Nurses and physicians attitudes towards factors related to hospitalized patient safety.

INTRODUCTION: The attitudes of healthcare staff towards patients' safety, including awareness of the risk for adverse events, are significant elements of an organization's safety culture. AIM OF RESEARCH: To evaluate nurses and physicians' attitudes towards factors influencing hospitalized patient safety.
MATERIALS AND METHODS: The research included 606 nurses and 527 physicians employed in surgical and medical wards in 21 Polish hospitals around the country. The Polish adaptation of the Safety Attitudes Questionnaire (SAQ) was used to evaluate the factors influencing attitudes towards patient safety.
RESULTS: Both nurses and physicians scored highest in stress recognition (SR) (71.6 and 80.86), while they evaluated working conditions (WC) the lowest (45.82 and 52,09). Nurses achieved statistically significantly lower scores compared to physicians in every aspect of the safety attitudes evaluation (p<0.05). The staff working in surgical wards obtained higher scores within stress recognition (SR) compared to the staff working in medical wards (78.12 vs. 73.72; p = 0.001). Overall, positive working conditions and effective teamwork can contribute to improving employees' attitudes towards patient safety.
CONCLUSIONS: The results help identify unit level vulnerabilities associated with staff attitudes toward patient safety. They underscore the importance of management strategies that account for staff coping with occupational stressors to improve patient safety.

Introduction

Patients’ safety constitutes an important aspect of health care delivery. The goal of patient safety programs is to prevent errors and reduce the potential for damage suffered by patients while receiving healthcare services. To sustain patient safety practices by staff, constant training and reinforcement of it for healthcare staff is required to avoid adverse events.

The International Classification for Patient Safety (ICPS) defines ‘patient safety’ “as the act of avoiding, preventing or improving adverse outcomes or injuries occurred throughout the medical-hospital process” [1]. According to the World Health Organisation (WHO), adverse events related to health care are one of the substantial reasons for death and disability of hospitalised patients. For the WHO, “patient safety means the reduction to an acceptable minimum level of risk of unnecessary harm related to health care”.

Medical errors affect health care systems around the world. The cost related to medical errors worldwide is estimated at USD 42 billion yearly [2]. Research has shown that the number of fatalities caused by medical errors in the USA every year exceeds 250,000, which makes them the third largest cause of death [3]. In low- and middle-income countries, however, every year in hospitals 134 million adverse events take place and 2.6 million result in death [1]. Analyses of European data—mainly from Denmark, France, Spain [1] found that medical errors and adverse events related to health care occur in 8–12% of hospitalisations. An OECD report concluded that 15% of hospital operating costs may be attributed to the treatment of adverse events [4]. Actions aimed at limiting causes of adverse events occurring during hospitalisation may improve patients’ health outcomes and lead to financial savings for healthcare organizations and national health systems [5].

Hughes et al. noted the importance of staff’s attitudes when creating a work environment where patient safety is a high priority [6]. Understanding medical staff’s attitudes towards factors conditioning patients’ safety are crucial to improve patients’ care and safety. Analyzing factors that contribute to the occurrence of adverse events helps create the conditions that foster changes in staff behaviours, which may make the healthcare environment safer [7]. Standardized systems with rules and procedures focused on patient safety for both personnel providing direct care and their managers also helps minimize the risk of personnel making mistakes [8]. Further, using tools like the Safety Attitudes Questionnaire (SAQ) for assessing healthcare staff attitudes about patient safety at the organizational level is an important part of fostering organizational change to improve patient safety [9-19]. It is also worth remembering that a patient’s safety during treatment is inherently related to the activities of people involved in delivering it—from nurses to physicians to administrators. High awareness of occupational safety, cooperation in an interdisciplinary team, assessment of the culture of work safety, as well as analysis and drawing conclusions may increase the quality and safety in real terms, and make the patient feel safer. On the other hand, it should be remembered that a safety culture is not only important for reducing the risk for harm to hospitalized patients, but is also key to ensuring a safe working environment for healthcare professionals. A first step toward building safety cultures is to conduct research to assess healthcare workers’ attitudes towards patient safety.

Poland has nascent infrastructure for monitoring patient safety. First, there is no mandatory reporting requirement for the numbers and types of medical errors. As a result, no systematic monitoring in this area is performed and the true scale of adverse events in hospitals in Poland is not precisely known. Studies using an internationally standardised tool have also not been performed to date. This study is a first step toward generating evidence to identify where organizations in Poland can direct efforts to improve patient safety.

Aim of research

To determine Polish nurses’ and physicians’ attitudes about patient safety practices in hospitals.

Detailed objectives:

What attitudes towards factors related to hospitalized patient safety are presented by nurses and by doctors?

What were the differences in attitudes towards safety in the group of nurses and doctors?

To what extent did the type of ward differentiate the attitudes towards safety of nurses and doctors?

What was the relationship between the respondents’ gender and attitudes towards safety?

What was the relationship between the time of employment of the respondents and their attitudes towards safety?

Materials and methods

This was a descriptive, cross-sectional study carried out on a group of nurses and physicians employed in surgical and medical wards in 21 Polish hospitals, located in different parts of the country. The selection of hospitals was based on a stratified selection procedure that accounted for geographic and service administrative area factors along with population density and hospital reference level, similar to those used in the RN4CAST methodology [20]. The study included only state multi-profile hospitals, serving patients 24h/7day care. The studies were performed in the years 2018–2019 after obtaining the consent of the Bioethical Commission of Jagiellonian University (KBE UJ) No. 1072.6120.111.2018.

Sample

The inclusion criteria were a) Polish national, b) employed at a study site, and c) actively working during the study as a nurse or physician in a given hospital. All other hospital staff was excluded from the study. Nurses on maternity leave, extended sick leave or study leave were excluded from participation.

The sample size necessary to detect differences in the mean percentage results of the safety attitude subscales between physicians and nurses was calculated, assuming equal numbers of doctors and nurses in the groups, 95% power and the FWER (family-wise error rate) value at the 0.05 level. It was shown that 1,050 persons would be sufficient to detect a small-size effect (eta squared 0.02), according to Cohen’s recommendations [21].

Instrument

The study was performed with the diagnostic survey method using the survey technique with SAQ-SF PL tool in the Polish adaptation by Malinowska-Lipień et al. [22]. The Safety Attitudes Questionnaire reliability had a Cronbach’s Alpha of 0.98. Before performing the analysis validity of the Polish adaptation of SAQ-SF, the Kaiser test was used to check whether the data meet the requirements of the factor analysis. The Kaiser-Mayer-Olkin (KMO) value, being the measure of the adequacy of the sample selection, was estimated at the level of 0.87 (df = 8630, p<0.001). This model explained 68% of the total variance of the analysed set of variables [22].

