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Year : 2020  |  Volume : 23  |  Issue : 4  |  Page : 470-475

Turkish surgical nurses' attitudes related to patient safety: A questionnaire study

Department of Nursing, Namik Kemal University, Merkez-Tekirdağ, Turkey

Date of Submission31-Dec-2018
Date of Acceptance20-Dec-2019
Date of Web Publication4-Apr-2020

Correspondence Address:
Dr. E Önler
Department of Nursing, Tekirdag Namik Kemal University, Degirmenalti Campus, School of Health, Suleymanpasa-Tekirdag
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_677_18

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Background: Surgical nurses work in demanding environments and play a vital role in maintaining and promoting patient safety due to the nature of their work. Hence it is important to know their attitudes toward patient safety. Aim: This research aimed to evaluate the patient safety attitudes of Turkish surgical nurses. Methods and Materials: This was a descriptive cross-sectional and questionnaire research. Data were collected from August 2015–January 2016 using the staff information form and the safety attitudes questionnaire (SAQ). The study population included 231 nurses who work in operating rooms, surgical intensive care, and surgical wards of four hospitals in western Turkey. Data were analyzed with frequency, percentage, mean, standard deviation, the Mann Whitney U test, and Kruskal Wallis tests using the SPSS 18. Results: The teamwork and safety climate scores of operating room nurses were higher than the scores of surgical intensive care and ward nurses. The stress recognition scores of surgical ward nurses were the highest, followed by the scores of the operating room and surgical intensive care nurses. The perception of management scores of operating room nurses was higher than those of surgical ward nurses, and nurses ages 18–30 were higher than those of nurses ages 31–40. None of the six domains of safety culture, including job satisfaction, teamwork, safety climate, the perception of management, stress recognition, and working conditions achieved a positive mean score over 75. Conclusion: This research paper provides an evaluation of the safety attitudes of surgical nurses. Findings can provide information for healthcare leaders to improve the safety culture.

Keywords: Nursing, patient safety, surgical units

How to cite this article:
Bahar S, Önler E. Turkish surgical nurses' attitudes related to patient safety: A questionnaire study. Niger J Clin Pract 2020;23:470-5

How to cite this URL:
Bahar S, Önler E. Turkish surgical nurses' attitudes related to patient safety: A questionnaire study. Niger J Clin Pract [serial online] 2020 [cited 2021 Sep 23];23:470-5. Available from:

   Introduction Top

Patient safety culture is a multilevel construct, including teamwork, safety climate, job satisfaction, working conditions, stress recognition, perception of management, and more.[1] Nurses play a vital role in maintaining and promoting patient safety due to the nature of their work,[2] and their assessments related to patient safety might be used as a valid indicator of overall hospital safety.[3]

Improving the multilevel construct of the factors that contribute to institutional safety is critical to ensuring patient safety.[4] Research on those safety factors can provide the needed information for healthcare leaders to improve safety outcomes. Despite that fact, there are few studies that focus on safety culture assessment in the perioperative setting.[5]

Since surgical units are highly complex and hazardous environments that have a high potential for patient harm and adverse events, it is essential to determine those factors which are most likely to contribute to a safer culture.[6] Surgical units represent a different culture than nonsurgical units. While their overall perceptions of safety are better than nonsurgical units, they underperform in interprofessional communication.[7]

In Wang and Tao's study[8] “teamwork within units” and “organizational learning and continuous improvement” were reported as strengths in surgical units, while “staffing” and “nonpunitive response to errors” were reported as weaknesses. In another study in surgical wards, nurses generally reported positive job satisfaction and good teamwork in their units, but there were indications that improvements in organizational management are needed.[9] Variability in perioperative safety culture across units was found in research on operating rooms (ORs) and intensive care units (ICUs).[10]

Several studies have sought to determine which potential factors influence the safety culture of nursing units and these include age, job experience, gender, safety training, the type of unit, a staff's position, job type, weekly working hours, and hospital type.[1],[2],[5],[7],[9],[11],[12],[13],[14],[15],[16],[17]

The goal of this research was to evaluate surgical nurses' patient safety attitudes in relation to the provision of safe healthcare. The following three main research questions were answered:

Q1: Do surgical nurses differ in their attitudes toward patient safety according to their age?

Q2: Do surgical nurses differ in their attitudes toward patient safety according to their working units?

Q3: Do surgical nurses differ in their attitudes toward patient safety according to their job experience?

