) |
|---|---|---|---|
| Age | < 30 | 112 | 37.21 |
| 30–40 | 104 | 34.55 | |
| > 40 | 85 | 28.24 | |
| Work experience | < 5 | 148 | 49.17 |
| 5–15 | 79 | 26.25 | |
| > 15 | 74 | 24.58 | |
| Gender | Male | 41 | 13.62 |
| Female | 260 | 86.38 | |
| Employment status | Permanent | 139 | 46.18 |
| Probationary | 41 | 13.62 | |
| Project-based | 105 | 34.88 | |
| Contractual | 16 | 5.32 | |
| Level of Education | Bachelor’s Degree | 294 | 97.67 |
| Master’s Degree | 7 | 2.33 | |
| Marital status | Single | 94 | 31.23 |
| Married | 207 | 68.77 |
The total mean score of patient safety culture was 2.93 ± 0.54 out of 5. The percentage of positive responses across the 12 dimensions of patient safety culture was 63.5%, while negative responses accounted for 21.8%, and neutral responses made up 14.7%. The total mean score of nurses’ responsibility was 108.3 ± 13.9 out of a possible 175. Overall, the nurses reported an acceptable perception of patient safety culture and a moderate-to-good level of responsibility. Details of the dimensions for both patient safety culture and nurses’ responsibility are presented in Table 3.
Table 3.
Mean and standard deviation of the patient safety culture and nurses’ responsibility and its subscales
| Variable | Subscale | Mean | Standard deviation | Positive responses (%) |
|---|---|---|---|---|
| Patient Safety Culture | Supervisor/manager expectations and actions | 3.04 | 0.61 | 65.2 |
| Hospital management support | 2.88 | 0.64 | 61 | |
| Feedback and communication | 2.96 | 0.66 | 60.5 | |
| Overall perceptions of patient safety | 2.91 | 0.68 | 61.3 | |
| Organizational learning | 2.89 | 0.72 | 62.4 | |
| Teamwork within units | 3.12 | 0.57 | 68.1 | |
| Open communication | 2.87 | 0.63 | 59.7 | |
| Non-punitive response to error | 2.71 | 0.69 | 56.4 | |
| Staffing | 2.68 | 0.72 | 53.9 | |
| Teamwork across units | 2.95 | 0.66 | 63.7 | |
| Handoffs and transitions | 2.90 | 0.69 | 64.5 | |
| Frequency of events reported | 3.01 | 0.62 | 65.3 | |
| Total | 2.93 | 0.54 | 63.5 | |
| Variable | Subscale | Score range | Mean | Standard deviation |
| Responsibility | Legal responsibility | 7–35 | 22.1 | 3.4 |
| Economic responsibility | 7–35 | 21.1 | 3.0 | |
| Ethical responsibility | 9–45 | 28.4 | 4.1 | |
| Altruistic responsibility | 12–60 | 36.7 | 5.8 | |
| Total | 35–175 | 108.3 | 13.9 |
Pearson’s correlation analysis showed a significant and positive correlation between patient safety culture and nurses’ responsibility (r = 0.61, p < 0.001, 95% CI: 0.53–0.68), indicating a moderate-to-strong association, suggesting that improvements in safety culture are associated with higher levels of responsibility. Further analysis demonstrated that all twelve dimensions of the patient safety culture, as measured by the Hospital Survey on Patient Safety Culture (HSOPSC), were also significantly and positively correlated with nurses’ responsibility (p < 0.001 for all). This indicates that various aspects of a strong safety culture are individually associated with greater responsibility among nurses (Table 4).
Table 4.
