# Analysis of Factors Influencing Safety Attitudes of Operating Room Nurses and Their Cognition and Attitudes toward Adverse Event Reporting

Authors: Xin Liao; Peijia Zhang; Xiaofeng Xu; Dan Zheng; Jing Wang; Yunfei Li; Li Xie
Journal: Journal of Healthcare Engineering
 (2022)

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## Abstract

Operating room nurses play a critical role in patient safety. The evaluation of safety attitudes of operating room nurses reflects their awareness and belief of patient safety. Currently, however, the research on the safety attitudes of operating room nurses is hard to track in the existing literature in China. Therefore, this paper was conducted to explore the factors influencing the safety attitudes of operating room nurses and their cognition and attitudes toward adverse event reporting. A total of 711 operating room nurses from 16 tertiary hospitals in Sichuan Province from March 1, 2018, to 2019 were selected. The general information of operating room nurses, such as age, gender, and years of service in the operating room, was obtained through the basic information questionnaire. The Chinese version of the Safety Attitudes Questionnaire (C-SAQ) was used to evaluate the safety attitude of operating room nurses, and the cognition and attitude of the subjects to adverse event reports were assessed through the questionnaire of cognition and attitude toward adverse event reporting. The average score of safety attitudes of operating room nurses was 4.20 ± 0.49. The two dimensions with a lower positive reaction rate of the safety attitudes of operating room nurses were stress recognition and working conditions. The main factors affecting the safety attitude of operating room nurses were night shifts, as well as cognition and attitudes toward adverse event reporting. There was a positive correlation between the total score of C-SAQ and the total score of cognition and attitudes toward adverse event reporting (P<0.01, r = 0.445). The safety attitude of operating room nurses is at the upper-middle level, but the stress recognition and working conditions need to be improved. Through the allocation of nursing human resources, the strengthening of hospital logistics support, and the establishment of nonpunitive nursing adverse event reporting system, the operating room safety can be significantly enhanced.


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## Body

## 1. Introduction

According to the report Patient Safety 2030 published by the National Institute for Health Research, the failure to ensure patient safety is a major problem while providing health services [1]. The WHO reports that approximately 134 million adverse events and 2.6 million associated deaths occur each year in low-income and middle-income countries due to unsafe medical environments provided by hospitals [2]. In addition, the promotion and application of the WHO Surgical Safety Checklist (2008) are significant; however, recent studies demonstrated that the Surgical Safety Checklist is only partially implemented in many hospitals [3, 4]. In Greek, medical personnel believe that surgical safety is important; however, there is a big cognitive gap in the implementation of responsibilities and standardized procedures [5]. Related studies in China have reported some safety issues, such as surgical site errors, gauze left in patients, and other serious medical malpractice. In 2019, a pregnant woman in Panzhihua City, Sichuan Province, died of three gauze pieces left in her abdomen after a cesarean section, which caused nurses in the operating room to reflect on patient safety. Therefore, it is of great practical significance to study the influencing factors of operating room safety accidents and analyze the attitude of operating room nurses for preventing errors and improving patient safety.A number of studies have shown that medical staff’s awareness of safety culture is closely related to clinical adverse events [6–8]. The key to maintaining patient safety lies in establishing a safety culture. Murray et al. pointed out that the medical staff’s safety attitudes toward patients are vital in the patient safety culture, and improved medical staff’s attitudes to patient safety promote patient health and safety [9]. Haugen et al. also proposed that the attitude and behavior of the surgical team reflected the development of safety procedures in the operating room [10]. On the other hand, reporting and analyzing adverse events is key to improving patient safety, which can not only make medical staff consciously avoid surgical errors but also improve the safety of the whole system [11]. Operating room nurses have frequent contact with patients, which is the first defense line to ensure patient safety. Therefore, to construct a safe operating room organizational culture, it is necessary to understand the status quo of operating room nurses’ safety attitudes as well as their cognition and attitudes toward adverse event reporting, so as to make targeted improvements to improve their behavior with the safety culture. In recent years, the tertiary grade A hospitals in China are favored by patients, and the number of operations is increasing year by year. However, the problem of operation safety has become increasingly prominent. The assessment of operating room nurses’ safety attitudes and their cognition and attitudes toward adverse event reporting can reflect their perception of patient safety and faith. However, only a few studies have addressed the safety culture of operating room nurses in China. Therefore, the present study aimed to investigate the safety attitude of operating room nurses from 16 tertiary hospitals in Sichuan Province, China, and explore whether the social demographic factors and operating room nurses’ cognition and attitudes toward adverse event reporting have an impact on patient safety.


## 2. Materials and Methods

### 2.1. Research Design

This cross-sectional survey was conducted from March 1, 2018 to 2019. The survey participants were operating room nurses across 16 tertiary hospitals in Sichuan Province who met the inclusion and exclusion criteria and were assimilated by the convenience sampling method. The paper participants were aware of the background and purpose of the paper. All participants in this paper provided informed consent. Inclusion criteria were as follows: voluntary participants; those who had obtained the nurse qualification certificate and were registered; those who had worked in the operating room of the inpatient department of a medical institution for ≥1 year. Exclusion criteria were as follows: those who were on leave; those who were to go abroad for further study; those who were in other hospitals. Elimination criteria were as follows: those who dropped out of the study; those questionnaires with missing value >20%.


