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IJOA
26,2
382
Received 18 May 2017
Revised 27 September 2017
Accepted 27 September 2017
International Journal of
Organizational Analysis
Vol. 26 No. 2, 2018
pp. 382-395
© Emerald Publishing Limited
1934-8835
DOI 10.1108/IJOA-05-2017-1170
Influence from organisational
factors on patient safety and
safety behaviour among nurses
and hospital staff
Espen Olsen
Faculty of Health Sciences, University of Stavanger, Norway
Abstract
Purpose – Hospital systems are expected to influence patient safety outcomes. The purpose of this study is
to explore organisational factors influencing patient safety and safety behaviour among nurses and other
hospital staff.
Design/methodology/approach – Based on a theoretical model, six dimensions were selected from the
hospital survey on patient safety culture. Moreover, one standardized dimension measuring safety behaviour
was included. The data were collected from 1,703 hospital workers completing a cross-sectional survey.
Findings – Confirmatory factor analysis and supplementary statistics supported the use of measurement
concepts applied in the study. A two-step statistical approach using structural equation modelling resulted in
a satisfactory final model illustrating direct and indirect influence of the explanatory factors used.
Research limitations/implications – The limitation of this study is the use of a cross-sectional survey
design.
Practical implications – The study illustrates how organisational factors are interconnected. The
theoretical model developed and tested can be applied to improve safety behaviour and patient safety in
hospital settings.
Social implications – The social implications of this study include the social relationships within the
hospital setting, illustrating how organisational factors influence both safety behaviour and perception of
patient safety levels.
Originality/value – A new theoretical model is developed and tested among hospital staff. The paper adds
a new perspective on how organisational factors influence perceived safety outcomes in hospital settings.
Keywords Performance management, Culture, Leadership, Human resource management, Safety,
Personnel psychology
Paper type Research paper
Introduction
Health-care organisations are trying to understand different methods and interventions that
can improve the hospital culture and create a positive environment to ensure patient safety.
Accordingly, models on the development of the improved hospital cultures need to be
developed. Such models can be incorporated in the quality improvement programs and
eventually become integrated parts of health-care workers’ routines, which involve
cooperating and working at different hospital levels.
The author would like to thank the participating hospital and all personnel giving their supporting to
the research project.
 After 15 years of the publication To error is human (Kohn et al., 2000) by the Institute of Influence from
Medicine, the levels of quality and patient safety still remain challenging (Chassin, 2013). organisational
Various efforts to promote workplace culture are still widely assumed to be the key factor
towards improvement of health-care deliveries (Morello et al., 2013; Pannick et al., 2014;
factors
Weaver et al., 2013). Culture improvement appears to be associated with different effects,
including better patient outcomes and enhanced health-care efficiency (Sacks et al., 2015).
Cooperation among different organisational levels on safety policies and practice is
something that has been emphasized as part of the general safety science literature (Zohar
383
and Luria, 2005). Today, this view has become widely acknowledged in health-care settings
(Dixon-Woods et al., 2014; Lawton et al., 2012; Wachter, 2012).
Several approaches and guidelines have been proposed on how to improve quality and
safety in health care but are not necessary based on empirical research of the hypothetical
relations among organizational factors at different levels. Thus, one essential research task
is to build on guidelines, theory and research to establish, explore and evolve models that
can illustrate and explain variance in safety outcomes.
This study builds on earlier studies that have modelled safety climate factors and safety
behaviour (Fugas et al., 2012; Olsen, 2010). Compared to health care, empirical research has
illustrated that the levels of safety climate might be better in other sectors (Olsen and Aase,
2010). To improve the levels of safety climate and outcomes, it is necessary to understand
how different safety climate concepts are related in health-care settings. Testing and
modifying theories using empirical data will provide health-care providers with increased
knowledge on how to improve health-care deliveries.
The safety climate approach captures attributes and elements of an organisation.
Compared to the broader organisational climate concept, safety climate is more specifically
related to safety. Safety climate assesses workforce perceptions of procedures and
behaviours in the work environment and captures how much priority is given to safety
compared to other organisational goals (Flin et al., 2006). When referring to organisational
factors in the current study, it will be limited to the safety climate perspective.
There is also a debate concerning whether safety climate and safety culture are
overlapping concepts. Whereas the safety climate and organisational climate approaches
more commonly applies quantitative methods, safety culture and organisational culture
climate approaches usually takes an ethnographic approach with the use of qualitative
methods. The safety climate approach is often described as taking a “snap shot” of the
underlying safety culture and of workers’ perceptions concerning organisational safety
factors (Flin, 2007; Olsen, 2009).
The aims of the present study were to:

