Page 4765
www.rsisinternational.org
INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)
ISSN No. 2454-6186 | DOI: 10.47772/IJRISS | Volume IX Issue X October 2025
Safety Performance and Patient Safety Culture: Examining their
Relationship in a Malaysian Private Hospital
Punida Sathivheil
a
* Siti Fatimah Md Shariff
a
a
Faculty of Technology and Applied Sciences, Open University, Malaysia
a
Putra Medical Centre, Alor Setar, Kedah, Malaysia
*Corresponding Author
DOI: https://dx.doi.org/10.47772/IJRISS.2025.910000393
Received: 12 October 2025; Accepted: 20 October 2025; Published: 13 November 2025
ABSTRACT
Patient safety is central to healthcare quality, and nurses play a pivotal role in sustaining safe practices.
Examining patient safety culture and its link to safety performance provides insights into areas for
improvement. This study aimed to (1) identify the perceived level of safety performance among registered
nurses, (2) assess the perceived level of patient safety culture, (3) determine the relationship of patient safety
culture on safety performance, and (4) evaluate the influence of sociodemographic factors in a private hospital
in Kedah, Malaysia.
A quantitative correlational cross-sectional design was conducted with 247 registered nurses selected through
purposive sampling. Data were collected using validated questionnaires and analysed with descriptive
statistics, chi-square tests, t-tests, ANOVA, regression, and Pearson correlation. Nurses reported highly
positive safety performance, with safety participation (98.0%), compliance (96.8%), and overall performance
significantly above benchmarks (p < 0.05). Patient safety culture was positively perceived in organizational
learning (89.9%), event reporting (91.1%), management support (65.2%), teamwork (59.9%), and
communication openness (57.1%). However, staffing (51.4% positive, 48.6% negative) and overall
perceptions of patient safety scored lower. Pearson correlation and regression confirmed a strong positive
relationship between patient safety culture and safety performance (p < 0.05). Sociodemographic
characteristics—age, education, years of service, and unit type were significantly associated with variations,
with older, more experienced, and highly educated nurses in surgical and intensive care units reporting
stronger safety culture and performance. Patient safety culture is a significant predictor of safety performance.
While overall perceptions were positive, staffing adequacy and communication openness remain challenges.
Leadership commitment, non-punitive reporting, and safe staffing policies are essential to strengthen safety
culture and improve patient outcomes.
Keywords: Patient Safety, Safety Performance, Impact, Nurses, Hospital
INTRODUCTION
Patient safety is increasingly recognized as a global health priority, particularly in the wake of challenges such
as rising patient acuity, staff shortages, and the demands of post-pandemic healthcare (World Health
Organization, 2020). Defined as the absence of preventable harm during healthcare delivery, patient safety is
fundamentally linked to a healthcare system’s ability to minimize risks to an acceptable minimum (Joint
Commission, 2017). Globally, approximately 10% of hospitalized patients experience adverse events, with
nearly 75% of these incidents deemed preventable (World Health Organization, 2020).
A crucial determinant of patient safety is the organizational culture that underpins healthcare delivery. Patient
safety culture encompasses the shared values, beliefs, and behaviours that support safety in healthcare
environments (Agency for Healthcare Research and Quality, 2024). Research suggests that a positive safety
Page 4766
www.rsisinternational.org
INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)
ISSN No. 2454-6186 | DOI: 10.47772/IJRISS | Volume IX Issue X October 2025
culture fosters teamwork, open communication, and non-punitive reporting, ultimately enhancing safety
performance (Cook, 2014; Sathia, Sumitra, Jeevitha, & Karuthan, 2020). Conversely, weak safety culture
environments are associated with underreporting of incidents, reduced communication, and higher rates of
preventable harm (Dirik & Intepeler, 2017).
Patient safety, defined as the prevention of avoidable harm and the minimization of risks during healthcare
delivery, is positioned as a global health priority. Reports by the World Health Organization (World Health
Organization, 2022) estimate that approximately 10% of hospital admissions result in adverse events, with up
to 75% of these being preventable. While the importance of safety culture is widely recognized,
operationalizing it remains a challenge. A positive safety culture is characterized by leadership support, open
communication, teamwork, continuous learning, and a non-punitive approach to error reporting.
While extensive international literature supports the importance of safety culture in improving safety outcomes
(Smits et al., 2012; El-Jardali, 2014), studies within Malaysia remain limited. Previous local research has often
concentrated on adverse event reporting systems rather than the direct relationship between safety culture and
nurses’ safety performance (Perjit & Ellisha, 2020). Given that nurses constitute the largest segment of the
healthcare workforce and serve on the frontline of patient care, their perception of safety culture is pivotal in
ensuring safe practices and preventing adverse events (Rusdi, Faridah, & Nur Syazana, 2024).
This study examines the critical issue of patient safety culture and its association with nurses’ safety
performance within healthcare organizations. In light of evolving healthcare challenge including rising patient
acuity, workforce shortages, aging populations, and the enduring impact of the COVID-19 pandemic, ensuring
the delivery of safe and high-quality care has become an increasingly complex and urgent priority.
