Safety Climate Assessment in Operating Room Nurses Through Safety Attitudes Questionnaire (SAQ)

. Introduction: Surgical safety is a global public health concern. The attitudes and perceptions of the surgical team regarding to the patient safety are associated to the safety climate and the prevalence of adverse events. Objective: To describe the safety climate according to sociodemographic characteristics and work professional conditions of operating room nurses from three Hospitals in Canary Islands, Spain. Method: This work presents a multicentre cross-sectional study. Data collection was obtained by means of The Safety Attitudes Questionnaire (SAQ), a self-completed questionnaire translated to the Spanish. A convenience sample with voluntary participation was selected. The safety climate was determined through six factors: Teamwork climate, Safety climate, Job satisfaction, Perception of the Unit and Hospital Management, Working conditions and Stress recognition . Results: The SAQ domains show variability in relation to sociodemographic characteristics and work professional conditions. Perception of the management and Working conditions are the domains lower valued in every sociodemographic characteristics studied. The size of the hospitals and Years of professional experience showed statistical differences in several domains. Conclusions: The age, years of profession, years of experience and type of hospital present strong relationship among patient safety perception.


Introduction
It is estimated that more than 234 million major surgical procedures are undertaken every year worldwide [1].Approximately 10% of patients admitted in hospitals suffer unexpected accidents or adverse events (AE) derived from health care causing to undesirable effects on their health or even death.In 2005 there were more than 4 million major surgical procedures in Spanish hospitals [2].Around 50% of the AE are considered avoidable [3].These data suggest that surgical patient safety is a major global concern in public health [1].
Studies on epidemiology about healthcare risks report that the second most frequent cause of AE derive from surgical procedures [4].Most of AE occurring in the operating room relies on either the nature and characteristics of major surgical procedures or the increased use of precise technologies.The complexity of the procedure increases or determine the probability of undesirable events [5].
Organizational culture refers to a set of beliefs, values, and prevailing attitudes that determine the functioning of an organization reflected in their daily actions [3].Historically, the health institutions have addressed AE from the perspective of the blame and hiding culture by using a model of error centred on the person.A safety culture is needed in order to achieve a model of error centred in the system, where errors are not considered personal failures, but a result from the interplay of multiple factors and opportunities that improve the system while prevent damage [3,6].Safety culture is essential in the prevention of AE and could be defined as "the product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to and proficiency of an organization´s health and safety management" [6].
Organization errors are responsible for the vast majority of AE.The human factor performs a very important role [7].The analyze of cultural, professional and organizational factors improves the understanding and prevention of errors [8].Healthcare provider attitudes about these factors are one component of safety culture [9].
When using questionnaires to study group-level perceptions, the most appropriate term to use is climate (e, g., safety climate, or teamwork climate).Climates are more readily measurable aspects of safety culture (perceptions are part of both definitions) but surveys are generally not capable of measuring all other aspects of culture like behavior, values, and competencies [9].
Few studies have been conducted on the assessment of safety culture in Spanish National Health System [10].In addition, surgical safety climates studies have never been conducted in this country.On the other hand, the nurse in the operating room is responsible for multiple health care tasks related to patient safety and is also in charge, according to the institution, of the surgical checklist.The Surgical Checklist is the quintessential tool for patient safety in the operating room created by World Health Organization [11].The safety climate in the operating room is associated with the correct use of the surgical checklist [12].Undoubtedly, the attitudes of the safety culture in nurses is reflected in the AE [13,14].
The objective of this study is to describe the safety climate according to sociodemographic characteristics and work professional condition of operating room nurses.Description of surgical safety climate is essential for the assessment of the surgical patient safety, minimize the AE and be able to carry out improvement actions according to National Quality Forum [9,10].
The improvement of safety climate has important benefits for patients and is associated with the reduction of nurses injuries [14].Likewise, promoting the safety culture in surgical areas may contribute to the sustainability of the health system and to reduce health care costs [15].

