Impact of patient safety culture on resilience and turnover intention: a multi-site study

Abstract

Background

A clear understanding of the influence of patient safety culture (PSC) on resilience and turnover intention is essential for building a stable, efficient, and safe healthcare workforce. While previous research has explored the relationship between PSCs and nurses’ resilience, no studies have specifically examined the association between PSCs and nurses’ turnover intention.

Aim

To assess PSC and its relationship with nurses’ resilience and turnover intention.

Methods

In this cross-sectional descriptive study, we used convenience sampling to recruit 117 registered nurses working in hospitals across 13 regions in Saudi Arabia. Data were collected between December 2023 and March 2024 via three instruments: the Hospital Survey on Patient Safety Culture, the Connor–Davidson Resilience Scale, and the Turnover Intention Scale. Pearson’s product‒moment correlation, independent sample t tests, and linear regression models were used to analyze the data.

Results

A total of 117 participants reported a low overall perception of PSCs, with an average positive response rate of 44.6%. The mean scores for resilience and turnover intention were moderate. PSC was positively and moderately correlated with resilience (r = .352, p < .001). However, there was a moderate negative correlation between PSCs and turnover intention (r = − .253, p < .01). The regression model yielded significant results (F [1, 113] = 16.01, p < .001, R² = 0.124), indicating that PSC (β = 0.800, p < .001) statistically significantly predicted resilience. Those who perceived higher PSC were more likely to have greater resilience. Furthermore, PSC (β = − 0.883.p = .006) statistically significantly predicted turnover intention. Individuals who perceived higher PSC were less likely to leave the hospital.

Conclusion

Improvements in PSCs are beneficial not only because they may increase resilience but also because of the associated reduction in turnover intention.

Introduction

Patient safety is a critical global concern in healthcare. Globally, nearly one in 10 patients are affected by unsafe care, with approximately three million deaths due to unsafe healthcare practices recorded annually [1]. These statistics underscore the urgent need to prioritize patient safety at all levels of healthcare systems.

Patient safety culture (PSC) reflects shared values, beliefs, and practices within an institution aimed at minimizing patient harm. PSC is vital for promoting safe care delivery and fostering trust among healthcare professionals [2, 3]. The development of a strong PSC is essential for ensuring patient welfare and enhancing the work environment for healthcare providers. In nursing, positive PSCs play a pivotal role in shaping workplace dynamics and improving patient and organizational outcomes.

Building on this foundation, addressing how PSCs are related to nurses’ resilience and intentions to leave is relevant. Resilience is a multifaceted and dynamic process that empowers nurses to adapt positively to workplace stressors while avoiding psychological harm [4]. It serves as a crucial psychosocial resource, enabling nurses to maintain their well-being and sustain effective performance in the face of occupational challenges. Effective PSC can provide nurses with a means of recovering from stress and maintaining performance at the highest level through training, teamwork, and attention to mental health [5]. In contrast, a weak PSC may result in burnout, increased stress, and lower resilience, potentially impacting care quality and, significantly, the health status of the nurses themselves [6]. This stark contrast underlines how well-developed PSCs can protect against adverse outcomes resulting from workplace stress.

In contrast, turnover intention, described as “the last in a sequence of withdrawal cognitions, a set to which thinking of quitting and intent to search for alternative employment also belong” [7]. It serves as a key indicator of actual turnover, which is usually affected by organizational culture factors. A supportive PSC directly influences turnover intention by strengthening nurses’ resilience through stability and empowerment [8]. A strong PSC decreases the probability of nurses leaving their jobs by creating feelings of safety, value, and satisfaction with the profession. It addresses workload issues, conflict resolution, and significant recognition factors in job retention [9]. Conversely, poor PSC increases turnover intention, which results in staffing shortages and a degraded quality of care [10].

PSC plays a critical role in shaping nurses’ resilience and intention to remain in their positions, as it is closely tied to the work environment and overall job satisfaction. Researchers have emphasized that organizations with high PSC prioritize core values such as respect, open communication, and accountability, enabling nurses to perform their duties with confidence and safety [3, 6]. These values can foster trust among team members and cultivate a sense of belonging and purpose within the institution [11, 12]. Such an environment could lay the groundwork for building resilience among nurses, who often face significant stress owing to patient emergencies, long shifts, and emotional challenges. A robust PSC empowers them to navigate these challenges effectively and recover, ensuring their ability to deliver safe and quality care [13, 14].