measure the relevance of organisational factors in relation to teamwork and safety
in a hospital setting;

explore associations between organizational dimensions at different levels in a
hospital setting to predict safety outcomes; and

validate the findings by analysing the data from the nurses and other hospital staff
separately.

Based on safety climate theory and models (Flin, 2007; Zohar, 1993), a theoretical framework
and a mediational model predicting patient safety perception and safety behaviour were
proposed and applied as a framework (Figure 1). Figure 1 is based on a multilevel
perspective on safety climate, as suggested by researchers (Flin, 2007; Flin et al., 2006; Olsen,
2010; Zohar, 1993). This perspective emphasises that different levels in organisations
IJOA cooperate on safety policies and practices. No specific line defines what dimensions fall
26,2 within or outside the safety climate domain (Flin et al., 2006).

Theoretical background and hypotheses

An important task in research is to develop and test theoretical models that can be used to
understand and improve hospital systems (Chesluk et al., 2015). Most researchers within the
384 research field of patient safety will agree that a system approach is necessary to understand
and improve patient safety. The capabilities, cooperation and handovers in the higher levels
of hospital systems should function to support the daily work of nurses in the sharp end
where personnel meets the patients (Dixon-Woods et al., 2014). Hence, hospital care should
be an integrated process. Moreover, the intention of hospital managers should be to support
the development of integration, and to build systems that enforce barriers supporting
patient safety and reducing risk. Still, integrated care can potentially mean different things
to different people (Kodner and Spreeuwenberg, 2002). As such, the practical implications of
integrated care and the system perspectives will probably vary in different health-care
settings, for instance, depending on contextual factors and the training and competence of
managers and health-care providers.
The priorities and choices of managers signals what is truly important to organisational
members and can have a direct influence on teams and leaders (Schein, 1985). In a patient
safety perspective, this implies that hospital managers have the potential to positively
influence patient safety leadership and the safety climate of hospital units. The view that top
managers influence local supervisory practices is in accordance with a multilevel
perspective on safety climate (Zohar, 2002a, 2002b, 2003; Zohar and Luria, 2003), which can
adequately be used to understand and improve health-care systems (Flin, 2007). To add
understanding of what types of leadership influences safety outcomes, transformational
leadership or other types of leadership theories can be applied (Zohar, 2002a).
Transformational leadership can function as an antecedent of climate strength (Zohar and
Tenne-Gazit, 2008). Additionally, transformational leadership at the group level potentially
has a direct influence on employee performance and an indirect influence via climate in units
(Liao and Chuang, 2007). Employees will internalize implied obligations of leadership-based
social exchange by expanding their role and behaving in ways consistent with contextual
behavioural expectations. It is therefore expected that some of the relationship between
leadership behaviour and safety outcomes might be moderated by safety climate in units
(Hofmann et al., 2003).
Research suggests that patient safety related leadership styles at different levels are
expected to have direct and indirect influence on patient safety (Flin, 2007). Still,

