Introduction
The Institute of Medicine (IOM) defines safety as the prevention of harm to patients, while emphasizing care delivery systems, such as prevention of mistakes, learning from past mistakes, as well as building a safety culture in healthcare organizations [1, 2]. The defining features of patient safety involve prevention of medical errors and avoidable adverse events, protection of patients from harms or injuries, collaborative efforts made by individual healthcare providers, as well as a strong and well-integrated healthcare system [3]. In a study in Sweden, it was found that about 105,000 patients suffered preventable injuries at hospitals, with 3,000 of whom died in a one-year period [4].
It is worth mentioning that a positive safety culture could lead to the prevention of adverse incidents threatening patient safety, thereby improving the quality of medical care [5]. Safety culture is the result of values, perceptions, competencies, attitudes, and patterns of individual and group behaviors, which determine the commitment, style, and skills of managing a safe and healthy organization [6, 7]. The assessment of the patient safety culture is highly effective in improving the quality of a care system in which providing safe care services should be given priority in healthcare organizations [8]. Patient safety culture helps recognize diverse facets of patient safety and factors influencing it. Among these factors, one could mention burnout and job satisfaction in healthcare and medical staff at hospitals [9].
Job satisfaction status can be determined by comparing one’s previous expectations about the job and the actual job experience [10, 11]. Burnout commonly refers to a prolonged response to chronic emotional and interpersonal stressors, which is characterized by depersonalization, emotional exhaustion, and lack of social accomplishments [12, 13]. Research shows that job burnout has a significant negative relationship with patient safety culture, with job satisfaction having a significant positive relationship with patient safety culture. Given the effective role of both factors of satisfaction and burnout in patient safety culture, one can manage these two variables in the workplace so as to improve patient safety culture [10]. Due to the importance of patient safety at medical centers and its direct relationship with patient satisfaction, this study was conducted to investigate the impacts of burnout and job satisfaction on patient safety culture in the medical staff of the Qom University of Medical Sciences in 2020.
Materials and Methods
This descriptive correlational study was conducted on 248 medical staff members of the Qom University of Medical Sciences in 2020, who included physicians, nurses, midwives, anesthesiologists, operating room technicians, and para-clinic technicians. Besides, it was conducted at teaching hospitals of the Qom City and was approved by the research deputy of the Qom University of Medical Sciences. The total target population in this study included 3,500 people. According to the correlation coefficient formula for the sample size and considering r= 0.25 between job satisfaction and safety culture based on Rabiee et al study [9], the study power and confidence interval were 90 and 95%, respectively, with the required sample size having been estimated at 163. Based on the type of sampling, 260 people were included in this study. Convenience sampling was used for sample selection. One of the inclusion criteria of the study was working medical staff willing to participate in this study. Another inclusion criterion was having at least an associate's degree and one year of work experience. In contrast, the exclusion criterion was concerned with the people not willing to complete the questionnaires and participate in the study. This research was conducted at the teaching hospitals of the Qom City. The job descriptive index (JDI), the hospital survey on patient safety culture (HSOPSO), and the Maslach burnout inventory were used to collect the data. The required data were extracted from the questionnaires and analyzed via SPSS version 20 (SPSS Inc., Chicago, IL, USA).
The demographic questionnaire included eight questions about the variables, including the participants' age and gender, work experience, marital status, education, organizational position, employment status, and work shift.
JDI Questionnaire: The job descriptive index (JDI) questionnaire is one of the most reliable tools for measuring job satisfaction. This questionnaire was developed by Smith, Kendall, and Hyulin in 1969. The JDI questionnaire measures the five subscales of job satisfaction, including the boss, coworkers, promotion, wage, and work conditions. This tool has 72 items, and the scoring is based on a 5-point Likert scale ranging from 1 to 5. In addition, the total score of the questionnaire is 360. The Persian version of this questionnaire was prepared by Behrozi et al (2008), with some modifications applied to the scoring procedure. The total score of the job description index with the Cronbach's alpha was 41%, and the total content validity was 0.750. However, it was enough to add the scores of the items for each subscale to obtain the score of that subscale. The questionnaire was observed and approved by several experts [14].