The development of a strong PSC becomes integral to ensuring a resilient nursing workforce and mitigating the risk of high turnover rates. Therefore, through this study, we seek to fill a critical gap in the healthcare literature by investigating the associations of PSCs with nurse resilience and turnover intention. While PSC has been widely studied in terms of its impact on patient outcomes, few studies have explored its association with the psychological well-being and career choices of nursing staff [15]. Nurses are at the frontlines of healthcare delivery, and a clear understanding of the factors associated with their resilience and turnover intentions is important for developing a stable, efficient, and safe healthcare workforce.

The theoretical underpinning of this study is the structuration theory of safety culture proposed by Groves et al. (2011) [16]. According to this theory, safety culture in healthcare systems arises from the interplay between individual actions, such as nurses’ choices and behaviors, and organizational structures, including policies, values, and systemic factors. A strong safety culture fosters an environment where nurses feel a sense of commitment and belonging, thereby enhancing resilience and reducing turnover intention. By promoting open communication, mutual respect, and accountability, organizations create structural conditions that empower nurses to adapt positively to workplace challenges. These supportive structures help mitigate stress and prevent burnout, enabling nurses to maintain well-being and confidence in their roles. In contrast, weak safety cultures fail to provide the necessary support, increasing stress and dissatisfaction, which can lead to higher turnover rates [17]. Thus, the structuration theory of safety culture is essential for understanding how the dynamic interaction between individual agencies and organizational structures influences nurses’ resilience and their decision to stay in or leave the organization.

Therefore, our purpose in this study was to assess PSC, resilience, and turnover intention among nurses working in acute care settings. The specific aims were to (1) assess the relationships among PSC, resilience, and turnover intention; (2) assess the mean differences in PSCs according to the participants’ demographic factors (i.e., gender, level of education, nationality, and attending patient safety training); and (3) determine whether PSCs may predict resilience and turnover intention.

Materials and methods

Design

This was a cross-sectional descriptive design. The study adhered to the reporting guidelines of the Strengthening the Reporting of Observational Studies in Epidemiology.

Setting and sample

The data were collected from 13 regions of Saudi Arabia via convenience sampling. Those who were registered nurses and working in acute care settings were eligible to participate in the study. Nursing interns, nursing students, and those who were not proficient in English were excluded. The sample size was calculated via G*Power 3.1.9 software (Heinrich-Heine-University, Düsseldorf, Germany). The criteria for running the inferential statistics were as follows: an alpha level of 0.05, a power of 0.8, and an effect size of 0.15. On the basis of these criteria, the minimum sample size to conduct the regression analysis was determined to be 92. However, we decided to add 15% to avoid any issues associated with missing data. The total sample size was 117.

Data collection

An online survey was utilized to collect data anonymously, with the survey link disseminated across popular social media channels (WhatsApp groups, Twitter). To enhance the recruitment strategy, the questionnaire was also distributed to chief nursing officers at regional hospitals. In addition, we distributed the survey via organizational email to nurses directly involved in patient care. Data were collected between December 2023 and March 2024. The data collection was extended to ensure an adequate sample size.

Measurements

The questionnaire was divided into four sections. The first section included participants’ demographics (i.e., age, gender, nationality, level of education, length of experience, and attending training courses regarding patient safety in the last 12 months).

The instruments used in our research were taken from prior studies and had been previously validated. The second section included the Hospital Survey on Patient Safety Culture (version 2.0), developed by the Agency of Health Research Quality (AHRQ) [2]. This self-report tool was developed for healthcare workers to indicate their perceptions regarding various aspects of patient safety and organizational practices. It consists of 34 items distributed across 10 dimensions: (1) teamwork; (2) staffing and work pace; (3) organizational learning-continuous improvement; (4) response to error; (5) supervisor, manager, or clinical leader support for patient safety; (6) communication about error; (7) communication openness; (8) reporting patient safety events; (9) hospital management support for patient safety; and (10) handoffs and information exchange. Through the evaluation of these aspects, healthcare facilities can identify their strengths as well as areas that require improvement, all with the overarching aim of enhancing patient care and safety outcomes. Subscales 1, 2, 3, 4, 5, 9 and 10 are rated on a 5-point Likert scale, where 1 signifies “strongly disagree” and 5 means “strongly agree”; While subscales 6, 7 and 8 are rated from 1 “Never” to 5 “always”. For Patient Safety Rating, it ranges from 1 “Poor” to 5 “Excellent”. The scoring and interpretation processes adhered to the HSOPS manual, as recommended by AHRQ [18]. Negative items are reversed, with ratings of 1 and 2 considered a negative stance on patient safety, a rating of 3 classified as neutral, and ratings of 4 and 5 reflecting a positive perception of patient safety. For each item, a score of > 75% is considered a strength, whereas a score of ≤ 50% indicates weak perceptions of safety culture, requiring improvement.

