Abstract
Background
Patient safety culture is a critical component of healthcare quality, influencing both staff behaviour and patient outcomes. While it has been widely studied in hospital settings, less is known about its variation across integrated health and social care systems.
Objective
To examine patient and client safety culture within a well-being services county in Finland from the perspective of employees.
Methods
A cross-sectional survey was conducted using the Finnish version of the Hospital Survey on Patient Safety Culture (SOPS 2.0) and the Net Safety Score (NSS). The sample included 2623 staff members from hospital, social and health and elderly services. Descriptive statistics, analysis of variance, Pearson correlations and linear regressions were used to analyse differences and associations.
Results
Among the SOPS dimensions, teamwork received the highest positive ratings (71.1%), whereas handoffs and information exchange scored the lowest (22.6%). Significant differences were observed across service areas, with elderly services consistently reporting lower scores. All safety culture dimensions were significantly correlated with the NSS. Regression analysis identified teamwork, staffing and work pace and organisational learning as the strongest significant predictors of the NSS in all the service areas. The overall proportion of positive responses for NSS was 52.6%. The model explained 47.4% of the variance in NSS in hospital services, 47.0% in elderly services and 35.8% in social and health services.
Conclusions
Patient and client safety culture varies significantly across service areas, with elderly services requiring targeted support. The NSS is a valid and practical tool for capturing staff perceptions of safety and can complement broader safety culture assessments. Its simplicity enables frequent monitoring and timely interventions, supporting continuous improvement in healthcare safety.
Keywords: Healthcare quality improvement, Health services research, Patient safety
WHAT IS ALREADY KNOWN ON THIS TOPIC
Patient and client safety culture is a foundational element of healthcare quality and is associated with improved outcomes and reduced adverse events.
WHAT THIS STUDY ADDS
This study identifies significant differences in patient and client safety culture perceptions across hospital, social and health and elderly services within a Finnish well-being services county.
It also demonstrates strong associations between the Net Safety Score and key patient and client safety culture dimensions, particularly teamwork, staffing and organisational learning.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The findings support the use of NSS as a practical, scalable tool for monitoring staff perceptions of patient and client safety, enabling more frequent assessments and timely interventions.
Patient and client safety culture varies significantly across service areas with elderly services showing a particular need for support, highlighting the importance of service-specific strategies in safety culture development.
Introduction
Safety culture was first defined in 1986, following the Chernobyl accident, as a set of characteristics and attitudes in organisations and individuals that ensures safety issues receive the attention warranted by their significance.1 Since then, the concept of safety culture has been adopted in other high-risk industries, including aviation and healthcare. In healthcare, patient safety culture2 has become an international key priority3–5 and refers to organised activities that create conditions for consistently reducing avoidable harm to patients.6 It encompasses the values, beliefs and norms shared by healthcare staff4 and covers dimensions such as leadership, teamwork and collaboration, safety systems, prioritisation of safety, resources and constraints, reporting and just culture, openness, learning and improvement, awareness of human limits and well-being.7
In recent years, reforms of integrated health and social care services have called to expand the concept of patient safety culture to cover also clients.8–10 This concept has traditionally focused on ensuring safe practices within healthcare settings for patients receiving medical care. However, recent reforms in integrated health and social care services in Finland have highlighted the need for a broader perspective. As health and social care systems increasingly operate in a unified manner, the safety of clients, that is, individuals receiving social care services, has become equally important. This broader approach acknowledges that risks to safety are not confined to clinical environments but also arise in social care contexts such as elderly care, ensuring that safety principles are applied consistently whether care is medical, social or a combination of both. Previous studies on safety culture have mainly focused on the tertiary healthcare sector such as acute11 and perioperative care,12 but knowledge on client safety culture in an integrated organisation is missing.9 Beyond hospitals, assessments of patient safety culture have also been conducted in outpatient healthcare settings and13 primary healthcare centres,14 and professionals in the tertiary care settings have demonstrated higher patient safety culture scores than primary and secondary care settings.15
Patient and client safety culture approach aims to cover the entire service chain8 but simultaneously challenges how to integrate and measure safety culture in historically distinct care and service practices and working cultures. Besides available patient safety culture instruments, there has been a need to develop a simple and pragmatic index to explore safety culture. The Net Safety Score (NSS)16 is a metric developed based on the widely used Net Promoter Score (NPS) for measuring customer satisfaction.17 This study addresses a context in which specialised hospital care, outpatient primary care, social services and elderly care are integrated within a regional organisation responsible for the health and social care and well-being of the population. This integration provides an opportunity to examine patient safety culture across services, offering insights into how safety culture manifests in a unified, cross-sectoral system.