### 2.2. Research Tool

The questionnaire included 12 items of age, gender, length of service in the operating room, mode of employment, initial education, final education, position, professional title, marital status, night shifts, weekly overtime hours, and adverse events reported in the past year.The C-SAQ was translated and revised by Guo Xia of Shanxi Medical University in 2009 according to the general version of SAQ [12]. The Cronbach’s α coefficient of each dimension was 0.72–0.85, and the overall value was 0.88, with adequate reliability and validity. The revised scale consists of 6 dimensions, which are teamwork climate, safety climate, perceptions of management, job satisfaction, working conditions, and stress recognition, with 31 items in total. The five grades of the Likert scale were as follows: 1 = strongly disagree, 2 = slightly disagree, 3 = neutral, 4 = slightly agree, and 5 = strongly agree. Among these, 6, 13, 28, 29, 30, and 31 were negative entries, with inverted scores. Each item was assigned a value of 1–5 points, and the total score of the scale was 31–155 points; the higher the score, the more positive the safety attitude.The Reporting of Clinical Adverse Events Scale was designed by Wilson et al. [13] and introduced by Nanjing University of traditional Chinese medicine in 2012. It was adopted and translated into a questionnaire suitable for China. Cronbach’s α coefficient of the questionnaire was 0.8484. It covers 5 dimensions of perceived blame, perceived criteria for identifying events that should be reported, perceptions of colleagues’ expectations, perceived benefits of reporting, and perceived clarity of reporting procedures, with a total of 28 items (14 positive and 14 negative items). The scale uses the Likert scale as follows: proficiency = 5, familiarity = 4, understanding = 3, being clear = 2, not knowing = 1, strongly agree = 5, agree = 4, neutral = 3, disagree = 2, strongly disagree = 1; the negative items were scored in reverse. The total score of the scale was the sum of the items, i.e., 28–140. The higher the score, the better the research participants’ awareness of adverse event reports, the more positive their attitudes, and the more positive their intention to implement.


## 2.1. Research Design

This cross-sectional survey was conducted from March 1, 2018 to 2019. The survey participants were operating room nurses across 16 tertiary hospitals in Sichuan Province who met the inclusion and exclusion criteria and were assimilated by the convenience sampling method. The paper participants were aware of the background and purpose of the paper. All participants in this paper provided informed consent. Inclusion criteria were as follows: voluntary participants; those who had obtained the nurse qualification certificate and were registered; those who had worked in the operating room of the inpatient department of a medical institution for ≥1 year. Exclusion criteria were as follows: those who were on leave; those who were to go abroad for further study; those who were in other hospitals. Elimination criteria were as follows: those who dropped out of the study; those questionnaires with missing value >20%.


## 2.2. Research Tool

The questionnaire included 12 items of age, gender, length of service in the operating room, mode of employment, initial education, final education, position, professional title, marital status, night shifts, weekly overtime hours, and adverse events reported in the past year.The C-SAQ was translated and revised by Guo Xia of Shanxi Medical University in 2009 according to the general version of SAQ [12]. The Cronbach’s α coefficient of each dimension was 0.72–0.85, and the overall value was 0.88, with adequate reliability and validity. The revised scale consists of 6 dimensions, which are teamwork climate, safety climate, perceptions of management, job satisfaction, working conditions, and stress recognition, with 31 items in total. The five grades of the Likert scale were as follows: 1 = strongly disagree, 2 = slightly disagree, 3 = neutral, 4 = slightly agree, and 5 = strongly agree. Among these, 6, 13, 28, 29, 30, and 31 were negative entries, with inverted scores. Each item was assigned a value of 1–5 points, and the total score of the scale was 31–155 points; the higher the score, the more positive the safety attitude.The Reporting of Clinical Adverse Events Scale was designed by Wilson et al. [13] and introduced by Nanjing University of traditional Chinese medicine in 2012. It was adopted and translated into a questionnaire suitable for China. Cronbach’s α coefficient of the questionnaire was 0.8484. It covers 5 dimensions of perceived blame, perceived criteria for identifying events that should be reported, perceptions of colleagues’ expectations, perceived benefits of reporting, and perceived clarity of reporting procedures, with a total of 28 items (14 positive and 14 negative items). The scale uses the Likert scale as follows: proficiency = 5, familiarity = 4, understanding = 3, being clear = 2, not knowing = 1, strongly agree = 5, agree = 4, neutral = 3, disagree = 2, strongly disagree = 1; the negative items were scored in reverse. The total score of the scale was the sum of the items, i.e., 28–140. The higher the score, the better the research participants’ awareness of adverse event reports, the more positive their attitudes, and the more positive their intention to implement.


## 3. Proposed Methods

### 3.1. Estimation of Sample Size

The sample size was 5–10-fold of the scale items. In this paper, 31 items comprised the C-SAQ and 28 items in the adverse event report cognition and attitude questionnaire. In order to make the sample size representative, we selected 590 cases (10 times of the scale items), but considering the incomplete or missing responses in the questionnaire, the sample size was expanded by 20% to 708 cases.


### 3.2. Preinvestigation

The number of people being investigated was determined by at least 5% of the sample size (590 × 5% = 30 cases). In February 2018, 40 nurses meeting the inclusion criteria were selected in the operating room of the inpatient department of a tertiary hospital for a presurvey. Two weeks later, the internal consistency and test-retest reliability of the research tools were calculated. According to the results of the presurvey and the problems encountered, the descriptions of some items in the questionnaires were adjusted and modified, and expert opinions were solicited to form the final version of the questionnaires. The preinvestigation revealed that Cronbach’s coefficient of the C-SAQ used in this paper was 0.89, the test-retest reliability was 0.90, and Cronbach’s coefficient and test-retest reliability of adverse event reporting cognition and attitude questionnaire were 0.86 and 0.87, respectively.