The instrument consists of 41 entries, divided into two parts, with part two consisting of a demographic profile. The first part contains 36 questions subdivided into six subscales. First, 1/ Teamwork climate—TC (questions from 1 to 6), which evaluates the perception of cooperation quality among staff; 2/Safety climate—SC (questions from 7 to 13)–evaluates the perception of employees’ organisational involvement in patient’s safety; 3/Job satisfaction—JS (questions from 15 to 19)–evaluates subjective feeling connected to professional experience; 4/Stress recognition—SR (questions from 20 to 23)–evaluates of the influence of stressors on work efficiency; 5/Perception of management–PM), evaluates at the ward and hospital level (questions from 24 to 28); and finally 6/Work conditions—WC) (questions from 29 to 32), which concern the quality of environmental and logistic support in the workplace (e.g. appliances, equipment and professionals). Five questions in part one are not included in any of the subscales, i.e. question 14 related to the assessment of a managing staffer in the context of providing safety, and questions from 33 to 36 concerning the evaluation of conflicts and cooperation among the members of the interdisciplinary team, i.e. nurses, doctors, pharmacists.

Answers are scored on a 5-point Likert scale (1 = strongly disagree (A); 2 = rather disagree (B); 3 = neutral answer (C); 4 = quite agree (D); 5 = strongly agree (E)), while questions 2, 11 and 36 were scored reversely. For each question, the questionnaire authors included the “does not concern” option. To calculate the score according to the diagnostic key, the conversion to the 100-point was implemented, i.e.: 1 = 0; 2 = 25; 3 = 50; 4 = 75; 5 = 100. The final score of the questionnaire takes the value from 0 to 100 points, where zero means the worst and 100 pts.–the best attitudes towards factors conditioning patients’ safety. Scores at the level of 75 pts. and higher are considered as a positive attitude in the area covering a particular subscale [23].

Data collection

The SAQ-SF was used in the research’ to evaluate attitudes of nurses and physicians towards factors patients’ safety. The survey questionnaire was independently filled in by nurses and physicians, who voluntarily agreed to participate. All potential participants were informed in writing and verbally by the hospital coordinator about the research aim and anonymity. In each hospital, a study project coordinator was responsible for data collection. In clinical departments, the questionnaire with an envelope attached to it was distributed during departmental staff meetings led by the hospital project coordinator. Participants had 4 weeks to complete the questionnaire. Completed questionnaires packed in a sealed plastic envelope were deposited into a secure box. After 4 weeks, the coordinator was responsible for collecting the boxes, securing them, and handing them over to the research team. Participants were informed that participation was voluntary and anonymous, that all responses would be kept confidential and that no individual responses would be available to hospital management.

Statistical analysis

All analyses were carried out using the R software version 3.6.1 (Development Core Team, Vienna, Austria). The statistical significance level was set at α = 0.05. The descriptive statistics for each subscale of SAQ was presented as average (x) and standard deviation (SD). For each respondent, mean values were independently calculated within each SAQ subscale. In the case respondents pointed to the “does not concern” answer, it was ignored while calculating the mean result of the scale. Questionnaires with over 10% of incomplete answers to the 36 questions of the SAQ were excluded from analyses [23].

The dependent variable was defined as the attitudes towards safety measured with the standardised SAQ-SF.

The independent variables included: professional group (nurses and physicians), gender, type of ward (surgical or medical unit), age category of the treated patients (adults and/or children), professional experience (<1 year, 1–4 years, 5–10 years, 11–20 years and > 20 years), number of nursing staff, number of physicians, number of beds in the ward.

Uni- and multi-variate analyses were used to compare mean percentage results of the SAQ subscales between the groups defined by categories of the following factors: professional group (nurses and physicians), gender (men and women), ward (surgical and medical unit), age group of the treated patients (adults, children, and both groups), work experience (<1 year, 1–4 years, 5–10 years, 11–20 years and > 20 years). A one-factor multi-dimensional analysis of variants was performed to estimate the influence of each factor separately on the combined set of dependent variables (safety climate, stress recognition, teamwork climate, working conditions, work satisfaction, perception of management). If the result of the one-way MANOVA was statistically significant, the one-way ANOVA analysis was performed, studying separately each dependent variable in order to identify those dependent variables that significantly contributed to obtaining a statistically significant global effect. Bonferroni correction was used for multiple comparisons, resulting in the criterion of rejecting a null hypothesis at a significance level p<0.008 instead of p <0.05 (six dependent variables). To estimate the relation between the number of beds, the number of nurses and the number of doctors in the ward and each of the SAQ subscales, one-dimensional linear and logistic regression models of multiple variables were used, standardised for a professional group, ward and professional experience.

Results

Altogether 3,605 questionnaires were distributed, including 2,382 for nurses and 1,223 for physicians; 2,672 forms were returned, including 1,934 from nurses and 738 from doctors. The survey response rates reached 74%, from which those missing over 10% answers within the scale SAQ-SF (Safety Attitudes Questionnaire Short Form) were rejected. As a result, 1,133 questionnaires were finally analysed, including 606 from nurses and 527 from physicians. The majority were women (743; 65.57%). A similar percentage of nurses and physicians were employed in medical versus surgical wards– 50.33% vs. 49.67% nurses and 50.28% vs. 49.72%. In both professional groups, the largest percentage of staff worked in the wards where adult patients were treated (97.51% nurses vs. 99.33% physicians respectively). Over a half of nurses (n = 316; 54.02%) had been working for at least 21 years. The largest percentage of physicians had been working for 11 to 20 years (n = 133; 25.88%) or over 21 years (n = 127; 24.71%).

Statistically significant differences associated with gender and seniority were found between the group of nurses and physicians (p<0.05). A borderline difference was found between the nurses and physicians groups in relation to the age of the treated patients (p = 0.048), Table 1.

Table 1

Characteristics of the studied group.

		nurses	physicians
		(N = 606)	(N = 527)
		N (%)	N (%)	p
Unit type, n (%)
	Medical units	305 (50.33)	265 (50.28)	1.000
	Surgical units	301 (49.67)	262 (49.72)
Gender, n (%)
	Women	553 (95.34)	190 (39.09)	0.000
	Men	27 (4.66)	296 (60.91)
Age group of treated patients, n (%)
	Adults	509 (97.51)	447 (99.33)	0.048
	Adults & children	13 (2.49)	3 (0.67)
Seniority, n (%)
	< 1 year	33 (5.64)	36 (7)	0.000
	1–4 years	65 (11.11)	112 (21.79)
	5–10 years	74 (12.65)	106 (20.62)
	11–20 years	97 (16.58)	133 (25.88)
	≥21 years	316 (54.02)	127 (24.71)

Note: p -value; N- number.

A multi-dimensional analysis showed that the teamwork climate (TC), safety climate (SC), job satisfaction (JS), stress recognition (SR), perception of management (PM) and work conditioning (WC) vary between the professional groups (nurses vs. physicians, F (6.1126) = 18.08, p<0.001), type of ward (medical vs. surgical, F (6.1126) = 3.49, p = 0.002), gender, F (6.1059) = 9.17, p<0.001) and seniority, F (24,3800) = 2.13, p = 0.001).

Both nurses and physicians received the highest mean results on the stress recognition subscale (SR) (71.6 and 80.86), while both groups evaluated work conditions (WC) the lowest (45.82 and 52.09). The analysis showed statistically significant differences between the groups of nurses and physicians in all 6 subscales, delineating different aspects of the evaluation of attitudes towards factors fostering patients’ safety. The results of nurses in those subscales were lower compared to physicians, Table 2.

Table 2

Comparison of Safety Attitudes Questionnaire (SAQ-SF) results in reference to socio-demographic features.