Aims
The aim of this study was to assess patient and client safety culture within a well-being services county in Finland from the perspective of employees with the following research questions:
How does patient and client safety culture differ across health and social care service areas?
How are the dimensions of patient and client safety culture associated with perceived safety in the organisation measured with NSS across health and social care service areas?
Methods
Setting
In Finland, patient and client safety is managed at the regional level by well-being services counties, which are responsible for coordinating health and social care services under a unified governance structure. At the start of 2023, a significant health and social care reform was implemented, consolidating 195 public social services and healthcare organisations into 22 well-being services counties. This reform was driven by the need to ensure equal access to services, reduce disparities in health and well-being and control the rising costs of care. Well-being services counties are tasked with organising healthcare and social welfare services; providing rescue services; overseeing the provision, guidance and supervision of these services; and driving their ongoing development.
The study was conducted in one of Finland’s largest well-being services counties, which employs personnel across hundreds of professional titles. The most common professions include registered nurses (approximately 4500), licensed practical nurses (around 3300), physicians (nearly 600) and public health nurses (about 600). In Finland, these professional titles are regulated under national legislation. Registered and public health nurses are licensed health professionals who hold a bachelor’s degree from a university of applied sciences. Licensed practical nurses hold a vocational qualification in social and healthcare (180 competence points) and use a protected occupational title. Other staff roles represented include physicians, social workers, psychologists, fire inspectors, laboratory technicians, information and communications technology professionals, instrument technicians and ward secretaries. The well-being services county provides a wide range of services, which are categorised into hospital services, social and healthcare services, services for the elderly and rescue services. However, rescue services were excluded from the scope of this study (online supplemental table 1).
Participants and data collection
A total sampling frame was applied. An electronic survey link was emailed to all employees of the well-being services county (n=23 492) between May and June 2024. The invitation covered personnel working in hospital services (n=8924), social and healthcare services (n=6498), elderly services (n=5377) and other services including management, corporate, organising and rescue services (n=2060). Among the invited employees, one-quarter were aged 35–44 years, 23% were 25–34 years, and 22% were either 45–54 or 55–64 years. Approximately 5% were <24 years old, and about 2% were >65. The mean age of the entire workforce in all service areas was 43.6 years, and 80.6% held permanent employment contracts. A total of 2786 employees responded to the survey (Figure 1). After excluding responses from management, corporate, organising, and rescue services, as well as cases with >50% missing data (n=15), the final sample consisted of 2623 respondents.
Figure 1. Flow chart of study participation. The group Other included management, corporate services, organising services and rescue services.
Instruments
Employees’ perceptions of patient and client safety culture was assessed using the Finnish version of the Hospital Survey on Patient Safety Culture (SOPS 2.0), originally developed by the Agency for Healthcare Research and Quality6 and translated by Turunen & Azimirad.18 SOPS 2.0 includes 10 dimensions: teamwork (three items), staffing and work pace (four items), organisational learning—continuous improvement (three items), response to error (four items), supervisor, manager or clinical leader support for patient safety (three items), communication about error (three items), communication openness (four items), reporting patient safety events (two items), hospital management support for patient safety (three items) and handoffs and information exchange (three items). Response options ranged from 1 (strongly disagree or never) to 5 (strongly agree or always), with an additional option: ‘does not apply/don’t know’. Item-level percent positive scores were calculated by summing the percentages of ‘strongly agree’ and ‘agree’ responses for positively worded items. For negatively worded items, the percentages of ‘strongly disagree’ and ‘disagree’ responses were summed.
While SOPS measures patient and client safety culture at the work community and organisational levels, the NSS reflects an employee’s individual perception of patient and client safety. The NSS is originally developed in Finland by the Finnish Centre for Client and Patient Safety16 and modelled after the NPS, a widely used indicator across industries for measuring customer satisfaction.17 The item used to measure the NSS was: “I would feel safe if I were a patient or client in my unit”, with response options ranging from 1 (completely disagree) to 5 (completely agree). The safety index was calculated by subtracting the percentage of respondents who selected 1 or 2 (completely or somewhat disagree) from the percentage who selected 4 or 5 (completely or somewhat agree). Neutral responses (3=neither agree nor disagree) were excluded from the calculation.