The Connor–Davidson Resilience Scale was used to measure resilience [19]. This instrument has 25 items divided into five subscales: positive acceptance of change and secure relationships (five items); trust in one’s instincts, tolerance of negative affect, and strengthening effects of stress (seven items); personal competence, high standards, and tenacity (eight items); control (three items); and spiritual influences (two items). The items are rated on a 5-point Likert scale, where 0 indicates “not true at all” and 4 means “true nearly all the time.” The total score ranges from 0 to 100, with a higher score indicating greater resilience.

The fourth section included the turnover intention scale, which was used to assess the intention to leave current employment [20]. It has three items rated on a 5-point Likert scale, where 1 signifies “strongly disagree” and 5 means “strongly agree.” The total score ranges from 1 to 5, with a higher score indicating a stronger intention to leave. The internal consistency reliability, as indicated by Cronbach’s α, was 0.953.

Ethical considerations

The study protocol was reviewed and approved by King Saud University [KSU-HE-23-839]. In the recruitment statement, nurses were informed about the purpose of the study, as well as the potential risks and benefits associated with participation. To ensure confidentiality, identifiers were not collected, and the data were reported in aggregated form. Informed consent was obtained, with nurses reporting that completing the questionnaire was indicative of their agreement to participate in the study. Participation was voluntary, and the nurses had the right to withdraw while completing the questionnaire without any consequences. The participants were aware that their involvement in the study would not yield any direct benefits but that it would play a crucial role in enhancing their understanding of PSCs, especially in developing countries such as those in the Middle East.

Data analysis

SPSS version 29 (IBM Corp., Armonk, NY, USA) was used to manage and analyze the data. Descriptive statistics (i.e., means, standard deviations [SDs], and percentages) were used to report participants’ demographics, perceptions of PSC, resilience, and turnover intentions. Pearson’s product‒moment correlation was used to determine the associations among PSCs, resilience, and turnover intention. Two simple linear regression models were used to determine whether PSCs could predict resilience and turnover intention. An independent samples t test was used to determine the mean differences in PSC according to demographic factors (i.e., gender, level of education, nationality, and attendance at training courses regarding patient safety).

Results

A total of 117 participants completed the survey (Table 1). The average age was 35.37 years (SD = ± 5.43), and the average years of experience in nursing was 11.9 years (SD = ± 6.9). Most participants were women (68.4%) or Saudi nationals (75.2%), and more than two-thirds (n = 85) had attended training courses on patient safety within the last 12 months.

Table 1.

Participant demographic characteristics (N = 117)

Variable (Range)	n (%) or M (SD)
Age	35.37 (5.43)
Gender
Male	37 (31.6%)
Female	80 (68.4%)
Nationality
Saudi	88 (75.2%)
Non-Saudi	29 (24.8%)
Years of Experience	11.9 (6.9)
Attending Training Courses on Patient Safety
Yes	85 (72.6%)
No	32 (27.4%)

The Hospital Survey on Patient Safety Culture scores revealed a mixed picture (Table 2). The average positive response rate for the PSC composites was 44.6%, ranging from 34% to 58.7%. The highest-rated dimension was communication about error, with an average positive response rate of 58.7%, followed by teamwork at 56.46% and organizational learning–continuous improvement at 49.7%. Conversely, the dimensions with the lowest positive response rates were staffing and work pace (29.65%), followed by response to error (34%) and handoffs and information exchange (36.3%). Notably, the majority of the participants reported that the number of safety events in the last 12 months was between one and two (33.3%). Also, the percentage of neutral responses varied across the items indicating that some nurses were uncertain or lacked sufficient knowledge about specific aspects of patient safety and organizational practices, which may led them to select the neutral option.

Table 2.