		Teamwork climate	Safety climate	Job satisfaction	Stress recognition	Perception of management	Work conditions
Group		Mean (sd)	Mean (sd)	Mean (sd)	Mean (sd)	Mean (sd)	Mean (sd)
Professional group, n (%)
	Nurses (N = 606)	62.38 (17.53)	63.41 (17.8)	60.95 (22.21)	71.6 (22.09)	52.33 (22.03)	45.82 (21.33)
	Physicians (N = 527)	66.76 (15.57)	66.06 (16.56)	68.5 (22.7)	80.86 (22.63)	59.47 (21.61)	52.09 (22.97)
	stat	F(1,1131) = 19.6, p<0.001	F(1,1131) = 6.68, p = 0.01	F(1,1131) = 31.9, p <0.001	F(1,1131) = 48.4, p <0.001	F(1,1131) = 30.1, p <0.001	F(1,1131) = 22.7, p <0.001
Gender, n (%)
	Women (N = 743)	62.92 (16.94)	63.65 (17.55)	62.21 (22.71)	74.09 (22.66)	53.88 (22.48)	46.74 (21.54)
	Men (N = 323)	67.86 (15.52)	66.56 (15.99)	69.8 (21.58)	79.83 (22.33)	59.75 (20.58)	52.9 (22.84)
	stat	F(1,1064) = 20.1, p <0.001	F(1,1064) = 6.54, p = 0.011	F(1,1064) = 25.9, p <0.001	F(1,1064) = 14.6, p <0.001	F(1,1064) = 16.1, p <0.001	F(1,1064) = 17.7, p <0.001
Unit type, n (%)
	Medical units (570)	63.64 (16.15)	64.66 (16.61)	64.97 (22.42)	73.72 (23.96)	54.91 (22.72)	48.25 (22.06)
	Surgical units (563)	65.2 (17.39)	64.63 (17.95)	63.94 (23.07)	78.12 (21.37)	56.4 (21.47)	49.23 (22.59)
	stat	F(1,1131) = 2.46, p = 0.117	F(1,1131) = 0, p = 0.976	F(1,1131) = 0.58, p = 0.447	F(1,1131) = 10.6, p = 0.001	F(1,1131) = 1.28, p = 0.258	F(1,1131) = 0.54, p = 0.461
Group of treated patients, n (%)
	Adults (N = 956)	64.56 (16.57)	64.86 (17.09)	64.66 (22.52)	75.77 (22.85)	55.69 (22.28)	48.17 (22.03)
	Adults & children (N = 16)	64.22 (22.98)	61.53 (22.14)	65.7 (23.14)	72.27 (19.49)	50.45 (17.39)	57.42 (19.53)
	stat	F(1,970) = 0.01, p = 0.935	F(1,970) = 0.59, p = 0.443	F(1,970) = 0.03, p = 0.854	F(1,970) = 0.37, p = 0.542	F(1,970) = 0.88, p = 0.35	F(1,970) = 2.79, p = 0.095
Seniority, n (%)
	< 1 year (N = 69)	66.49 (15.71)	65.52 (14.43)	65.98 (20.82)	78.99 (19.09)	62.62 (19.55)	50.63 (23.66)
	1–4 years (N = 177)	63.77 (16.3)	63.09 (16.72)	61.84 (23.84)	78.58 (21.19)	55.52 (22.45)	51.45 (23.13)
	5–10 years (N = 180)	62.68 (17.21)	62.88 (16.99)	64.13 (22.86)	79.54 (21.76)	54.48 (22.7)	46.84 (21.22)
	11–20 years (N = 230)	63.53 (16.9)	64.91 (17.35)	65.07 (24.1)	75.86 (24.88)	55.63 (21.39)	47.83 (22.27)
	≥21 years (N = 443)	65.44 (16.76)	65.36 (17.93)	65.12 (22)	72.74 (22.9)	54.98 (22.43)	48.6 (22.32)
	stat	F(4,1094) = 1.39, p = 0.235	F(4,1094) = 1.06, p = 0.374	F(4,1094) = 0.8, p = 0.523	F(4,1094) = 4.24, p = 0.002	F(4,1094) = 1.95, p = 0.1	F(4,1094) = 1.2, p = 0.31

Note: sd- Standard deviation; stat– statistics; p -value.

The staff working in surgical wards obtained higher mean results in stress recognition compared with the staff working in medical units (78.12 vs. 73.72; p = 0.001). Analyses found a statistically significant difference between men’s and women’s responses within all the six subscales, with women scoring significantly lower–p<0.05. A statistically significant difference was shown between the professional experience of the surveyed staff and stress recognition (SR) (p = 0.002). Persons of lower seniority scored higher in the SR subscale, as shown in Table 2.

The largest percentage of both nurses and physicians showed positive attitudes (score ≥ 75 points) in relation to the safety of patients, towards stress recognition (39.1% and 61.5% respectively) and job satisfaction (21.5% and 36.4%). Work conditions received the lowest scores (5.8% and 13.1%). Except for stress recognition (SR), in other subscales, positive attitudes (≥75 points) were reported by fewer than 40% of the surveyed nurses and physicians. In all six subscales, a significantly higher percentage of physicians than nurses reported positive attitudes towards safety (p<0.05), Table 3.

Table 3

Comparison of Safety Attitudes Questionnaire (SAQ-SF) results among nurses and physicians.

Teamwork climate (TC)	Category *	Nurses (N = 606)		Physicians (N = 527)		p
		n	%	n	%
	≥ 75	116	19.1	134	25.4	0.013
	< 75	490	80.9	393	74.6
Safety climate (SC)	≥ 75	133	21.9	148	28.1	0.021
	< 75	473	78.1	379	71.9
Job satisfaction (JS)	≥75	130	21.5	192	36.4	0.000
	< 75	476	78.5	335	63.6
Stress recognition (SR)	≥ 75	237	39.1	324	61.5	0.000
	< 75	369	60.9	203	38.5
Perception of management (PM)	≥ 75	76	12.5	106	20.1	0.001
	< 75	530	87.5	421	79.9
Work conditions (WC)	≥ 75	35	5.8	69	13.1	0.000
	< 75	571	94.2	458	86.9

*≥75 pts.

–positive result. <75 pts.- negative result.

Note: p -value; N- number.

Statistical analysis further showed that each increase in the number of beds over the bed number contracted with the National Health Fund (Polish: NFZ) by 10 was connected with the increase in stress recognition by 2.5 units (B*(SE) = 2.5(0.7); p = 0.001) and the decrease in job satisfaction by about 1.6 points (B*(SE) = -1.6(0.8); p = 0.030).

Discussion

The study is the first one to capture nurses’ and physicians’ attitudes towards patient safety in Polish hospitals based on the standardized version of the SAQ. In the five out of six SAQ subscales, a positive result, i.e. 75 pts. or more, was obtained by less than 40% of surveyed nurses and physicians. That finding suggests there is a need for significant investments in developing proactive patient safety cultures across Polish hospitals.

When comparing the findings internationally, the analyses showed that Polish nurses received lower mean results in the SR subscale than nurses working in Australia [9] or in Norway [10], but higher than nurses working in Sweden or Albania [11, 12]. Polish nurses also obtained higher results than nurses working in Asian countries (China, Turkey, Saudi Arabia, Iran) [13-16], African (Kenya) [17] or in Americas (Brazil and Pittsburgh) [18, 19] (Table 4).