Data analysis
Statistical analyses included descriptive and multivariate analyses. The data comprised 0.2%–1.5% missing values per SOPS item. Two items within the handoffs and information exchange dimension had >30% ‘does not apply’ responses and were therefore excluded from the analyses. All other ‘does not apply’ or ‘don’t know’ responses were recoded as missing. Participants’ background characteristics were reported as frequencies, whereas SOPS dimensions were summarised using means and SD. Internal reliabilities for the SOPS dimensions were assessed using Cronbach’s alpha coefficients, with values >0.70 considered acceptable. Correlations between the SOPS dimensions for the total sample were calculated using Pearson’s correlation coefficients. Differences in the overall SOPS mean between services were analysed using analysis of variance. The assumptions for regression analysis were met, as the variance inflation factors were within acceptable limits (<5). Linear regressions for all the service areas were conducted separately with the NSS as the dependent variable and the SOPS dimensions as independent variables. The model was adjusted for work experience in the organisation and unit, as well as hours worked. Model variance was assessed using adjusted R². Statistical significance was set at p<0.05. All analyses were conducted using SPSS V.29.0.
Results
Of the participants (n=2623), 39% worked in hospital services (n=1023), 38% in social and health services (n=1009) and 23% in elderly services (n=591) (table 1). The largest professional group consisted of licensed healthcare professionals, such as registered nurses (n=1141).
Table 1. Background characteristics of the participants (n=2623) by service areas.
| Total sample n=2623 |
Hospital services n=1023 |
Social and health services n=1009 |
Elderly services n=591 |
|
|---|---|---|---|---|
| n (%) | n (%) | n (%) | n (%) | |
| Profession | ||||
| Licensed healthcare professionals, eg, RNs | 1141 (43.5) | 675 (66.0) | 343 (34.1) | 123 (20.9) |
| Title-protected professionals, eg, LPNs | 649 (24.7) | 91 (8.9) | 198 (19.6) | 360 (60.9) |
| Licensed social care professionals | 210 (8.0) | 5 (0.5) | 181 (17.9) | 24 (4.1) |
| Workers with higher university degrees, eg, psychologists | 170 (6.5) | 53 (5.2) | 114 (11.3) | 3 (0.5) |
| Physicians | 140 (5.3) | 81 (7.9) | 59 (5.8) | 0 (0.0) |
| Care assistants | 63 (2.4) | 5 (0.5) | 26 (2.6) | 32 (5.4) |
| Other* | 241 (9.2) | 112 (10.9) | 84 (8.3) | 47 (7.9) |
| Missing | 9 (0.3) | 1 (0.1) | 4 (0.4) | 2 (0.3) |
| Work experience in organisation, years | ||||
| <1 | 160 (6.1) | 39 (3.8) | 85 (8.4) | 36 (6.1) |
| 1‒5 | 769 (29.3) | 264 (25.8) | 328 (32.5) | 177 (29.9) |
| 6‒10 | 500 (19.1) | 200 (19.6) | 185 (18.4) | 115 (19.5) |
| >10 | 1185 (45.2) | 518 (50.6) | 410 (40.6) | 257 (43.5) |
| Missing | 9 (0.3) | 2 (0.2) | 1 (0.1) | 6 (1.0) |
| Work experience in current unit, years | ||||
| <1 | 428 (16.3) | 129 (12.6) | 194 (19.2) | 105 (17.8) |
| 1‒5 | 1082 (41.3) | 368 (36.0) | 441 (43.7) | 273 (46.2) |
| 6‒10 | 438 (16.7) | 201 (19.6) | 156 (15.5) | 81 (13.7) |
| >10 | 658 (25.1) | 319 (31.2) | 214 (21.2) | 125 (21.1) |
| Missing | 17 (0.6) | 6 (0.6) | 4 (0.4) | 7 (1.2) |
For example, administrative staff and maintenance services
LPN, Licenced Practical Nurse; RN, Registered Nurse.
