Patient safety culture in Slovenian out-of-hours primary care clinics

This was a cross-sectional study that took place in Slovenian OOHC clinics from 16 March to 1 May 2015. The study was part of an international study entitled Patient Safety Culture in European Out-of-Hours Services (SAFE-EUR-OOH), which was led by a coordinating research group from Norway. The study was a project by the European research network for out-of-hours primary health care (EurOOHnet) (25).

In Slovenia, there are 60 OOHC clinics and all were invited to participate; 37 of them agreed to do so. There are 10 health care regions in Slovenia, which correspond to geographical regions: Murska Sobota, Maribor, Ravne na Koroškem, Celje, Krško, Novo Mesto, Ljubljana, Kranj, Nova Gorica, and Koper. The participating OOHC clinics were grouped according to these regions: seven OOHC clinics from the Ljubljana region, five from the Kranj and Ravne na Koroškem regions, four from the Koper region, three from the Murska Sobota, Maribor, Celje, Krško, and Novo Mesto regions, and one from the Nova Gorica region.

In each OOHC clinic, the person in charge of data collection asked all the employees (physicians, nurse practitioners, nurse managers, trainees, practice nurses, radiology technicians, and office managers) to participate. Following this procedure, 438 people were invited to participate. The participation was voluntary and anonymous.

The key national researcher for Slovenia (ZKK) collected the e-mail addresses of all the invited employees of the 37 participating OOHC clinics in Slovenia. An e-questionnaire was sent by the coordinating research group in Norway to these employees on 16 March 2015. After two weeks, an automatic reminder was sent to those who had not responded. The e-questionnaires were sent using the computer programme, Qualtrics.

We used the Slovenian version of the SAQ-AV (24), which has been translated from English according to standard procedures (26). The SAQ-AV is a 62-item questionnaire where the respondents rate their agreement using a 5-point Likert scale: 1=disagree strongly, 2=disagree slightly, 3=neutral, 4=agree slightly, 5=agree strongly (27). “Not applicable” was included as a response category in all questions, and combined with missing values in the data analyses. The scores of negatively worded items were reversed, so that higher scores in the data set always indicated a more positive evaluation of the OOHC clinics’ patient safety culture. Additionally, there were also some demographic questions (sex, age, function, work experience, shifts, and type of employment). “Variable shifts” describes the different types of possible working hours: days, evenings, nights, and variable/rotating shifts. The Slovenian version of the SAQ-AV has five safety climate factors: Perceptions of Management, Job Satisfaction, Safety Climate, Teamwork Climate, and Communication (24). The total score of the SAQ-AV was calculated according to the Baker and Hershaw equation (28): [(Σ<!-- S -->items 1-62)∗<!-- * -->100/(5∗<!-- * -->62)]∗<!-- * -->1.25-25.$$\begin{array}{} [(\Sigma\text{items } 1\text -62)^* 100/(5^* 62)]^* 1.25\,\text -\, 25. \end{array} $$

Similarly, the scores of the individual factors were calculated as: [(Σ<!-- S -->items)∗<!-- * -->100/(5∗<!-- * -->Nofitems)]∗<!-- * -->1.25-25.$$\begin{array}{} \rm[(\Sigma items)^* 100/(5^*\, N\,\,of\,\,items)]^* 1.25\,\,\text-\,\, 25. \end{array} $$

So, the minimum score was 0 and the maximum score was 100 for the overall SAQ-AV score, as well as for each of the factors.

Statistical analysis was carried out using the SPSS 22.0 programme. We performed bivariate analysis using the independent t-test and one-way ANOVA, and multivariate analysis using linear regression. The variables that proved significant in the bivariate analyses were entered into the multivariate analysis. We set the limit of statistical significance at p<0.05.

Out of 438 invited participants, 250 answered the questionnaire (57.1% response rate). There were 110 (44.0%) women in the sample (Table 1).

Table 1

Demographic characteristics of the Slovenian out-of-hours primary health care clinics’ employees participating in the study (N=250).