Table 4

Compilation of study results on nurses’ and physicians’ attitudes towards factors conditioning safety of patients treated in hospitals.

	COUNTRIES
		Teamwork Climate	Safety Climate	Job Satisfaction	Stress Recognition	Perceptions of Management	Working Conditions
	NURSES
EUROPE	Poland n = 606	62.38	63.41	60.95	71.6	52.33	45.82
	Norway n = 73 [10]	75.0	70.6	80.4	78.0	-	72.7
	Sweden n = 80 [11]	67.2–68.8	62.3–63.3	70.6–72.0	66.1–69.9	48.2–48.5	55.6–59.5
	Albania n = 132 [12]	45.7	36.8	40.6	46.7	44.8	29.2
ASIA	China n = 271 [13]	73.9	69.2	74.0	59.0	67.8	73.5
	Turkey n = 89 [14]	46.27	46.44	58.91	65.12	46.83	51.93
	Saudi Arabia n = 418 [15]	75.5	75.5	92.7	41.9	68.1	82.1
	Iran n = 244 [16]	74.6	67.97	68.27	71.22	61.82	65.62
AFRICA	Kenya n = 122 [17]	72.0	65.7	77.7	56.9	63.5	55.9
AMERICA	Brazil n = 46 [18]	80.82	80.53	86.41	64.39	68.54	73.41
	US, Pittsburgh n = 1,828 [19]	72.5	72.8	71.3	68.8	59.9	66.7
AUSTRALIA	Australia, Canberra n = 27 [9]	75.62	70.60	74.07	79.86	51.54	50.69
	PHYSICIANS
EUROPE	Poland n = 527	66.76	66.06	68.5	80.86	59.47	52.09
	Sweden n = 119 [11]	69.2–72.2	53.5–60.6	68.8–69.8	68.7–76.2	49.3–56.0	52.5–57.6
	Albania n = 209 [12]	52.3	38.7	39.5	49.7	46.8	42.4
ASIA	China n = 250 [13]	75.5	71.1	75.7	65.8	69.7	71.4
AFRICA	Kenya n = 49 [17]	68.8	65.3	80.6	45.3	67.6	60.7
AMERICA	US, Pittsburgh n = 1,352 [19]	81.2	74.6	80.7	69.1.	71.6	73.6
AUSTRALIA	Australia. Canberra n = 24 [9]	89.41	82.89	82.08	84.90	46.52	62.24

Seniority or years of work experience also influenced the findings in ways consistent with international studies. According to this research, nurses with lower seniority demonstrated a better awareness of the negative impact of stress on patient safety. These results are similar to the results obtained by Aljadhey et al. [15], which documented that the increase of seniority corresponds to the decrease in stress recognition. The research by Żuralska et al. further showed that in difficult situations, nurses of lower seniority implemented a style more frequently focused on the task and seeking support than nurses of higher seniority. Nurses with fewer years of service took more cognitive and behavioural effort in order to manage stressful situations [24].

The results of the research by Rasool et al. [25] and Ganndi et al. [26] indicate that professional stress is a crucial element negatively influencing safety and work efficiency. When comparing physician specific findings to international results, Polish physicians participating in this study reported the highest mean value of the 6 subscales for stress recognition (SR) (80.86 points), which was similar to Australian doctors (84.90 points); however, it was higher than reported by Polish nurses (71,6 pts). This finding suggests that stress reduction measures for Polish physicians would be an important component for improving safety culture.

Effective teamwork can ameliorate or contribute to workplace associated stressors in ways that affect patient safety. In this study, Polish nurses received higher mean score in the teamwork subscale (TC) (62.38 pts.) than nurses working in Albania (45.7 pts.) [12] and Turkey (46.27 pts.) [14]. These results, however, were much lower compared to European countries such as Norway and Sweden [10, 11], Asia nations (China, Saudi Arabia, Iran) [13, 15, 16], countries in the Americas (Brazil, and US-PA, Pittsburgh) [18, 19], Australia [9] or Sub-Saharan Africa (Kenya) [17]. Polish physicians scored higher mean values in the area of team work (TC) than physicians from Albania [12], while lower than physicians working in Sweden, China, Kenya, America and Australia [9, 11, 13, 17].

The teamwork results could be attributed to the fact that physicians are prioritised in the hierarchy of the Polish healthcare system. Hierarchies impact teamwork dynamics and may prevent equal contribution of skills and knowledge of team members who are not doctors. Effective cooperation of various professionals in a team constitutes an important element of care and their patient safety.

In the assessment of safety climate (SC), Polish nurses received higher mean results (63.41 pts.) than nurses working in Albania (36.8 pts.) [12] and Turkey (46.44 pts.) [14], but definitely lower mean values than nurses working in Norway or Sweden [10, 11], as well as in the area of Asia (China, Saudi Arabia, Iran) [13, 15, 16], Americas (Brazil, and the state of Pennsylvania US-Pittsburgh) [18, 19], Australia (Australia) [9] or Africa (Kenya) [17]. Within the safety climate (SC) subscale, Polish physicians obtained higher mean results compared with the physicians from Sweden and Albania [11, 12], (Table 4).

Our study showed that nurses received a mean result of 60.95 pts. in the area of job satisfaction (JS), while physicians scored 68.5 pts—a difference that was highly significant. This result indicated that although nurses and physicians overall liked working in this hospital, nevertheless, nurses job satisfaction was significantly lower, which may affect patient safety. Kunaviktikul et al. [27] found that nurses who are not satisfied with their job tend to commit medical errors and that improvement in working conditions—including teamwork—is an important element to increase job satisfaction [27].

The results are consistent with the results of other authors, who showed that both nurses and physicians’ evaluation of hospital management (PM) and work conditions (WC) is low from the perspective of their impact on the safety of treated patients [9, 11, 19]. Low scores in this subscale may be interpreted as the perception of managerial weakness in the context of patients’ safety. According to Alayed et al. [28] the evaluation of management may be low due to the lack of direct contacts of employees with the managing staff or the lack of perception of the supervisor’s engagement. Authors of other studies indicated that regular audits of staff managing healthcare facilities, common analysis of threats to patients’ safety in wards, along with the provision of resources and support from supervisors were related to a very positive attitude of the employees to the factors conditioning patients safety [29, 30].

Our study also showed that 87% of nurses (530/606) and almost 80% of physicians (421/527) gave low ratings to work conditions (WC) on patient safety. Similarly, low ratings of working conditions on patients’ safety was also observed in other countries [9, 11, 12, 14, 16, 17, 31, 32] (Table 4). The results of our study within the subscale WC were lower than the data obtained from nurses employed in Norway, Sweden or Brazil [33, 34]. The analysis of the OECD (Organisation for Economic Cooperation and Development) data, indicated that in a country with a higher nurse rate (number of nursing working per 1,000 patients) working conditions (WC) were scored higher (Table 4) [33]. The analysis of data from the OECD presenting the rate of nurses and doctors per 1,000 patients in particular countries indicates that in a country with a higher nurse rate work conditions (WC) were scored higher.

