Table 1.

Studies on the relationship between safety culture and infection prevention and control processes

First author, year	Design, number and types of sites or units and study period	Intervention(s)	Safety culture measurement tool and domains	Infection prevention and control process(s) measured	Study-reported findings and relation to safety culture	Comments
Daugherty 2012	Cross-sectional research; 46 units in 1 academic hospital; 6-month period between 2009 and 2010	No intervention	Safety Attitudes Questionnaire (SAQ): teamwork, safety climate, management support, job satisfaction, stress recognition, working conditions, perceptions of hospital management, and perceptions of unit management	Hand hygiene adherence	Higher safety culture scores were significantly associated with higher hand hygiene adherence across 4 SAQ domains (safety climate, job satisfaction, working conditions, and perceptions of hospital management Significant absolute differences of 5–8% in mean hand hygiene adherence were found between units with the highest domain scores and those with the lowest domain scores. “It remains unclear whether certain domains are more significant than others in predicting staff behaviors”	Single time measurement of safety culture Single-site study
Garland 2013	Cross-sectional research; proportional stratified random sample of dental hygienists across about 750 offices; study period not reported	None	Questionnaire regarding attitudes about infection control guidelines: knowledge, attitudes and practice behaviors, dentists’ barriers influencing implementing infection control guidelines, and compliance with practice guidelines. Items include supervisor expectations and access to infection control supplies. Qualitative thematic analysis of open-ended questions	Dental hygienists self-reported compliance with infection control guidelines	Significant association between the attitude that “infection control is not practical” and other negative attitudes: infection control guidelines are inconvenient and cumbersome to use (Spearman Rho rs = 0.540), having no time to use infection control guidelines (rs = 0.582), and not wanting to change infection control behaviors (rs = 0.549) Significant association between infection control guidelines implementation and positive attitudes regarding: familiarity with the infection control guidelines (rs = 0.537), belief in the relevance of infection control guidelines to patients (rs = 0.462), access to necessary supplies (rs = 0.549), belief that supervisors expects them to use infection control guidelines (rs = 0.529). “Higher compliance with infection control guidelines was associated with positive safety beliefs and practices. Safety culture appears to be a factor in compliance with infection control guidelines”	Single time measurement of safety culture 99% of respondents belonged to the American Dental Hygienists’ Association; results might not be representative of members of other professional associations
Hessels and Genovese-Schek 2016	Cross-sectional research; 11 units in 5 hospitals including community, acute care, trauma, teaching and non-teaching; 7-month period in 2015	No intervention	Two tools combined: (1) Hospital Survey on Patient Safety Culture (HSOPSC): teamwork within units, supervisor/manager expectations and actions promoting patient safety, organizational learning-continuous improvement, management support for patient safety, overall perceptions of patient safety, feedback and communication about error, communication openness, teamwork across units, staffing, handoffs and transitions, nonpunitive response to errors; and (2) Gershon Standard Precaution and Safety Climate Survey: frequency of events reported, standard precaution practices, standard precaution environment	Adherence to standard precautions. Specifically, hand hygiene, personal protective equipment, disposal of needles or other sharp, and soiled linen handling	Although 94% of nurses reported positive scores on unit safety climate, observed standard precautions adherence was 62% (unit range 31–80%) Better self-reported staffing was significantly associated with lower standard precautions adherence (r2 = − 0.85, p = 0.03) but not teamwork within units (r2 = − 0.6, p = 0.09). Significant relationships between safety climate dimensions and specific standard precautions items included: teamwork within units and sharps adherence (r2 = − 0.75, p = 0.03); management support for patient safety and hand hygiene (r2 = − 0.70, p < 0.01); staffing and hand hygiene (r2 = − 0.84, p < 0.01). “The relationship between safety climate and adherence to standard precautions warrants further investigation.”	Single time measurement of safety culture Nurses were the only respondents for culture measurement
Hsu 2020 (ePub 2015)	Cross-sectional research; 103 ICUs in Michigan Keystone project; 2004	Adoption of CUSP	Safety attitudes questionnaire, (scales of teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management, and working conditions)	Process was assessed at ICU level regarding willingness to adopt CUSP interventions	ICUs with lower perceived safety climate, greater stress recognition, higher perceptions of management, and better working conditions were more likely to adopt CUSP	Safety culture at baseline was used in the analysis
Lyles 2014	Qualitative research; 4 long-term acute-care hospitals; 2012	None	18 items from a previously validated tool by Sinkowicz-Cochran	Attitudes and beliefs about a Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae (KPC) control program and QI at the facility	Administrative staff reported higher organizational culture than frontline staff. The high degree of convergence in motivation, understanding, and beliefs related to implementation of a KPC control bundle suggests that all levels of staff may be able to align perspectives when faced with a key infection control problem and quality improvement initiative
Meeks 2011	Cross-sectional research; 2 county hospitals; 2006–2008	None	Safety Attitudes Questionnaire; domain of teamwork safety climate. Also, another potential measure of teamwork, time from entry into the operating room to time to incision (cut time)	Compliance with all Surgical Care Improvement Project antibiotic prophylaxis guidelines	Gynecologic surgery was the only independent predictor of compliance for elective procedures. Contrary to expected, safety domain scores and agreement with statements on collaboration and teamwork were not predictive of compliance. However, a shorter surgical cut time, particularly in emergency cases, was identified at the hospital with better teamwork scores.	Safety culture measured at a single point in time Did not find significant association