Nurses, as the largest segment of the healthcare workforce and the frontline providers of patient care, are
central to fostering patient safety. Their roles in medication administration, monitoring, care coordination, and
advocacy make their performance a direct determinant of safety outcomes. However, evidence indicates that
workforce constraints often reduce nursing care to task-oriented practices, undermining holistic care and
weakening the safety culture. Studies suggest that nurse empowerment and performance enhancement are
directly linked to improved safety outcomes.
This study seeks to address this gap by examining nurses’ perceived safety performance and its relationship
with patient safety culture. The research objectives are to assess levels of safety performance and patient safety
culture among nurses, evaluate the influence of demographic factors, and determine the relationship between
safety culture and performance.
Through these objectives, the study aimed to provide a comprehensive understanding of the patient safety
culture influences nurses’ safety performance within the private healthcare sector. By addressing both
individual and organizational factors, the research aimed to generate insights that could guide policy, inform
management strategies, and support the development of interventions designed to foster safer healthcare
environments.
METHODOLOGY
This study employed a quantitative, cross-sectional design to investigate nurses’ perceptions of safety culture
and safety performance. The population comprised registered nurses working in clinical departments of a
private hospital in Kedah. Inclusion criteria were full-time registered nurses with active clinical roles, while
nurses in administrative or non-clinical positions were excluded.
Data were collected using a structured self-administered questionnaire, adapted from validated tools such as
the Hospital Survey on Patient Safety Culture (Agency for Healthcare Research and Quality, 2022) and the
Safety Performance Questionnaire (Griffin & Neal, 2000). The instrument included sections on demographics,
safety culture dimensions, and safety performance indicators. Reliability and validity were established in
previous studies, with Cronbach’s alpha exceeding acceptable thresholds.
Page 4767
www.rsisinternational.org
INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)
ISSN No. 2454-6186 | DOI: 10.47772/IJRISS | Volume IX Issue X October 2025
Ethical approval was obtained from the hospital’s ethical review board, and written informed consent was
secured from all participants. Data collection was conducted over a four-week period in 2023. Statistical
analyses, including descriptive statistics, correlation, and multiple regression, were performed to examine
relationships between variables and test hypotheses.
The survey data from the questionnaires were extracted and recoded using MS Excel 2016, then imported and
analyzed with SPSS version 25. Univariate descriptive analyses, including frequency and percentage
distributions, were conducted for categorical socio-demographic variables. Reliability, which reflects the
consistency or stability of measurements under varying conditions, was assessed using Cronbach’s Alpha.
According to existing research, a Cronbach’s Alpha value above 0.7 is considered acceptable. Reliability
analysis was carried out for all domains containing Likert scale items. Descriptive statistics summarized
respondents’ demographic characteristics and highlighted overall response trends, while the chi-square
goodness-of-fit test was employed to assess levels of safety performance and patient safety culture among
nurses.
Reliability analysis is essential in assessing the consistency and stability of a measurement instrument.
Cronbach’s Alpha is commonly used to evaluate the internal consistency of a set of items. The following
analysis evaluates the reliability of the survey instrument used in this study. Table 1 summarizes the reliability
analysis results, highlighting the Cronbach’s Alpha values for each domain and the overall scale.
Table 1: Reliability Analysis
Domain
Cronbach's Alpha
N of Items
Safety Performance
0.979
8
Patient Safety Culture
0.828
25
All items
0.830
33
Reliability test was conducted to assess various dimensions of patient safety culture and safety performance
among nurses. The overall Cronbach’s Alpha for the 33-item scale was 0.830, indicating a high level of
internal consistency. The safety performance domain achieved an excellent reliability score (0.979), suggesting
that the items within this scale are highly consistent. The patient safety culture domain also demonstrated good
reliability (0.828). These results confirm that the instrument used for this study is reliable and suitable for
measuring safety performance and patient safety culture. Given that all Cronbach’s Alpha values exceed 0.8,
the measurement scales exhibit strong internal consistency, making them appropriate for further analysis. The
reliability analysis for study reveals that each domain the Cronbach's Alpha >0.8. As per the survey-related
research literature, the Cronbach Alpha value above 0.8 is good
RESULTS
Distribution of Respondent Socio-Demographic
The study of socio-demographic variables is crucial in understanding workforce composition and its
implications in various professional settings. The analysis of key socio-demographic factors, including gender,
age, level of education, length of service, and type of working unit. The chi-square test is utilized to assess
whether the observed distributions significantly differ from expected distributions, providing valuable insights
into workforce characteristics.
Table 2: Distribution of Respondent by Demographic Characteristics
Socio-Demographic
Frequency (N)
Percentage %
Gender
17
6.9%
230
93.1%
Page 4768
www.rsisinternational.org
INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)
ISSN No. 2454-6186 | DOI: 10.47772/IJRISS | Volume IX Issue X October 2025
Age
57
23.1%
167
67.6%
22
8.9%
1
0.4%
Level of Education
194
78.5%
52
21.1%
1
0.4%
Length of Service
49
19.8%
160
64.8%
22
8.9%
16
6.5%
Type of Working Unit
70
28.3%
102
41.3%
17
6.9%
13
5.3%
9
3.6%
8
3.2%
12
4.9%
16
6.5%
Table 2 provide insight into the distribution of gender, age, education level, length of service, and type of
working unit among the respondents.