Pearson correlation coefficients between patient safety culture dimensions and nurses’ responsibility
| Nurses’ Responsibility | Dimension patient safety Culture | r * | P-value** | 95% CI (Lower-Upper) |
|---|---|---|---|---|
| Supervisor/manager expectations and actions | 0.47 | < 0.001 | 0.38–0.55 | |
| Hospital management support | 0.55 | < 0.001 | 0.47–0.62 | |
| Feedback and communication | 0.50 | < 0.001 | 0.41–0.58 | |
| Overall perceptions of patient safety | 0.52 | < 0.001 | 0.43–0.60 | |
| Organizational learning | 0.45 | < 0.001 | 0.36–0.54 | |
| Teamwork within units | 0.49 | < 0.001 | 0.40–0.57 | |
| Open communication | 0.43 | < 0.001 | 0.33–0.52 | |
| Non-punitive response to error | 0.54 | < 0.001 | 0.45–0.62 | |
| Staffing | 0.46 | < 0.001 | 0.37–0.54 | |
| Teamwork across units | 0.48 | < 0.001 | 0.39–0.56 | |
| Handoffs and transitions | 0.44 | < 0.001 | 0.34–0.53 | |
| Frequency of events reported | 0.42 | < 0.001 | 0.32–0.51 | |
| Total patient safety culture | 0.61 | < 0.001 | 0.53–0.68 |
* r; Pearson Correlation Coefficient
** p-value; Correlation is significant at the 0.05 level
Using SmartPLS 4, the measurement model met all reliability and validity criteria, with Cronbach’s alpha and composite reliability above 0.70, AVE above 0.50, and discriminant validity confirmed via the Fornell–Larcker criterion and HTMT (< 0.85).
The structural model showed that patient safety culture had a significant positive effect on nurses’ responsibility (β = 0.59, t = 9.23, p < 0.001), supporting Hypothesis 1. A β value of 0.59 suggests a moderate-to-strong effect size, which implies that enhancing safety culture could have a practically significant impact on nurses’ sense of responsibility in clinical settings.
Regarding Hypothesis 2 on the moderating role of demographic factors, multi-group analysis was conducted across all variables (age, gender, education level, marital status, employment status, and work experience). The results indicated that only two demographic variables age and work experience moderated the relationship significantly. The positive effect of safety culture on responsibility strengthened with increasing age and longer work experience (Table 5). For transparency, non-significant moderators (gender, education level, marital status, and employment status) had shown β values ranging from 0.04 to 0.12 and p-values > 0.05, indicating no meaningful moderation.
Table 5.
Structural model results and moderating effects of age and work experience (multi-group analysis)
| Relationship | Group/Moderator | β | t-value | p-value | 95% CI (Lower-Upper) | Interpretation |
|---|---|---|---|---|---|---|
| Patient Safety Culture → Responsibility | Overall model | 0.59 | 9.23 | < 0.001 | 0.50–0.68 | Significant positive effect (H1 supported) |
| Age < 30 years | 0.46 | 5.85 | < 0.001 | 0.38–0.57 | Positive effect in younger nurses | |
| Age 30–40 years | 0.58 | 7.92 | < 0.001 | 0.48–0.68 | Stronger effect in mid-age nurses | |
| Age > 40 years | 0.67 | 9.11 | < 0.001 | 0.57–0.77 | Stronger effect in older nurses | |
| Moderation by age |
Difference (> 40 vs. < 30 years) |
--- | --- | --- | --- | Significant moderation: effect increases with age |
| Patient Safety Culture → Responsibility |
Work experience: < 5 years |
0.49 | 6.20 | < 0.001 | 0.38–0.60 | Positive effect in less experienced nurses |
|
Work experience: 5–15 years |
0.61 | 8.15 | < 0.001 | 0.51–0.71 | Stronger effect in mid-level experience nurses | |
|
Work experience: > 15 years |
0.70 | 9.37 | < 0.001 | 0.60–0.80 | Stronger effect in highly experienced nurses | |
| Moderation by work experience |
Difference (> 15 vs. < 5 years) |
--- | --- | --- | --- | Significant moderation: effect increases with experience |
Model fit indices confirmed good fit and substantial predictive relevance for nurses’ responsibility, with SRMR = 0.067 (< 0.08), NFI = 0.92 (> 0.90), R² = 0.34 (> 0.26), and Q² = 0.28 (> 0) (Table 6).
Table 6.
Model fit indices and predictive relevance
| Index | Value | Recommended Threshold | Interpretation |
|---|---|---|---|
| Standardized Root Mean Square Residual (SRMR) | 0.067 | < 0.08 | Good model fit |
| Normal Fit index (NFI) | 0.92 | > 0.90 | Acceptable to good model fit |
| Coefficient of Determination (R2) for Responsibility | 0.34 | > 0.26 | Substantial explained variance |
| Predictive Relevance (Q2) for Responsibility | 0.28 | > 0 | Strong predictive relevance |
Discussion
This study investigated the relationship between patient safety culture and nurses’ responsibility, finding a significant positive correlation. Strengthening a patient safety culture appears to be associated with an increased sense of responsibility among nurses, as safety-focused environments may promote more accountable nursing practices.