Hospital survey on patient safety culture (HSOPS) scores

HSOPS			44.6%
Variables	Negative n (%)	Neutral n (%)	Positive n (%)
1. Teamwork			56.46%
In this unit, we work together as an effective team.	16 (14)	18 (16)	80 (70)
During busy times, staff in this unit help each other	17 (14.9)	23 (20.2)	74 (64.9)
There is a problem with disrespectful behavior by those working in this unit. *	42 (37.2)	32 (28.3)	39 (34.5)
2. Staffing and Work Pace			29.65%
In this unit, we have enough staff to handle the workload	36 (31.6)	28 (24.6)	50 (43.9)
Staff in this unit work longer hours than is best for patient care.*	66 (57.9)	28 (24.6)	20 (17.5)
This unit relies too much on temporary, float, or PRN staff.*	46(40.7)	36(31.9)	31(27.4)
The work pace in this unit is so rushed that it negatively affects patient safety.*	49 (43)	31 (27.2)	34 (29.8)
3. Organizational Learning-Continuous Improvement			49.7%
This unit regularly reviews work processes to determine if changes are needed to improve patient safety	27 (23.7)	20 (17.5)	67 (58.8)
In this unit, changes to improve patient safety are evaluated to see how well they worked.	17 (14.9)	33 (28.9)	64 (56.1)
This unit lets the same patient safety problems keep happening. *	43 (37.7)	32 (28.1)	39 (34.2)
4. Response to Error			34%
In this unit, staff feel like their mistakes are held against them. *	50 (43.9)	30 (26.3)	34 (29.8)
When an event is reported in this unit, it feels like the person is being written up, not the problem. *	54 (47.4)	36 (31.6)	24 (21.1)
When staff make errors, this unit focuses on learning rather than blaming individuals.	21 (18.4)	33 (28.9)	60 (52.6)
In this unit, there is a lack of support for staff involved in patient safety errors.*	46 (40.4)	31 (27.2)	37 (32.5)
5. Supervisor, Manager, or Clinical Leader Support for Patient Safety			45.1%
My supervisor, manager, or clinical leader seriously considers staff suggestions for improving patient safety.	22 (19.1)	32 (27.8)	61 (53.0)
My supervisor, manager, or clinical leader wants us to work faster during busy times, even if it means taking shortcuts.*	51 (44.3)	31 (27.0)	33 (28.7)
My supervisor, manager, or clinical leader takes action to address patient safety concerns that are brought to their attention.	19 (17)	33 (29.5)	60 (53.6)
6. Communication About Error			58.7%
We are informed about errors that happen in this unit	15 (13)	34 (29.6)	66 (57.4)
When errors happen in this unit, we discuss ways to prevent them from happening again	17 (14.8)	28 (24.3)	70 (60.9)
In this unit, we are informed about changes that are made based on event reports.	20 (17.5)	28 (24.6)	66 (57.9)
7. Communication Openness			41.5%
In this unit, staff speak up if they see something that may negatively affect patient care	19 (17)	36 (32.1)	57 (50.9)
When staff in this unit see someone with more authority doing something unsafe for patients, they speak up.	16 (14)	42 (36.8)	56 (49.1)
When staff in this unit speak up, those with more authority are open to their patient safety concerns.	20 (17.4)	41 (35.7)	54 (47.0)
In this unit, staff are afraid to ask questions when something does not seem right.*	43 (37.4)	50 (43.5)	22 (19.1)
8. Reporting Patient Safety Events			47.2%
When a mistake is caught and corrected before reaching the patient, how often is this reported?	23 (20)	43 (37.4)	49 (42.6)
When a mistake reaches the patient and could have harmed the patient, but did not, how often is this reported?	15 (13.2)	40 (35.1)	59 (51.8)
9. Hospital Management Support for Patient Safety			47.7%
The actions of hospital management show that patient safety is a top priority.	19 (16.7)	22 (19.3)	73 (64.0)
Hospital management provides adequate resources to improve patient safety.	22 (19.1)	30 (26.1)	63 (54.8)
Hospital management seems interested in patient safety only after an adverse event happens.*	57 (49.6)	30 (26.1)	28 (24.3)
10. Handoffs and Information Exchange			36.3%
When transferring patients from one unit to another, important information is often left out.*	51 (44.3)	34 (29.6)	30 (26.1)
During shift changes, important patient care information is often left out.*	50 (43.9)	31 (27.2)	33 (28.9)
During shift changes, there is adequate time to exchange all key patient care information.	22 (19.5)	30 (26.5)	61 (54.0)
Number of safety events reported in a year	Frequency	%
1–2	39	33.3
3–5	18	15.4
6–10	7	6.0
> 11	8	6.8
Patient Safety Rating	Frequency	%
1	11	9.4
2	31	26.5
4	49	41.9
5	24	20.5

*Revered items

Note: Strength ≥ 75%; Requires improvement > 50%

The mean scores with SDs and ranges for the resilience and turnover intention scales are displayed in Table 3. The average total score for resilience was moderate (mean = 64.23, SD = 22.25). The average scores for the resilience subscales were moderate as well, with the highest scores for personal competence, high standards, and tenacity (mean = 20.9, SD = 7.7) and the lowest score for spiritual influences (mean = 5.32, SD = 2). The mean score for turnover intention was also moderate (mean = 2.79, SD = 1.27).