H3

Figure 1. Safety climate – Safety climate Safety climate – Safety outcomes

hospal level Safety leadership – unit level
Theoretical unit level
framework and Hospital management Organisaonal learning –
Safety behaviour
hypothesized support for paent safety H1 H4 Connuous improvement H5
Supervisor/manager
mediational model to expectaons & acons
promong safety
predict safety Teamwork across Overall percepon of
Staffing
behaviour and overall hospital units paent safety
patient safety
perception
H2
organisational climate theories often neglect how factors in the organisations influence Influence from
leaders. However, leadership in health-care settings does not exist in a vacuum, and the organisational
culture and context of organisations can influence the role leaders take. Understanding the
factors contributing to leadership is fundamental to ensure a future supply of leaders that
factors
are able to positively influence patient safety and employee outcomes (Cummings et al.,
2008). In the current study, hospital management and teamwork across units are considered
to be key contextual factors influencing the patient safety leadership and safety climate of
units. This view corresponds with research suggesting that organisational factors influence 385
the functioning of teams, in addition to leader behaviour of such teams (Cummings et al.,
2008).
The quality of teamwork and cooperation can be poor in hospital settings. One study
revealed that only 33 per cent of nurses rated the quality of collaboration and
communication with the physicians as high or very high. Moreover, results indicated that it
was difficult for nurses to speak up about poor cooperation and to suggest improvements
(Thomas et al., 2003). Cooperation and teamwork across units might be good or
dysfunctional. Research suggests that poor cooperation and incivility often can be the case
in hospital settings, because of power struggles, conflicting values, work expectations and
organisational conditions (Hallberg, 2007). Moreover, professional cultures can hinder inter-
professional collaborative practice (Hall, 2005). In fact, instead of valuing cooperation and
teamwork, opposing values like competition, might be evident. Physicians might often be
motivated by accomplishment and power instead of affiliation. One reason for this is that
prior to becoming physicians’, experts typically have competed for good grades and the best
jobs. Outperforming others might have been more important than teamwork. Hence,
teamwork and consensus building are not necessary parts of expert cultures in hospital
settings (Atchison and Bujak, 2001). Additionally, attributes related to the organisation have
the potential to increase bullying and burnout (Giorgi et al., 2016), which are incompatible
with the development and improvement of patient safety.
Another challenge is that hospitals rely on effective, inter-professional teamwork but
typically do not support it (Chesluk et al., 2015). Challenges and internal boundaries might
include scattered patients, fragmented information, uncoordinated teams and unreliable
processes that can impact the timeliness and safety of care. To handle these challenges
hospital members must rely on personal presence and memory. Chesluk et al. (2015)
suggested that hospitals must make an effort towards pulling health-care teams together, as
it is likely that a higher level of non-integrated care will influence patient safety leadership
and safety climates of hospital units, in a negative manner. Rather than teamwork across
units the opposite may be the case, as there can be unresolved conflicts between hospital
groups and different work processes across departments. This, in turn, is related to
increased patient risk (Chesluk et al., 2015). Hence, research (Chesluk et al., 2015) suggests
that more teamwork across units has the potential to increase the premises and performance
of unit leaders, and may also have a direct influence on safety climate in hospital units.
It has been suggested that workers should take the time to stop and resolve unexpected