Overall patient and client safety culture in the well-being services county
Teamwork received the highest proportion of positive responses (71.1%), whereas handoffs and information exchange had the lowest (22.6%). The overall positive response rate across the total scale was 48%. Mean scores on a 1–5 scale followed a similar trend, with teamwork receiving the highest average rating (M=3.85, SD=0.82), followed by supervisor, manager or clinical leader support (M=3.72, SD=0.88). The lowest mean was observed in handoffs and information exchange (M=2.73, SD=1.10). The overall SOPS score had a mean of 3.42 (SD=0.64).
Cronbach’s alpha values for the patient and client safety culture dimensions ranged from 0.67 to 0.89. The total SOPS scale demonstrated excellent internal consistency (α=0.93) (table 2).
Table 2. Patient and client safety culture dimensions (SOPS) and NSS compared between the service areas.
| Total sample | Hospital services | Social and health services | Elderly services | ||||
|---|---|---|---|---|---|---|---|
| α | Positive responses % | Mean* (SD) | Mean* (SD) | Mean* (SD) | Mean* (SD) | P | |
| Teamwork | 0.67 | 71.1 | 3.85 (0.82) | 3.88 (0.77) | 3.91 (0.83) | 3.68 (0.86) | <0.001 |
| Staffing and work pace | 0.69 | 47.5 | 3.28 (0.87) | 3.29 (0.85) | 3.48 (0.81) | 2.94 (0.90) | <0.001 |
| Organisational learning—continuous improvement | 0.68 | 40.6 | 3.16 (0.89) | 3.18 (0.90) | 3.19 (0.89) | 3.06 (0.89) | 0.019 |
| Response to error | 0.81 | 43.5 | 3.54 (0.88) | 3.57 (0.88) | 3.62 (0.84) | 3.36 (0.91) | <0.001 |
| Supervisor, manager or clinical leader support | 0.79 | 63.6 | 3.72 (0.88) | 3.76 (0.91) | 3.76 (0.89) | 3.56 (0.93) | <0.001 |
| Communication about error | 0.89 | 49.0 | 3.53 (0.88) | 3.64 (1.00) | 3.40 (1.11) | 3.52 (1.02) | <0.001 |
| Communication openness | 0.76 | 53.5 | 3.62 (0.79) | 3.59 (0.73) | 3.65 (0.81) | 3.60 (0.76) | 0.250 |
| Reporting patient safety events | 0.87 | 49.8 | 3.69 (1.02) | 3.62 (0.97) | 3.64 (1.10) | 3.81 (0.99) | 0.005 |
| Hospital management support | 0.72 | 41.3 | 2.92 (0.88) | 2.87 (0.89) | 3.00 (0.87) | 2.87 (0.99) | 0.006 |
| Handoffs and information exchange† | 22.6 | 2.73 (1.10) | 3.00 (1.06) | 2.63 (1.09) | 2.44 (1.07) | <0.001 | |
| SOPS total score | 0.93 | 48.3 | 3.42 (0.64) | 3.46 (0.64) | 3.45 (0.65) | 3.30 (0.64) | <0.001 |
| NSS | 3.78 (1.07) | 3.88 (1.02) | 3.92 (1.02) | 3.36 (1.12) | <0.001 | ||
Scale 1‒5.
Includes only one item.
NSS, Net Safety Score; SOPS, Survey on Patient Safety Culture .
Comparisons of patient and client safety culture across health and social care service areas and professions
Comparisons of patient and client safety culture dimensions across different service areas, hospital services, social and health services and elderly services revealed several statistically significant differences (table 2). Teamwork scores were significantly higher in hospital services (M=3.88, SD=0.77) and social and health services (M=3.91, SD=0.83) compared with elderly services (M=3.68, SD=0.86; p<0.001). Similarly, staffing and work pace was rated highest in social and health services (M=3.48, SD=0.81), followed by hospital services (M=3.29, SD=0.85), and lowest in elderly services (M=2.94, SD=0.90; p<0.001). Significant differences were also observed in organisational learning—continuous improvement (p=0.019), response to error (p<0.001), supervisor, manager or clinical leader support (p<0.001) and handoffs and information exchange (p<0.001), with elderly services consistently reporting lower scores. Communication about error differed significantly across service areas (p<0.001), whereas communication openness did not (p=0.250). Interestingly, reporting patient safety events was rated highest in elderly services (M=3.81, SD=0.99, p=0.005). Hospital management support also showed significant variation across service areas (p=0.006). NSS also differed significantly across service areas. Social and health services had the highest score (M=3.92, SD=1.02), whereas elderly services had the lowest (M=3.36, SD=1.12) (table 2).