Notably, key dimensions such as hospital management support, non-punitive response to errors, and overall safety perceptions showed particularly strong relationships with responsibility. This underscores the critical role of leadership and organizational environment in shaping professional conduct. It seems that when nurses feel supported and not blamed for errors, they are more inclined to engage in open reporting and assume personal accountability. This interpretation aligns with studies by Lee et al. (2023), who emphasized the role of leadership commitment in fostering professional responsibility [37], and Kakemam et al. (2022), who highlighted the impact of perceived safety on ethical behavior in Iranian hospitals [38]. However, some studies have found weaker or inconsistent associations between specific dimensions of safety culture and responsibility. For example, Zhang et al. (2018) reported that in resource-limited settings, staff showed high personal responsibility despite a weak safety culture, possibly due to intrinsic professional values [39]. This suggests that contextual and cultural factors can influence these relationships and should be considered when interpreting results.
The present study found moderate correlations between nurses’ responsibility and factors like feedback and communication about errors, and teamwork, emphasizing the role of collaboration and constructive feedback in promoting shared care standards. Significant correlations were also observed with supervisor/manager expectations and actions promoting safety, staffing, and organizational learning. Adequate staffing is essential for patient safety and enabling nurses to fulfill their responsibilities effectively. Insufficient staffing leads to overload and stress, reducing nurses’ ability to act responsibly. In contrast, well-staffed environments support ethical and accountable care, highlighting the need to address workforce issues, especially in under-resourced hospitals [40, 41]. These findings reinforce the importance of addressing workforce issues in healthcare policy and planning, especially in under-resourced hospitals where staff shortages are chronic. From a practical standpoint, healthcare leaders should improve staffing, adopt non-punitive policies, promote team training, and include patient safety and ethics in nursing education to strengthen professional responsibility.
Finally, although slightly lower in magnitude, handoffs and transitions, open communication, and frequency of events reported were still significantly and positively associated with responsibility. These findings imply that even more operational or technical components of patient safety culture, such as smooth handovers and the regular reporting of incidents, contribute to an environment where responsibility is expected and practiced.
The presence of uniformly positive correlations across all dimensions might also be partially influenced by shared method bias, since both constructs were assessed via self-report questionnaires. This is a methodological limitation that should be considered when interpreting the strength of these associations. Future studies could use objective or mixed methods to validate these relationships.
The structural equation modeling supported the hypothesis that patient safety culture significantly predicts nurses’ responsibility. This result extends prior correlational findings by confirming a directional, causal pathway between these two constructs. Importantly, this relationship remained significant after accounting for demographic variables as covariates in the model. The finding is consistent with Lee et al. (2023), who also found that support from hospital management and clinical leaders strengthens patient safety culture and, in turn, enhances nurses’ sense of responsibility [42].
Multi-group analysis further revealed that age and work experience moderated the relationship between safety culture and responsibility. Specifically, older nurses and those with more years of professional experience exhibited stronger associations between these constructs. One explanation is that experienced nurses are more familiar with professional norms of responsibility and may have a more refined understanding of how safety culture supports these norms. They may also feel a stronger ethical duty to model responsible behavior for less experienced colleagues. In a similar study by Nyberg et al. (2024), greater focus on patient safety was observed among nurses with increasing age and experience within this professional group [43]. Also, Purabdollah et al. (2022) reported that older and more experienced nurses demonstrated higher levels of responsibility [44]. Nonetheless, this finding may not apply to all settings. In high-turnover or temporary staffing situations, even experienced nurses might lack the stability needed to internalize safety culture. Therefore, retention strategies and supportive leadership are essential to maintain responsibility at all levels.
Overall, the results underscore the importance of cultivating a positive and comprehensive patient safety culture as a strategy to enhance nurses’ responsibility. This is particularly vital in high-risk and complex healthcare environments where professional responsibility can directly influence patient outcomes. Furthermore, tailored interventions that account for demographic differences, organizational culture, and systemic constraints are essential.