Maslach Burnout Inventory Questionnaire: The job burnout questionnaire consists of 22 items and a dual scale of frequency and intensity for measuring the three aspects of burnout, including emotional fatigue, personal success, and depersonalization [15]. Muslim and Jackson reported internal reliability coefficients of 0.9, 0.79, and 0.71 for emotional fatigue, depersonalization, and individual success, respectively. The validity and reliability of this questionnaire were confirmed for the first time in Iran [16, 17]. The reliability coefficient of the questionnaire was estimated at 78% by the Cronbach's alpha method. Given the standardization of the burnout questionnaire, it had necessary validity for measuring the burnout level. The method of scoring the items of this questionnaire was based on a 7-point Likert scale. In addition, options for this test included never, little, very little, medium, above average, high, and very high. When the subjects read this scale, they would express their feelings according to the options available to them. Muslim and Jackson used three methods for determining validity of this questionnaire. Questions 1, 2, 3, 6, 8, 13, 14, 16, and 20 were related to the subscale of emotional fatigue. In addition, questions 5, 10, 11, 15, and 22 were related to the depersonalization subscale. Furthermore, questions 4, 7, 9, 12, 17, 18, 19, and 21 were related to the subscale of lack of personal success. The scoring options of this test included scores of never, very low, low, average, medium to high, high, and very high. In fact, some questions were calculated in reverse or directly for the scoring purpose. Accordingly, the dependence of the individuals' scores in the present questionnaire was calculated with a score that gave a completely familiar personality to a person; the correlation between the dimensions of job experience and burnout was calculated; and the correlation between the individuals' scores in this questionnaire and various consequences was calculated, which was assumed to be related to burnout [15, 18].
Hospital Survey on Patient Safety Culture (HSOPSO): The HSOPSC, as designed by the US Agency for Health Research and Quality (2004), was used. This questionnaire consisted of 42 items for measuring patient safety culture using a 5-point Likert scale, ranging from strongly opposed to strongly agree. The scoring method of this questionnaire was based on a 5-point Likert scale that ranged from strongly disagree, disagree, having no opinion, agree, and, strongly agree. The study of Moghari et al confirmed the validity and reliability of this questionnaire for working in Iran [19, 20]. Dimensions with a response greater than 75 were considered as strengths, and dimensions
with an average response of smaller than 50 were considered weaknesses requiring intervention. Besides, dimensions between these two values were considered neutral. To get the overall score of the questionnaire, the total score of all questions were added to each other, with this score ranging from 15 to 75. Besides, the larger the score was, the higher the patient safety culture would be [21].
Descriptive and inferential statistics were utilized to analyze the data. Besides, data distribution was assessed by the Kolmogorov–Smirnov test. Moreover, the independent-samples t-test and the one-way ANOVA were used to compare the mean scores among the groups after checking the normality of data. The chi-square test was used for the comparison of the qualitative variables. In addition, the Pearson correlation test was performed to assess the relationship between JDI, patient safety culture, and job burnout. Data analysis was performed using SPSS version 20 (SPSS, Chicago, IL). The significance level was considered 0.05
The research proposal was approved by the vice-chancellor for research at the Qom University of Medical Sciences. In addition, the Medical Ethics Committee (MEC) of the Qom University of Medical Sciences approved the study protocol (Code of Ethics IR.MUQ.REC1399.114). The questionnaire was completed with informed consent obtained from the participants. All employees' information was protected, and the results of the study were published in the groups.
Results
From 260 questionnaires distributed, a total of 248 staff members completed and delivered the questionnaires (a response rate of 95.4%). The mean age of the staff was 32.04 ± 7.9 years, with 208 staff members (83.9%) having been female. Based on our findings, the majority of the staff were married (63.3%), 76.2% had graduate degrees, and more than 30% of them were officially employed on a fulltime basis. In addition, less than half of the respondents in the current study were nurses (44.1%). Table 1 shows demographic and occupational features of the study participants.