The study sample was predominantly female, with 230 respondents (93.1%) compared to 17 males (6.9%),
reflecting the gender distribution typical in healthcare professions. Most participants were aged 36–45 years
(67.6%), followed by 25–35 years (23.1%), while only a small proportion were above 46 years, indicating a
largely middle-aged workforce. In terms of education, the majority held diploma qualifications (78.5%), with
fewer holding degrees (21.1%) and only one respondent (0.4%) possessing a master’s degree. Regarding
length of service, most had 6–10 years of experience (64.8%), suggesting a stable and experienced workforce.
Departmental distribution showed the largest concentration in surgical (41.3%) and medical units (28.3%),
with smaller numbers in operation theatre, paediatrics, accident and emergency, intensive care, haemodialysis,
and oncology. Overall, the findings indicate a workforce that is predominantly female, middle-aged, diploma-
qualified, and moderately experienced, with the surgical and medical units comprising the largest segments.
Patient safety is a critical component of healthcare quality, influencing overall patient outcomes and
institutional reputation. This study analysed safety performance and patient safety culture domains using
descriptive statistics and t-tests to determine their significance. The findings provide valuable insights into the
strengths and areas requiring improvement within the healthcare system.
This study examines level of patient safety culture and safety performance by analysing both positive and
negative responses from participants. Positive responses are those where respondents select “Agree” or
“Strongly Agree,” while negative responses are those marked as “Not Sure,” “Disagree,” or “Strongly
Disagree.” The use of a Likert scale survey to assess patient safety culture offers a structured, data-driven
Page 4769
www.rsisinternational.org
INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)
ISSN No. 2454-6186 | DOI: 10.47772/IJRISS | Volume IX Issue X October 2025
method for evaluating safety perceptions within healthcare organizations. This approach is supported by Sorra
(2016), conducted Hospital Survey on Patient Safety Culture (HSOPSC) had categorized survey responses on
patient safety culture based on positive and negative scores.
Table 3: Level of Safety Performance and Patient Safety Culture among Nurses
Domain
Categories
N
%
Chi-Square
P Value
Safety Participation
Negative
5
2.0%
227.405
0.000
Positive
242
98.0%
Safety Compliance
Negative
8
3.2%
216.036
0.000
Positive
239
96.8%
Safety Performance
Negative
8
3.2%
216.036
0.000
Positive
239
96.8%
Staffing
Negative
120
48.6%
0.198
0.656
Positive
127
51.4%
Management Support for Patient Safety
Negative
86
34.8%
22.773
0.000
Positive
161
65.2%
Team Work
Negative
99
40.1%
9.721
0.002
Positive
148
59.9%
Organizational Learning/Continuous
Improvement
Negative
25
10.1%
157.121
0.000
Positive
222
89.9%
Communication Openness
Negative
106
42.9%
4.96
0.026
Positive
141
57.1%
Overall Perceptions of Patient Safety
Negative
100
40.5%
8.943
0.003
Positive
147
59.5%
Frequency of Event Reporting
Negative
22
8.9%
166.838
0.000
Positive
225
91.1%
Patient Safety Culture
Negative
109
44.1%
3.405
0.065
Positive
138
55.9%
Table 3 presents an analysis of level of safety performance and patient safety culture nurses’ responses were
categorized into positive and negative. A total of 247 nurses participated in this study, of nurses’ responses
was categorized into positive (agree/strongly agree) and negative (not sure/disagree/strongly disagree)
perceptions using a Likert-scale survey for each domain. A chi-square goodness-of-fit test (p < 0.05) was
applied to examine whether the distribution of responses differed significantly from an equal distribution.
Overall, safety performance domains demonstrated overwhelmingly positive results. Safety participation
received the highest positive response (98.0%, χ² = 227.405, p = 0.000), followed by safety compliance and
safety performance, both at 96.8% with highly significant chi-square values. Similarly, several patient safety
culture domains reflected strong positive perceptions. Organizational learning and continuous improvement
Page 4770
www.rsisinternational.org
INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)
ISSN No. 2454-6186 | DOI: 10.47772/IJRISS | Volume IX Issue X October 2025
(89.9%, χ² = 157.121, p = 0.000) and frequency of event reporting (91.1%, χ² = 166.838, p = 0.000) indicated
particularly strong support for a learning-oriented and transparent safety environment. Moderate positive
perceptions were recorded for overall patient safety (59.5%, χ² = 8.943, p = 0.003), communication openness
(57.1%, χ² = 4.96, p = 0.026), management support (65.2%, χ² = 22.773, p = 0.000), and teamwork (59.9%, χ²
= 9.721, p = 0.002).
In contrast, staffing emerged as a domain of concern, with nearly equal proportions of positive (51.4%) and
negative (48.6%) responses, showing no significant difference (χ² = 0.198, p = 0.656). Similarly, the overall
perception of patient safety culture (55.9% positive, 44.1% negative) did not reach statistical significance (χ² =
3.405, p = 0.065).
The one-sample t-test results further confirmed that nurses’ perceived safety performance and patient safety
culture scores were significantly above the benchmark value of 4.0 (p < 0.05). Moreover, the significant
correlation between safety culture and safety performance underscores the role of a positive safety culture in
enhancing safety practices. These findings collectively suggest that strong organizational policies, leadership
support, and collaborative teamwork contribute to fostering a positive patient safety environment, although
staffing issues remain a notable challenge.