### 3.3. Data Collection and Sorting

The investigator communicated with the head nurse of the operating room of the tertiary class A hospitals in advance by telephone and then distributed the questionnaires to the participants in each hospital at the agreed time. In the morning class meeting, the following parameters were considered: the research purpose, inclusion and exclusion criteria, matters needing attention when filling out the questionnaire, confidentiality commitment to the survey data, and informed consent. The researcher handed out the questionnaires to the nurses on the spot. The time for filling out the questionnaires was 15–20 min. The nurse filled out the questionnaires anonymously and put them in a recycling box, from where the researcher retrieved them.


### 3.4. Quality Control

After consulting relevant literature, resurvey, and experts, the first drafts of the questionnaires were set and modified. The words used were accurate and standardized to ensure that the respondents could understand the contents accurately and reduce the possibility of wrong and random answers. Each returned questionnaire was classified and numbered, and the questionnaires with the same option and more than 3 missing items were excluded. In the data entry stage, logic error checking was carried out to ensure the accuracy of the data.


### 3.5. Research Ethics

This paper was approved by the Ethics Committee and Hospital Management of West China Hospital, West China Second Hospital, West China Stomatological Hospital, West China Fourth Hospital, Army General Hospital, Chengdu Third People's Hospital, Chengdu Orthopedic Hospital, Chengdu University of Traditional Chinese Medicine Affiliated Hospital, Chengdu Hospital of Integrated Traditional Chinese and Western Medicine, Sichuan Cancer Hospital, Chengdu University Hospital, Wenjiang Fifth People’s Hospital, Chengdu Women and Children’s Central Hospital, Chengdu Second Hospital, and West China Hospital Shangjin Branch Hospital (No. 153). The present study described the research participants, and the consent of the investigation was obtained, which was in line with the principle of voluntary harmlessness. In this paper, the general personal data of the respondents were confidential and filled in anonymously. The results were limited to this paper, and no other interests were involved.


### 3.6. Statistical Analysis

EpiData3.1 was used to establish a database for all the collected data, and SPSS17.0 software was used for statistical analysis. For the general information of operating room nurses, enumeration data were described by frequencies (percentages), and measurement data were presented as mean ± standard deviation. The score of C-SAQ was described by mean ± SD. The positive response rate of each dimension or item was equal to the number of positive responses/the total number of responses. Positive items such as “slightly agree” and “strongly agree” were counted as positive responses, while the reverse items were opposite; “disagree” and “strongly disagree” were counted as negative responses. For the analysis of the general situation of safety attitudes of operating room nurses, a one-way analysis of variance (ANOVA) or two-samplet-test was used. Pearson’s correlation test was used to analyze the correlation between C-SAQ score and adverse event reporting cognition and attitude score. Multiple linear regression analysis was used to explore the factors influencing the safety attitudes of operating room nurses. The entry standard was 0.05, and the exclusion standard was 0.10. P<0.05 was considered statistically significant.


## 3.1. Estimation of Sample Size

The sample size was 5–10-fold of the scale items. In this paper, 31 items comprised the C-SAQ and 28 items in the adverse event report cognition and attitude questionnaire. In order to make the sample size representative, we selected 590 cases (10 times of the scale items), but considering the incomplete or missing responses in the questionnaire, the sample size was expanded by 20% to 708 cases.


## 3.2. Preinvestigation

The number of people being investigated was determined by at least 5% of the sample size (590 × 5% = 30 cases). In February 2018, 40 nurses meeting the inclusion criteria were selected in the operating room of the inpatient department of a tertiary hospital for a presurvey. Two weeks later, the internal consistency and test-retest reliability of the research tools were calculated. According to the results of the presurvey and the problems encountered, the descriptions of some items in the questionnaires were adjusted and modified, and expert opinions were solicited to form the final version of the questionnaires. The preinvestigation revealed that Cronbach’s coefficient of the C-SAQ used in this paper was 0.89, the test-retest reliability was 0.90, and Cronbach’s coefficient and test-retest reliability of adverse event reporting cognition and attitude questionnaire were 0.86 and 0.87, respectively.


## 3.3. Data Collection and Sorting

The investigator communicated with the head nurse of the operating room of the tertiary class A hospitals in advance by telephone and then distributed the questionnaires to the participants in each hospital at the agreed time. In the morning class meeting, the following parameters were considered: the research purpose, inclusion and exclusion criteria, matters needing attention when filling out the questionnaire, confidentiality commitment to the survey data, and informed consent. The researcher handed out the questionnaires to the nurses on the spot. The time for filling out the questionnaires was 15–20 min. The nurse filled out the questionnaires anonymously and put them in a recycling box, from where the researcher retrieved them.


## 3.4. Quality Control

After consulting relevant literature, resurvey, and experts, the first drafts of the questionnaires were set and modified. The words used were accurate and standardized to ensure that the respondents could understand the contents accurately and reduce the possibility of wrong and random answers. Each returned questionnaire was classified and numbered, and the questionnaires with the same option and more than 3 missing items were excluded. In the data entry stage, logic error checking was carried out to ensure the accuracy of the data.


## 3.5. Research Ethics

This paper was approved by the Ethics Committee and Hospital Management of West China Hospital, West China Second Hospital, West China Stomatological Hospital, West China Fourth Hospital, Army General Hospital, Chengdu Third People's Hospital, Chengdu Orthopedic Hospital, Chengdu University of Traditional Chinese Medicine Affiliated Hospital, Chengdu Hospital of Integrated Traditional Chinese and Western Medicine, Sichuan Cancer Hospital, Chengdu University Hospital, Wenjiang Fifth People’s Hospital, Chengdu Women and Children’s Central Hospital, Chengdu Second Hospital, and West China Hospital Shangjin Branch Hospital (No. 153). The present study described the research participants, and the consent of the investigation was obtained, which was in line with the principle of voluntary harmlessness. In this paper, the general personal data of the respondents were confidential and filled in anonymously. The results were limited to this paper, and no other interests were involved.


