considerable effort to developing several theoretical frameworks concerning the processes through which climate forms and develops (Ashforth, 1985; Ostroff, Kinicki, & Tamkins, 2003; Schneider, Ehrhart, & Macey, 2011; Schneider & Reichers, 1983). Specifically, climate has been conceptualized as a product of structural elements of the work environment (e.g., size,
centralization; Payne & Mansfield, 1973; Payne & Pugh, 1976), as arising through attraction- selection-attrition (ASA) processes (e.g., degree of fit between individual values and
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organizational values [Schneider, 1987; Schneider, Goldstein, & Smith, 1995]), and as a result of symbolic interactionism (e.g., collective sense-making processes occurring during interactions among employees; Blumer, 1969; Schneider & Reichers, 1983). Empirically, the interactionist perspective has arguable received the most empirical support in the general climate literature to date (Cannon-Bowers, Salas, & Converse, 1993; Mohammed, Klimoski, & Rentsch, 2000; Smith-Jentsch, Mathieu, & Kraiger, 2005). Conversely, there has been limited investigation to date regarding how facet-specific climates, such as patient safety climate, develop.
In one of the few theoretical discussions of the patient safety climate construct, Reiman and colleagues (2010) proposes that climate perceptions are shaped by organizational processes, social processes, and individual psychological processes. Similarly, in their integrative modelsof organizational climate for healthcare, MacDavitt, Chou, and Stone (2007) and suggest both macro level organizational structures and leadership impact unit level processes of supervision, group behavior, and the degree to which quality is emphasized, as well as work design factors. These unit level characteristics, in turn, are predicted to impact outcomes for both patient and healthcare workers.
There have been few empirical studies to date investigating the antecedents of patient safety climate and those that have been conducted have tended to be relatively weak in both theoretical development and empirical design. Overall, studies investigating the antecedents of patient safety climate have tended to focus on shared physical location/level of interaction, individual differences of respondents (e.g., job position, age, tenure or experience) or psychosocial aspects of the work environment (e.g., empowerment, leadership support, teamwork). For example, Sorra and Dyer (2010) reported that between 2% and 10% of the
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variance in individual responses to individual patient safety climate items could be attributed to hospital membership. They also found that unit/department membership accounted for 6% to 23% of the variance in individual perceptions of climate. However, the primary purpose of this study was psychometric validation and there was no theoretical reasoning offered to guide interpretation of these results.
Sexton, Holzmueller, and colleagues (2006) also found significant variation in teamwork climate among units in a study of labor and delivery units in 44 U.S. hospitals. At the unit level, results also indicated that familiarity with unit colleagues was positively correlated with
teamwork climate. Additionally, their results suggested signification variation in climate perceptions based on which hospital a unit was nested in. Similar results were found by France and colleagues (2009) in a study of 67 ICUs from 41 U.S. hospitals. Using hierarchical
clustering to account for ICUs nested within the same hospital and random effects regression modeling, results indicated that unit membership was a significant, unique predictor of patient safety climate.
Armstrong, Laschnger, and Wong (2009) investigated employee perceptions of empowerment and work environment characteristics as predictors of patient safety climate. Measures of work environment characteristics focused on mainly psychosocial aspects of environment including collaborative relationships among staff members, support for nurse participation in case processes, and nurse manager ability, leadership, and support for nurses. Results from a random sample of 152 nurses found that perceptions of empowerment and perceptions of hospital characteristics were both unique predictors of patient safety climate and in combination they accounted for 50% of the variance in individual climate perceptions.
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Similarly, a study of 800 Saudi Arabian clinicians found that management support (β = 0.32), the organization‘s error reporting system (β = 0.27), and access to adequate information technology and staffing resources (β = 0.20) were significant unique predictors of individual patient safety climate perceptions (Walston, Al-Omar, & Al-Mutari, 2008). Type of hospital (e.g., private vs. state owned) was not found to be a significant predictor of climate perceptions, however. As these results demonstrate, however, the majority of studies examining potential predictors of individual patient safety climate perceptions have relied on cross-sectional designs to date; precluding causal inferences from being drawn.
While not specifically focused on predictors of climate, a study that examined both hospital climate and unit climate found a significant interaction between the two. The
characteristics of the interaction suggested that a highly positive patient safety climate at the unit level can compensate for lower organizational patient safety climate in terms of promoting positive safety behavior and safe outcomes (Zohar & Luria, 2005; Zohar et al., 2007). These results support the notion that individuals can differentiate between organizational and unit level patient safety climate and that both organizational membership and unit membership may exert parallel, but orthogonal influences on one‘s perception of climate.
Descriptive findings compiled from large patient safety climate surveys also suggest several factors may influence individual perceptions of patient safety climate (e.g., AHRQ, 2009, 2010; Campbell et al., 2010; )Descriptive statistics reported by Campbell and colleagues (2010) suggest potentially meaningful variation among unit types (critical care, emergency, operating room, medical, surgical, other). For example, the reported descriptive statistics suggest that the inpatient units (e.g., ICU) tended to have more positive patient safety climate than short-term
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care units such as the emergency department and operating room. Within each unit type, however, they also reported a large amount of variation. No statistical tests were conducted, however to determine if these trends were statistically meaningful. Similarly, Sexton and colleagues (2006) reported variation among clinical areas in a study of ICU, OR, general inpatient, and general ambulatory care units. For example, some clinical areas none of the respondents reported a negative climate for speaking up, whereas nearly half of the respondents in other clinical areas did. However, statistical comparisons were not reported.
Findings from examinations of individual differences as predictors of patient safety climate have tended to be mixed. For example, several studies have found professional affiliation to be related to patient safety climate (e.g., Campbell et al., 2010; France et al., 2009; Walston, Al-Omar, & Al-Mutari, 2008; Thomas, Sexton, & Helmreich, 2003; Sexton, Holzmueller et al., 2006). However, others have not found support for this relationship (e.g., Kho et al., 2009). In terms of demographic individual differences, there has been limited evidence to date that gender or age are related to individual patient safety climate perceptions (Kho et al., 2009; Walston, Al- Omar & Al-Mutari, 2008). There has also been only limited evidence that years of experience or tenure is related to individual patient safety climate perceptions (France et al., 2009; Jasti et al., 2009). However, studies of general organizational climate have found tenure to be significantly related to climate perceptions (Gonzales-Roma et al., 1999).
Meta-analytic results from the safety climate literature also suggest a potential feedback loop between patient outcomes and climate perceptions. In a sample of 25 studies including over 17, 000 participants, Clarke (2006) found that safety climate accounted for 22% of the variance in accident/injury rates. However, this relationship was moderated by study design. Safety
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climate was positively related to accidents in both prospective designed studies (ρ = .35), in which accidents were recorded after administration of the climate survey, and retrospective designed studies (ρ = .22), in which participants self-reported accidents or injuries experienced during a given period of time prior to the climate survey. However, only the credibility values for prospective studies met the criteria for validity generalization—suggesting that results from prospective studies regarding the effects of safety climate on accident rates were the most robust across occupational settings.
Overall, the theoretical and empirical findings regarding how patient safety climate perceptions form have generally align with theories of general organizational climate and general safety climate which suggest that multiple influences shape individual climate perceptions, but that the most proximal—interaction with workgroup members—may exert the most pronounced influence (Ashforth et al., 1985). These results also parallel empirical studies that have found support for both proximal and distal predictors of individual perceptions of general
organizational climate (Joyce & Slocum, 1984) and team climate (Smith-Jentsch et al., 2010).
2.3 Patient Safety Climate as a Predictor Variable: What Impact Does Climate Have on