This study examines the relationship between patient safety culture and safety performance using statistical
correlation and regression analyses. The research aims to determine whether an impact of patient safety culture
contributes to improved safety performance among nurses. Using a sample of 247 respondents, the study
employs Pearson’s correlation, simple linear regression, and multiple regression analyses to assess the strength
and significance of these relationships. Analysis of the relationship analysis will be presenting as following
data presentation
Table 4: Correlation between Patient Safety Culture and Safety Performance
Correlation between Patient Safety Culture and Safety Performance
Safety Performance
Patient Safety Culture Pearson 0.811
**
Correlation
Sig. (2-tailed) .000
N 247
**. Correlation is significant at the 0.01 level (2-tailed). α=0.05
Table 4 presents an analysis on the relationship between patient safety culture and safety performance, a
statistical correlation analysis was conducted using a sample of 247 respondents. Pearson’s correlation
coefficient was used to measure the strength and direction of the relationship. The significance level was set at
p < 0.05 to determine statistical relevance. The Pearson correlation coefficient between patient safety culture
and safety performance was found to be 0.811, indicating a strong positive relationship. The p-value was
0.000, demonstrating statistical significance at a 95% confidence level. The strong correlation (r = 0.811)
highlights the critical role of patient safety culture in influencing safety performance.
The Pearson correlation analysis demonstrated a strong and statistically significant positive relationship
between patient safety culture and safety performance (p < 0.05) among registered nurses. This suggests that
improvements in safety culture are associated with proportional improvements in nurses’ safety performance.
The multiple linear regression analysis further validated this relationship, identifying patient safety culture as a
significant predictor of safety performance. These results indicate that healthcare institutions with higher levels
Page 4771
www.rsisinternational.org
INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)
ISSN No. 2454-6186 | DOI: 10.47772/IJRISS | Volume IX Issue X October 2025
of patient safety culture are more likely to achieve better safety-related behaviours among nurses, leading to
fewer incidents, higher compliance with safety protocols, and improved patient care outcomes.
DISCUSSION
This study’s findings, highlighting the relationship between patient safety culture and safety performance
among registered nurses, while considering the influence of sociodemographic characteristics. Overall, the
results indicated that both patient safety culture and safety performance were perceived positively, with mean
scores significantly exceeding the benchmark value of 4.0 (p < 0.05). Reliability testing confirmed the internal
consistency of the instrument (Cronbach’s alpha > 0.7), supporting its appropriateness for assessing these
constructs. These results affirm the central role of safety culture in shaping nurses’ safety behaviours, reducing
errors, and improving care outcomes (Neal & Griffin, 2006; Wu, Mao, Zhao, & Li, 2019).
Demographic analysis revealed significant variations in workforce characteristics. The majority of respondents
were female (93.1%), aged 36–45 years (67.6%), and held diploma-level education (78.5%). Length of service
was concentrated in the 6–10-year range (64.8%), while most nurses worked in surgical units (41.3%). Chi-
square tests confirmed that these distributions were statistically significant (p < 0.05). Further analysis
demonstrated that these sociodemographic factors were significantly associated with variations in PSC and SP
scores. Older, more experienced, and higher-educated nurses reported stronger safety perceptions, while those
in high-acuity areas such as surgical and intensive care units scored higher than their peers in other
departments. These findings are consistent with international evidence that experience, education, and unit-
specific demands shape safety-related attitudes and practices (Chih, Yang, & Lin, 2019; Lee, Dahinten,
MacPhee, & Jacobs, 2018).
The study also evaluated patient safety culture domains. High scores were observed for safety participation (M
= 4.45, SD = 0.53), safety performance (M = 4.41, SD = 0.50), and frequency of safety event reporting (M =
4.28, SD = 0.59). Organizational learning/continuous improvement was also rated positively (M = 4.25, SD =
0.57). These results suggest strong engagement in safety activities, frequent reporting of incidents, and a
commitment to continuous learning. However, staffing recorded the lowest score (M = 3.69, SD = 1.09), while
communication openness was comparatively weaker (M = 3.97, SD = 0.73). A one-sample t-test confirmed
that most domains scored significantly higher than the benchmark of 4.0 (p < 0.05), except for communication
openness (p = 0.490), which was neutral. These findings highlight critical strengths, but also expose ongoing
challenges in workforce adequacy and open communication, which have been recognized internationally as
persistent barriers to sustaining safety culture (El-Jardali, Dimassi, Jamal, Jaafar, & Hemadeh, 2011; Noor,
Ismail, Yasin, & Siti, 2022).
Pearson correlation revealed a strong, positive, and statistically significant relationship between patient safety
culture and safety performance (p < 0.05), indicating that improvements in safety culture are directly
associated with enhanced safety performance. Regression analysis confirmed patient safety culture as a
significant predictor of safety performance, supporting the central research objectives. ANOVA and t-tests
demonstrated significant differences across age, education, and gender groups, while chi-square tests
confirmed the association between demographic factors and patient safety culture/safety performance domains.