problems as they arise (Weick and Sutcliffe, 2001). However, when the pressure on
production and in the organisation is high, taking time to resolve immediate problems may
be difficult. Different pressures will potentially reduce workers mindfulness, which again
may decrease organisations’ ability to manage the unexpected (Weick and Sutcliffe, 2001).
As such, safety climate and safety behaviour are expected to be related (Dejoy et al., 1995;
Flin et al., 2006; Olsen, 2010; Zohar, 1993).
Organisational learning and continuous improvement have been considered key
elements to positively increase patient safety levels. A recent review study (Goh et al., 2013)
IJOA concluded that health-care leaders should foster a patient safety culture, where collaborative
26,2 learning is encouraged. Moreover, blame culture should be replaced, patient safety
prioritized and individuals who identify serious mistakes should be rewarded. Developing
learning cultures in hospital setting requires strong leaders who promote safety and ensure
appropriate resources. Safety culture and learning are strongly associated in the literature,
and it is difficult to imagine a strong safety culture, where learning elements are not
386 incorporated. Factors related to learning are likely to be helpful in supporting a patient
safety culture, as preventing mistakes could reduce patient risks (Goh et al., 2013). Key
elements of learning cultures are the capability to learn from mistakes, have group problem-
solving capability and allow knowledge transfer (Kemper and Boyle, 2009). Leaders in
health-care settings play a crucial role in supporting a culture of learning, which again may
result in several positive hospital outcomes (Odwazny et al., 2005).
Staffing levels have become an established indicator applied to predict patient safety
outcomes. A recent review of 17 quantitative studies (Papastavrou et al., 2014) explored
associations between rationing of nursing care and outcomes in health-care setting. Rationing
was related to patient falls, nosocomial infections and low patient and nurse satisfaction levels.
Generally, rationing and staffing levels appears to be important organisational variables,
associated with patient safety and quality of care (Papastavrou et al., 2014). In another study
(Paquet et al., 2013), it was revealed that reduced absenteeism, overtime and nurse/patient
ratios mediated the influence from leadership on patient safety outcomes. Leaders have the
possibility to develop and influence staffing adequacy (Houser, 2003; Laschinger and Leiter,
2006). However, it is likely that hospital managers also have the power to influence staffing
adequacy, for instance, through budgets and different types of decision-making.
In the current study, hospital-level dimensions are expected to influence safety
leadership and safety climate at the unit level, as illustrated in Figure 1. Further,
safety leadership at the unit level is expected to influence safety climate at the same level.
Safety leadership and safety climate at the unit level are finally expected to influence
perception of patient safety and safety behaviour. Hospital level dimensions refer to hospital
management support for patient safety and teamwork across hospital units.
Safety leadership at the unit level refers to supervisor/manager expectations and actions
promoting safety. Safety climate at the unit level refers to organisational learning and
continuous improvement and staffing.
Safety outcomes refer to overall perceptions of patient safety and safety behavior:
H1. Safety climate at the hospital level is positively related to safety leadership.
H2. Safety climate at the hospital level is positively related to safety climate at the unit
level.
H3. Safety leadership at the unit level is positively related to safety outcomes.
H4. Safety leadership at the unit level is positively related to safety climate at the unit
level.
H5. Safety climate at the unit level is positively related to safety outcomes.