Materials and Methods
A multicentre cross-sectional study design was selected.To evaluate surgical nurses´ safety climate the Safety Attitudes Questionnaire (SAQ) was translated into Spanish and self-completed using a convenience non-representative sample by voluntary participation.
The SAQ demonstrates good psychometric properties and has been adapted to use in intensive care units (ICU), operating rooms, general inpatient settings and outpatient (medical ward, surgical ward, etc.).It has been also validated into several languages but not into Spanish [16][17][18], and its use allows valid comparison between hospitals, patient care areas, and types of caregivers, and tracking of change over time [9].
The population under study were nurses from surgical areas of three third level main public hospitals of Gran Canaria Island (Las Palmas).Operating room nurses, in both elective and urgent surgeries, were included.Nurses not assigned in the operating room and with less than six months of experience in the surgical area were excluded from the study.
182 surgical nurses were the study population.The sample consists of 125 (68.68%) surgical nurses aged between 25 and 64 years old.The distribution by gender, hospital, age, years of experience and profession, represented a normal distribution.The sample was not probabilistic but it was well balanced in terms of nurses' proportion, in both, elective and urgent surgeries.The characteristics of the sample are described in Table 1.

Measuring instrument
The SAQ was created and validated in 2006 by teamwork from The University of Texas.The SAQ is a selfadministered questionnaire that allows obtaining a snapshot of the safety climate through surveys of frontline worker perceptions.It contains 41 items and is answered using a five-point Likert scale.The final score varies between 0 and 100, 100 represents the best perception, and a positive response value according to safety is considered when the score is equal or greater than 75 [9,19].
Safety climate perception is evaluated through six factors or dimensions and is defined as follows:  Teamwork climate: perceived quality of collaboration between personnel. Safety climate: perceptions of a strong and proactive organizational commitment to safety. Job satisfaction: positivity about the work experience. Perception of management of the unit and the Hospital: approval of managerial action. Working conditions: perceived quality of the work environment and logistical support (staffing, equipment, etc). Stress recognition: acknowledgement of how performance is influenced by stressors [9].A SAQ short version was translated into Spanish, and the following working method was applied: 1.The translation was confronted with the questionnaire of Gutierrez's work [20] and the first draft of the questionnaire was written.2. The questionnaire validity content was reviewed by three experts (two assistants experts and one academic expert).3. A sample of volunteer surgical nurses (n = 5) was selected to apply the questionnaire.Nurses expressed their opinions and suggestions about the questionnaire.The results of the pilot questionnaire were analysed and the findings based on the expected data were explored.The final questionnaire was drafted after the correction of errors and addition of eight closed demographic questions.

Data collection
Staff meetings were attended to hand-deliver the questionnaires.Several visits to the unit were also done on different days and hours, to hand out the questionnaire to the nurses who could not attend at the meeting day and also from emergency teams.

Ethical aspects
Ethical aspects of the research were reviewed and approved by the Ethics and Research Committee of University Hospital of Gran Canaria Dr. Negrín and Insular Maternal and Child Hospital Complex of the Canary Islands.Each professional was asked for a writing consent together with a presenting letter of the questionnaire, ensuring their confidentiality, privacy and voluntary participation in the study.The anonymity questionnaire and the consent document were not coded to allow data union.In accordance with the principles set out in the Declaration of Helsinki, the data provided were treated with caution to protect the privacy of personal information, according to the code of ethics of Spanish Nursing and the Organic Law 15/1999 of 13 of December on Personal data Protection.Authorization for use was also obtained from the authors of the questionnaire.

Data analysis
The answers were placed in a database and each response was scored according to the indications of the SAQ author.Items numbers 2 and 11 are negatively worded and reverse scored.The not answered items, blank items, were not included in the statistical analysis.The items corresponding to each SAQ dimension were taken to calculate the average.The average SAQ dimension with each of the demographic variables was analyzed.Analysis of variance ANOVA, multiple mean´s comparison with post-hoc tests and, non-parametric tests (Kruskal-Wallis test) were used for statistical and differences significant finding.The Pearson correlation coefficient was used for the relationship degree study of quantitative demographic variables of scale.Statistical analysis was performed using the SPSS 23.0 programme (SPSS Inc., Chicago, IL, USA).

