The Enabling, Enacting, and Elaborating Factors of Safety Culture Associated With Patient Safety: A Multilevel Analysis

Abstract

Purpose: Worldwide, 1 in 10 hospital patients is harmed while receiving care. Despite evidence that a culture of safety is associated with greater patient safety, these effects and the processes by which safety culture impacts patient safety are not yet clearly understood. Therefore, the purpose of this study was to examine the effects of various safety culture factors on nurses' perceptions of patient safety using an innovative theoretical model.

Design: This descriptive, correlational study drew on deidentified, publicly available data from the 2018 Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture. The study sample included 34,514 nurses who provided direct care to patients in medical and surgical units in 535 hospitals in the United States.

Methods: Multilevel linear regression was used to examine the effects of 11 safety culture factors on nurses' overall perceptions of patient safety. The 11 safety culture factors were grouped as enabling, enacting, and elaborating processes, and entered in separate blocks.

Findings: All 11 safety culture factors were associated with nurse-perceived patient safety, and all but two of the 11 factors uniquely predicted nurse-perceived patient safety. Staffing adequacy was the strongest predictor of nurse-perceived patient safety, followed by hospital management support for patient safety (both enabling processes), and continuous organizational learning and improvement (an elaborating process).

Conclusions: Hospital administrators and managers play a key role in promoting a safety culture and patient safety in healthcare organizations through enabling and elaborating processes.

Clinical relevance: Organizational efforts should be made to provide sufficient staffing and hospital-wide support for patient safety. However, all staff, administrators, and managers have a role to play in patient safety.