Methods
Study design
The study used cross-sectional survey data collected from employed hospital staffs at a
hospital in Norway. The Norwegian Centre for Research Data registered and approved the
study’s procedures.
Sample and setting Influence from
The study was conducted in a relatively large regional Norwegian university hospital. The organisational
target group included health-care workers at the hospital, as well as other personnel
employed primarily in the same working environment as the health-care personnel. A total
factors
of 1,703 workers answered the survey, resulting in a response rate of 49 per cent; 89 per cent
of these had direct patient contact; 60 per cent worked between 20 and 37 h per week. Nurses
with or without specialist education represented the largest proportion (42 per cent) of the 387
sample, followed by physicians (11 per cent).
The survey was hand-delivered to the target group via department leaders who were
provided information from research group representatives about the research project and
anonymity of responses. General information about the survey was also included on the
cover of the survey. The respondents were asked to return the completed surveys in sealed
envelopes, which were returned to the research group. Finally, completed surveys were
scanned to develop a SPSS-file containing the data.
The sample was divided in three sub-samples according to the aim of the paper; nurses
(n = 750), other personnel (n = 953) and the total sample (n = 1703).

Measures
Several instruments have been developed to measure safety climate across sectors (Colla
et al., 2005; Flin, 2007; Flin et al., 2006), and the existing research has identified some core
variables used to measure safety climate (Flin, 2007). In the current study, a validated
Norwegian version of the hospital survey on patient safety culture (HSOPSC) was selected
as the instrument (Olsen, 2008). HSOPSC has been used in more than 30 countries worldwide
(Hammer et al., 2011). The psychometric qualities of HSOPSC compared to other
instruments have been well established (Flin, 2007). HSOPSC consists of two single-item
outcome measures and two overall patient safety outcome dimensions that have been
assessed to validate ten safety climate dimensions (Sorra and Nieva, 2004). Items in HSOPSC
are measured on five-point (1 to 5) Likert-type scales with verbal anchors.
In accordance with Figure 1, the following dimensions were selected from HSOPSC.
Hospital management support for patient safety. This dimension consisted of three items
measuring employees’ perception of hospital management support for patient safety. A
sample item includes, “The actions of hospital management show that patient safety is a top
priority”.
Teamwork across hospital units. The second dimension consisted of four items
measuring workers perception of teamwork across units. A sample item includes, “There is
a good cooperation among hospital units that need to work together”.
Supervisor/manager expectations and actions promoting safety. The third dimension
consisted of four items measuring workers’ perceptions of their unit leader expectations and
actions promoting safety. A sample item includes, “My supervisor/manager seriously
considers staff suggestions for improving patient safety”.
Organisational learning – continuous improvement. This dimension consisted of three
items measuring workers perception of organisational learning and continuous
improvement within the unit. A sample item includes, “We are actively doing things to
improve patient safety”.
Staffing. Staffing dimension was measured by four items regarding workers perceptions
of adequate staffing level within the unit. A sample item includes, “We have enough staff to
handle the workload”.
IJOA Overall perception of patient safety. This dimension comprised four items measuring
26,2 workers overall perception of patient safety. A sample item includes, “Patient safety is never
sacrificed to get more work done”.
Stop working in dangerous situations (safety behaviour). Although a safety behaviour
dimension is not part of HSOPSC, it was added to test the hypothesised model (Figure 1).
This measure comprised three items concerning workers’ safety behaviour and their
388 decision to stop working in dangerous situations. Preoccupation with failure and proactive
wariness of the unexpected are described as key components of mindful organising and
implementation in everyday hospital practice (Vogus and Hilligoss, 2016). This dimension
has previously been validated (Olsen, 2010; Olsen and Aase, 2010) and was considered
adequate for the current study. Items were measured on a five-point Likert scale (1 =
strongly disagree, 2 = disagree, 3 = neither, 4 = agree and 5 = strongly agree). The items
were I ask my colleagues to stop work that is dangerously accomplished, I notify if I see
dangerous situations and I stop working if I consider the situation to be dangerous for me or
my colleagues.

Analysis plan
AMOS 21 (Arbuckle, 2012) was used to perform confirmatory factor analysis (CFA) and
structural equation modelling (SEM). The maximum likelihood estimation was used in
AMOS. All testing was assessed exclusively on dimensions in Figure 1, which is of study
interest. The fit measures applied included comparative fit index (CFI), root mean square
error of approximation (RMSEA), incremental fit index (IFI) and Tucker–Lewis INDEX
(TLI). Thresholds of acceptable fit were as follows and included a holistic assessment based
on of several indicators (Hair et al., 2006): CFI (>0.90), RMSEA (<0.08), IFI (>0.90), TLI
(>0.90). The remaining analysis of the data was generated using SPSS 21 (SPSS, 2012).
Missing data were handled with the series mean procedure in SPSS before estimating CFA
and SEM using AMOS. Composite scale scores for included dimensions were created prior
to the treatment of missing data by obtaining the mean of the responses to items of the
dimension after reverse coding the reverse items (Sorra and Nieva, 2004). Consequently, 1
was the lowest possible score on composite scores while 5 was the highest. Cronbach’s alpha
was estimated to determine the internal consistency of the measures. Pearson’s R was
estimated to examine the discriminant validity and associations among measures.
Analytical techniques to test mediation effects are still evolving (Shrout and Bolger,
2002). The aim of this study was to reveal both direct and indirect effects using a system
safety and multilevel perspective. In the development of theoretical frameworks and model
testing, it has been recommended to use an exploratory approach to remove insignificant
relationships (Zhao et al., 2010). Two sequential steps using SEM and an exploratory
approach were therefore used to develop a final structural model. In the first step, all
structural relations were specified according to Figure 1 and tested using three samples:
nurses, other hospital staff and the total sample. A criteria was specified that structural
relations between two latent factors should be significantly valid (p < 0.05) in at least two of
the three samples. Structural relations that did not meet this criteria were removed before
proceeding to step 2 to obtain a final and robust model consisting of mainly significant
structural associations.