Significant positive correlations were identified among all patient and client safety culture dimensions (online supplemental table 2). Teamwork was significantly correlated with all other dimensions, with the strongest associations observed with response to error (r=0.574, p<0.01) and communication openness (r=0.556, p<0.01). Organisational learning showed strong correlations with supervisor, manager or clinical leader support (r=0.619, p<0.01) and communication about error (r=0.595, p<0.01). Response to error was also strongly associated with communication openness (r=0.597, p<0.01) and supervisor support (r=0.607, p<0.01). Communication about error and communication openness were highly correlated (r=0.624, p<0.01), as were reporting patient safety events and communication about error (r=0.547, p<0.01). Although handoffs and information exchange showed weaker correlations with other dimensions, all associations were statistically significant (eg, r=0.258 with hospital management support, p<0.01).
All patient and client safety culture dimensions were significantly correlated with the NSS, which had 0.7% missing values and 3.6% (n=70) ‘does not apply’ or ‘don’t know’ responses. The overall proportion of positive responses for NSS was 52.
The regression models explained a substantial proportion of the variance in the NSS in all the service areas. The model explained 47.4% in hospital services, 47.0% in elderly services and 35.8% in social and health services. As shown in table 3, teamwork, staffing and work pace and organisational learning emerged as the strongest positive predictors of NSS across all the service areas. Additionally, response to error and hospital management support had significant associations with NSS in hospital services, and reporting patient safety events and hospital management support had significant associations with NSS in elderly services.
Table 3. Associations between the Net Safety Score (NSS) and patient and client safety culture dimensions.
| Hospital services | Social and health services | Elderly services | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Beta | SE | P | Beta | SE | P | Beta | SE | P | |
| Teamwork | 0.246 | 0.062 | <0.001 | 0.369 | 0.072 | <0.001 | 0.203 | 0.076 | <0.001 |
| Staffing and work pace | 0.271 | 0.052 | <0.001 | 0.164 | 0.062 | 0.001 | 0.133 | 0.066 | 0.011 |
| Organisational learning | 0.186 | 0.066 | 0.001 | 0.235 | 0.075 | <0.001 | 0.200 | 0.080 | 0.002 |
| Response to error | 0.108 | 0.066 | 0.049 | 0.043 | 0.079 | 0.533 | 0.053 | 0.086 | 0.457 |
| Supervisor, manager or clinical leader support | −0.042 | 0.062 | 0.430 | 0.071 | 0.072 | 0.293 | 0.005 | 0.079 | 0.939 |
| Communication about error | 0.057 | 0.066 | 0.208 | −0.079 | 0.071 | 0.269 | 0.058 | 0.074 | 0.373 |
| Communication openness | −0.064 | 0.079 | 0.423 | 0.001 | 0.090 | 0.988 | 0.078 | 0.096 | 0.233 |
| Reporting patient safety events | 0.021 | 0.051 | 0.636 | 0.010 | 0.055 | 0.857 | 0.132 | 0.058 | 0.011 |
| Hospital management support | 0.125 | 0.052 | 0.003 | 0.001 | 0.064 | 0.981 | 0.125 | 0.072 | 0.023 |
| Handoffs and information exchange | 0.019 | 0.039 | 0.623 | 0.060 | 0.044 | 0.208 | 0.064 | 0.052 | 0.187 |
| Adjusted R square | 0.474 | 0.358 | 0.470 | ||||||
Adjusted for work experience in organisation and unit, and hours worked.
Discussion
This study contributes to the existing literature by generating novel insights and highlighting notable differences in patient and client safety culture across integrated hospital, social and health and elderly services. Previous research has typically examined safety culture in isolation—either in hospitals13 or in primary care settings14—leaving a unified perspective largely unexplored. The results of this study show that elderly services consistently reported lower scores across most dimensions, including teamwork, staffing and work pace and supervisor support. These findings align with earlier research suggesting that resource constraints and staffing challenges are more pronounced in long-term care settings, which may negatively influence perceptions of patient and client safety culture.19 20 In contrast, social and health services reported the highest scores in several dimensions, which might be due to the elective nature of services (compared with, eg, emergency care) and clients with less multimorbidity.