## 3.6. Statistical Analysis

EpiData3.1 was used to establish a database for all the collected data, and SPSS17.0 software was used for statistical analysis. For the general information of operating room nurses, enumeration data were described by frequencies (percentages), and measurement data were presented as mean ± standard deviation. The score of C-SAQ was described by mean ± SD. The positive response rate of each dimension or item was equal to the number of positive responses/the total number of responses. Positive items such as “slightly agree” and “strongly agree” were counted as positive responses, while the reverse items were opposite; “disagree” and “strongly disagree” were counted as negative responses. For the analysis of the general situation of safety attitudes of operating room nurses, a one-way analysis of variance (ANOVA) or two-samplet-test was used. Pearson’s correlation test was used to analyze the correlation between C-SAQ score and adverse event reporting cognition and attitude score. Multiple linear regression analysis was used to explore the factors influencing the safety attitudes of operating room nurses. The entry standard was 0.05, and the exclusion standard was 0.10. P<0.05 was considered statistically significant.


## 4. Experimental Results and Analysis

In this paper, 755 cases were investigated, among which 711 were effective samples. The recovery rate of the questionnaires was 94.2%. The general information of the 711 operating room nurses is summarized in Table1.Table 1
Survey results of general information of operating room nurses (n = 711).
VariablesNumber of peopleConstituent ratio (%)Age (year)≤2517424.526–3538053.436–459613.5>45618.6GenderMale537.5Female65892.5Length of service in the operating room (year)≤320228.44–1027839.1>1023132.5Mode of employmentContract system49769.9Fixed establishment21430.1Initial educationSecondary specialized school26537.3Junior college30743.2Bachelor degree or above13919.5Final educationSecondary specialized school152.1Junior college22631.8Bachelor degree or above47066.1PostNurse55678.2Teaching teacher12517.6Head nurse and above304.2Professional ranks and titlesNurse20729.1Nurse practitioner33246.7Nurse in charge15722.1Deputy chief nurse and above152.1Marital statusUnmarried25335.6Married44863Divorce or separation101.4Night shiftsYes47767.1No23432.9Weekly overtime hours (h)No overtime11015.5≤522631.86–1020829.2>1016723.5Adverse events reported in the past yearYes27438.5No43761.5The total average score of C-SAQ of the operating room nurses was 4.20 ± 0.49, and the overall positive response rate was 80.55%, which was in the upper-middle level. The scores of each dimension from high to low were perceptions of management, job satisfaction, safety climate, teamwork climate, stress recognition, and working conditions. Perceptions of management, job satisfaction, safety climate, and teamwork climate with a positive response rate >80% were considered as advantageous dimensions, while stress recognition and working conditions with a positive response rate <80% were considered as the dimensions to be improved. Table2 is the total score and scores of various dimensions of safety attitudes of operating room nurses. Table 3 is the positive response rate of each item of safety attitudes of operating room nurses.Table 2
Total score and scores of various dimensions of safety attitudes of operating room nurses (n = 711).
DimensionTotal scoreTotal average scoreAverage score of all itemsPositive response rate (%)Teamwork climate (items 1–6)3025.25 ± 3.344.21 ± 0.5681.95Safety climate (items 7–13)3529.69 ± 4.194.24 ± 0.6082.98Perceptions of management (items 14–17)2017.68 ± 2.784.42 ± 0.6987.03Job satisfaction (items 18–22)2521.38 ± 3.874.28 ± 0.7783.46Working conditions (items 23–27)2519.87 ± 3.653.97 ± 0.7374.04Stress recognition (items 28–31)2016.19 ± 4.134.05 ± 1.0378.20Total score155130.05 ± 15.274.20 ± 0.4980.55Table 3
Positive response rate of each item of safety attitudes of operating room nurses (n = 711).
ItemContentPositive responders (n)Positive response rate (%)Rank14Patient safety is the top priority in this clinical area management.67494.80110I know the proper channels to direct questions regarding patient safety in this clinical area.67294.5124I have the support I need from other personnel to care for patients.67094.2335It is easy for personnel here to ask questions when there is something that they do not understand.66693.6742Disagreements in this clinical area are resolved appropriately (i.e., not who is right, but what is best for the patient).64390.4459Medical errors are handled appropriately in this clinical area.63989.87619Working here is like being part of a large family.63188.75712I would feel safe being treated here as a patient.62387.6288The culture in this clinical area makes it easy to learn from the errors of others.62187.34931I am less effective at work when fatigued.61686.641024This department does a good job of training new personnel.61586.501115Management supports my daily efforts.61486.36127I am encouraged by my colleagues to report any patient safety concerns I may have.61185.941321I like my job.60284.671425Trainees in my discipline are adequately supervised.59783.971518I am proud to work in this clinical area.59683.831616I get