For example, older and more experienced nurses consistently reported higher safety scores, while those with
advanced qualifications demonstrated greater adherence to safety practices. Nurses in high-demand units,
particularly surgical and intensive care, also scored higher, reflecting the impact of unit-specific safety
structures. These results resonate with both local and global studies emphasizing that supportive organizational
environments, leadership engagement, and adequate staffing are crucial for sustaining PSC (Mistri, Albolino,
& Toccafondi, 2023; Juanda, Sutrisno, & Rahmawati, 2024; Rusdi, Abdullah, & Karim, 2024).
All five objectives were successfully achieved, providing valuable insights into the factors that shape nurses’
positive patient safety culture behaviours towards achievement of safety performance. First, the study found
that nurses perceived patient safety culture at a moderate level, with teamwork within units rated highest and
non-punitive response to error rated lowest. This indicates the need for leadership to cultivate a more
supportive environment that encourages open reporting without fear of blame.
Page 4772
www.rsisinternational.org
INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)
ISSN No. 2454-6186 | DOI: 10.47772/IJRISS | Volume IX Issue X October 2025
Second, nurses reported moderately high levels of safety performance, both in compliance with protocols and
participation in safety activities, reflecting their commitment to maintaining safe practices. Third, the study
demonstrated a strong positive relationship between patient safety culture and safety performance, reinforcing
global evidence that organizational culture is a cornerstone of patient safety. Fourth, regression analysis
confirmed that patient safety culture significantly predicts safety performance, explaining 42.7% of the
variance. This highlights the importance of systemic interventions aimed at strengthening safety culture to
achieve tangible improvements in safety outcomes. Finally, demographic factors such as age, education, and
years of service were significant predictors of safety performance, suggesting that culture-driven
organizational factors are more influential than individual characteristics.
The findings had demonstrated that patient safety culture is both a determinant and predictor of safety
performance among nurses. While overall results were positive, weaknesses in staffing adequacy and
communication openness highlight areas requiring targeted intervention. By addressing these challenges
through organizational reform, policy initiatives, and continuous professional development, healthcare
institutions can strengthen patient safety culture, enhance nurse well-being, and ultimately ensure safer patient
outcomes and greater trust in the healthcare system
Overall, this study concludes that building and sustaining a positive patient safety culture is essential for
enhancing nurses’ safety performance. The findings contribute new evidence from the Malaysian private
healthcare context and provide practical implications for hospital management and policymakers to prioritize
safety culture as a strategic component of healthcare quality and safety
RECOMMENDATION
The findings of this study carry significant implications for nursing practice, healthcare leadership, and policy
development. The results emphasize the importance of cultivating a strong patient safety culture as a
foundation for improving safety performance across healthcare organizations.
From a practice perspective, continuous professional development, structured mentoring, and empowerment
programmes should be prioritised to enhance nurses’ knowledge, confidence, and commitment to patient
safety. Encouraging teamwork, effective communication, and shared accountability within nursing units can
foster a supportive environment that promotes safer clinical practices and reduces preventable incidents.
Organisational interventions such as leadership training, peer mentoring systems, and safe staffing models are
supported by emerging evidence. Studies show that transformational leadership behaviours by nurse managers
enhance incident reporting, staff morale, and overall safety outcomes (Oweidat, 2019; Boamah et al., 2017). A
positive and open safety culture requires visible leadership commitment and non-punitive systems that
encourage learning from mistakes (Ren Jye et al., 2019).
Moreover, insufficient staffing and poor communication have consistently been reported as barriers to patient
safety in Malaysian hospitals, where only 23% of respondents perceived staffing as adequate, and “non-
punitive response to error” scored the lowest (18%) in national surveys (Ren Jye et al., 2019). Addressing
these gaps through safe staffing models and open feedback mechanisms is therefore essential.
Implementation flexible staffing model able to effectively address healthcare workforce shortages by
combining centralized float pools, internal travel nurses, telehealth staffing, and digital on-demand platforms
supported by predictive analytics. This model integrates a stable core workforce with flexible internal
resources that can be redeployed based on patient acuity, reducing dependence on costly external agency staff
(Bae and Mark, 2021). Internal travel nurse programs enhance retention and consistency while lowering
onboarding costs and improving organizational resilience (Griffiths et al., 2019). Additionally, digital on-
demand platforms enable the rapid deployment of pre-credentialed clinicians to fill unexpected vacancies,
improving efficiency and coverage (Dyrbye et al., 2023). Collectively, these strategies have been shown to
reduce turnover and premium labor costs while sustaining high-quality patient care (Bae and Mark, 2021;
Griffiths et al., 2019; Dyrbye et al., 2023).
Page 4773
www.rsisinternational.org
INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)
ISSN No. 2454-6186 | DOI: 10.47772/IJRISS | Volume IX Issue X October 2025
For future research, incorporating qualitative interviews or focus groups is strongly recommended. Such
approaches can elicit deeper insights into nurses’ lived experiences, uncovering barriers to open
communication, workload challenges, and fear of reporting. Qualitative findings can complement quantitative
outcomes, offering a holistic understanding of the cultural and organisational factors that influence safety
performance. Prior evidence confirms that leadership style and culture directly shape communication openness
and willingness to report incidents (Oweidat, 2019).
A mixed-methods or longitudinal design would further strengthen the evidence base by linking qualitative
insights with measurable safety outcomes, guiding the design of targeted interventions to enhance teamwork,
psychological safety, and leadership effectiveness.