Elderly services differ significantly from the other two service areas in terms of professional composition. Licensed practical nurses and care assistants, who typically have lower levels of formal education, represent the largest occupational group in elderly services. In contrast, the number of physicians and staff with higher education is generally lower in this sector. Educational background may partly explain the lower perceptions and competencies related to patient and client safety practices, such as teamwork. Additionally, physicians—who are more prevalent in hospital and social and health services—tend to rate patient and client safety more positively than nurses.13 19 Also, in the context of geriatric hospitals, nurses with higher education levels have demonstrated greater competence in patient safety, which is positively associated with more frequent and effective safety practices. This highlights the importance of continuing education and specialised training to enhance safety culture in elderly care settings.21 The other explication might be that nurses generally have higher frequency of direct patient contact and thereby increased exposure to adverse events, which can influence their perceptions of safety culture.22 Furthermore, staff shortages are especially severe in older people’s care, contributing to increased workloads, time pressure and a heightened risk of adverse incidents. These shortages are particularly problematic in elderly care settings due to the high dependency levels of patients.23 Increased workloads and time constraints are associated with higher rates of missed care and adverse events, which can compromise both care quality and patient and client safety.
Addressing employee safety and well-being in elderly care settings is critically important, as these factors have been shown to be positively associated with improved patient safety outcomes.24 The findings also highlight the diverse origins of services that were previously considered distinct and culturally separate. Hospital and primary care services are fundamentally structured around multiprofessional teamwork, which is essential for delivering safe and effective care. This collaborative model depends on a shared and robust foundation of safety protocols and practices to ensure consistency and reliability across disciplines. Effective communication and mutual respect among team members are vital components of a strong patient safety culture—without them, high-quality care cannot be sustained.25 Similarly, interprofessional collaborative practice not only enhances patient outcomes and reduces medical errors but also helps mitigate employee burnout,26 underscoring the necessity of its advancement in modern healthcare systems.
The study identified strong intercorrelations among the dimensions of patient and client safety culture, suggesting a cohesive and interdependent structure. These findings imply that improvements in one domain may positively influence others. For example, fostering open communication may enhance error reporting and organisational learning, ultimately contributing to a more resilient safety culture. The regression analysis further highlighted the predictive strength of specific dimensions—teamwork, staffing and work pace and organisational learning—on staff’s overall perception of patient and client safety culture, as measured by the NSS. Previous studies have similarly identified teamwork as the most positively rated dimension,15 24 27 while staffing has consistently been rated the least favourable.19 20 24 These dimensions likely reflect core elements of a psychologically safe and well-functioning work environment, which in turn shape staff perceptions of safety. The strong associations observed in this study support the validity of the SOPS framework and its utility in guiding patient and client safety improvement efforts.
Practical implications
The safety of patients and clients—as well as the overall safety culture of a healthcare organisation—is strongly influenced by staff perceptions of the safety environment.28 29 The NSS offers healthcare administrators timely insights into staff safety perceptions without the burden of lengthy surveys or complex assessments. This rapid feedback is especially valuable in fast-paced clinical environments, where immediate action may be required. NSS also helps identify areas in need of improvement, as units with low scores can be quickly flagged for targeted interventions. Given the strong correlation between staff perceptions of patient and client safety and actual safety outcomes,29 30 routine monitoring of NSS can significantly contribute to enhancing both care quality and organisational safety culture. Therefore, NSS emerges as a promising and pragmatic tool for assessing staff perceptions of safety.