Results
Concept validity and reliability
Confirmatory factor analysis conducted using maximum likelihood extraction yielded a
satisfactory fit among nurses (CFI: 0.93, RMSEA: 0.047, IFI: 0.93, TLI: 0.90), other hospital
staff (CFI: 0.90, RMSEA: 0.052, IFI: 0.90, TLI: 0.88) and the total sample (CFI: 0.92, RMSEA: Influence from
0.049, IFI: 0.92, TLI: 0.89). Hence, the results do not suggest that factorial structures clusters organisational
differently across subsamples.
Descriptive statistics are presented in Table I. Cronbach’s alpha and Pearson’s R
factors
supported the validity and reliability of measures (Table II). Organizational learning–
continuous improvement had the lowest Cronbach’s alpha score (0.53), but the concept
validity and reliability were considered satisfactory based on CFA. It is also beneficial not to
change standardized HSOPSC dimensions to allow future research to compare the findings
389
across studies and conduct meta-analyses based on the same dimensions.

Structural equation modelling

Step 1. In the first testing of structural relations in Figure 1, some of the paths, specifically
teamwork across hospital units ! Staffing (2), Patient safety leadership ! Overall
perception of patient safety (3), Patient safety leadership ! Safety behaviour (2), had two or
more insignificant relationships (number of insignificant beta coefficients in parentheses).
SEM indicated satisfactory model fit among nurses (CFI: 0.92, RMSEA: 0.046, IFI: 0.92,
TLI: 0.91), other hospital staff (CFI: 0.90, RMSEA: 0.052, IFI: 0.90, TLI: 0.88) and the total
sample (CFI: 0.91, RMSEA: 0.48, IFI: 0.91, TLI: 0.90). Nevertheless, because of the
insignificant relations, some model adjustment had to be made based on Step 1.
Step 2. In Step 2, all paths with two or more insignificant relationships in Step 1 were
removed before conducting the final testing. Assessments in Step 2 yielded satisfactory
model fit among nurses (CFI: 0.92, RMSEA: 0.047, IFI: 0.92, TLI: 0.90), other hospital staff
(CFI: 0.90, RMSEA: 0.051, IFI: 0.90, TLI: 0.88) and the total sample (CFI: 0.92, RMSEA: 0.048,
IFI: 0.92, TLI: 0.89).

Total sample Nurses Other personnel

Dimensions Mean SD Mean SD Mean SD

1. Hospital management support for patient safety 2.79 0.77 2.67 0.74 2.88 0.77
2. Teamwork across units 3.11 0.53 3.08 0.52 3.08 0.54
3. Supervisor/manager expectations and actions promoting safety 3.93 0.65 3.93 0.65 3.93 0.65
4. Organizational learning–continuous improvement 3.41 0.65 3.42 0.65 3.41 0.66
5. Staffing 3.28 0.79 3.28 0.79 3.27 0.79
6. Safety behaviour – stop working in dangerous situations 3.89 0.55 3.97 0.55 3.90 0.60 Table I.
7.Overall perceptions of patient safety 3.53 0.71 3.47 0.69 3.58 0.73 Descriptive statistics

Pearson correlations (total sample)

