Safety Culture at Primary Healthcare Level: A Cross-Sectional Study among Employees with a Leadership Role

Patient safety culture is part of the patient safety concept and is defined as a product of the attitudes, values, competencies and patterns of behaviour of individuals and groups that determine healthcare in an organisation (1).

The safety of patients at the primary level of healthcare varies considerably from the safety of patients at a secondary or tertiary level. At the primary level, there is a very large amount of contact with patients, which are usually complex interactions (2), and the uncertainty that is typical of work at the primary level is very important (3). So, patient safety here should focus on accepting uncertainty, exploring probabilities, and diminishing danger. It is also important to strive for openness and transparency in the area of patient safety (4).

Although patient safety in primary care has not been explored to the same extent as in secondary and tertiary levels, recently more and more studies are emerging (5, 6). The most common theme within the topic was safety culture. Some studies used a qualitative approach followed by a survey or an audit (7, 8) while others utilized quantitative tools to assess safety culture (9,10,11,12,13,14,15,16). One study also assessed the effect of intervention on the safety culture (17). In general, studies showed that patient safety culture was perceived positively among primary care professionals (12). However, awareness of the safety problems was only raised after getting together and discussing patient safety, therefore, measuring safety culture alone was not enough (11). There seems to be some differences among different health professionals regarding the perception of safety culture (10, 18).

An effective leadership is critical to the development of a safety culture within an organization (19). Competent and thoughtful leaders contribute to improvements in safety and organisational culture. They understand that systemic flaws exist and that each step in a care process has the potential for failure simply because humans make mistakes (20,21,22). This commitment is needed from all organisational leaders (governing boards and clinical leaders) as well as management. Also, leadership commitment must be expressed through actions observable to employees (23).

To establish a positive safety culture in primary care, the first step is to evaluate the current patient safety culture, which will provide basic understanding to safety-related perceptions of the healthcare providers (5). Therefore, we wanted to assess the self-perceived level of safety culture among the employees in the Ljubljana Community Health Centre. We focused only on the employees with a leadership function and hypothesized that the perception of safety culture would be perceived as positive.

This study showed that patient safety culture was, on average, perceived positively by the employees with a leadership function in the largest community health centre in Slovenia.

Previous studies in patient safety culture at the primary healthcare level in Slovenia showed that it was perceived positively but there was still a lot of room for improvement (16). For example, more attention should be devoted to improving team collaboration with a clearer description of professional team roles (18). A study on safety culture in Slovenian hospitals using a different instrument showed that the unit-level dimensions of patient safety were perceived better than the dimensions at the hospital-level. This study also showed a raising awareness of problems of patient safety among stuff (26). This was also confirmed in our study demonstrating that patient safety is universal.

In primary care, providers with different professional backgrounds are involved in the management of patients. A good team leader is very important, not only for an effective team management and function but also for a safety culture. Namely, the role of leadership is critical to facilitate or constrain a positive safety culture. They can crucially affect a positive interdisciplinary action team, and a positive learning culture but, on the other hand, diminish a punitive culture (27). Leaders are in a position to enable a culture of safety (28, 29). Therefore, our study focused only on the employees with a leadership function.

The finding that the participants with a leadership function perceived a safety culture positively can be a good sign, indicating an actual positive safety culture in the organization. However, studies showed that there were differences in the perception of a safety culture between healthcare leaders and staff. Probably, frontline staff may be more aware of actual safety challenges than the leaders (30) and it is possible that, if frontline staff were included in the study, the safety culture would have been perceived less positively.

The perceptions of different domains were relatively homogenous. Some domains, such as Teamwork Climate, Safety Climate, and Working Conditions and Satisfaction were scored slightly higher and some, such as Stress Recognition, slightly lower. Teamwork Climate was perceived positively also by other studies in Slovenia and abroad (10, 16, 18). The domain Stress Recognition includes items through which the employees indicate that they are aware of the fact that fatigue and high workload affect a safety culture in a negative way. In Slovenia, workloads at the primary care level are high (31). But, according to the results of the present study, this is only partly recognized by the leaders as an issue that can affect a safety culture.

The second domain that scored lowest was Communication. This domain covers the items such as the effect of communication on the management of patients and communication about safety issues. This domain was also perceived as low by other studies in Slovenian primary care (16). It seems that this safety culture domain needs improvement.

There were no large differences in a safety culture perception regarding the characteristics of the participants. It is especially important that no differences were observed between different units. The degree to which staff share the perceptions within the same unit is a validity criterion for measurements of organisational climate (32). The degree of consensus amongst staff in a unit is a measure of the organisational climate’s strength (1, 32). Organizational climates with diverging perceptions amongst staff are regarded as weak, with limited power to predict staff practices (33). Since no significant variations were found in the present study, we can say that organisational climate is strong in the Community Health Centre Ljubljana. It also can indicate that leaders act as a unified community with common goals and leadership methods.

Our study has some methodological consideration that we should mention. The response rate was considerably high but we have no information on the non-respondents so this could be a source of a bias. Also, we used a Slovenian version of the SAQ-AV – Short Form, in which domains are slightly different than in the original version so a direct comparison to other studies that used the same questionnaire is limited. We studied only the leaders in one (albeit the largest) primary health organization in Slovenia, so the results cannot be generalized to the whole population. Also, the questionnaire was self-administered so a certain level of social desirability by the respondents must be taken into account, i.e. answering the questions in such a way that would show the situation in a desirable way, not in an actual way.

The safety culture among leaders in primary healthcare organizations in Slovenia is perceived as positive. There is also a strong organizational culture. Certain improvements are needed, especially in the field of communication and stress recognition with regards to safety culture. The results could help the management of the healthcare centres to introduce a system approach to patient safety, to tackle the weak points and improve them, to initiate a continuous assessment of safety culture, and to increase awareness of a no-blame culture. Additional studies are needed to determine a safety culture in all employees of the primary healthcare organizations in Slovenia, with a special emphasis on the differences between leaders and other staff.