Table 3.

Resilience and turnover intention score

Variables	M	SD	Range
Resilience	64.23	22.25	0–100
Positive acceptance of change and secure relationship	12.70	4.23	0–20
Adapt when changes occur	2.57	0.97	0–4
Close and secure relationship	2.40	1.01	0–4
Can deal with whatever comes	2.57	1.01	0–4
Past successes give me confidence in dealing with new challenges	2.77	1.06	0–4
Tend to bounce back after illness or hardships	2.47	1.03	0–4
Trust in one’s instincts, tolerance of negative affect, and strengthening effects of stress	17.52	6.56	0–28
See the humorous side of things	2.55	1.03	0–4
Coping with stress strengthen	2.63	1.05	0–4
Under pressure, focused and think clearly	2.57	1.06	0–4
Prefer to take lead in problem solving	2.49	1.16	0–4
Make unpopular or difficult decisions	2.49	1.02	0–4
Can handle unpleasant feelings	2.50	1.09	0–4
Have to act on a hunch	2.36	1.04	0–4
Personal competence, high standers and tenacity	20.90	7.70	0–32
Best effort no matter what	2.72	1.05	0–4
Can achieve my goals	2.70	1.05	0–4
Things look hopeless, I don’t give up	2.76	1.03	0–4
Not easily discouraged by failure	2.60	1.04	0–4
Think of myself as a strong person	2.68	1.07	0–4
I like challenges	2.52	1.09	0–4
I work to attain my goals	2.53	1.04	0–4
Pride in my achievements	2.64	1.08	0–4
Control	7.77	2.91	0–12
Know where to turn for help	2.53	1.08	0–4
Have a strong sense of purpose	2.70	1.09	0–4
In control of my life	2.59	1.00	0–4
Spiritual influences	5.32	2.00	0–8
Things happen for a reason]	2.60	1.07	0–4
Sometimes fate or God can help	2.74	1.12	0–4
Turnover intention	2.79	1.27	1–5
I often seriously consider leaving my current job.	2.79	1.27	1–5
I intend to quit my current job.	2.72	1.32	1–5
I have started to look for other jobs.	2.72	1.29	1–5

An independent samples t test (Table 4) was used to assess the mean differences in PSCs according to the participants’ demographic factors. There were no significant differences between male and female participants regarding their perceptions of PSCs (p > .05). However, the undergraduate participants reported significantly higher mean scores for PSCs (mean = 3.24, SD = ± 0.361, p < .001) than did the participants with higher educational levels. Furthermore, expatriate nurses reported greater perceptions of PSCs (mean = 3.39, SD = ± 0.423, p < .001) than local nurses did. In addition, those who had attended training courses regarding patient safety within the last 12 months had greater mean scores for PSC (mean = 3.19, SD = ± 0.409, p = .016) than their counterparts did.

Table 4.

Mean differences in patient safety culture according to demographic factors

Demographic Factors	Categories	N	Patient Safety Culture			95% CI
			M (SD)	p	t	LLCI	ULCI
Gender	Male Female	37 78	3.12 (0.328) 3.15 (0.414)	0.333	0.433	− 0.187	0.120
Level of Education	Undergraduate Graduate	66 49	3.24 (0.361) 3.00 (0.384)	< 0.001	3.41	0.099	0.377
Nationality	Local Expatriate	86 29	3.06 (0.338) 3.39 (0.423)	< 0.001	4.29	− 0.486	− 0.179
Attending Patient Safety Training	Yes No	84 31	3.19 (0.409) 3.02 (0.292)	0.016	2.16	− 0.332	− 0.0144

M: mean; SD: standard deviation; LLCI: lower limit confidence interval; ULCI: upper limit confidence interval

Table 5 presents the correlations between the scores for PSCs, turnover intention, and resilience. There was a weak negative correlation between PSCs and turnover intention (r = − .253, p < .01). PSC was positively and moderately correlated with resilience (r = .352, p < .001); positive acceptance of change and secure relationships (r = .318, p < .001); personal competence, high standards, and tenacity (r = .373, p < .001); and control (r = .390, p < .001). However, PSC was weakly correlated with trust in one’s instincts, tolerance of negative affect, and strengthening effects of stress (r = .292, p < .01) and spiritual influences (r = .289, p < .01). Years of experience was positively correlated with PSCs, resilience, positive acceptance of change, and control but negatively correlated with turnover intention.