   Materials and Methods Top

Design, setting, and participants

This study used a descriptive cross-sectional design with self-administered questionnaires. The study was conducted in surgical units, including the surgical wards, surgical intensive care units (SICU), and operating rooms (ORs) in four public hospitals (two state and two university hospitals) located in western Turkey. The total number of nurses employed in the surgical units was 409; including 138 ward nurses, 157 SICU nurses, and 114 OR nurses. A stratified sampling method was used in the selection of the sample. The minimum study population required to make statistical estimates with 95% confidence and a ± 5% sampling error was calculated to be 198 nurses (67 surgical ward nurses, 76 SICU, and 55 OR nurses). As a result, the study population included 231 surgical nurses (57.75 of the sample population), including 89 surgical ward nurses, 83 SICU nurses, and 59 OR nurses who had agreed to participate in the study and worked at least one year in their current hospital. The period of one year was regarded to be adequate for perceiving the safety culture in the organization.

Data collection

Data were collected from August 2015–January 2016 using the safety attitudes questionnaire and staff information forms. The researchers visited the hospitals and provided information about the aim of the study to staff before distributing questionnaires to voluntary participants. The participants answered the questionnaire anonymously, and the questionnaire took approximately 15 min to complete. There was no time limit for answering the questionnaire, and the questionnaires were collected by the researcher after they were completed. The researchers obtained permission from Baykal,[18] one of the authors who adapted the SAQ to Turkish, to use the scale.

   Research Instrument Top

Safety attitudes questionnaire

Safety attitudes questionnaire, which has been used extensively internationally, was originally developed by Sexton et al. (2006) to determine the health staff's attitudes toward patient safety.[19] There are different versions of the scale that can be used in ICUs, ORs, and so on. The Turkish version that can be used in all departments was translated and has been validated by Baykal et al.[18] The Turkish version of the SAQ includes 46 items and 6 domains, including job satisfaction (11 items), teamwork (12 items), safety climate (5 items), perception of management (7 items), stress recognition (5 items), and working conditions (6 items).[18] All items are based on a five-point Likert type response scale (“strongly disagree” to “strongly agree“). This scale was converted to a 0–100 scale: 0, strongly disagree; 25, slightly disagree; 50, neutral; 75, slightly agree; 100, strongly agree. SAQ scale scores greater than 75 (out of 100) were considered favourable.[11],[15],[20] Some items on the scale (numbers 21., 36., 37., 38., 39., 40., 41., 42., 43., and 45) are negatively worded. Increases in the total score of the scale indicate that employees' attitudes toward patient safety are more positive. Cronbach's alpha values for the Turkish version of the SAQ ranged from 0.72–0.93 in the original reliability and validity study for the total scale and its domains.[18] In this study, Cronbach's alpha values ranged from 0.71–0.89 for the total scale and its domains.

Staff information form

The staff information form included three background demographic variables: working unit, age, and job experience.


This study was approved by the Research Ethics Committee of Faculty of Medicine at the Tekirdaǧ Namık Kemal University (Protocol number 2015/108/10/03). Approval from the hospitals and the informed consent of the staff were obtained.

Data analysis

Data were analyzed using the SPSS (statistical package for social sciences) software version 18 IBM Corp, Chicago, Illinois. Along with descriptive statistics such as frequency, percentage, mean, and standard deviation, the Mann Whitney U test was used to assess whether the difference in the means of two groups was statistically significant. Kruskal Wallis was used to assessing whether the difference in means of more than two groups was statistically significant, and the Mann Whitney U test was used to determine which group caused the difference. The statistical significance level was regarded as P < 0.05.

   Results Top

Staff demographics

The number of nurses between 18 and 30 years old was 40.7%. About 38% of nurses were ward nurses, 25.5% were OR nurses, and 35.9% were SICU nurses. In addition, 31.6% of the nurses had 1–5 years of job experience [Table 1].
Table 1: Demographics of the study participants

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Patient safety attitudes of surgical nurses in the sample population

There was a statistically significant difference across the working unit for all domains except job satisfaction and working conditions. None of the six domains achieved a positive mean score over 75. While the lowest scores belonged to safety climate (35.76 ± 17.48), the job satisfaction scores (50.67 ± 17.24) were the highest. The teamwork scores (KW = 14.135, P = 0.001), safety climate scores (KW = 12.357, P = 0.002), and perception of management scores (KW = 6.733, P = 0.035) of the OR nurses were all statistically significantly higher than those of the SICU nurses and the surgical ward nurses. However, the stress recognition scores of the surgical ward nurses were statistically significantly higher than those of the OR nurses and the SICU nurses (P = 0.000) [Table 2]. There was no statistically significant difference across the age groups for all domains except for perception of management. The perception of management scores of nurses between 18 and 30 years old was statistically significantly higher than the scores of nurses between 31 and 40 years old (KW = 11.292, P = 0.004) [Table 3]. There was no statistically significant difference across years of job experience for all domains (P > 0.05) [Table 4].
Table 2: Patient safety attitudes scores by working unit

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Table 3: Patient safety attitudes scores by age (n= 231)

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Table 4: Patient safety attitudes scores by job experience

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   Discussion Top

Measuring patient safety culture enables the identification of aspects that need to be improved.[20] In this research, none of the six domains—teamwork, safety climate, perception of management, stress recognition, job satisfaction, and working conditions—achieved a positive mean score over 75. This result indicates that all domains need improvement.

