The culture in safety culture: exploration of patient safety culture in Saudi Arabian operating theatres.

Abstract

Surgical patients are highly susceptible to preventable harm in health systems that tolerate inadequate patient safety: the World Health Organization recognises that half of preventable adverse events happen in surgical care. Each year, seven million surgical patients are estimated to suffer serious complications from adverse events and up to one million die. Improving safety culture and non-technical skills can reduce adverse events and improve patient safety. This study explores safety culture in operating theatres in Saudi Arabia, where many employees work in an environment that is radically different from their own, in a language that they know imperfectly. It targets cultural differences and their relevance to safety culture dimensions, including teamwork, communication, job satisfaction, stress recognition, working conditions, and perceptions of management. The concept of safety culture is complex, and to achieve sufficient breadth and depth this study employs a sequential explanatory mixed methods design. All health care professionals working in operating theatres in the Saudi Arabian Ministry of Health hospitals in Riyadh City were surveyed using the internationally validated Safety Attitudes Questionnaire, administered in both English and Arabic. Items pertaining to local culture were added to assist in measuring cultural factors related to patient safety. Furthermore, twenty semi-structured interviews with non-Arabic-speaking female nurses were also conducted. Returned surveys (n = 649; 60.8 % response rate) were subjected to reliability and validity tests. Cronbach’s alpha values for each dimension ranged between 0.71 and 0.82, except for the perception of management dimension (0.44). Confirmatory factor analysis showed that all dimensions except perception of management had good psychometric properties, indicating the tool’s applicability to Saudi Arabian context. Respondents’ mean perceptions ranged between 3.5 and 4 out of 5 for each dimension, which is comparable to similar studies in different international settings. Along with revealing significant differences between sites, analysis indicates that nurses, younger professionals, females and non-Arabic speaking professionals have significantly lower favourable perceptions of the dimensions under investigation, and that nurses rate their quality of communication with other professionals significantly lower than the ratings they received from them. Cultural background, including language, influences perceptions of the safety culture. Communication, cultural background, and gender are found to comprise a new patient safety dimension, multicultural workplace. This dimension (α = 0.79; ẋ = 3.6; SD = 0.96) has strong, positive correlations with other valid dimensions except stress recognition. Site, profession, and gender are significant predictors of this new dimension. Both the open-ended questions and the semi-structured interviews reveal culture as an important factor, influencing several aspects of safety culture. Many issues were related to the concept of a multicultural workplace, and the strong correlation of this with other dimensions of safety climate indicates its relevance and importance to the safety culture. Nurses, of whom the majority were female and non-Arabic speaking, had significantly lower perceptions of safety culture than other respondents. The influence of context, gender, cultural background and language on safety culture is evident. Cultural integration, initiated in classes about local culture and language, is recommended to bridge gaps between local and multinational workforces. Recommendations of enhancement to teamwork, communication, equity of team members and conflict resolution should provide a better, safer environment for hospital staff and patients if implemented.