The mean overall score ± standard deviation of the SAQ was 56.6±16.0 points; of Perceptions of Management 53.6±19.6 points; of Job Satisfaction 48.5±18.3 points; of Safety Climate 59.1±22.1 points; of Teamwork Climate 72.7±16.6; and of Communication 51.5±23.4 points.

The highest climate scores of patient safety culture were reported in the Nova Gorica region and the lowest in Koper. Perceptions of Management was scored highest in the Krško region, and Job Satisfaction, Safety Climate, Teamwork Climate, and Communication were scored highest in the Nova Gorica region. There were significant differences across regions in terms of the overall total SAQ-AV score, and of the climate factors Perceptions of Management, Job Satisfaction, and Communication (Table 2).

Table 2

The scores of SAQ-AV and its factors in the Slovenian out-of-hours primary health care clinics of different Slovenian regions.

Bivariate analyses for the overall total SAQ-AV score revealed that physicians (t=1.992, p<0.048), practice nurses (t=1.882, p=0.049), those working in variable shifts (t=4.842, p<0.001), those working full-time (t=5.581, p<0.001), and those working in the Ravne na Koroškem region (t=4.571, p<0.001) had significantly higher scores when compared to the other categories.

For the factor Perceptions of Management, bivariate analyses showed that those working in variable shifts (t=2.139, p=0.046), full-time (t=2.930, p=0.004), in the Ravne na Koroškem region (t=2.918, p=0.005), in the Krško region (t=2.827, p=0.012), and in the Kranj region (t=2.835, p=0.007) had significantly higher scores when compared to the other categories.

For the factor Job Satisfaction, bivariate analyses revealed that those working in variable shifts (t=4.022, p=0.001), full-time (t=4.550, p<0.001), and in the Ravne na Koroškem region (t=4.816, p<0.001) had significantly higher scores when compared to the other categories.

Bivariate analyses for the factor Safety Climate showed that practice nurses (t=3.821, p<0.001), and those working in variable shifts (t=4.506, p<0.001), full-time (t=5.514, p<0.001), and in the Ravne na Koroškem region (t=3.230, p=0.002) had significantly higher scores when compared to the other categories.

For the factor Teamwork Climate, bivariate analyses revealed that physicians (t=3.106, p=0.002), those working in variable shifts (t=2.489, p<0.001) or full-time (t=4.052, p<0.001), and participants working in the Maribor region (t=-2.735, p=0.009) had significantly lower scores when compared to the other categories.

Bivariate analyses for the factor Communication showed that physicians (t=2.075, p=0.039), those working in morning shifts (t=4.238, p<0.001), those not working in afternoon shifts (t=-6.064, p<0.001), those working in variable shifts (t=3.243, p=0.005), those working full-time (t=3.328, p=0.003), and those working in the Ravne na Koroškem region (t=2.122, p=0.035), in the Ljubljana region (t=2.146, p=0.033), and in the Nova Gorica region (t=2.208, p=0.026) had significantly higher scores when compared to the other categories. Participants working in afternoon shifts had significantly lower scores when compared to those working in morning, afternoon, or variable shifts.

Variables significantly associated with higher SAQ-AV scores in the multivariate analysis were employees working in the Ravne na Koroškem region, those with variable shifts, and those with full-time jobs. Higher scores in the factor Job Satisfaction were significantly associated with variable shifts, a full-time job, and working in the Ravne na Koroškem region. Employees working in variable shifts and having a full-time job scored significantly higher on both the Safety Climate and Teamwork Climate factors. On the contrary, those working in the Maribor region scored significantly lower on these factors. Employees working in variable shifts, having a full-time job, and working in the Ravne na Koroškem, Ljubljana and Nova Gorica regions scored significantly higher in the factor Communication (Table 3).

Table 3

Multivariate analysis for the scores of SAQ-AV and its five factors in the Slovenian out-of-hours primary health care clinics.