Staffing resources, therefore, are an important component for building capacity to foster patient safety systems and cultures. For Poland, the rate of nurses per 1,000 patients is 5.1, while in Norway—18.0, in the USA and Australia—11.9, in Brazil—10.11, in Sweden—10.9 [33, 34]. In reference to our study, the above data may be treated as a signal of a great need to increase the number of nurses in medical and surgical wards in order to optimise patients’ safety hospitalised in the wards. In the RN4CAST study, the connection between the nurse staffing, education and hospital mortality was documented [35]. Research by Aiken et al. further indicated that the increase of workload for nurses by one patient increased the risk of the patient’s death within 30 days of admission to the hospital [35]. Hence, evidence suggests that improved working conditions and increased nurse staffing leads to patient safety improvements.

Other studies by Wagner et al. and McHugh et al. showed that working in good conditions correlates to greater satisfaction and motivation to work, lower stress level among employees and higher patients’ safety [36, 37]. Under Polish conditions, the present results indicate the need for management actions aimed at improving working conditions and reducing work stress by the hospital. It is also necessary to improve communication and cooperation within the treatment team, recognizing the competencies and responsibilities of individual members. It can be expected that the above actions will contribute to the improvement (attitude) towards safety among nurses and physicians employed in the hospital.

The cohesion of the results concerning nurses’ and physicians’ attitudes towards patient safety conditions of those treated in the medical and surgical wards in hospitals in Poland and in other culturally and geographically differing countries points to a universal character of the patient safety cultures. The recently introduced Global Patient Safety Action Plan: 2021–2030, which includes broadly developed strategies that can be adapted to the national context, can be used to do this [38]. Their implementation will help ensure that patient safety is improved both nationally and globally. Studies like this one are a first step toward capturing the necessary baseline data from which positive changes can be made.

Research limitations

The study has some limitations. Firstly, the data were collected exclusively from surgical and medical wards. That is why direct results of the study are limited to the specific conditions of the wards studied, and one has to be careful before generalisation for other types of hospital wards. Secondly, the research was voluntary. The 21 out of 949 hospitals located all over the country had directors and staff who agreed to allow the research in their organization. Subsequent future studies should expand research to a larger number of hospitals and different types of wards (including pediatric, intensive care and psychiatric) with additional inclusion of the influence of factors conditioning attitudes towards safety on the frequency of adverse events, including international studies comparing different countries. In addition, in subsequent studies, to accurately assess the accuracy of the scale, it should also be tested by comparing different groups of medical professions, and their selection would take into account a comparable number of respondents.

Conclusions

The results are valuable to identify areas for improvement related to patient safety, including at the unit level. Managers’ awareness of the importance of coping with staff occupational stress, working conditions and effective teamwork can contribute to improving employees’ attitudes towards patient safety. The differences noted between countries are important because they demonstrate a consistency in the measurement of the SAQ tool across languages and health systems, thereby allowing for future comparative country studies and the potential for international benchmarking of patient safety culture. Overall, this study contributes to the growing body of literature that highlights how the conditions that foster patient safety during hospitalization can be consistent across any healthcare organization.

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(XLSX)

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31 Aug 2021

PONE-D-21-20381

Attitudes of nurses and physicians towards factors affecting hospitalized patient safety

PLOS ONE

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Reviewer #1: Yes

Reviewer #2: No

**********

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Reviewer #1: Yes

Reviewer #2: I Don't Know

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Reviewer #2: Yes

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Reviewer #1: The manuscript is technically sound, in which the authors have been able to demonstrate a good command of existing literature; they have provided a detailed explanation of the methodology used including rigorous data analysis; the results section is well presented; discussion is done with sufficient details and robust literature that has compared the country context with that of other countries both high- income and low- and middle- income countries; and the limitations and conclusions are well described. This indicates that the manuscript is "presented in an intelligible fashion" and to the best of my knowledge, it is "written in standard English". The authors have included all the important data in the manuscript and they have indicated in their submission that in terms of data availability - "No - some restrictions will apply".

Additionally, regarding the content of the manuscript, the authors have done an excellent work that contribute a significant body of knowledge in this very important aspect of quality of care, namely “patient safety”. They have presented original research that was done in Poland involving 21 (out of 949) hospitals all over the country. The “introduction” section of the manuscript is well presented indicating good command of existing literature and building well on the justification for conducting the study. In this section, I suggest that the authors make a correction in the last sentence of the second paragraph on page 3 which reads: “The analysis of factors contributing to the occurrence of adverse events is underlying condition for changes in the staff's behaviour, which may makes healthcare environment safer [7];” by replacing the word “makes” with “make” so that it will read as follows: “The analysis of factors contributing to the occurrence of adverse events is underlying condition for changes in the staff's behaviour, which may make healthcare environment safer [7].

In the “materials and methods” section in the fourth paragraph on page 5, I suggest that the authors delete the word “towards” in the following sentence: “Its first part includes questions related to the following subscales:: 1/ Teamwork climate -…….; 2/Safety climate - SC (questions from 7 to 13) – evaluates the perception of employees' organisational involvement in towards patient’s safety; 3/Job satisfaction - JS (questions from 15 to 19) –……”, so that it will read: “……..of employees' organisational involvement in patient’s safety;” The statistical analysis is well described with adequate details.

The results section is well presented logically and in details.

The authors have done an excellent job in the discussion section by providing detailed discussion backed up with comprehensive literature comparing the Polish situation with that of other countries and in different contexts including a sub-Saharan African country (Kenya). This makes the discussion section robust and rich with data from high income and low- and middle-income countries. The paragraph 8 on pages 14-15, has corroborated the findings of a recent systematic review on patient safety culture, in terms of the importance of having adequate number of staff, effective communications, supervisor’s (management) support, and teamwork in building a “patient safety culture” [1]. The paragraph 9 points to the needs for using similar strategies in the various countries with different cultural and geographical contexts. In here, I suggest that the authors add a mention of also implementing the recently launched “Global Patient Safety Action Plan: 2021-2030”, which is broad and with well elaborated strategies that can be adapted into country context that will ensure that patient safety is improved at country and global level [2].

The “research limitations” section is well written pointing out the key limitations. The “conclusion” section is logically written based on the findings. Their emphasis on the need for managers to address “occupational stress” is also supported with the study by Park and Kim (2013) in Korea in which they found that “job stress” was one of the factors that affected “patient safety incidents” [3].

1. Reis CT, Paiva SG, Sousa P. The patient safety culture: a systematic review by characteristics of Hospital Survey on Patient Safety Culture dimensions. Int J Qual Health Care. 2018;30(9):660-677. DOI: 10.1093/intqhc/mzy080.

2. World Health Organization. Global patient safety action plan 2021–2030: towards eliminating avoidable harm in health care. ISBN 978-92-4-003270-5 (electronic version). Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO. Available at: https://www.who.int/teams/integrated-health-services/patient-safety/policy/global-patient-safety-action-plan Accessed on 11th August, 2021.

3. Park YM, Kim SY. Impacts of Job Stress and Cognitive Failure on Patient Safety Incidents among Hospital Nurses. Saf Health Work. 2013;4(4):210-215. doi: doi: 10.1016/j.shaw.2013.10.003

Reviewer #2: - Spelling, grammar and English need detailed review and edition.

Title

- Better if you specify specific factors

- It looks like attitude towards factors not patient safety

- It is very confusing title

Abstract

- Key words seem like sentence

- Why medical and surgical nurses only

Introduction

- Why you want to study this and how you do it differently are not stated well.