Results
A total of 182 questionnaires were distributed and 134 were returned, 9 of them did not meet the inclusion criteria and were excluded.The overall participation was 73.63%.Tables 2 summarize the percentage of responses in each item of the questionnaire.

Gender
All domains showed better ratings among women, with the exception of the Stress recognition domain that was higher values in men.Furthermore, the Stress recognition domain obtained values, greater than 75, according to patient safety (77.08).No significant differences were found.The lowest values for both genders were recorded for Working conditions followed by Perception of the management.

Age
There was a negative trend for the dimensions of the SAQ that increases with age, showing lower values between 40-44 years of age, with the exception of the Stress recognition domain, which increases its value in that range (80.59).There were no existing significant differences between the domains in the age range 40-44 years, showing in this age range greater distance from averages.All domains improve at the end of the working life then, excluding Working conditions (35.42) and the Perception of the management (51.25),falling in most of the nurses older than 59 years old.Over the time, the differences in these two last factors were statistically significant (p = 0.014, p = 0.020).

Educational level
No statistical differences were found according to the educational level.It was observed that the higher the educational level, the lower the value of the domains.This result was observed for all the domains with the exception of Stress recognition, that showed values greater than 75 (78.13) in the master level.

Working relationship
Temporary hired nurses showed an overall higher value on the domains, being the interim 1 contrast, the Stress recognition domain showed the highest values to interim nurses (82.32) and the lowest to temporary hired nurses (62.07).These differences were significant (p = 0.000), as well as differences in the Perception of the management domain (p = 0.030) between eventually hired and interim nurses.The Job satisfaction domain showed values of p close to 0.05 (p = 0.051).Figure 3 shows significant differences (* p < 0.05).
1 Note: Nurses working relationship in Spanish public hospitals consist in a range of nurses form by temporary hired nurse, interim nurse ("enfermero interino" in Spanish) and permanent nurse.Interim nurses have a working relationship indefinite in time and do not count with privileges of permanent nurses.

Type of surgery
Differences in the score of the domains among nurses performing scheduled surgeries and urgent surgeries were not observed.The Stress recognition domain showed that nurses carrying out urgent surgeries had greater rating, according to patient safety (77.20),than those performing scheduled surgeries (69.01).The differences in Stress recognition among the types of surgery were not statistically significant, although values of p close to 0.05 were observed (p = 0.053).When considering perception of the unit supervisor, nurses who perform surgeries scheduled showed best ratings (54.64) compared to those performing emergency surgeries (46.60), with significant differences (p = 0.048).

Years of professional experience
Lower dimension values were observed for nurses with more years of experience.The 15-19 years of professional experience range showed the lowest values for all the domains.This finding was not observed for the Stress recognition (81.67) domain wherein values increased.The maximum value was registered in nurses with less than one professional year (100), although differences between domains were not statistically significant.All domains improved slightly during the rest of the working life, with the exception of the Working conditions (39.06) and the Perception of the management (50.50)domains, with lower perceptions values in nurses with more than 39 professional years.Differences during professional years were statistically significant for Working conditions (p = 0.003) and Perception of the management (p = 0.001), as well as for the overall value of SAQ (p = 0.004).
Perceptions of the SAQ domains improve with years of experience in the surgical area, showing higher scores for nurses with more than 30 years of experience in the surgical area.All the domains showed similar values before 30 years of experience in the surgical area, with the exception of the Working conditions and Stress recognition domains which lower values between 10 and 19 years of experience.The differences were not significant regardless of the domain examined.Higher scores were obtained for the smaller hospitals while the larger hospital with a greater number of staffing surgical nurses showed lower scores.These differences were significant when examining the overall SAQ value (p = 0.027) and in three domains: Safety climate (p = 0.002), Job satisfaction (p = 0.042) and Teamwork climate (p = 0.000).Figure 5 presents the significant differences (*p < 0.05).