adequate, timely info about events that might affect my work.59583.681717This is a good place to work.59283.261820Morale in this clinical area is high.58682.421926Problem personnel are dealt with constructively by our department.58682.42201The physicians and nurses here work together as a well-coordinated team.58582.282130Fatigue impairs my performance during emergency situations (such as rescuing cardiac arrest patients).56279.042211I receive appropriate feedback about my performance.55377.782322All kinds of technical operation procedures are concise.55277.64243The suggestions about safety would be acted upon if they were expressed to management.54075.95259I am more likely to make errors in tense or hostile situations.53174.682628When my workload becomes excessive, my performance is impaired.51572.432727The levels of staffing in this clinical area are sufficient to handle the number of patients.46064.702813In this clinical area, it is difficult to discuss errors.41157.81296In this clinical area, it is difficult to speak up if I perceive a problem with patient care.39255.133023This clinical area has sufficient support from the logistics department.37452.6031As shown in Table4, the score of teamwork climate varied in nurses with different positions, night shifts (with or without), and weekly overtime hours (P<0.05). Also, significant differences were detected in the scores of safety climate and perceptions of management among nurses of different ages, positions, and night shifts (with or without) (P<0.05). Significant differences were observed in the scores of job satisfaction among nurses in different age groups, length of service in operating room, and positions (P<0.05). As shown in Table 5, the total score of C-SAQ is positively correlated with the total score of cognition and attitudes toward adverse event reporting (P<0.01, r = 0.445). Multiple linear regression analysis was conducted with the total score of safety attitudes of operating room nurses as the dependent variable, the general information of operating room nurses, and the total score of their cognition and attitudes toward adverse event reporting as independent variables. Table 6 shows the independent variable assignment of factors influencing the C-SAQ of operating room nurses. The results showed that night shifts, awareness, and attitude toward adverse event reporting were the main influencing factors of safety attitudes of operating room nurses (P<0.05). Table 7 presents multiple linear stepwise regression analysis of safety attitudes of operating room nurses.Table 4
Univariate analysis of C-SAQ of operating room nurses (n = 711).
Variable groupTeamwork climate (mean ± SD)Safety climate (mean ± SD)Perceptions of management (mean ± SD)Job satisfaction (mean ± SD)Working conditions (mean ± SD)Stress recognition (mean ± SD)C-SAQ total score (mean ± SD)Age (year)≤2525.29 ± 3.2829.56 ± 3.8217.85 ± 2.4721.94 ± 3.6020.76 ± 3.5016.03 ± 4.10131.43 ± 14.3826–3525.07 ± 3.5129.44 ± 4.5317.43 ± 3.0320.99 ± 4.2019.48 ± 3.7616.36 ± 4.12128.77 ± 16.5436–4525.52 ± 2.9030.35 ± 3.6217.91 ± 2.4621.48 ± 3.2819.51 ± 3.3615.39 ± 4.68130.90 ± 12.18>4525.84 ± 3.0330.51 ± 3.7318.36 ± 2.2922.1 ± 3.020.30 ± 3.3216.82 ± 3.14130.05 ± 13.02F1.2192.082.6843.2325.6031.9812.677P0.3020.1010.0460.0220.0010.1150.046Length of service in the operating room≤325.31 ± 3.4529.55 ± 4.0517.89 ± 2.5121.96 ± 3.6120.61 ± 3.5015.78 ± 4.11130.95 ± 15.244–1025.09 ± 3.3029.22 ± 4.4017.46 ± 2.9921.01 ± 4.1719.62 ± 3.7216.49 ± 4.15129.21 ± 16.13>1025.39 ± 3.3029.97 ± 4.0517.79 ± 2.6821.38 ± 3.5719.55 ± 3.5816.19 ± 4.11130.28 ± 15.27F0.5770.7821.653.615.671.720.794P0.5620.4580.1940.0270.0050.1790.452Mode of employmentContract system25.31 ± 3.3729.76 ± 4.2517.66 ± 2.8321.54 ± 4.0020.11 ± 3.7015.94 ± 4.25130.33 ± 15.85Fixed establishment25.10 ± 3.2729.50 ± 4.0617.71 ± 2.6621.00 ± 3.5319.32 ± 3.4616.75 ± 3.77129.39 ± 13.85T0.7650.758−0.21.72.66−2.410.752P0.4440.4480.8390.090.0080.0160.452Initial educationSecondary specialized school25.53 ± 3.2530.21 ± 3.9417.97 ± 2.6521.74 ± 3.4620.01 ± 3.6015.92 ± 4.26131.39 ± 14.51Junior college25.09 ± 3.4629.71 ± 4.3817.57 ± 2.9321.34 ± 4.1720.02 ± 3.8016.21 ± 4.00129.94 ± 16.47Bachelor degree or above25.06 ± 3.2228.63 ± 4.0517.36 ± 2.6320.78 ± 3.8519.28 ± 3.3416.63 ± 4.14127.74 ± 13.64F1.4856.6412.6722.8552.2711.3692.628P0.2270.0010.070.0580.1040.2550.073Final educationSecondary specialized school25.93 ± 3.5330.47 ± 3.3118.87 ± 2.0723.27 ± 2.8922.13 ± 2.9515.13 ± 4.61135.80 ± 11.21Junior college25.00 ± 3.3429.56 ± 4.0817.63 ± 2.7121.46 ± 3.8920.08 ± 3.7515.96 ± 4.00129.68 ± 15.03Bachelor degree or above25.35 ± 3.3329.72 ± 4.2717.66 ± 2.8321.28 ± 3.8819.70 ± 3.5916.33 ± 4.17130.05 ± 15.27F1.1450.3851.421.993.821.121.13P0.3190.6810.2430.1370.0220.3260.324PostNurse25.28 ± 3.3229.27 ± 2.4117.18 ± 2.6921.44 ± 3.8420.02 ± 3.6516.31 ± 3.90130.47 ± 15.17Teaching teacher24.76 ± 3.5029.18 ± 4.6417.73 ± 3.2320.81 ± 4.1819.21 ± 3.7815.77 ± 4.87126.90 ± 16.36Head nurse and above26.80 ± 2.5929.70 ± 4.1218.87 ± 1.8022.63 ± 2.4819.90 ± 2.6015.53 ± 4.85135.05 ± 15.27F4.6383.8464.933.032.531.294.667P0.010.0220.0070.0490.080.2770.01Professional ranks and titlesNurse25.31 ± 3.2629.75 ± 4.0717.88 ± 2.6321.98 ± 3.7320.71 ± 3.4215.80 ± 3.97131.44 ± 15.23Nurse practitioner25.07 ± 3.5529.52 ± 4.4317.44 ± 2.9721.10 ± 4.0519.57 ± 3.8316.33 ± 4.21129.03 ± 16.27Nurse in charge25.47 ± 3.0130.00 ± 3.8717.92 ± 2.5621.18 ± 3.6619.48 ± 3.4116.38 ± 4.12130.44 ± 13.17Deputy chief nurse and above25.93 ± 2.8429.20 ± 3.4717.60 ± 2.2921.40 ± 3.2018.87 ± 3.1116.20 ± 4.72129.20 ± 12.73F0.7770.5561.632.375.510.851.116P0.5070.6440.1810.070.0010.4670.342Marital statusUnmarried25.46 ± 3.2529.70 ± 4.0517.77 ± 2.4921.67 ± 3.7020.34 ± 3.5716.10 ± 4.02131.05 ± 13.96Married25.12 ± 3.3329.69 ± 4.1817.65 ± 2.8621.22 ± 3.9119.61 ± 3.6316.25 ± 4.14129.54 ± 15.46Divorce or separation25.70 ± 5.4829.10 ± 7.5216.40 ± 5.0821.10 ± 5.7219.70 ± 5.3115.60 ± 6.45127.60 ± 32.04F0.920.11.221.133.330.210.918P0.3990.9050.2970.3250.0360.8130.4Night shiftsNo25.85 ± 3.0530.18 ± 3.9918.15 ± 2.5221.19 ± 3.9819.81 ± 3.6916.25 ± 4.14131.99 ± 14.58Yes24.95 ± 3.4429.44 ± 4.2717.45 ± 2.8721.77 ± 3.6019.99 ± 3.5516.05 ± 4.12129.10 ± 15.52t3.4122.2043.31−1.88−0.640.632.383P0.0010.0280.0010.060.5220.5310.017Weekly overtime hoursNo overtime25.18 ± 3.6429.22 ± 4.4817.75 ± 2.9021.78 ± 3.9720.19 ± 3.5314.69 ± 4.64128.82 ± 16.42≤525.05 ± 3.3529.63 ± 4.1917.67 ± 2.8721.38 ± 3.7620.10 ± 3.6315.95 ± 3.93129.78 ± 15.456–1024.97 ± 3.0629.48 ± 3.4517.65 ± 2.4521.06 ± 3.6719.44 ± 3.3416.86 ± 4.19129.46 ± 13.21>1025.90 ± 3.3930.32 ± 4.4717.68 ± 2.9721.51 ± 4.1719.89 ± 4.0716.66 ± 3.68131.96 ± 16.55F2.9191.9310.040.941.547.831.237P0.0330.1230.9910.4210.204<0.0010.295Table 5
Correlation between C-SAQ and operating room nurses’ cognition and attitudes toward adverse event reporting (r value).
ProjectTeamwork climateSafety climatePerceptions of managementJob satisfactionWorking conditionsStress recognitionReport cognitionImplement intentionDepartment culturePunishment environmental scienceAdministration expectTotal score of cognition and attitudes of adverse event reportingC-saq total scoreTeamwork climater10.316∗∗0.372∗∗0.316∗∗0.348∗∗0.328∗∗0.360∗∗0.306∗∗0.294∗∗0.287∗∗−0.0420.664∗∗0.357∗∗P<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.0010.259<0.001<0.001Safety climater0.316∗∗10.625∗∗0.526∗∗0.269∗∗0.279∗∗0.326∗∗0.265∗∗0.246∗∗0.191∗∗−0.132∗∗0.739∗∗0.271∗∗P<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001Perceptions of managementr0.372∗∗0.625∗∗10.732∗∗0.344∗∗0.377∗∗0.457∗∗0.392∗∗0.413∗∗0.346∗∗−0.208∗∗0.850∗∗0.410∗∗P<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001Job SatisfactionR0.316∗∗0.526∗∗0.732∗∗10.165∗∗0.300∗∗0.344∗∗0.292∗∗0.332∗∗0.290∗∗−0.258∗∗0.742∗∗0.297∗∗P<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001Working conditionsr0.348∗∗0.269∗∗0.344∗∗0.165∗∗10.237∗∗0.244∗∗0.232∗∗0.192∗∗0.143∗∗0.0450.612∗∗0.256∗∗P<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.0010.227<0.001<0.001Stress recognitionr0.328∗∗0.279∗∗0.377∗∗0.3000.237∗∗10.675∗∗0.564∗∗0.554∗∗0.527∗∗−0.150∗∗0.423∗∗0.732∗∗P<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001Report cognitionr0.360∗∗0.326∗∗0.457∗∗0.344∗∗0.244∗∗0.675∗∗10.763∗∗0.704∗∗0.661∗∗−0.105∗∗0.481∗∗0.869∗∗P<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.0010.005<0.001<0.001Implement intentionr0.306∗∗0.265∗∗0.392∗∗0.292∗∗0.232∗∗0.564∗∗0.763∗∗10.795∗∗0.703∗∗−0.084∗∗0.415∗∗0.861∗∗P<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.0010.025<0.001<0.001Department culturer0.294∗∗0.246∗∗0.413∗∗0.332∗∗0.192∗∗0.554∗∗0.704∗∗0.795∗∗10.736∗∗−0.124∗∗0.411∗∗0.855∗∗P<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.0010.001<0.001<0.001Punishment environmental sciencer0.287∗∗0.191∗∗0.346∗∗0.290∗∗0.143∗∗0.527∗∗0.661∗∗0.703∗∗0.736∗∗1−0.142∗∗0.349∗∗0.811∗∗P<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001Administration expectr−0.042−0.132∗∗−0.208∗∗−0.258∗∗0.045−0.150∗∗−0.105∗∗−0.084∗∗−0.124∗∗−0.142∗∗1−0.157∗∗0.128∗∗P0.259<0.001<0.001<0.0010.227<0.0010.0050.0250.001<0.001<0.0010.001Total score of cognition and attitudes of adverse event reportingr0.664∗∗0.739∗∗0.850∗∗0.742∗∗0.612∗∗0.423∗∗0.481∗∗0.415∗∗0.411∗∗0.349∗∗−0.157∗∗10.445∗∗P<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001C-SAQ total scorer0.357∗∗0.271∗∗0.410∗∗0.297∗∗0.256∗∗0.732∗∗0.869∗∗0.861∗∗0.855∗∗0.811∗∗0.128∗∗0.445∗∗1P<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.0010.001<0.001Note. P∗<0.05; ∗∗P<0.01.Table 6
Independent variable assignment of factors influencing C-SAQ of operating room nurses.
Research variablesAssignmentSafety culture scoreContinuous variableAge group1 = ≤25 year, 2 = 26–35 year, 3 = 36–45 year, 4 ≥ 45 yearLength of service in the operating room1 = ≤3 year, 2 = 4–10 year, 3 ≥ 10 yearMode of employment1 = Contract system, 2 = Fixed establishmentInitial education1 = Secondary specialized school, 2 = Junior college, 3 = Bachelor degree or aboveFinal education1 = Secondary specialized school, 2 = Junior college, 3 = Bachelor degree or abovePost1 = Nurse practitioner, 2 = Teaching teacher, 3 = Head nurse and aboveTitle1 = Nurse, 2 = Nurse practitioner, 3 = Nurse in charge, 4 = Deputy chief nurse and aboveMarital status1 = Unmarried, 2 = Married, 3 = Divorce or separationNight shifts0 = No, 1 = YesWeekly overtime hours1 = No overtime, 2 = ≤5 hours, 3 = 6–10 hours, 4 ≥ 10Score of adverse event scaleContinuous variableTable 7
Multiple linear stepwise regression analysis of safety attitudes of operating room nurses (n = 711).