Table 1. Demographic features of the employees participating in the current study
Variables |
Frequency |
Percent |
|
Sex |
Female |
208 |
83.9 |
Male |
40 |
16.1 |
|
Marital status |
Single |
91 |
36.7 |
Married |
157 |
63.3 |
|
Education |
Associate degree |
32 |
12.9 |
Graduate |
189 |
76.2 |
|
Master's degree |
17 |
6.9 |
|
PhD |
7 |
2.8 |
|
Proficiency |
3 |
1.2 |
|
Employment status |
Officially hired |
96 |
38.7 |
Experimental employment |
9 |
3.6 |
|
Employment contract |
15 |
6 |
|
Contractual |
47 |
19 |
|
Tarh (Employees of compulsory service program) |
63 |
25.4 |
|
Corporative |
18 |
7.4 |
|
Organizational position |
Doctor |
8 |
3.2 |
Nurse |
103 |
41.5 |
|
Midwife |
41 |
16.5 |
|
Anesthesiologist |
37 |
14.9 |
|
Operating room technician |
52 |
21 |
|
Para-clinic technician |
7 |
2.8 |
|
Work shift |
Day |
28 |
11.3 |
Evening |
40 |
16.2 |
|
Night |
4 |
1.6 |
|
Rotational |
176 |
70.9 |
The mean scores and standard deviation of the HSOPSO, JID, and frequency of burnout were 135.4 ± 10.1, 68.07 ± 13.2, and 53.8 ± 4.5 respectively. Table 2 shows the mean scores of the studied variables in the hospital staff.
Table 2. The mean and standard deviation of the HSOPSO, JID, and frequency of burnout
Variables |
Mean ± SD |
Minimum |
Maximum |
Age |
32.04± 7.9 |
22 |
50 |
Employee's history |
7.69 ± 5.14 |
2 |
25 |
HSOPSO |
135.4 ± 10.1 |
112 |
178 |
Frequency of burnout |
53.8 ± 4.5 |
44 |
64 |
Severe burnout |
53.9 ± 4.9 |
44 |
69 |
Job satisfaction |
68.07 ± 13.2 |
32 |
100 |
Job score |
8.02 ± 2.3 |
1.00 |
10.00 |
Boss score |
52.2 ± 11.7 |
14.00 |
70.00 |
Coworker score |
3.4 ± 0.8 |
1.00 |
5.00 |
Promotion score |
19.9 ± 6.8 |
7.00 |
50.00 |
Wage score |
17.5 ± 5.04 |
9.00 |
45.00 |
Work condition score |
2.9 ± 0.8 |
1.00 |
5.00 |
In this study, we expected that job satisfaction and burnout would affect patient safety culture. The Pearson correlation coefficient test was performed to assess the relationships among the questionnaires of JID, HSOPSO, and Maslach burnout (Table 3). The results showed a significant relationship between job satisfaction (r: 0.643) and patient safety (p < 0.000) so that with an increase in job satisfaction among the employees, patient safety culture improved. In addition, burnout (r: -0.53) was shown to be inversely correlated with patient safety that decreased with an increase in burnout (p < 0.000). Besides, the results showed that employee satisfaction affected changes to patient safety culture.
Table 3. Correlation of HSOPSO and burnout scores with job satisfaction and its dimensions
Variable |
Correlation |
P-value |
|
Burnout |
-0.53 |
0.000 |
|
Job satisfaction |
Total job satisfaction |
0.631 |
0.000 |
Job score |
0.417 |
0.000 |
|
Boss score |
0.262 |
0.000 |
|
Coworker score |
0.292 |
0.000 |
|
Work condition score |
0.396 |
0.000 |
As the presumption of the test, a significant relationship was assumed between demographic factors and patient safety culture and job satisfaction. However, the present study showed no significant relationship between HSOPSO scores and gender, marital status, job status, and organizational status. Besides, there was no significant difference between the education level and HSOPSO, yet the highest mean and standard deviation scores were observed between HSOPSO and the staff's educational level, especially the master's degree (64.8 ± 19.9). According to descriptive statistics, women were more likely to get engaged in HSOPSO than men, and single employees were more likely than married ones. Table 4 shows the relationship between demographic characteristics and HSOPSO.