Discussion
Age, professional experience and operating room working experience variables showed direct correlation and similar trends.Nurses under the age of 30 (with less professional experience and less operating room working experience) and over 55 years old showed better perceptions.This phenomenon might be due to factors such as trust, inexperience, awareness of the risks and motivation that might be modified over their working life.The differences between nurses with different working relationship suggest the same phenomenon, since this is related to the professional years in the public health service.On the other hand, perceptions were greater among nurses in all domains, with the exception of the Stress Recognition.This result suggests some sensitivity of nurses about perceptions related to certain aspects of their work.Job satisfaction [21,22] and estimations in burnout dimensions [23,24] have also shown differences.All these data must be taken into account to set up more balanced and secure work.Based on the above assumptions, an analysis of safety climate of the surgical team must be done in a cautious way.Nurses are one of the largest groups of health professionals and it is possible to extrapolate some of their ratings.Nurses and doctors use the same psychometrics to evaluate Job satisfaction factor [25].Instead, the same thing does not happen with other domains [26].
Stress Recognition items differ from those in other SAQ scales in where self-behavior is assessed.It does not measure frontline healthcare workers´ understanding in a highly stressful environment could put them in adverse conditions that might result in harm to their patients, as the SAQ authors intended.Stress Recognition subscale does not fit into the overall safety climate construct measure by the SAQ and, therefore it is not reflective of safety climate.The Stress Recognition score must be assessed separately from the other SAQ domains.The workers fatigue and burnout are related with Stress Recognition score [27].Stress Recognition values should be interpreted with caution in this study.Some values are described according to the patient's safety, which could indicate the opposite situation.
Working conditions and proper staffing were the dimensions worse evaluated in two studies about safety culture in Spain [10,20].Comparing the values obtained in the present study with the results described in the previous Spanish research, even lower results were shown.In addition, nurses perceived that staffing is insufficient in the present study (68%).Based on these considerations, Saturn warns of the risk of trivialising this fact in the year 2009, and the trend in Gutierrez article is confirmed [20].Finally, a worsening in the results of the present study is observed.
Regarding to the Perception of the management domain, a poor evaluation among professionals was found.The results were in agreement with several hospitals in other countries, being the worst rating factor attributed to the lack of safety [9,10,16,28].The present study shows identical values in nurses that Gutierrez article in ICUs [20] and the Saturn study showed weaknesses in the support of the management of hospitals with respect to patient safety [10].It has been described that managers show best estimations of safety climate in hospitals than their own employees [29], this could be due to the lack of communication and management strategies without taking into account the participation of the workers.Effective measures, like a better and fluid communication between workers and management has been associated with an improvement of the outcomes of patient safety in nurses [30].Likewise, the management influence is striking about patient safety.The answers on the dimension "Support of the management of the hospital about patient safety" show high correlations and influence on the overall rating in the study of Saturn [10] in accordance with the results herein reported.Significant differences were found between one of the two hospitals of the same hospital complex, where management department is shared, and the largest hospital with different management.
Another relevant aspect in the Perception of the Management factor is the best assessment of unit supervisors towards nurses performing scheduled surgeries (p = 0.048).This could be due to the coincidence of their schedules working hours, showing weak perceptions between the emergency teams who do not always share working hours with the supervisors.Supervisors of the surgical areas must take these perceptions into consideration, showing a closer relationship to nurses from emergency teams.
The variability of Teamwork Climate among hospitals was also found in another operating room safety climate study [31].Perceptions of Teamwork Climate did not exceed values in relation with the patient safety of the hospitals studied.It has been associated institutions with low stages of Teamwork climate and safety climate with a higher rate of AE and work-related accidents in nurses [14].Correlation exists between the increase of teamwork and a lower frequency of errors in surgery or to its elimination and correction [12].It is obvious that the human factor and the teamwork climate have a great contribution to patient safety and also to the quality of the service.Managers cannot keep track of the Teamwork climate that is generated in their institutions, because they put at risk the sustainability of these.In this framework, programs that encourage an open communication in the organization, as well as organizational strategies that involve knowing networks and social structures at work are needed [32].The completion rate depends on the institution [11], showing the large hospital the lowest values [33].Strategies related to the use of the checklist, communication and teamwork, form a triad that improves surgical safety: teamwork improves the efficient use of the checklist, and this one improves the communication of the team, leading to the improvement of safety culture [11].Further research is needed to assess these events and variables, since the association is even weaker due to the scarcity of studies.
In general, the results obtained by applying the SAQ were not in agreement with a safety climate in the surgical area.The average global scores in surgical clinical areas of the three public hospitals suggest deficiencies in aspects referring to patient safety and significant potential for improvement.The average grade of safety culture in Spanish hospitals, in the Saturn study, was 7, showing scores below 6 in 25% of cases [10].According to these data, Canary hospitals, and therefore their surgical clinical areas, could be among the fourth part of the national health system hospitals with worse rating and at a greater risk.
The largest hospital obtained the worst values, similar findings were found in other studies done in mainland Spain about safety culture in hospitals [10] and a subsequent study about safety climate in ICUs, not existing anymore recent study.Teamwork is easier in smaller hospitals, managers and supervisors feel closed and it is perceived that the staff number is sufficient [20].
However, the smaller monograph maternity and children hospital showed the best value on the Job satisfaction domain (75.12), existing statistical significant differences in relation with the largest hospital (p =. 042).The characteristics of patients and processes differ in maternity and children hospitals and can be extrapolated to the valuations of the SAQ dimensions [21].
The most important limitation lies in the adaptation to the Spanish language of the SAQ questionnaire.Although a method for the translation of the questionnaire was used, this is quite simple according to the recommendations for a correct validation [34].On the other hand, the sample is small in comparison with other studies with the SAQ tool [31].
The three hospitals are public Canarian Hospitals (Servicio Canario de Salud) and they are in the same area (Gran Canaria), therefore it is difficult to extrapolate the results when there is the same administrative unit for the three institutions under the organisational and functional unit of the hospital.The existence of a maternity and children hospital in the hospitals studied could also distort the comparisons of results with other general hospitals.Moreover, the study population was only formed by surgical nurses, offering a partial result of the surgical team safety climate.

