Table I.
Methodological characteristics of reviewed studies
| Study | Sample and setting | Design | Variables and measurement tool | Study findings |
|---|---|---|---|---|
| Burstrom et al. (2014) | Participants were physicians and nurses recruited into the study to complete a questionnaire pre- and post-intervention. They were sampled from the emergency department of two hospitals in two different cities in central Sweden: a county hospital and a university hospital. There was relatively equal gender distribution of 92 physicians and 83 nurses among participants at the country hospital and similarly with 35 physicians and 99 nurses (post-intervention participant numbers) | A repeated cross-sectional survey study where participants completed the Hospital Survey on Patient Safety Culture questionnaire before and after a quality improvement project | The 51-item Hospital survey on Patient Safety Culture was administered pre- and post-intervention. The Swedish version of the survey is a reliable and valid measure (Magid et al., 2009) and includes 15 dimensions with one to four items answered on a 5-point Likert scale | The overall rating of safety culture on most dimensions by doctors and nurses at both hospitals and at both measurement points was low (below the midpoint). However, a higher score was measured post-intervention on two dimensions with participants from the country hospital: teamwork within hospital and communication openness. At the university hospital, a higher score was measured at follow-up for the two dimensions: teamwork across hospital units and teamwork within hospital |
| Camargo et al. (2012) | The survey study was conducted in 62 urban EDs across 20 US states. There were 3,562 participants consisting of nurses (52.5%), physicians (22.2%) and other health personnel (25.3%) | A quantitative, descriptive cross-sectional study with survey methods | A 50-item Safety Climate questionnaire with 9-subscales was administered. The scale was reported to be a reliable and valid measure of Safety Climate (Patterson et al., 2010) with each item answered on 5-point Likert scale. Data were also collected on the number of adverse events and near misses in each ED | The overall rating of Safety Climate was 3.5/5 and was especially low on the subscale of Inpatient Coordination (2.4). No data were provided to compare safety climate as a function of profession. A higher safety climate score was not associated with the number of adverse events but was significantly associated with a higher incidence of intercepted near misses |
| Grover et al. (2017) | The study was set in a single major metropolitan emergency department in Melbourne, Australia. Participants were 12 registered nurses (9 female and 3 male) | A qualitative phenomenological study to address the question what are emergency nurses’ perceptions and attitudes towards teamwork? | Five semi-structured interview questions to ascertain and measure attitudes towards the teamwork aspect of patient safety climate | Participants perceived teamwork as an effective construct in resuscitation, simulation training, patient outcomes and staff satisfaction. Team support through back-up behaviour and leadership were perceived as critical elements of team effectiveness. Times were also reported when teamwork failed due including inadequate resources and skill mix |
| Källberg et al. (2017) | The study was conducted in 2 hospital EDs in Sweden at one large urban hospital and one medium-size country hospital. Participants were 10 physicians and 10 registered nurses | A qualitative phenomenological study using semi-structured interviews to investigate patient safety risks | Individual semi-structured interviews with a series of questions to describe events and situations in the ED where patient safety was compromised | Four main categories of patient safety risk were derived from inductive content analysis of the interview data: high workload, lack of control, communication failure and organisational failures |
| Lambrou et al. (2015) | EDs in 5 public general hospitals in Cyprus. Participants 174 nurses and 50 physicians | A descriptive correlational study to measure the association between perceptions of professional practice environment and patient safety | The 39-item Revised Professional Practice Environment (RPPE) Scale measures eight professional practice environment characteristics [Erickson]. A 60-item SAQ adapted for ED environments to measure perceptions of safety culture (Agency for Healthcare Research and Quality, 2016) | Physicians assessed the professional practice environment more positively than nurses. The mean SAQ score was 3.18/5 and safety culture was significantly predicted by three RPPE subscales: Leadership and autonomy, Control over practice, and cultural sensitivity |
| Lisbon et al. (2016) | The study setting was an emergency department of an academic hospital in the USA. Participants were 113 emergency department staff including physicians, nurses and ancillary personnel at time 1 of the study; however, only 59 participants completed the full study | A repeated cross-sectional survey study where participants completed questionnaires on day 1, 45 and 90 of TeamSTEPPS training to develop a high-functioning team to improve patient safety | TeamSTEPPS Knowledge Test (Sarac et al., 2010) is a 21-question multiple-choice format exam to measure patient safety knowledge. The AHRQ hospital survey on patient safety (Sarac et al., 2010) assesses staff attitudes on patient safety culture in the hospital setting | χ2 tests showed knowledge and attitudes significantly improved 45 days from baseline and were sustained by day 90 |