Independent variablePartial regression coefficientStandardization Partial regression coefficienttPPartial regression coefficient 95% CIβStandard error(Constant)84.3465.76714.625<0.00173.023–95.67Age group1.2531.1130.071.1260.261−0.932–3.437Length of service in the operating room−0.6481.13−0.033−0.5740.566−2.866–1.57Mode of employment−0.6321.69-0.019−0.3740.708−3.951–2.686Initial education0.1591.0960.0050.1450.885−1.993–2.31Final education0.3571.0780.0120.3310.741−1.76–2.474Post−1.0171.109−0.035−0.9180.359−3.194–1.159Title−1.2921.212−0.065−1.0660.287−3.672–1.088Marital status−1.5951.365−0.053−1.1690.243−4.274–1.085Night shifts−3.2131.233−0.099−2.6060.009−5.634–0.792Weekly overtime hours0.4310.5350.0280.8050.421−0.619–1.481Score of adverse event scale0.4820.0370.4412.855<0.0010.408–0.556This paper described the safety attitude of the operating room nurses from 16 tertiary class A hospitals in Sichuan Province, China. The results showed that the nurses in the operating room had a positive attitude toward safety. The cognition and attitudes toward night shifts and adverse event reporting were the main influencing factors of the safety attitude of operating room nurses.The results of this paper showed that the positive reaction rate of the total score of operating room nurses’ safety attitudes was >80%, indicating that the operating room nurses of tertiary class A hospitals had a positive safety culture, which was similar to those of previously reported studies conducted in Turkey [11, 14]. Patient safety is a common concern of global healthcare. While hospital managers are concerned about patient safety, health departments worldwide have been committed to continuously enhancing patient safety. Armutlu et al. [15] believe that hospital managers play a major role in creating and developing a safety culture and climate. At present, patient safety and adverse events have become a research hotspot in the field of nursing management in China. Nursing managers’ perspective on safety management has also changed, and their positive safety attitudes directly affect the safety attitude and belief of the whole nursing team. On the other hand, the average education level of nurses in China’s tertiary class A hospitals is higher than that of other hospitals. Although the present study did not find any influence of education on the safety attitude of operating room nurses, Zhang et al. [16] showed that nursing managers with high education levels had higher stress recognition. Audet et al. [17] also proposed that the education level of medical staff may be a factor affecting patient safety, which might be related to strong learning ability, comprehensive knowledge base, and active thinking of highly educated individuals. In addition, in recent years, Chinese patients have been increasingly aware of safeguarding their rights. Moreover, the Internet has reduced the information inequality between doctors and patients, and the increase in patients’ complaints has also promoted the safety management of hospitals.Evidence [18] has indicated that a positive response rate >80% is an advantage, a rate between 50 and 79% indicates a need for improvement, while a rate <50% suggests urgent improvement required. In this paper, the parameters with high positive reaction rates are teamwork climate, perceptions of management, and safety climate, which are consistent with the results of Yu et al. [19] and Ramos and Calidgid [8]. The domains to be improved in the safety attitude of operating room nurses were stress recognition and working conditions. The operating room is characterized by great pressure and a high workload. Today, the increasing operations in tertiary class A hospitals and the growing demand for nursing cooperation have led to increased susceptibility of operating room nurses to adverse work pressure reactions. The tense working environment causes a negative impact on the nurses and patients, which is manifested as an increased rate of infection or patient mortality [20]. Yalçın Akgul and Aksoy [21] showed that increased organizational stress of operating room staff may negatively affect their attitudes toward patient safety, suggesting that reducing the pressure of operating room staff may be conducive to improving patient safety. According to previous studies [22], a healthy working environment can improve nurses’ job satisfaction and reduce work pressure and fatigue, contributing to high-quality nursing. Also, it is suggested that managers should not ignore the negative influence of nursing staff on patient safety due to work pressure. Liu et al. [23] proposed that reasonable allocation and organizational support of nursing resources are directly related to improving patient safety. Therefore, we can reasonably allocate human resources, implement hierarchical management and postmanagement, and arrange the work of nurses according to their work experience, professional title, ability, and personality traits, so that they can relieve certain pressures through team cooperation and communication. On the other hand, psychological training can be conducted to improve nursing staff’s ability to adapt to pressure and help them to better manage and relieve pressure.In the present study, the score of the working condition dimension was the lowest. It is shown that some operating room nurses in tertiary class A hospitals in