Dimensions 1 2 3 4 5 6 7

1. Hospital management support for patient safety (0.78)

2. Teamwork across units 0.44 (0.68)
3. Supervisor/manager expectations and actions promoting safety 0.29 0.27 (0.76)
4. Organizational learning–continuous improvement 0.29 0.25 0.47 (0.53)
5. Staffing 0.43 0.27 0.36 0.26 (0.68)
6. Safety behaviour – stop working in dangerous situations 0.18 0.20 0.36 0.33 0.12 (0.63)
Table II.
7. Overall perceptions of patient safety 0.47 0.35 0.46 0.40 0.58 0.31 (0.75) Pearson correlations
and Cronbach’s alpha
Notes: All correlations are significant at the p < 0.01 level. Total sample (in diagonal)
IJOA After removing several of the original paths in Figure 1, only two of the paths had
26,2 insignificant relationships (Figure 2). These were the staffing influence on safety behaviour
among nurses and patient safety leadership influence on safety behaviour among other
hospital staff. The remaining paths were significant; therefore, the final structural model
was considered satisfactory and robust. Surprisingly, and opposite of what was expected,
staffing had a negative influence on safety behaviour among other hospital staff and the
390 total sample.

Discussion
Generally, the results support the measurement concepts applied in the current study. All
items had satisfactory statistical variation, and correlations among concepts were adequate,
illustrating discriminant validity. With the exception of organizational learning–continuous
improvement, which had a marginally lower reliability score, reliability coefficients,
assessed by Cronbach’s alphas, were satisfactory. The cross-validation approach using
confirmatory factor analysis revealed that measurement concepts generally fit the data
within recommended criteria among both nurses and other hospital staff, as well as in the
total sample. As such, the psychometric properties supported the use of measurement
concepts.
The overall finding of the current study was that several factors in combination
contribute directly and indirectly to the variation in the outcome measures. As such, the
organisational factors grasp dimensions and illustrate structural relationships that are
relevant for the variation in perception of patient safety and safety behaviour. Cross-
validation indicated that relationships have relevance across settings, enhancing the
theoretical robustness of findings. Hence, this study contributes to improved understanding
of how structural and cultural characteristics are associated, which is crucial to improve
system safety in health-care settings (Goh et al., 2013).
The findings support the use of a multilevel perspective to understand and improve
patient safety. Higher levels on hospital level dimensions positively influenced safety
leadership and safety climate at the unit level, which subsequently influenced the outcome
measures. The majority of relationships in the final model were robust, with significant
findings across sub-samples.
An essential question based on the theoretical model applied is whether the proximal or
the distal factors have the highest influence on the outcome factors. Empirical findings