Table 4. The relationship between HSOPSO and demographic characteristics
Variable |
HSOPSO |
P-value |
|
Gender |
Male |
44.1±10.8 |
0.933 |
Female |
55.3±13.6 |
||
Marital status |
Single |
55 ±14.7 |
0.390 |
Married |
48.3±13.1 |
||
Employment status |
Officially hired |
54.6 ±14.5 |
0.400 |
Experimental employment |
59±18.9 |
||
Contract employment |
56.03±10.9 |
||
Contractual |
52 ± 13.2 |
||
Compulsory medical service staff |
51.5 ± 13.07 |
||
Corporative |
58.2 ± 16.5 |
||
Organizational position |
Doctor |
48.95±7.9 |
0.545 |
Nurse |
54.9±14.17 |
||
Midwife |
49.7±16.4 |
||
Anesthesiologist |
58.5±10.08 |
||
Operating room technician |
53.3± 11.06 |
||
Para-clinic technician |
64.8 ±19.9 |
||
Education |
Associate degree |
51.05±10.8 |
0.062 |
Graduate |
54.2±14.17 |
||
Master's degree |
64.10±12.9 |
||
PhD |
49.7±9.09 |
Discussion
In the present study, job satisfaction and burnout, among other variables of gender, marital status, job status, and organizational position had a significant relationship with patient safety culture.
Job satisfaction and burnout had a direct relationship and an inverse relationship with patient safety, respectively. In fact, if employees are satisfied with their job, they will pay more attention to patient safety culture, while with burnout, no attention is paid to patient safety.
Furthermore, there was no significant relationship between demographic characteristics and patient safety [22, 23]. However, in the study of Shariati et al, there was a significant relationship between patient safety and some demographic factors [24]. In another study, there was a significant correlation between staff's occupational characteristics and patient safety [25]. Besides, in Rahimi's study, there was a relationship between patient safety dimensions and some demographic characteristics [26]. A study by Rabiee et al showed a significant relationship between patient safety and job satisfaction. In addition, it was reported that people satisfied with their work would demonstrate safe behaviors [9].
In addition to demographic characteristics of employees, the relationship between job satisfaction and safety culture was addressed in this study to identify the influential factors. Upon recognizing these factors, patient safety culture will be improved, with many studies done on this field [27]. Job dissatisfaction makes employees leave the health system, perform incorrect tasks, and provide inadequate medical services, thereby reducing patient safety. Kang, in her study, referred to the relationship between employee satisfaction and patient safety enhancement as well as all related aspects of patient satisfaction [28].
In this study, data on the variable of job satisfaction indicated that employees were relatively satisfied with their work. This result was similar to that of Habibi et al [19]. To increase employee satisfaction, suitable conditions must be provided for employees to enjoy their work. Research shows that burnout is associated with a 2-fold increase in the likelihood of unsafe care, unprofessional behavior, and poor patient satisfaction, thereby leading to a decrease in patient safety, being consistent with our study [29].
Past research shows that some work shifts may lead to exhaustion and low job satisfaction among employees [30, 31]. The effects and consequences of burnout, as one of the major organizational challenges, were investigated in various studies. In addition, the effects of this syndrome on job performance were verified. Besides, improper and harmful work conditions along with working in the shift system for longer periods of time during irregular shifts are among the risk factors for burnout. Furthermore, the results of recent studies confirm the relationship between patient safety culture and the incidence rate of this disorder [32, 33].
As observed from the lenses of the public health, knowledge of the association between safety culture and the psychological health of healthcare professionals can provide leaders with an opportunity for synergistically intervening in the domains of occupational health and patient safety as they are connected to each other. Accordingly, it is recommended that strategies be adopted to promote patient safety culture so as to reduce the risk of burnout development and to provide an effective improvement in the quality of healthcare services [34]. Given the relationship of satisfaction and burnout with patient safety in various studies, employees need to feel that hospital managers value them and that they are in complete safety while performing their duties. Accordingly, we should pay attention to staff problems and their welfare to increase job satisfaction at an organizational level so as to achieve acceptable levels of patient safety.
The main limitation in the study was that a number of the participants did not have the opportunity for completing the questionnaire due to the lack of time. Thus, it is suggested that more research be conducted with a larger number of samples.
Conclusion
According to the findings, suitable conditions must be provided for employees to enjoy their work so as to increase employee satisfaction. Besides, there should be an incident reporting system because this system can lead to a positive outlook in employees on the safety improvement of patients.
Acknowledgement
The authors would like to extend their gratitude to all staff who contributed to this study.
Conflict of interest: None declared.
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