Safety culture, perceived organizational support, and quality of healthcare: the views of nurses and patients in Saudi Arabia

This thesis investigated the association between hospital nurses’ attitudes to safety culture and patients’ views about quality of care in King Abdulaziz Medical City (KAMC), Saudi Arabia. In addition, this thesis examined the relationship between hospital nurses’ perceptions of safety culture and their perceived organizational support. At the same time, the association between hospital nurses’ perceptions of organizational support and patients’ perceptions of the quality of care was investigated. Analysis of the research literature revealed that the associations between quality of healthcare and safety culture and organizational support had not been investigated together in any systematic way. The conceptual framework of quality of healthcare that underpins this thesis drew from the Donabedian model (1980). The thesis critically analysed the outcomes of patient experience studies represented in Campbell et al (2000). In addition, the thesis drew from other theories and concepts such as organizational culture and behaviour, safety culture, patient-centeredness, and organizational support. Although many studies have investigated the issue of patient safety culture in relation to preventable medical errors, however, few studies have explored the relationship between patient safety culture and patients’ experiences of the quality of healthcare they receive. Moreover, no studies in Saudi Arabia have examined safety culture in relation to organizational support. In addition, no study in Saudi Arabia has examined the association between patients’ experiences of quality of healthcare and nurses’ perceptions of organizational support. This thesis employed two linked studies (the nurse study and the patient study). The nurse study (n= 395) targeted hospital nurses while the patient study (n= 727) targeted in-patients in KAMC wards. The two studies were linked by matching the answers of patients with the nurses involved in their care during their stay in hospital. The two linked studies employed a cross-sectional survey method to collect quantitative and qualitative data. The Hospital Survey on Patient Safety Culture (HSOPSC), the Consumer Assessment of Healthcare Providers and Systems (CAHPS), and the Perceived Organizational Support (POS) questionnaire were used. The participants were selected using purposive (for nurses) and consecutive (for patients) sampling techniques. 80.7% and 79.0% of responses rates were found amongst patients and nurses, respectively. The data were subjected first to simple descriptive statistical analysis. Theses analysis revealed that the patients have the following characteristics: 43.5% were males, 97.1% were Saudi, 84.7% had diploma or high school or less, and 81.5% were married. In terms of socio-demographic of nurses: 92.9% were females, 90.6% were non-Saudi, and 57.2% were married. Explanatory Factor Analysis (EFA) revealed that HSOPSC (12 domains) and CAHPS (6 domains), as originally theorized from prior studies, were in fact found to have quite different factor structures in the Saudi healthcare context. The two linked studies suggested the need for a simpler cognitive theoretical structure for both safety culture and quality of healthcare in Saudi environment. The explanation for these findings may be the cultural and linguistic differences between the Western and Saudi contexts. In addition, the diversity of the healthcare systems may also be an explanatory factor in these differences. Thus these two linked studies in this thesis discovered that within the groups studied, safety culture was best represented by only two factors: facilitators and threats to patient safety; and also the thesis discovered that within the groups studied, quality of healthcare was best represented by only two factors: interpersonal care communication and technical quality of care. These findings, while not consistent with the predictions of the developers of the tools, were nevertheless consistent with Donabedian’s model (1980) and the review of patient experience studies conducted by Campbell et al (2000). Canonical correlations from these two linked studies indicated the following: (i) Positive and strong correlation between safety culture and quality of healthcare; (ii) Positive and moderate correlation between safety culture and POS; and (iii) Positive and strong correlation between organizational support and quality of healthcare. This indicates those nurses' perceptions of safety culture and organizational support may have a significant impact upon the patients' perceptions of quality of healthcare services. The nationality of nurses (n= 395) showed a small but significant difference (F= 5.105, p value < 0.05) with their perceptions of both safety culture and organizational support. Non-Saudi nurses were more likely recognizing facilitators to patient safety and organizational support than Saudi nurses. The work experience revealed a statistically significant difference (F= 6.559, p value < 0.05) in relation to organizational support. Junior nurses needed for organizational support more than senior nurses. The nurses’ age showed a small but significant correlation (r = 0.12 and p value < 0.05) with threats to patient safety. With increase of nurses’ age, they tended to have stronger perceptions on threats to patient safety. The length of stay had weak and negative correlation (r = - 0.11 and p value < 0.05) with patients’ perceptions on quality interpersonal care communication. The longer patients stay in hospital, the poorer perceptions on interpersonal care communication. Among patients’ demographic features, “education level” was the only one showed a statistically significant difference (F= 2.862, p value < 0.05) with their perceptions of quality of healthcare. Educated patients tended to rate lower perceptions on technical quality of care. The qualitative data were processed through the use of thematic matrix display tables in order to find meaningful concepts or themes. The qualitative findings from nurses’ data suggested that there were five themes which may affect patient safety in KAMC: workload, culture of blame, staff turnover, job satisfaction, and room/ward design and accessibility. The qualitative findings from patients’ data suggested six themes affecting quality of healthcare services in KAMC: communication, catering “food services”, cleanliness and quietness, pain management, educational facilities, and diagnosis. The findings from the two linked studies in this thesis were consistent with previous work performed by Donabedian (1980) and Campbell et al (2000) in which quality of healthcare can be defined through interpersonal care communication and technical quality of care. However, the structure of safety culture and quality of healthcare in Saudi context identified by participants in the two studies in this thesis were actually found to be quite different from those in the literature. The results of the two linked studies showed simpler structures than the theorized structure. This different structure between Saudi and Western context were consistent with other studies investigated safety culture and quality of healthcare structures among different cultures and languages such as Weech-Maldonado, Morales et al. 2003; Chen and Li 2010; Elliott, Sherman et al. 2012; Fujita, Seto et al. 2013. While the research limitations were discussed in the thesis, this thesis also has strengths that are noteworthy. This thesis was the first research in Saudi Arabia that has examined the relationships among safety culture, quality of healthcare, and organizational support. This thesis used sophisticated statistical tests such as EFA to examine HSOPSC and CAHPS in Saudi context. In addition, this thesis used a unique technique to connect patients' and nurses' answers. This connection helped to identified links between potential problems among safety culture, quality of healthcare and organizational support. The combined data from nurses and patients studies in this thesis provided Saudi policy makers in healthcare with an enriched view of the quality environment in hospitals. Moreover, the findings of this thesis helped pinpoint where quality efforts need to be focused. The thesis concluded with a discussion of future research avenues. It is suggested that similar studies ought to be conducted in MOH and private hospitals. It is also suggested similar studies ought to target other hospital staff groups such as doctors, pharmacists, and technicians. Finally, it would be most useful to conduct longitudinal studies and also more detailed qualitative studies of these phenomena.