Conclusion
This study demonstrates that a strong patient safety culture is significantly associated with nurses’ professional responsibility in hospital settings. Hospital management support, non-punitive response to error, and overall safety perceptions were the dimensions most strongly associated with responsibility, and age and work experience moderated these relationships. These findings suggest that developing safety culture can be a strategic pathway to strengthening nurses’ responsibility and improve care quality. This study contributes to practice by providing a practical framework for leadership-driven, context-sensitive interventions in nursing management.
Policy implications and recommendations
Given the significant positive effect of patient safety culture on nurses’ responsibility identified in this study, the following evidence-informed and actionable strategies are recommended for healthcare institutions:
Focus on enhancing specific safety culture dimensions with the strongest associations
Since hospital management support for patient safety, non-punitive response to error, and overall perceptions of patient safety showed the strongest correlations with nurses’ responsibility, targeted strategies should focus on these areas. For instance, hospitals can conduct regular leadership walk-rounds to demonstrate managerial commitment, implement anonymous reporting tools to reduce fear of punishment, and monitor staff perceptions of safety through quarterly surveys.
Design age- and experience-sensitive training programs to enhance responsibility
As the relationship between safety culture and responsibility was significantly stronger among nurses over 40 and those with more than 15 years of experience, training should be tailored accordingly. For junior nurses, interactive workshops and simulation-based learning can help foster responsibility early in their careers, while senior staff may benefit from leadership development programs that encourage mentorship roles.
Establish a formal, non-punitive error reporting protocol
Based on the importance of non-punitive response to error, hospitals should adopt anonymous digital reporting systems and ensure managerial follow-up focuses on system improvement rather than individual blame. Feedback loops (e.g., monthly safety bulletins) should show how reported issues lead to actual changes.
Integrate responsibility indicators into annual performance appraisals
Hospitals can define and monitor specific professional behaviors, such as adherence to protocols, patient advocacy, and timely documentation, and use competency-based evaluations linked to continuing education or incentives to promote accountability.
Limitation
This study was conducted in a specific regional and institutional context, which may limit the generalizability of the findings to other healthcare settings. The sample was drawn from a single hospital, increasing the risk of sampling bias and limiting external validity. Additionally, the use of self-reported questionnaires introduces potential social desirability bias and common method bias, as responses for both independent and dependent variables were collected from the same source. The cross-sectional design further restricts the ability to infer causal relationships, even though structural equation modeling (SEM) was used for analysis. Longitudinal or multi-method designs in future studies could address these limitations.
Suggestions for future research
Future studies might explore longitudinal designs to better understand causal relationships between patient safety culture and nurses’ responsibility over time. It would be beneficial to replicate this research across diverse hospital settings and cultural contexts to assess the consistency and generalizability of the findings Further research could also examine the role of other potential moderating or mediating variables, such as organizational support, leadership style, or job satisfaction. Qualitative or mixed-methods approaches may provide deeper insights into how nurses perceive and enact responsibility within the context of patient safety.
Acknowledgements
This study is approved by Sirjan School of Medical Sciences with ID 403000004. The researchers would like to thank all the participants who contributed to completing the questionnaires.
Abbreviations
- HSOPSC
Hospital Survey on Patient Safety Culture
- PLS-SEM
Partial Least Squares Structural Equation Modeling
- HTMT
Heterotrait–Monotrait ratio
- SRMR
Standardized Root Mean Square Residual
- NFI
Normed Fit Index
- R²
Coefficient of Determination
Author contributions
ARY designed the study and prepared the initial draft. ARY contributed to data collection and analysis. ARY, RS, and ZN supervised the entire study and finalized the article. All authors have read and approved the manuscript.
Funding
There was no funding.
Data availability
All data is presented as part of the tables or figures. Additional data can be requested from the corresponding author.
Declarations
Ethics approval and consent to participate
This study is approved by the Sirjan School of Medical Sciences Ethics Committee under ID number IR.SIRUMS.REC.1403.031. All methods were carried out in accordance with relevant guidelines and regulations. Written informed consent was obtained from all subjects and/or their legal guardians. To ensure anonymity and confidentiality, no identifiable personal information (e.g., names or contact details) was collected, and all data were stored securely in encrypted digital files accessible only to the research team. Also, all procedures were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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