Aim

- What about other specific objectives

Methods and materials

- Specify the validity and reliability of tool

- What do you do to improve the quality of your tool?

- How you select data collectors

- You need comprehensive literature search to include all independent variables

- The operational definition is not clear, please write it clearly and in detail

- What about inclusion and exclusion criteria?

- How you minimize confounding factors

Result, discussion and limitations

- How you minimize correlation

- It’s difficult to add up the number of nurses and doctors’ response, how do you do it?

- How do you classify the age group?

- Why surgical and medical ward only

- You need to explain the possible reasons in study differences and similarities

- Some of works you should do did not need to be stated as limitations

-

**********

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Reviewer #1: Yes: Eliudi Saria Eliakimu

Reviewer #2: No

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14 Oct 2021

Dear Reviewers,

The authors would like to thank the reviewer for his/her thorough review of the manuscript. We believe that this revised version, which includes reviewers’ suggestions, is more accurate and communicates better the main message of the article.

We will gratefully respond to any further comments on the text.

The paragraph is marked in yellow in the manuscript.

Thank you again for taking the time to review our paper and for your constructive comments.

Following comments have been modified in a new version of the manuscript:

Yours sincerely,

IML

Reviewer(s)' Comments to Author:

Reviewer: 1

I suggest that the authors make a correction in the last sentence of the second paragraph on page 3 which reads: “The analysis of factors contributing to the occurrence of adverse events is underlying condition for changes in the staff's behaviour, which may makes healthcare environment safer [7];” by replacing the word “makes” with “make” so that it will read as follows: “The analysis of factors contributing to the occurrence of adverse events is underlying condition for changes in the staff's behaviour, which may make healthcare environment safer [7].

Authors' response:

We would like to thank the Reviewer for his due remark. Has been changed.

In the “materials and methods” section in the fourth paragraph on page 5, I suggest that the authors delete the word “towards” in the following sentence: “Its first part includes questions related to the following subscales:: 1/ Teamwork climate -…….; 2/Safety climate - SC (questions from 7 to 13) – evaluates the perception of employees' organisational involvement in towards patient’s safety; 3/Job satisfaction - JS (questions from 15 to 19) –……”, so that it will read: “……..of employees' organisational involvement in patient’s safety;”

Authors' response:

We would like to thank the Reviewer for his due remark. Has been changed.

In here, I suggest that the authors add a mention of also implementing the recently launched “Global Patient Safety Action Plan: 2021-2030”.

https://wfsahq.org/news/latest-news/whas-global-patient-safety-plan-2021-30/

Authors' response:

We would like to thank the Reviewer for the suggestion to refer to the "Global Patient Safety Action Plan: 2021-2030" in this manuscript. Used in the text under “Discussion”, paragraph 9.

We have included the suggestion as follows:.

The recently introduced Global Patient Safety Action Plan: 2021-2030, which includes broadly developed strategies that can be adapted to the national context, can be used to do this. Their implementation will help ensure that patient safety is improved both nationally and globally. Therefore, all the more a safety culture should permeate the attitudes, beliefs, values, skills and practices of healthcare professionals, managers and leaders of healthcare organizations

Reviewer: 2

Spelling, grammar and English need detailed review and edition.

Authors' response:

The text has been corrected.

Title

- Better if you specify specific factors

- It looks like attitude towards factors not patient safety

- It is very confusing title

Authors' response:

We would like to thank the Reviewer for his attention. We changed the manuscript title to:

Nurses and physicians attitudes towards factors related to hospitalized patient safety

Abstract

- Key words seem like sentence

Authors' response:

We would like to thank the Reviewer for his correct remark, the key words have been changed and clarified to:

safety, attitudes, patients, nurses, physicians

- Why medical and surgical nurses only

Authors' response:

The research was carried out according to the protocol of the RN4CAST project, which included the study of a nurse from the surgical and medical departments. The study group worked in 21 hospitals representing a representative sample for Poland, and selected according to the geographical area of the country, population density, taking into account the hospital's reference level. The study was cross-sectional and correlational. In line with the assumptions of the RN4Cast project, internal medicine and surgery departments were selected because they provide multidisciplinary care provide health care to the majority of urgently hospitalized adult patients, provide multidisciplinary care and employ a large number of nurses.

Introduction

- Why you want to study this and how you do it differently are not stated well.

Authors' response:

This research was conducted in accordance with the RN4CAST project protocol. Replication the RN4CAST protocol could help to analyse developing a culture safety. In addition, the inclusion of a new short safety assessment tool (SAQ questionnaire - the new tool used for this study) it is useful in the assessment of patient safety determinants by managers. When shaping a safe culture in health care organization, it should be remembered that ensuring the safety of patient care is primarily human resources - staff involved in the treatment process - mainly doctors and nurses. High awareness of occupational safety, cooperation in an interdisciplinary team, assessment of the culture of work safety drawing conclusions and making the right decisions may will increase the safety of hospitalized patients. On the other hand, it should be remembered that a strong safety culture is not only key to reducing harm to patients, but is also key to ensuring a safe working environment for healthcare professionals, which is why it is so important to undertake research to assess attitudes towards safety.

Aim

- What about other specific objectives

Authors' response:

Specific objectives were included in the manuscript.

Detailed objectives:

1. What attitudes towards factors related to hospitalized patient safety are presented by nurses and by doctors?

2. What were the differences in attitudes towards safety in the group of nurses and doctors?

3. To what extent did the type of ward differentiate the attitudes towards safety of nurses and doctors?

4. What was the relationship between the respondents' gender and attitudes towards safety?

5. What was the relationship between the time of employment of the respondents and their attitudes towards safety?

Methods and materials

- Specify the validity and reliability of tool

Authors' response:

As suggested by the Reviewer, the text of the manuscript has been supplemented in the "Material and methods" section, paragraph 3.

The Safety Attitudes Questionnaire reliability had a Cronbach's Alpha of 0.98. Before performing the analysis validity of the Polish adaptation of SAQ-SF, the Kaiser test was used to check whether the data meet the requirements of the factor analysis. The Kaiser-Mayer-Olkin (KMO) value, being the measure of the adequacy of the sample selection, was estimated at the level of 0.87 (df=8630, p<0.001). This model explained 68% of the total variance of the analysed set of variables (Malinowska – Lipień, et al. 2021).

What do you do to improve the quality of your tool?

Authors' response:

The subsequent study is planned to improve the quality of the tool.

- How you select data collectors

Authors' response:

At the hospital, a hospital coordinator was appointed to liaise with the research team and ensure consistency in data collection in line with the study guidelines. In clinical departments, the questionnaire was distributed among departmental staff by the hospital project coordinator. Participants had 4 weeks to complete the questionnaire. The completed anonymous questionnaires were deposited through an opening in securely closed boxes. Neither the coordinators nor anyone else at the hospital level had access to the contents of the boxes, they were only opened by a team of researchers. After 4 weeks, the coordinators collected the boxes, secured them and sent them by courier over to the research team. Before starting the study every participant was informed that participation was voluntary and anonymous, all responses are kept confidential and no individual responses would be available to the hospital management.