Table 5.

Correlations between patient safety Culture, turnover Intention, resilience and their dimensions

Variables	1	2	3	4	5	6	7	8	9
1. HSOPS	1
2. Turnover Intention	− 0.253**	1
3. Resilience	0.352***	0.114	1
4. Positive acceptance of change and secure relationship	0.318***	0.161	0.927***	1
5. Trust in one’s instincts, tolerance of negative affect, and strengthening effects of stress	0.292**	0.132	0.975***	0.887***	1
6. Personal competence, high standers and tenacity	0.373***	0.061	0.974***	0.854***	0.929***	1
7. Control	0.390***	0.104	0.945***	0.829***	0.912***	0.922***	1
8. Spiritual influences	0.289**	0.116	0.877***	0.835***	0.815***	0.830***	0.790***	1
9. Years of Experience	0.209*	− 0.189*	0.193*	0.228*	0.169	0.173	0.197*	0.073	1

Note: *p < .05; **p < .01, ***p < .001

Two simple linear regression models were constructed to determine whether PSCs have the potential to predict resilience and turnover intention while controlling for demographic characteristics (Table 6). The first model yielded significant results (F [1, 113] = 16.01, p < .001, R² = 0.124), indicating that PSC (β = 0.800, p < .001) statistically significantly predicted resilience. Those who perceived higher PSC were more likely to have greater resilience. The second model also yielded significant results (F [1, 113] = 7.736, p < .01, R² = 0.064), indicating that PSC (β = − 0.883. p = .006) statistically significantly predicted turnover intention. Individuals who perceived higher PSC were less likely to leave the hospital.

Table 6.

Influence of patient safety culture on resilience and turnover intention

Outcomes	Patient Safety Culture
	Ba	β b	t	P	95% CI
					Lower	Upper
Resilience	0.800	0.352	4.00	< 0.001	0.404	1.196
Model Summary	F(1, 113) = 16.01, R2 = 0.124, p < .001
Turnover Intention	− 0.883	− 0.253	2.78	0.006	-1.426	− 0.240
Model Summary	F(1, 113) = 7.736, R2 = 0.064, p < .01

Note: Simple linear regression models were used. Predictor: Patient Safety Culture. Outcome variables: resilience and turnover intention; R²: adjusted R-squared value

Discussion

The overall level of good PSC was 44.6%, which was lower than the recommended 75% standard set by the AHRQ (2021) [2]. In a recent study in SA, researchers reported 55.21% and 60% positive responses, respectively [21]. However, there was considerable variation across dimensions, which requires further investigation.

The communication about error dimension recorded the highest positive response rate at 58.7%, indicating a moderate level of perceived openness in addressing errors. While it ranked highest among the dimensions evaluated, it fell short of the threshold typically regarded as a strong score in PSC assessments [2]. Studies have highlighted the variability in performance for this dimension across healthcare contexts. For example, previous researchers [22] emphasized that communication about errors is often perceived more positively in hospitals that foster continuous learning environments and actively engage staff in feedback processes. They observed that proactive interventions, such as training programs for nonpunitive communication, can lead to sustained improvements in this dimension, with positivity rates exceeding 60% in their mixed-methods analysis of Saudi hospitals. Similarly, previous researchers [23], in their study of public hospitals in Vietnam, reported that structured feedback mechanisms and leadership engagement were critical to achieving higher ratings for communication about errors.

The second highest scoring dimension was teamwork, with a positive response rate of 56.5%. While this ranks higher than the other dimensions in this study do, the findings highlight the need to address specific interpersonal challenges, particularly in fostering respect among team members. Effective teamwork is universally recognized as a cornerstone of PSC [22, 23]. Globally, studies underscore the critical role of teamwork in enhancing communication, coordination, and error prevention. For example, surveys on the PSC database consistently identify teamwork as one of the most positively rated dimensions in high-performing organizations, often exceeding 70% positivity in hospitals with strong safety cultures [2].

Staffing challenges emerged as a critical area for improvement, with only 29.6% positive responses regarding adequate staffing to handle workloads. This mirrors findings from studies by [24, 25], where staffing and workload scored among the lowest at 24% and 21.1%, respectively. Insufficient nursing staff has been identified as a significant concern that negatively impacts patient safety, with long working hours further exacerbating challenges in maintaining a safe care environment [21, 25]. The dimension of response to error revealed notable weaknesses, with 34% positive responses indicating that staff perceive mistakes as being held against them, which is consistent with previous studies [24, 25] where hierarchical structures and fear of reprisal have been identified as barriers to open communication.