| Rasmussen et al. (2014) | The study setting was an emergency department (ED) at a Danish regional hospital. A total of 98 nurses and 26 doctors were participants in the study | A quantitative, descriptive cross-sectional study with survey methods to measure the relationship between work environment and adverse events (AEs) | The SAQ was used to measure safety climate and teamwork. A Danish scale to measure reporting behaviour and learning environment. Involvement in an adverse event during the preceding month was reported using 43 items covering the classification of AEs from the Danish Patient Safety Database | There were significant positive relationships between the number of reported AEs and poor safety climate, poor team climate, poor inter-departmental working relationships and increased cognitive demands |
| Rigobello et al. (2017) | The study setting was an emergency department of a university teaching hospital in Sao Paulo, Brazil. There were 125 participants recruited into the study which was made up of mostly nurses, physicians and other health professionals | A quantitative, descriptive cross-sectional study with survey methods | The main variable was safety attitudes which were measured with the Portuguese version of the Safety Attitudes Questionnaire (Sexton et al., 2006). The SAQ measures six dimension of safety attitudes: stress recognition, perceptions of management, safety climate, teamwork climate, job satisfaction and working conditions | Of the six dimensions, participants only rated job satisfaction positively. The other dimensions were rated negatively, especially perceptions of management, safety climate and working conditions |
| Shaw et al. (2009) | The setting was 21 emergency departments in paediatric hospitals in the USA. A total of 1,747 staff members (49%) responded to a survey on the climate of safety including nurses, physicians and medical technicians | Quantitative cross-sectional design with survey methods | A validated survey to assess characteristics of emergency department physical structure, staffing patterns, overcrowding, medication administration, teamwork and methods for promoting patient safety (checked as either absent or present). A validated survey on the climate of safety. The survey has 19 questions regarding staff perceptions of the climate of safety each using a 5-point Likert-type scale | There was a wide range (28–82%) in the proportion reporting a positive safety climate across the 21 sites. Physicians’ ratings of the climate of safety were higher than nurses’ ratings. Characteristics associated with an improved climate of safety were a lack of ED overcrowding, a sick call back-up plan for physicians and the presence of an ED safety committee |
| Tourani et al. (2015) | The study setting was 11 EDs in hospitals affiliated with the Tehran Medical Science University in Iran. There were 270 participants comprised of doctors and nurses | Quantitative cross-sectional design with survey methods | The standard questionnaire of Hospital Survey on Patient Safety Culture (HSOPSC) was the main measurement tool which includes 42 statements that focus on 12 different aspects of patient safety | Half of the participants believed there was a problem in the error prevention procedures and systems, 30% reported their supervisor does not pay attention to their recommendations to improve the patients, and 40% reported hospital management show interest in the patients’ safety only when something goes wrong. More than half of the participants believed the nature of tasks in emergency wards, high workload, poor staffing and more than 40 h work a week has caused the staff in the emergency wards to work intensively with 57% of participants reporting there is lack of coordination among the wards |
| Verbeek-Van Nord et al. (2014), Verbeek-Van Nord et al. (2014) | The setting was 33 emergency departments in the Netherlands. Participants were 480 nurses, 159 physicians and 91 other health professionals | Quantitative cross-sectional design with survey methods | A Dutch version of the 40-item Hospital Survey on Patient Safety Culture (Alzahrani, 2015) to measure safety culture covering 11 patient safety culture dimensions | Six dimensions of safety culture were positively associated with the reported level of patient safety: teamwork across units, frequency of event reporting, communication openness, feedback about and learning from errors, hospital management support for patient safety. Physicians rated overall perceptions of patient safety higher than nurses |
| Wang et al. (2014) | The study setting was 8 hospitals in Guangzhou, China to include one medical unit, one surgical unit, one intensive care unit and one emergency department from each hospital. A total of 463 registered nurse were participants in the study | Quantitative cross-sectional design with survey methods | The 42-item Hospital Survey on Patient Safety Culture (HSOPSC) measures 12 patient safety culture dimensions. A 7-item adverse events questionnaire was employed to measure the frequency of different adverse patient events from 0 = never to 6 = every day | Data were pooled across the four units and eight hospitals and showed an average patient safety culture score of 3.46/5 with most dimensions being rated below strong, especially hospital management support for patient safety and overall perceptions of safety. A higher mean score on two dimensions of the HSOPSC, “Organizational Learning-Continuous Improvement” and “Frequency of Event Reporting”, was significantly related to lower occurrence of adverse events |