Importantly, the NSS is designed as a lightweight and repeatable measure that can be readily embedded into existing organisational processes rather than implemented as a stand-alone intervention. Its single-item format enables integration into routine staff surveys or continuous monitoring systems with minimal additional burden. This simplicity supports sustainability by facilitating regular data collection, longitudinal tracking and integration into quality improvement cycles.16 From a systems perspective, the sustainability of NSS depends on its integration into organisational governance and decision-making structures. The tool is explicitly intended for use by managers and safety leaders, enabling comparison across units and over time. Embedding NSS results into dashboards, safety committees and accountability processes ensures that measurement informs action, which is an essential condition for sustaining improvement efforts in complex health systems. 31 Furthermore, digital integration (eg, incorporation into survey platforms or workflow systems) enables automated data collection and real-time feedback, enhancing scalability and responsiveness.16
However, interpreting the NSS requires careful contextualisation. While a 52.6% positive response rate may seem modest, it represents a meaningful baseline within the well-being services county, where perceptions of patient and client safety are shaped by complex systemic factors. NSS should therefore be used in combination with contextual knowledge and, where needed, complemented by more in-depth assessments. At the same time, its responsiveness and ease of use make it particularly valuable as an early warning signal, prompting timely discussion and deeper investigation when scores decline. Guidance also emphasises that results should be reviewed collaboratively with staff to support shared sensemaking and local ownership of improvements.16 Overall, NSS holds promise as both a diagnostic and developmental tool. Its sustainability derives from its simplicity, adaptability and capacity to be embedded within existing measurement, governance and digital infrastructures, supporting its use as part of a continuous, system-wide learning and improvement process rather than a one-off measurement exercise.
Strengths and limitations
A key strength of this study was its assessment of patient and client safety culture across population-level, integrated health and social care services. The SOPS instrument was chosen because it was previously translated in Finnish and currently in use in other well-being services counties as well. Although the primary instrument was originally developed for hospital settings, it proved effective in this broader context after the removal of two items from the handoffs and information exchange dimension. This adjustment was necessary because health and social services, unlike hospital and elderly services, primarily operate during daytime hours and typically do not involve formal handovers of patient or client information. The findings also suggest a cohesive structure among the safety culture dimensions and, importantly, demonstrate the potential of the NSS as a simple, one-question method for assessing safety culture. However, further research is needed to establish interpretive guidelines for NSS scores. Its value becomes more meaningful when used repeatedly over time to generate long-term surveillance data. This was the first time when the patient and client safety culture study was conducted in that particular well-being services county including health and social care. The results lay the foundation for monitoring the development of patient and client safety culture in the future.
There are, of course, some limitations. The most notable is the relatively low response rate (11.9%), which may affect the generalisability of the findings. In particular, the low response rate supports the development of shorter measures, such as NSS, as employees do not respond to long surveys. Moreover, recoding the response options ‘does not apply’ and ‘don’t know’ as missing values may undermine the reliability of the results. Therefore, further critical development of the instrument is needed. Given the diverse nature of services in integrated health and social care, the composition of occupational groups varies substantially. Additionally, patient and client safety culture should be examined using longitudinal designs to better capture the effects of natural variation, such as changes in population needs or staff composition and education levels, as well as the impact of interventions.
Conclusion
This study provides new insights into the state of patient and client safety culture within a Finnish well-being services county. Significant differences were observed across service areas, with elderly services consistently reporting lower scores. These disparities underscore the need for targeted strategies to strengthen safety culture in settings that may face greater structural and resource-related challenges. The strong interrelationships among safety culture dimensions highlight the interconnected nature of safety practices, particularly in areas such as communication, leadership and organisational learning. The NSS demonstrated robust associations with key safety culture dimensions and offers a practical, scalable approach to monitoring staff perceptions of safety. While NSS is not a substitute for comprehensive surveys, its simplicity and responsiveness make it a valuable tool for enhancing real-time feedback and supporting continuous improvement in healthcare organisations. Future research should explore longitudinal trends in NSS and its relationship with patient outcomes to further validate its utility. Tailored multidimensional interventions that address service-specific challenges, especially in elderly care, are essential for fostering a robust and equitable patient and client safety culture across all sectors of integrated health and social services.
Supplementary material
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: This study involves human participants and was approved by IRB of the Wellbeing Services County of South-Western Finland, number: T779_2025 Tutkimuslupa 437074. According to Finnish legislation and the Finnish National Board on Research Integrity, this study did not require an ethical committee review or ethical assessment. Participants were informed that participation was voluntary and that they could withdraw at any time without consequences. Participants gave informed consent to participate in the study before taking part, and participants were able to request additional information if needed.
Data availability free text: Data are not publicly available.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability statement
Data may be obtained from a third party and are not publicly available.
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