The findings revealed differences regarding PSC in terms of education, nationality, and training. Nurses with a diploma or bachelor’s degree had higher levels of perception of PSC than those with higher educational levels. This may be because nurses who hold a diploma or bachelor’s degree are typically bedside nurses and have direct daily contact with patients, whereas those with higher degrees often hold administrative positions. This result is supported by a study conducted in Saudi Arabia showing that a lower perception of PSC was more noticeable among employees with higher education [26]. In contrast, nurses in Ethiopia [27] and South Korea [28] who held a diploma had a lower perception of PSC than did those who held a bachelor’s degree in science in nursing. These variations may be attributed to the fact that other studies have compared diploma holders and BSN holders, unlike our study. These differences may also be attributed to the variations in educational backgrounds that exist among countries.

The perception of PSC was greater among expatriate nurses, perhaps because they are required to fulfill annual duties, such as completing courses in some domains, to renew their employment contracts at healthcare facilities. However, other researchers reported no difference in the perception of PSC level on the basis of participants’ nationality [29]. Furthermore, we found a positive impact of attending training courses and ongoing education on PSCs. This finding is reinforced by many studies showing that healthcare professionals who have enrolled in training courses have a good perception of PSC [27, 30, 31]. In a qualitative study, poor PSC was attributed to a lack of sufficient training programs and ongoing education for staff [32]. Therefore, the presence of continuous training courses for staff may improve the level of PSC, thus reducing errors and harm to patients [33].

The participants demonstrated moderate resilience, indicating that they had some ability to bounce back from negative emotional and stressful experiences. The participants may have relied more on personal competencies and tenacity to enhance resilience in the workplace because they are directly reinforced through clinical practice, while they may have relied less on spirituality. These results reflect those of Lie et al. (2020), who reported that nurses rely on personal competence and professional experiences through good psychological quality, which contributes to solving problems and increasing resilience in the work environment.

In this study, nurses showed moderate turnover intention levels, which indicated that nurses experienced some level of disengagement but not to the point that they were forced to leave their jobs. Previous researchers also pointed out that nurses in SA agreed with the intention to leave their jobs [34]. Another study performed in Jourdan reported that nurses from public hospitals reported the highest scores for intent to stay [35]. On the other hand, some studies have shown high levels of nurses’ desire to leave their jobs. Nurses in a study performed in China reported a high level of turnover intention in 15 hospitals [36]. In addition, a network meta-analysis of 18 cross-sectional studies from 23 countries revealed that more than 27% of intensive care unit nurses worldwide had intentions to leave their jobs [37].

The current results show that PSC is positively and moderately correlated with overall resilience, particularly with subdimensions such as positive acceptance of change, secure relationships, personal competence, high standards, tenacity, and control. This finding is consistent with a study conducted in Saudi Arabia, which suggested that greater resilience in nurses was associated with more positive perceptions of PSCs [6]. In contrast, in the current study, PSC was correlated with trust in one’s instincts, tolerance of negative affect and the strengthening effects of stress and with spiritual influences. These findings may indicate that PSCs are clearly associated with individual and behavioral competencies and control rather than with emotional aspects, which may include spirituality and the ability to tolerate stress in the work environment. These results reflect previous findings suggesting that PSCs may be influenced more by behavioral and personal competencies than by spiritual or purely emotional dimensions [38]. Accordingly, previous researchers have indicated the association between patient safety and resilience in the clinical environment [39, 40].

Therefore, giving importance to resilience as a factor that impacts patient safety requires the adoption and implementation of resilience-related programs [41].

Highlighting the correlations between patient safety culture and turnover intention among nurses is important for understanding the impact of patient safety culture on nurses’ professional choices. The present study revealed a moderate negative correlation between patient safety culture and turnover intention. A well-implemented patient safety culture in hospitals may reduce nurses’ intention to leave work. This finding is consistent with the results of many studies that have shown the same correlation between patient safety culture and the intention to leave [17, 34, 42, 43]. This study concludes that strengthening the elements of patient safety culture within hospitals is a significant factor in enhancing nurse retention, along with many other contributing factors.

Additionally, years of experience was positively correlated with PSCs and resilience but negatively associated with turnover intention. A previous study reported that long years of experience supported nurses in developing resilience and that mental strength made them resistant to stress [44]. Research has shown that the intention to leave is associated with years of experience, with less experienced nurses being more likely to plan to leave the profession [45].