The lowest score belonged to safety climate. Safety climate is defined as the staff's perceptions of a strong and proactive organizational commitment to safety and includes questions related to error reporting and working in accordance with rules or guidelines.[19]

In a study by Olsson et al., safety climate was reported to be one of the weakest factors, which was similar to the findings of the study presented here.[9] Underreporting of adverse events is also known to be a major healthcare concern universally.[21]

Job satisfaction, which is defined as positivity about one's work experience,[19] had the highest score but it could not achieve a positive mean score over 75. This result is consistent with previous studies that found that although job satisfaction scored highest among the SAQ domains, job satisfaction levels were evaluated as unsatisfactory because scores did not reach the cutoff point for a positive mean score.[13],[16] It has also been found that nurses who are dissatisfied in their work are more prone to making medical errors.[22] Thus, nursing managers should attach importance to improving nurses' job satisfaction levels. This can be done by improving working conditions and teamwork, which previous studies have found to be important aspects of increasing job satisfaction.[22],[23]

There was a statistically significant difference across the working unit for all domains except job satisfaction and working conditions. OR nurses perceived teamwork to be better than SICU and surgical ward nurses (P = 0.001). Teamwork among healthcare professionals is important for ensuring patient safety, as well as for increasing job satisfaction and decreasing the stress levels of staff.[24],[25],[26] The results of this study are similar to those of another study that assessed OR staff's attitudes toward patient safety and found the strongest positive responses among all domains the SAQ were reported for teamwork.[14] These results may be attributable to the vital importance of teamwork in the operating room.

OR nurses reported a better safety climate (P = 0.002) than both surgical ward nurses and SICU nurses, and they had a better perception of management (P = 0.035) than surgical ward nurses. These results may be because safety climate strategies such as the WHO's surgical safety checklist are most focused on ORs rather than in SICUs and surgical wards.

Stress recognition relates to nurses' recognition of the influence of work-related stressors on their job performance.[19] Unlike the other domains of the SAQ, which ask nurses to assess a variety of influences on the safety culture of their workplace, stress recognition requires them to assess themselves.[16] This difference in the focus of assessment has to be taken into consideration while interpreting findings related to this domain. Positive attitudes toward stress recognition were more evident in the surgical ward nurses and OR nurses than in the SICU nurses (P = 0.000). Surgical ward nurses and OR nurses seem to have better mechanisms for recognizing stress in their jobs than SICU nurses.

Across all domains of the SAQ, the only perception of management resulted in statistically significant differences (P > 0.05), based on the difference in age, while years of job experience did not result in any statistically significant differences. Managers play a vital role in safety and quality improvement.[27],[28] Interestingly, the perception of management scores of nurses between 18 and 30 years old was significantly higher than those same scores of nurses between 31 and 40 years old (P = 0.004). This finding does contrast with previous studies in which the safety attitudes of older nurses rated higher than those of their younger colleagues.[12],[13],[14],[15] There could be two explanations for this finding. Firstly, this may be because experienced nurses can evaluate safety issues more critically than inexperienced nurses. Secondly, it is also possible that young nurses are more supported by management than older nurses because they are inexperienced. A Swedish study on surgical wards unexpectedly found that long job experience among nurses was related to lower adherence to the use of disposable gloves.[9] Thus, we suggest that managers provide more support regarding safety and adequately supervise compliance with protocols among older nurses as much as younger ones.

Limitations of the study

This study is not without limitations. Data were collected from the surgical units of four Turkish hospitals. Some nurses were on maternity or annual leave. Some nurses refused to participate in the study, while others could not complete the questionnaire because of intense work pressure. Therefore, the results of this study are limited to the responses given by the nurses in the sample group and cannot be generalized to all Turkish hospitals and all units of the hospitals in the sample population.

   Conclusions and Clinical Implications Top

This study has provided an overview for healthcare leaders regarding how surgical nurses perceive safety culture. We evaluated 6 domains of safety culture including job satisfaction, teamwork, safety climate, the perception of management, stress recognition, and working conditions. None of the six domains achieved a positive mean score over 75. We recommend providing more support and effective strategies to increase the safety culture of surgical nurses, for surgical ward and SICU nurses. Moreover, we recommend further studies using both quantitative and qualitative methods to gain a deeper understanding of the safety attitudes of health staff.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]


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