Conclusions
Surgical nurses present different perceptions about patient safety according to sociodemographic characteristics and working conditions.Some characteristics present a strong relationship in the perceptions of certain SAQ domains.The age, years of profession and experience show variability in the Working conditions and Perception of the management domains.On the other hand, the characteristics of the hospital also have relation with nurses' safety perceptions.The type of hospital suggests greater influence in the Job satisfaction, Teamwork climate and Safety climate domains.The gender, educational level and type of surgery show trends in patient safety perceptions, but these are weak.
Nurses' perceptions of patient safety have multifactorial influences, which require further study.The study of these relationships will involve the creation of more efficient and safer work teams.In addition, the use of effective and validated tools for the analysis and evaluation of safety climate in the surgical area is required.The SAQ is shown as an effective tool for operating theatre and presents appropriate psychometric properties, the SAQ validation to the Spanish could meet these needs.36.Puedo acceder con facilidad y de forma sistemática a la información sobre decisiones diagnósticas y terapéuticas.37. Los estudiantes de enfermería están correctamente supervisados.38.Percibo que la colaboración con las enfermeras es buena en el área quirúrgica.39.Percibo que la colaboración con los médicos es buena en el área quirúrgica.40.Percibo que la colaboración con el servicio de farmacia es buena en el área quirúrgica.41.Son frecuentes los problemas de comunicación que provocan retrasos en la prestación de cuidados.

Figure 1 :
Figure 1: Distribution of SAQ factors according to gender.

Figure 2 :
Figure 2: Distribution of SAQ factors according to age.

Figure 3 :
Figure 3: Distribution of SAQ factors according to working relationship.

Figure 4 :
Figure 4: Distribution of SAQ factors according to years of professional nursing and years of experience

Figure 5 :
Figure 5: Distribution of SAQ factors by hospital.

Table 1 .
Characteristics of the sample

Table 2 .
Response rate of items SAQ scale