- You need comprehensive literature search to include all independent variables

Authors' response:

The research results presented in the reviewed manuscript concern attitudes towards the patient safety of nurses and doctors assessed with the SAQ questionnaire. The independent variables were data obtained only from the SAQ questionnaire. The authors agree with the Reviewer that independent variables do not include all possible variables. There is no analysis regarding the age of the respondents. However, the questionnaire does not include such data.

The analysis was carried out in accordance with the principles described in the refences:

10. Bondevik GT, Hofoss D, Husebø SB, Tveter Deilkås EC. Patient safety culture in Norwegian nursinghomes. BMC Health Services Research. 2017, 17:424. doi 10.1186/s12913-017-23.

11. Milton J, Chaboyer W, Åberg ND, Andersson AE, Oxelmark L. Safety attitudes and working climate after organizational change in a major emergency department in Sweden. Int Emerg Nurs. 2020, 3;100830. doi: 10.1016/j.ienj.2020.100830.

12. Gabrani A, Hoxha A, Simaku A, Gabrani J. Application of the Safety Attitudes Questionnaire (SAQ) in Albanian hospitals: a cross-sectional study. BMJ Open. 2015;5:e006528, doi: 10.1136/bmjopen-2014-006528.

13. Jiang K, Tian L, Yan C, Li Y, Fang H, Peihang S, Li P, Jia H, Wang Y, Kang Z, Cui Y, Liu H, Zhao S, Anastasia G, Jiao M, Wu Q, Liu M. A cross-sectional survey on patient safety culture in secondary hospitals of Northeast China. PLoS One. 2019, 14(3):e0213055. doi:10.1371/journal.pone.0213055.

14. Bahar S, Önler E. Turkish surgical nurses' attitudes related to patient safety: A questionnaire study. Niger J Clin Pract. 2020, 23(4):470-475. doi: 10.4103/njcp.njcp_677_18.

- The operational definition is not clear, please write it clearly and in detail

Authors' response:

As suggested, the definition according to WHO and The International Classification for Patient Safety (ICPS) was included.

For the WHO, “ patient safety means the reduction to an acceptable minimum level of risk of unnecessary harm related to health care”. The International Classification for Patient Safety (ICPS) defines ‘patient safety’ “as the act of avoiding, preventing or improving adverse outcomes or injuries occurred throughout the medical-hospital process”

- What about inclusion and exclusion criteria?

Authors' response:

As suggested by the Reviewer, the text of the manuscript has been supplemented in the "Material and methods" section, paragraph 2.

The inclusion criterion was employment and active work during the study as a nurse or physician in a given hospital. All other hospital staff was excluded from the study. Nurses on maternity leave, extended

sick leave or study leave were excluded from participation.

- How you minimize confounding factors

Authors' response:

Potential confusing factors have been limited by through clear written instructions attached to the each questionnaire, and also by detailed familiarization of hospital coordinators with the meaning of the study and method of filling in forms, which was then handed over to participants. The research team provided necessary additional information and monitored the process of obtaining completed forms.

Result, discussion and limitations

- How you minimize correlation

Authors' response:

Comparison of teamwork climate (TC), safety climate (SC), job satisfaction (JS), recognition of stress (SR), management perception (PM), working conditions (WC) between occupational groups, types of departments, genders, age groups patients covered by the care and seniority of nurses and doctors was first carried out using MANOVA - to take into account the influence of these factors on all aspects of safety attitudes at the same time, and taking into account the correlations between them.

- It’s difficult to add up the number of nurses and doctors’ response, how do you do it?

Authors' response:

For some analyzes (e.g. unit type, gender, and work experience), the nurses 'and physicians' scores were summed up as both occupational groups completed the same SAQ. Both the questions of the questionnaire and the calculation method are the same for both occupational groups.

- How do you classify the age group?

Authors' response:

In the studies, the study group was not divided by age, but only by work experience and the group of patients treated in the study unit (adults and adults & children). The time frame of work experience and the division into a group of patients are consistent with the original version of the SAQ.

- Why surgical and medical ward only

Authors' response:

Studies for this manuscript were performed according to the RN4CAST project protocol. This study was carried out in a group of nurses working in departments, surgical and internal medicine departments, in 21 hospitals with 24-hour permanent duty, representative a representative sample for Poland, and selected according to the geographical area of the country, population density taking into account the hospital's reference level. The study was cross-sectional and correlational. In line with the RN4Cast project, the medical and surgical departments were selected because they provide multidisciplinary care and employ a large number of nurses.

- You need to explain the possible reasons in study differences and similarities

Authors' response:

Included in the manuscript.

Polish nurses received higher mean score in the teamwork subscale mean results in the subscale concerning teamwork (TC) (62.38 pts.) than nurses working in Albania (45.7 pts.) [12] and Turkey (46.27 pkt.) [14], but critically lower compared to European countries as Norway and Sweden [10-11], Asia (China, Saudi Arabia, Iran) [13, 15-16], Americas (Brazil, and US-PA, Pittsburgh) [18-19], Australia [9] or Africa (Kenya) [17]. The evaluation of team work by Polish nurses may result from the fact that position of physician is being prioritised in the hierarchy of the Polish healthcare system. This opinion has an impact on the teamwork and may prevent equal contribution of skills and knowledge of from other health team members those team members who are not doctors. Effective cooperation of various professionals in a team constitutes an important element of care and their patient safety.

In the aassessment of safety climate (SC), Polish nurses received higher mean results (63.41 pts.) than nurses working in Albania (36.8 pts.) [12] and Turkey (46.44 pkt.) [14], but definitely lower mean values than nurses working in Norway or Sweden [10-11], as well as in the area of Asia (China, Saudi Arabia, Iran) [13, 15-16], Americas (Brazil, and the state of Pennsylvania US-Pittsburgh) [18-19], Australia (Australia) [9] or Africa (Kenya) [17]. Within the safety climate (SC) subscale, Polish physicians obtained higher mean results compared with the physicians doctors from Sweden and Albania [11-12]

- Some of works you should do did not need to be stated as limitations

Authors' response:

The presented limitations of the work result from other assumptions of the presented research and the lack of available data. The authors consider these issues to be important to consider in future research (e.g., different types of wards, more hospitals, different medical professions). The authors believed that these were more limitations rather than the results of the research performed. Limitations, the reduction of which in subsequent studies will allow for a better understanding of the factors that determine the patient's safety.

Submitted filename: Response to Reviewers_PLOS ONE_27_09_2021-1.docx

Click here for additional data file.

25 Oct 2021

PONE-D-21-20381R1Nurses and physicians attitudes towards factors related to hospitalized patient safetyPLOS ONE

Dear Dr. Malinowska-Lipień,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Dear Authors,The comments from Reviewer-2 is well received and valid points. Therefore, may I request you to kindly strengthen the method section especially quantifying the outcome and mentioning the confounding factors, perhaps in the limitation. Also my request you to kindly do language edits before you submit the next version.Thanks

Please submit your revised manuscript by Dec 09 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Sandul Yasobant, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: One typing error for correction in the fourth (04th) paragraph of “Discussion section” - the first sentence, which reads: “In the aassessment of safety climate (SC), Polish nurses received…….”. Spellings for the word assessment need to be corrected.

Reviewer #2: - Thank you for addressing most of the comments

- Still your English and grammar need detailed review and edition

Title

- Why nurses and doctors were your priority? What about other health professionals?