The findings of this study carry significant implications for nursing practice, healthcare leadership, and policy
development. The results emphasize the importance of cultivating a strong patient safety culture as a
foundation for improving safety performance across healthcare organizations.
From a practice perspective, continuous professional development, structured mentoring, and empowerment
programs should be prioritized to enhance nurses’ knowledge, confidence, and commitment to patient safety.
Encouraging teamwork, effective communication, and shared accountability within nursing units can foster a
supportive environment that promotes safer clinical practices and reduces preventable incidents.
In terms of leadership and management, the study highlights the necessity of strong managerial commitment
and proactive leadership in advancing patient safety. Nursing leaders should implement non-punitive error
reporting systems, conduct regular safety walkarounds, and promote structured interdisciplinary
communication through standardized tools such as SBAR. Visible leadership engagement and continuous
feedback mechanisms are essential for building trust, accountability, and a learning-oriented organizational
culture (World Health Organization, 2021).
At the policy level, the results reinforce the need for the establishment of safe nurse-to-patient ratios, equitable
workforce distribution, and the inclusion of patient safety culture assessments within accreditation and quality
assurance frameworks. Policymakers should prioritize strategies that ensure adequate staffing and resource
allocation to support a sustainable and resilient healthcare workforce.
Regarding future research, it is recommended that longitudinal or mixed-method approaches be employed to
provide deeper insights into the causal relationships between patient safety culture and safety performance.
Expanding research across multiple healthcare institutions and incorporating interprofessional perspectives
would enhance the validity and applicability of findings. Further exploration of digital health integration,
leadership resilience programs, and the relationship between safety culture and patient outcomes is also
encouraged to advance the field of healthcare management and safety research.
CONCLUSION
This study confirmed that patient safety culture is a critical determinant of safety performance among
registered nurses, providing robust evidence of the link between organizational culture and quality of care.
Both safety culture and safety performance were positively perceived by the participants, with overall scores
exceeding established benchmarks. Statistical analyses revealed a strong positive correlation. A supportive
safety culture characterized by teamwork, effective leadership, open communication, and continuous learning
was shown to enhance compliance with safety practices. It also reduces errors and promotes high-quality, safe,
and reliable patient care. These findings reinforce the notion that cultivating a positive safety culture is not
only beneficial for nurses’ professional practice but also essential for achieving optimal patient outcomes.
In addition, socio-demographic characteristics were found to significantly influence nurses’ perceptions and
behaviours related to safety. Variables such as age, level of education, years of professional experience, and
type of work unit played a critical role in shaping safety-related attitudes and performance. Older, more
experienced, and highly educated nurses, as well as those working in high-acuity units such as surgical and
intensive care settings, generally demonstrated stronger safety culture perceptions and higher safety
Page 4774
www.rsisinternational.org
INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)
ISSN No. 2454-6186 | DOI: 10.47772/IJRISS | Volume IX Issue X October 2025
performance scores. This suggests that interventions aimed at strengthening safety culture should not adopt a
“one-size-fits-all” approach but rather be tailored to the demographic composition and clinical context of the
nursing workforce.
Despite the overall positive results, the study also revealed challenges in two key domains: staffing adequacy
and communication openness. These weaker areas highlight persistent systemic barriers that may compromise
nurses’ ability to fully engage in safe practice. Inadequate staffing ratios, coupled with limited opportunities
for transparent communication, can hinder teamwork, contribute to fatigue, and reduce error reporting,
ultimately increasing the risk of adverse patient outcomes. Addressing these gaps requires a multi-pronged
approach that includes the establishment of safe nurse-to-patient ratios, the implementation of non-punitive
error reporting systems, and the promotion of a culture of psychological safety where nurses feel empowered
to voice concerns without fear of blame or retaliation.
The implications of these findings extend beyond individual institutions and highlight the urgent need for
leadership commitment and policy-level reforms. Strong leadership engagement is necessary to model desired
safety behaviors, allocate resources for workforce support, and reinforce accountability structures. At the same
time, continuous professional development programs should be prioritized to enhance nurses’ competencies,
strengthen teamwork, and embed patient safety principles into everyday practice. By adopting these strategies,
healthcare organizations can cultivate a culture of trust and learning that not only reduces errors but also
supports the well-being of healthcare workers.
To build on these findings, future research should adopt qualitative or mixed-method designs to capture the
depth of nurses’ experiences in communicating and reporting safety concerns. Such approaches, combined
with organizational reforms like leadership development and safe staffing practices and model, will be vital in
fostering an open, learning-oriented safety culture across healthcare institutions.
In conclusion, this study demonstrates that patient safety culture serves as a cornerstone of safety performance
in nursing practice. Strengthening this culture requires a sustained commitment from organizational leaders,
policy-makers, and frontline staff alike. By addressing systemic challenges and investing in workforce
development, healthcare organizations can build a safer, more resilient, and sustainable healthcare system that
prioritizes both patient outcomes and professional excellence.
ACKNOWLEDGEMENTS
I express my sincere appreciation to Programme Director Dr. Siti Fatimah for her valuable support and
insightful comments, and to Supervisor Dr. Aini Ahmad for her guidance and constructive feedback
throughout the research process.