Miller M 2012	Cross-sectional research; 386 academic and community hospitals with intensive care units; 2003–2009	None	A 5-point Likert scale measuring 3 items: leadership driving safety culture, staff receptivity to change in clinical processes, whether the respondent would feel safe being treated at the facility as a patient. Respondents were lead infection control professionals.	Daily interruption of sedation in mechanically ventilated patients	Leadership emphasis on safety culture (odds ratio 1.87, 95% confidence interval 1.02–3.43); staff receptivity to change (odds ratio 2.17, 95% confidence interval 1.16–4.06); and involvement in an infection prevention collaborative (odds ratio 1.78, 95% confidence interval 1.02–3.12) significantly associated with daily interruption of sedation use The perception by respondents that they “would feel safe being treated” at the hospital was not statistically associated with routine use of daily interruption of sedation	Safety culture measured at a single point in time
Nelson 2011	Two cross-sectional research surveys; 149 academic and community hospitals; fall 2008	No intervention	Two tools adapted from Patient Safety Climate in Healthcare Organizations (PSCHO), including: (1) Senior Management Engagement scale: understanding of current safety issues in the facility, taking supportive care when necessary, appreciating that frontline care providers are often best qualified to solve patient safety issues; and (2) Leadership on Patient Safety scale: senior executives’ ability to articulate values consistent with patient safety and reducing hospital-associated infections	Measures of structure: presence of hospital epidemiologist and infection preventionist	An independent budget for the infection prevention and control department was a significant predictor of more positive perceptions of safety culture Infection preventionists perceived senior management engagement more positively than quality directors (21.4% vs 20.4%, p < 0.01)	Single time measurement of safety culture This study evaluated measures of structure (not a process). It examined perceptions of two patient safety climate measures from infection preventionists and quality directors
Pogorzelska-Maziarz 2016	Cross-sectional research; 972 teaching and non-teaching acute-care hospitals; winter 2011	No intervention	Leading a Culture of Quality for Infection Prevention (LCQ-IP): quality focus, change orientation, openness, change actions, work group cooperation and respect, alignment (with leadership and direction), accountability, workload, psychological safety. Respondents were infection preventionists.	CLABSI policies	Mean LCQ-IP scores increased with number of CLABSI policies in place (p = 0.047)	Single time measurement of safety culture. Study goal was to evaluate psychometric properties of the LCQ-IP instrument; study findings supported tool validity
Robbins 2016	Qualitative; 158 key informants; 6 hospitals; study period not specified	Comprehensive unit-based safety programs (CUSP) —Stop BSI initiative	Qualitative methods addressed management and organizational factors that contribute to creating a nonpunitive environment for speaking up	How hospital CLABSI prevention efforts encouraged or hindered employees’ efforts to speak up to prevent errors or identify opportunities for improvement	Leader behavior, employee training, and error reporting systems facilitated employees improvement-oriented speaking in hospitals implementing evidence-based practices for CLABSI prevention
Sinkowitz-Cochran 2012	Two cross-sectional research surveys; 16 VA Medical Centers; October 2006 and July 2007	None	Organizational Culture (OC) – staff engagement, overwhelmed stress/chaos, leadership	Hand hygiene; gowning and gloving practices	Higher staff engagement and hospital leadership were associated with better hand hygiene (p < 0.01 and = 0.04, respectively) and gowning/gloving practices (p < 0.01). Conversely, higher overwhelmed/stress-chaos scores were associated with poorer hand hygiene (p < 0.01) and gowning/gloving practices (p < 0.01). All 3 OC factors of Staff Engagement, Hospital Leadership, and Overwhelmed/Stress-Chaos were significantly associated with gowning and gloving among nurses (p < 0.01, < 0.01, and = 0.02, respectively). “Differences by job type also suggest that OC may influence not only knowledge and attitudes of health care personnel, but also practices and outcomes.”	Multi-site study evaluated differences in organizational culture by staff role
Talbot 2013	QI initiative; 1 academic medical center; 2009–2012	To improve hand hygiene adherence and align efforts with pursuit of a culture of safety, the hospital adopted multiple strategies including training, peer feedback, marketing and financial incentives, as well as structured unit-based and individual accountability interventions	Not measured directly, although the response of underperforming units’ improvement plans provided leaders with insight into the safety culture in each poorly performing clinical area (e.g., exhibiting a collegial mindset and desire to work as a team or, alternatively, dysfunction and a lack of leadership)	Hand hygiene	Improvements in hand hygiene were sustained across the entire health system. Leadership engagement through a formal accountability structure coupled with institutional financial incentives encouraged both nursing and physician leadership to pursue a culture of consistent, sustained HH adherence	Safety culture not measured
Yanke 2018	Qualitative study; one VA 57-bed facility; July–November 2013; four focus groups including attending physicians (1), resident physicians (1), and RNs and HTs (2)	Department of Veteran Affairs C. difficile prevention bundle	Qualitatively identified domains include organizational support, communication	C. difficile prevention bundle adherence, hand hygiene; contact isolation precautions	Following hand hygiene protocol of increased time required for handwashing and contact isolation precautions were prominent barriers to bundle adherence among all groups. Another barrier was patient care workload