China believe that the current human resource allocation is insufficient and there are potential safety hazards [24]. The correlation between nurse staffing and patient safety is evident. As nursing care increases, so does the risk, incidence rate, and even death rate of patients. Even if the overall allocation of nursing staff is adequate, the acceleration of patient turnover increases the risk of patient safety and death [25, 26]. According to a previous study in Holland [27], the role of nurses in clinical work, nursing behavior, and nursing autonomy are closely related to manpower allocation. Nurses differ from doctors in their role, clinical behavior, thinking mode, decision-making power, and information transmission. But autonomy can help nurses to carry out satisfactory activities in the nursing management and multidisciplinary teamwork [28]. European and American countries are gradually increasing the professionalism and autonomy of nurses while nurses generally lack autonomy in China's medical system. Increasing the allocation of nurses to improve patient expectations and reduce adverse events cannot address patient safety. To ensure the quality of medical care, it is necessary to ensure the full availability of human, property, material, and other resources [29]. Therefore, it is suggested that the managers should appropriately increase the allocation of nursing staff and logistic support in the operating room. With the gradual improvement of staffing, economic incentives can be used to stimulate the enthusiasm of the nursing staff.In this paper, the median night shift and the cognition and attitudes toward adverse event reporting were the main factors influencing the safety attitude of operating room nurses. Night shift operating room nurses scored lower on patient safety attitudes than nonnight shift operating room nurses, which was similar to the research results of D’Oliveira and Anagnostopoulos and Roelen et al. [30, 31]. Nurses on night shifts have less manpower, great responsibility, and high risk, with irregular life and long-term sleep deprivation, which is susceptible to job burnout that affects personal health, memory, and mental function performance, leading to low safety attitude scores. In the United States, there is little variation in the number of day and night shifts in various departments of hospitals, and there are specialized night nurses [32]. Therefore, nursing managers should provide humanistic care for night shift nurses, arrange the night shifts scientifically and rationally, and employ an incentive mechanism to arouse the enthusiasm of night shift nurses, so as to provide 24-hour uninterrupted high-quality nursing for patients.The cognition and attitudes of operating room nurses toward adverse event reporting and also the main factors influencing the safety attitude were positively correlated with operating room nurses’ safety attitudes. Relevant studies [8, 33] also showed a low reporting rate of adverse events by nurses. Atwal et al. [34] recommend that organizations with a strong patient safety culture adopt a positive attitude toward incident reporting. Nurses’ indecision in reporting adverse events might be related to a widespread culture of punitive responses and blame for errors. They fear being held accountable and punished by their superiors and are less motivated to report adverse events [8]. Although the WHO Surgical Safety Checklist can effectively improve the safety of patients with a high acceptance among the medical staff, there is still a gap in the awareness of when to use the checklist, which suggests that medical managers can provide training on adverse event reporting for operating room nurses to improve their awareness [35–37]. In addition, the adverse event reporting rate is closely related to the adverse event reporting process and feedback mechanism [21]. Thus, it is suggested that managers establish a fair, open, communicative, and nonpunitive adverse events reporting culture, optimize the reporting process, and train the nursing staff to master the reporting process so that the personnel are willing to report promptly and accept the errors and problems calmly [38, 39]. Only when the staff exhibits satisfactory cognition and attitudes to the adverse event report can they understand and prevent the errors in nursing work.


## 5. Conclusion

This paper confirmed that nurses in the operating room of the tertiary class A hospitals in Chengdu, China, had a positive attitude toward safety, but their stress recognition and working conditions needed improvement. Thus, nursing managers should optimize the allocation of nursing human resources in the operating room, strengthen logistics support, and establish a fair and nonpunitive adverse event reporting system to create a safety climate and enhance the nurses’ safety attitudes and beliefs.This paper only investigated the safety culture of some tertiary hospitals in Western China but not other secondary and community hospitals, which limited the popularization of the study results. Second, the safety attitude of nurses who participated in this study might be influenced by society and institutions, which in turn affects the responses to some questionnaires.



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