ETHICAL APPROVAL
This study involving human participants received ethical approval from the institutional ethics committee.
Written informed consent was obtained from all participants prior to their inclusion in the study.
REFERENCES
1. Aboul-Fotouh AM, Ismail NA, Ez Elarab HS, Wassif GO. Assessment of patient safety culture among
healthcare workers in an Egyptian university hospital. East Mediterr Health J. 2012;18(4):372-7.
https://doi.org/10.26719/2012.18.4.372
2. Agency for Healthcare Research and Quality. Hospital survey on patient safety culture: User’s guide
[Internet]. Rockville (MD): U.S. Department of Health & Human Services; 2022 [cited 2025 Sep 5].
Available from: https://www.ahrq.gov
3. Agency for Healthcare Research and Quality. Surveys on patient safety culture (SOPS) database report
[Internet]. Rockville (MD): U.S. Department of Health & Human Services; 2024 [cited 2025 Sep 5].
Available from: https://www.ahrq.gov
Page 4775
www.rsisinternational.org
INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)
ISSN No. 2454-6186 | DOI: 10.47772/IJRISS | Volume IX Issue X October 2025
4. Ahlstedt S, Johansson B, Lantz A. Understanding the factors that influence nurses’ motivation to remain
in nursing care: A qualitative study. J Nurs Manag. 2019;27(5):1043-52.
https://doi.org/10.1111/jonm.12734
5. Bae SH, Mark B. Revisiting nurse staffing and patient outcomes: an integrative review. Nurs Econ.
2021;39(1):25–36.
6. Beth K, Tamara P. Patient safety culture in nephrology nurse practice settings: Results by primary work
unit, organizational work setting, and primary role. Nephrol Nurs J. 2015;42(3):221-9.
7. Boamah SA, Laschinger HK, Wong C, Clarke S. Effect of transformational leadership on job
satisfaction and patient safety outcomes. Nurs Outlook. 2017;66:180–9.
https://doi:10.1016/j.outlook.2017.10.004.
8. Clancy CM. Improving patient safety: Insights from the Institute of Medicine report. Patient Saf Qual
Healthc. 2018;15(2):12-9.
9. Cook RI, Woods DD, Miller C. Nurses’ role in patient safety: A critical review. J Nurs Saf.
2014;18(3):75-89.
10. Chih CT, Chen HY, Huang HT, Hsiao SY. The impact of nurse demographics and work environment on
patient safety culture in Taiwan: A cross-sectional study using the Chinese Safety Attitudes
Questionnaire. BMC Health Serv Res. 2019;19:606. https://doi.org/10.1186/s12913-019-4299-2\
11. Dyrbye LN, Shanafelt TD, Johnson PO, Johnson LM, Satele DV, Sloan JA. A cross-sectional study
exploring the relationship between on-demand staffing models and clinician wellbeing. J Nurs Manag.
2023;31(2):276–84.
12. Chih HH, Hsu CY, Wang HH. Relationships between demographic variables and safety culture
dimensions among hospital nurses in Taiwan. BMC Nurs. 2019;18:50. https://doi.org/10.1186/s12912-
019-0379-3
13. Juanda D, Syahrul S, Isnaini N. Organizational culture and patient safety: A cross-sectional study in
Aceh Province, Indonesia. J Nurs Manag. 2024;32(2):145-54. https://doi.org/10.1111/jonm.13920
14. Juanda I, et al. Organizational culture and its relationship to patient safety culture among nurses in Aceh
Province, Indonesia. J Nurs Manag. 2024;32(2):245-54.
15. Joint Commission. Patient safety systems chapter [Internet]. Oakbrook Terrace (IL): Joint Commission;
2017 [cited 2025 Sep 5]. Available from: https://www.jointcommission.org
16. Joint Commission International. America’s hospitals: Improving quality and safety. Annual report 2017.
Oakbrook Terrace (IL): Joint Commission International Resources; 2017.
17. Joint Commission International. JCI publishes 8th edition of international accreditation standards for
hospitals and academic medical centers [Internet]. Oakbrook Terrace (IL): JCI; 2024 Jul [cited 2025 Sep
5]. Available from: https://www.jointcommission.org/en/knowledge-library/news/2024-07-jci-
publishes-8th-edition-of-international-accreditation-standards/
18. Griffiths P, Maruotti A, Recio Saucedo A, Redfern OC, Ball JE, Briggs J, et al. Nurse staffing, nursing
assistants and hospital mortality: retrospective longitudinal cohort study. BMJ Qual Saf.
2019;28(8):609–17.
19. Indra CK, Elida A, Ahmad S, Retno H, Windhu H. The relationship between characteristics of hospital
staff and patient safety culture behavior. Eurasian J Biosci. 2020;14:2547-54.
20. Neal A, Griffin MA. A study of the lagged relationships among safety climate, safety motivation, safety
behavior, and accidents at the individual and group levels. J Appl Psychol. 2006;91(4):946-63.
21. Neal A, Griffin MA. The influence of safety climate on safety performance: A meta-analysis. J Organ
Behav. 2000;27(3):561-83.