Another aspect discussed was the ability of perceptions of PSCs to predict resilience and turnover intentions among nurses while controlling for demographic variables. The first model assessed resilience as the dependent variable, which indicates that 12.4% of the variance in resilience is explained by PSCs. This finding suggests that PSCs make considerable contributions to enhancing the level of resilience among nurses regardless of other personal or institutional factors. These results align with findings that link patient safety culture to increased resilience among nurses [6]. Conversely, some evidence suggests that high resilience among nurses may contribute to the development of a safe climate [46].

On the other hand, PSC explains approximately 6.4% of the variance in turnover intention. This study proposed that nurses’ intention to leave their job may decrease to an acceptable level if they find that there is an environment that supports PSC in healthcare organizations. Many studies have investigated the influence of patient safety culture on turnover intention rates among nurses in different settings and countries [17, 47, 48]. Accordingly, PSC is considered a factor contributing to nurses’ retention in their jobs, as it fosters a safe climate for continued work and positive professional development, thus protecting the organization from shortages.

Study limitations

This national-level study is among the few to examine the relationships among PSCs, turnover intention, and resilience. However, several limitations should be acknowledged. The cross-sectional design and data collected at a single time point limit causal inference and may not reflect long-term perceptions. Convenience sampling and reliance on self-reported data may affect generalizability and introduce social desirability bias. Additionally, the sample was predominantly composed of Saudi women, reflecting the gendered nature of the nursing workforce in Saudi Arabia; a more diverse sample would have strengthened the findings.

Another limitation was related to including only those who were proficient in English. Although the survey was conducted in English, it is unlikely that this created barriers to participation, as nurses in Saudi Arabia are educated in English, and English is the common language among both local and expatriate nurses. Nevertheless, it cannot be fully assumed that all nurses working in Saudi Arabia possess the same level of English proficiency. Accordingly, future researchers are encouraged to address this limitation by translating the questionnaire to accommodate a broader range of nurses and to enhance the overall representativeness of the sample.

Implications and recommendations for further research

These findings underscore PSCs’ vital role in workforce stability and overall healthcare quality. Strengthening PSCs through adequate staffing, effective incident management, open communication, and a nonpunitive culture can enhance both nurses’ well-being and patients’ well-being. Building nurses’ resilience via mindfulness, stress management, and peer support programs may further reduce turnover intention. Policymakers and administrators should integrate PSC-focused training and recognition systems into organizational practices. Future research should evaluate intervention effectiveness, explore additional personal and institutional factors influencing resilience, and examine the role of emotional and spiritual well-being in shaping perceptions of patient safety.

Conclusion

On the basis of the structuration theory of safety culture, this study explored various aspects of patient safety culture. Furthermore, this study demonstrated how patient safety culture is related to resilience and turnover intentions among nurses. The most prominent aspect of perceptions for nurses regarding PSC appears in the area of communication and teamwork, whereas the less common perceptions are systemic issues in staffing, error response, and handoffs. The moderate overall PSC score (44.6%) reflects a healthcare environment where safety structures exist; however, there is a need for improvement, which includes some individual actions and organizational structures. Moreover, PSCs are positively associated with resilience and negatively associated with turnover intention. Thus, patient safety culture in a health organization may be shaped by individuals’ capabilities. The structuration theory of safety culture supports the idea that a healthy structure is built through the interaction between institutional norms and individual interactions. Therefore, there is a need to examine the interaction of individuals, in addition to the institutional aspect, because both parties contribute to developing a patient safety culture. There are differences in perceptions of PSC by educational level, nationality, and training history, which may indicate unequal access to patient safety culture structurers. This calls for the need to highlight implicit and unclear organizational differences.

Author contributions

All the authors contributed to this study on the basis of the criteria of the International Committee of Medical Journal Editors. All the authors have approved the manuscript and agreed to submit it to the journal. Conceptualization, methodology & data collection (AI., ZA., EH), acquisition (AI, ZA), analysis (AI, WS), writing-original draft preparation, review and editing (AI., ZA., WS, KA, EH), The final manuscript was read, reviewed, and approved by all authors (A AI., ZA., WS, KA, EH).

Funding

This study was funded by the Ongoing Research Funding Program (ORF-2025-837), King Saud University, Riyadh, Saudi Arabia.

Data availability

Data available on request from the corresponding author [AI].

Declarations

Ethical statement

This study was approved by the Ethics Committee of King Saud University, with ethics approval [KSU-HE-23-839]. Informed consent was obtained from all participants prior to data collection. This study adhered to the principles of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.