Hospital mgmt. n.s./0.26***/0.18*** Paent safety 0.32***/n.s./ 0.15* Safety

support for
leadership behaviour
paent safety
0.65***/0.59***/0.61*** 0.31***/0.70***/0.51***
0.25***/0.23***/0.24*** 0.33***/ 0.22***/0.24***
Org. learning Overall
Teamwork 0.33***/0.50***/0.41***
connous percepon of
across units n.s./0.15**/0.13**
improvement paent safety
n.s./–0.15**/ –0.12**
0.22***/0.31***/0.27***
0.51***/0.45***/0.48***
0.68***/0.53***/ 0.61***
Nurses/Other personnel/Total sample
Staffing
Figure 2.
Modified mediational
model to predict Notes: Standardized beta coefficients are distributed in the following order: Nurses/Other
overall patient safety personnel/Total sample. The full model including manifest and latent variable were estimated,
perception and safety but only latent factors are illustrated to ease the presentation. Safety behaviour: Stop working
behaviour
in dangerous situations. n.s. = not significant; *p < 0.05; **p < 0.01; ***p < 0.001
suggest that patient safety leadership has a very strong influence on organizational learning Influence from
and continuous improvement, which again have a strong influence on safety behaviour. organisational
Another finding revealed strong influence of staffing on overall perception of patient safety.
Hospital leaders have the possibility of maintaining staffing adequacy (Houser, 2003;
factors
Laschinger and Leiter, 2006). The positive influence of patient safety leadership on staffing
supports this assumption. Staffing levels also greatly depends on hospital management’s
support of patient safety. In other words, leaders at different hospital levels influence the
perceptions of staffing adequacy. Interestingly, staffing was not significantly related to 391
safety behaviour among nurses. Contrary to what was expected, staffing had negative
influence on safety behaviour among other hospital staff and for the total sample. One
interpretation of this finding is that the need for critical safety behaviour is generally lower
when staffing level is adequate and high, for instance because of better planning and
proactive risk understanding. However, results among other personnel and the total sample
suggest that it is not efficient to have hospital workers that have to stop working (safety
behaviour) because of inadequate staffing.
Teamwork across units plays an important role in influencing patient safety leadership,
as well as organisational learning and continuous improvement. As such, both teamwork
across units and hospital management support for patient safety are distal factors that have
a great potential to positively influence patient safety from the blunt end. Closer to the sharp
end, patient safety leadership has a direct positive influence on safety behaviour among
nurses but not a significant influence on overall perception of patient safety. Conclusively,
the results suggest that unit leaders in hospitals have a great responsibility to influence the
functioning of unit safety climate and motivate unit staff to learning. Moreover, it is
essential that leaders build adequate staffing and positive patient safety practices.
Developing unit safety climate depends on several input factors, such as team tasks,
team composition and organisational support. Several factors such as leadership, team
objectives and reflexivity are crucial (West, 2012), to achieve positive outcomes of
teamwork. These theoretical perspectives underlie the interpretation of the current study.
Given the general input and general mechanisms of the functioning of teams, it is essential
that hospital leaders assess and adapt workload in teams to the general staffing level, and
additionally, when possible, adjust staffing levels with the use of skilled substitutes. If
leaders fail in these areas, the empirical investigation of this study suggest that the patient
safety level in hospitals will decline.
This study has several limitations. All components assessed with SEM are based on
cross-sectional data; therefore, associations are not proven over time. Self-reported measures
were also applied, which could lead to measurement bias (Christian et al., 2009). However, to
increase objectivity and validity psychometric techniques were used. Finally, it is important
to emphasize that other safety climate factors could have been included in the current study
based on the safety climate approach.

Conclusions
Based on the two-step approach applied in the current study, it was expected that some
adjustment of the proposed theoretical model was needed. The benefits of the SEM
approach are that it allows for theoretical model modification (Zhao et al., 2010); thus, it is an
appropriate exploratory method. This approach contributes to the building of theory and
must be considered valuable in sense of supporting the development of health-care
improvement strategies. Models illustrating how concepts are interrelated contribute to
support nomothetic validity, explaining how organisational factors are interrelated. Future
research can build on theoretical associations between concepts, as well as develop empirical
IJOA evidence regarding associations between concepts used in this study. The findings
26,2 demonstrate that unit safety climate and outcomes measures do not exist in a vacuum.
Specifically, it is illustrated that leadership, management and teamwork across units are
related both directly and indirectly. Hospitals should emphasize building cultures of patient
safety, by incorporating factors illustrated in the current study. A multilevel approach
including managers and leaders at all hospital levels, should be applied to achieve this goal,
392 and secure teamwork across units. Focusing on teamwork across units will potentially have
a great influence on unit safety climate and will contribute directly and indirectly towards
improving patient safety. When recruiting hospital managers and leaders, it is important to
consider personality traits, skills and attitudes which might support patient safety and a
systems approach.
Conclusively, unit leaders must work to improve organisational learning and continuous
improvement, which aims at developing learning cultures at unit levels. It is also crucial that
unit leaders ensure and maintain staffing adequacy or, when possible, adjust workload
according to staffing levels. Unit leaders should motivate hospital staff to engage in safety
behaviour and to be mindful of expected and unexpected risk.

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Corresponding author
Espen Olsen can be contacted at: espen.olsen@uis.no

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