- “Nurses and physicians’ attitudes towards factors related to hospitalized patient safety”, please specify what factor you intend to study?

- “What about other staff nurses…” need further explanation?

Methods

- Operationalize patient safety, attitude in quantitative way (quantify it)

- How you minimize confounding factors needs further explanation

- Which age group is adult and which one is children

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Eliudi Saria Eliakimu

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: plos review.docx

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2 Nov 2021

Dear Reviewers,

The authors would like to thank the reviewer for his/her thorough review of the manuscript. We believe that this revised version, which includes reviewers’ suggestions, is more accurate and communicates better the main message of the article.

We will gratefully respond to any further comments on the text.

The paragraph is marked in green (English and grammar) and yellow (other changes) o in the manuscript.

Thank you again for taking the time to review our paper and for your constructive comments.

Best regards,

Reviewer #1:

One typing error for correction in the fourth (04th) paragraph of “Discussion section” - the first sentence, which reads: “In the aassessment of safety climate (SC), Polish nurses received…….”. Spellings for the word assessment need to be corrected.

Response: The text was checked in terms of language and grammar. The corrected text is highlighted in green in the manuscript.

Reviewer #2:

- Still your English and grammar need detailed review and edition

Response: The text was checked in terms of language and grammar. The corrected text is highlighted in green in the manuscript.

Title

- Why nurses and doctors were your priority? What about other health professionals?

Response: In Poland, the largest group of medical professions are nurses and doctors. It is doctors and nurses who play the main role in the process of diagnosis and treatment and patient care. According to the report of the National Health Fund, he works in hospitals (https://ezdrowie.gov.pl/portal/home/zdrowe-dane/zecja/zecja-dotyczace-liczby-personelu-medycznego-w-umowach-z-narodowym-funduszem-zdrowia ):

nurses - 192 223

doctors - 113 724

physiotherapists - 38 416

midwives - 25 033

laboratory diagnosticians - 760

pharmacists - 18 564

In the "Research limitations" part, the question of extending the study group to include representatives of other medical professions was taken into account. Therefore: "In addition, in subsequent studies, to accurately assess the accuracy of the scale, it should also be tested by comparing different groups of medical professions, and their selection would take into account a comparable number of respondents."

- “Nurses and physicians’ attitudes towards factors related to hospitalized patient safety”, please specify what factor you intend to study?

Response: The research used the international SAQ scale, which allows the assessment of patient safety in 6 areas: 1/Teamwork Climate; 2/ Safety Climate; 3/ Job Satisfaction; 4/Stress Recognition; 5/Perceptions of Management; 6/ Working Conditions. The research was carried out on the basis of the SAQ questionnaire adapted to Polish conditions (Malinowska-Lipień I, Brzyski P, Gabryś T, Gniadek A, Kózka M, Kawalec P, et al. Cultural adaptation of the Safety Attitudes Questionnaire - Short Form (SAQ-SF) in Poland. PLoS One. 2021 Feb 5;16(2):e0246340. doi: 10.1371/journal.pone.0246340).

- “What about other staff nurses…” need further explanation?

Response: In Poland, according to the report of the Ministry of Health on a national scale, the largest number of beds was intended for patients requiring surgical treatment - 39.3 thousand. and for internal medicine patients - 23.0 thousand (Report - pp. 44 - 45, chart 18 (English version), therefore it was decided that the research should focus on this group of nurses and doctors. Of course, it is a correct remark that in subsequent studies it is necessary to include staff working in all types of wards, this was taken into account parts in "Research limitations" (Report: https://stat.gov.pl/files/gfx/portalinformacyjny/pl/defaultaktualnosci/5513/1/9/1/zdrowie_i_ochrona_zdrowia_w_2018.pdf)

“Subsequent future studies should expand research to a larger number of hospitals and different types of wards (including pediatric, intensive care and psychiatric) with additional inclusion of the influence of factors conditioning attitudes towards safety on the frequency of adverse events, including international studies comparing different countries”.

Methods

- Operationalize patient safety, attitude in quantitative way (quantify it)

Response: The SAQ results were presented both as quantitative (Table 1) and qualitative (Table 2) data. The results of own research and quantitative data were compared in the discussion with the results of research carried out in 11 different countries. In all these studies, quantitative data were presented, our results were additionally enriched with qualitative data presented in Table 3. The results of the individual 6 subscales were divided into> = 75 points and <75 points, where * ≥75 pts. - positive result. <75 pts.- negative result.

- How you minimize confounding factors needs further explanation

Response: The "Materials and methods" section describes the data collection process in detail, ensuring such conditions minimized disruptive factors.

At the hospital, a hospital coordinator has been appointed to work with the research team and ensure consistency in data collection in line with the guidelines of the study. In clinical departments, the questionnaire with a plastic envelope attached to it was distributed during departmental staff meetings led by the hospital project coordinator. Participants had 4 weeks to complete the questionnaire. Completed questionnaires packed in a sealed plastic envelope were thrown into a sealed box with a hole. After 4 weeks, the coordinator was responsible for collecting the boxes, securing them and handing them over to the research team. Participants were informed that participation was voluntary and anonymous, that all responses would be kept confidential and that no individual responses would be available to hospital management.

- Which age group is adult and which one is children

Response: The SAQ questionnaire in the "BACKGROUND INFORMATION" section has a question about the majority of patients in the ward. There are three distractors 1- adults; 2 kids; 3- both groups (original version of the SAQ: https://med.uth.edu/chqs/wp-content/uploads/sites/75/2020/03/SAQ-Short-Form-2006.pdf ; Polish version of SAQ: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246340 ). In Poland, adult departments cover patients from 18 years of age, and children's departments up to 18 years of age.

Submitted filename: Response to Reviewers_31-10-2021.docx

Click here for additional data file.

8 Nov 2021

PONE-D-21-20381R2Nurses and physicians attitudes towards factors related to hospitalized patient safetyPLOS ONE

Dear Dr. Malinowska-Lipień,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Dear Authors,The current draft still requires English language editing, as correctly pointed out by one of our reviewers. Please re-submit it with help of a professional proof reader. Thanks

Please submit your revised manuscript by Dec 23 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Sandul Yasobant, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: still it needs to be edited with english editor. Grammar and preposition needs to be properly addresed.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

16 Nov 2021

Dear Reviewer,

The authors would like to thank the reviewer for review of the manuscript.

We believe that this revised version, which includes reviewers’ suggestions, is more accurate and communicates better the main message of the article.

We will gratefully respond to any further comments on the text.

The article has been linguistically proofread by a professional proof reader. In the manuscript, the corrected text is highlighted in yellow.

Thank you again for taking the time to review our paper and for your constructive comments.

Best regards,

Iwona Malinowska-Lipień

Submitted filename: Response to Reviewer_16-11-2021.docx

Click here for additional data file.

22 Nov 2021

Nurses and physicians attitudes towards factors related to hospitalized patient safety

PONE-D-21-20381R3

Dear Dr. Malinowska-Lipień,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Sandul Yasobant, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Almost all comments were addressed properly and i still suggest you to improve your english and grammer.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

24 Nov 2021

PONE-D-21-20381R3

Nurses and physicians attitudes towards factors related to hospitalized patient safety

Dear Dr. Malinowska-Lipień:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Sandul Yasobant

Academic Editor

PLOS ONE