22. Jaafar M, Abdul Rahman H, Don MS. Quality of care in healthcare organizations: A review of
Malaysia’s status and future directions. Int J Health Care Qual Assur. 2016;29(1):65-80.
https://doi.org/10.1108/IJHCQA-10-2014-0110
23. Jarrar M, et al. Quality of care and patient safety in Malaysian hospitals: A review of current literature.
Int J Health Care Qual Assur. 2016;29(6):600-13.
24. Nieve J, Sorra J. Hospital survey on patient safety culture: User’s guide [Internet]. Rockville (MD):
Agency for Healthcare Research and Quality, U.S. Department of Health & Human Services; 2014
[cited 2025 Sep 5]. Available from: https://www.ahrq.gov
Page 4776
www.rsisinternational.org
INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)
ISSN No. 2454-6186 | DOI: 10.47772/IJRISS | Volume IX Issue X October 2025
25. Lee SH, Phan PH, Dorman T, Weaver SJ, Pronovost PJ. Handoffs, safety culture, and practices:
Evidence from the hospital survey on patient safety culture. BMC Health Serv Res. 2019;19:126.
https://doi.org/10.1186/s12913-019-3951-8
26. Nivea V, Sorra J. Hospital survey on patient safety culture. Rockville (MD): Agency for Healthcare
Research and Quality; 2004. Contract No.: 290-96-0004.
27. Noor Arzahan IS, Ismail Z, Yasin SM. Safety culture, safety climate, and safety performance in
healthcare facilities: A systematic review. Saf Sci. 2022;147:105585.
28. Hamzah AR, Mutaman J, Mohammad SD. Nurse level of education, quality of care, and patient safety
in the medical and surgical wards in Malaysian private hospitals: A cross-sectional study. Glob J Health
Sci. 2010;7:433-9.
29. Smits M. The psychometric properties of the ‘Hospital Survey on Patient Safety Culture’ in Dutch
hospitals. BMC Health Serv Res. 2012;12:8. https://doi.org/10.1186/1472-6963-12-8
30. Perjit K, Ellisha O. Patient safety incidents in Malaysian hospitals: Trends and challenges. Malays J
Public Health Med. 2020;20(1):123-9.
31. Rusdi S, Sutanto A, Adnyasari R. The role of empowerment in enhancing patient safety culture: A
literature review. Open Access Maced J Med Sci. 2024;12(F):105-13.
https://doi.org/10.3889/oamjms.2024.12045
32. Mistri A, Rawal T, Patel P. Patient safety culture in healthcare: A systematic literature review of
measurement, challenges, and strategies. BMC Health Serv Res. 2023;23(1):845.
https://doi.org/10.1186/s12913-023-09925-0
33. Malaysian Patient Safety Council. Malaysian Patient Safety Goal: Guidelines on implementation and
surveillance. Putrajaya: Ministry of Health Malaysia; 2021.
34. Malaysian Patient Safety Council. Malaysian Patient Safety Goals annual report 2019. Putrajaya:
Ministry of Health Malaysia; 2019.
35. Malaysian Patient Safety Council. Malaysian Patient Safety Goals annual report 2020. Putrajaya:
Ministry of Health Malaysia; 2020.
36. Oweidat IAA. Leadership behaviors, organizational culture, and incidents reporting practices as
perceived by Jordanian nurses: literature review. Open J Nurs. 2019;9:988–97.
https://doi:10.4236/ojn.2019.99073
37. Qasim A, Loai A, Omar T. Predictors of perceptions of patient safety culture and frequency of event
reporting by critical care nurses in Oman: A model-building approach. Crit Care Shock.
2017;22(4):178-85.
38. Sathia P, Sumitra R, Jeevitha K, Karuthan C. Nurse empowerment and patient safety culture: An
empirical analysis. Asian J Nurs Res. 2020;9(2):88-102.
39. El-Jardali F. Creating a strong patient safety culture in healthcare organizations. J Healthc Manag.
2014;32(5):210-24.
40. World Health Organization. Global patient safety action plan 2021–2030: Towards eliminating
avoidable harm in health care. Geneva: WHO Press; 2020.
41. Wu G, Deng X, Zhang Y. Patient safety culture and its relationship with hospital safety performance: A
cross-sectional study. Health Sci J. 2019;13(5):683.
42. Ririk H, Djazuly C, Ririn I. The effect of patient safety culture on the quality of nurses’ performance. J
Medico Manaj Rumah Sakit. 2021;10(1):13-21.
43. Ren Jye AK, Chin ZH, Peter S, Bartholomew P, Senok J. Hospital survey on patient safety culture in
Sarawak General Hospital: a cross-sectional study. Med J Malaysia. 2019;74(5):385–8.
44. World Health Organization. Patient safety: Preventing errors in healthcare [Internet]. Copenhagen:
WHO Regional Office for Europe; 2020 [cited 2025 Sep 5]. Available from:
http://www.euro.who.int/en/health-topics/Health-systems/patient-safety
45. World Health Organization. Global patient safety action plan 2021–2030: Towards eliminating
avoidable harm in health care [Internet]. Geneva: WHO; 2021 [cited 2025 Sep 5]. Available from:
https://www.who.int/publications/i/item/9789240032705
46. Hamzah M, Mu’taman S, Sobri J. The impact of education level on work culture and patient safety. J
Healthc Educ. 2015;21(4):78-92.