NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
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NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY:
A NARRATIVE SYNTHESIS
by
KATHLEEN ELIZABETH ARCHIBALD SAMOIL
BSc, University of Alberta, 2010

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF REQUIREMENTS FOR THE
DEGREE OF
MASTER OF SCIENCE IN NURSING
In
THE SCHOOL OF GRADUATE STUDIES
Trinity Western University

Supervisory Committee:
Dr. Richard (Rick) Sawatzky, Trinity Western University
Dr. Sheryl Reimer-Kirkham, Trinity Western University
Kris Gustavson, Provincial Health Services Agency

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Abstract
The question that this thesis sought to answer was whether discernible trends could be
found in studies that involve the use of questionnaires to ascertain nurses’ perceptions of
supervisory leadership for safety in the context of patient safety culture. A focused literature
search was conducted to retrieve relevant studies. The resulting 35 studies were analyzed using
the knowledge synthesis method of narrative review. Narrative review was selected on the basis
that it would allow for comparisons of studies that used different research designs and
questionnaires. The sample of included studies comprised 24 studies that used the Hospital
Survey on Patient Safety Culture, 6 studies that used the Safety Attitudes Questionnaire, 2
studies that used the Safety Climate Survey, 1 study that used the Survey on Safety in Nursing
Homes and 1 study that used the RN4CAST. One study used qualitative interviews.
The result of this thesis was the determination that patient safety culture assessments
should be interpreted in relation to the specific context in which the assessment is conducted.
Results are therefore not generalizable and discernible trends among the studies could not be
identified. Two important themes were identified in the narrative review. The first theme was the
importance of the cultural background of the participants, including ethnicity or nationality,
organizational culture of the worksite, and cultural milieu of the geographic location. The second
theme was that the assessment of patient safety culture should be repeated at intervals and
examined in the context of the workplace at the time of each assessment. There is benefit to
combining qualitative and quantitative methods to assess patient safety culture.

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Acknowledgements
I am grateful to all of you who supported me through this thesis, and particularly Dr.
Sawatzky, Dr. Reimer-Kirkham, and Ms. Gustavson. To my entire cohort, in particular my
confidante Danielle Chatterton, thank you for your knowledge and experience that enriched our
program of study together. To Sam and Jo, words cannot do justice to the gratitude I have for
your efforts to cultivate and support my lifelong learning.

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Table of Contents
Abstract ........................................................................................................................................... 2
Acknowledgements ......................................................................................................................... 3
Chapter One: Introduction and Background ................................................................................. 10
Introduction...................................................................................................................... 10
Definitions ....................................................................................................................... 12
Patient safety .............................................................................................................. 12
Safety culture, safety climate, and patient safety culture ........................................... 13
Supervisory leadership ............................................................................................... 15
Problem and Study Purpose ............................................................................................. 15
Project Description, Purpose, and Objectives.................................................................. 17
Chapter Summary ............................................................................................................ 19
Chapter Two: Patient Safety Culture and Perception of Supervisory Leadership ........................ 20
Supervisory Leadership and its Relationship to Patient Safety Culture .......................... 20
Why Measure Safety Culture? ......................................................................................... 20
How Safety Culture is Measured ..................................................................................... 21
The Use of Patient Safety Culture Results ...................................................................... 22
Patient Safety Culture Questionnaires ............................................................................. 23
Hospital Survey on Patient Safety Culture ................................................................ 23
Safety Attitudes Questionnaire .................................................................................. 25
Other instruments ....................................................................................................... 26
Chapter Summary ............................................................................................................ 27

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Chapter Three: Research Method, Design, and Procedures ......................................................... 28
Method of Analysis.......................................................................................................... 28
Literature Search and Screening ...................................................................................... 29
Inclusion and Exclusion................................................................................................... 30
Data Extraction ................................................................................................................ 32
Quality Assessment ......................................................................................................... 33
Ethical Considerations ..................................................................................................... 34
Chapter Summary ............................................................................................................ 35
Chapter Four: Findings ................................................................................................................. 36
Introduction...................................................................................................................... 36
Description of the Included Studies................................................................................. 36
Data Collection Instruments ............................................................................................ 38
Study Data: Hospital Survey on Patient Safety Culture .................................................. 38
Middle Eastern studies ............................................................................................... 38
Far Eastern studies ..................................................................................................... 44
European studies ........................................................................................................ 45
United States studies .................................................................................................. 49
Summary of HSOPSC studies.................................................................................... 50
SAQ Studies .................................................................................................................... 50
Middle Eastern studies ............................................................................................... 50
European studies ........................................................................................................ 52
Brazilian study ........................................................................................................... 53

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Summary of SAQ studies ........................................................................................... 53
Other Instruments ............................................................................................................ 54
Middle Eastern study ................................................................................................. 54
European studies ........................................................................................................ 55
United States study..................................................................................................... 56
Summary of studies using other instruments ............................................................. 56
Analysis of Similarities and Differences across Studies and Contexts of Care .............. 56
Chapter Summary ............................................................................................................ 59
Chapter Five: Discussion and Conclusion .................................................................................... 60
Benchmarks ..................................................................................................................... 61
Culture ............................................................................................................................. 63
Interventions .................................................................................................................... 64
Implications and Recommendations ................................................................................ 67
Conclusion ....................................................................................................................... 68
References ..................................................................................................................................... 69
Appendices .................................................................................................................................... 82
Appendix A – Included Studies Using Hospital Survey on Patient Safety Culture ........ 82
Appendix B – Included Studies Using Safety Attitudes Questionnaire .......................... 96
Appendix C – Included Studies Using a Method Other than HSOPSC or SAQ ........... 100
Appendix D – QualSyst Manual for Evaluating Quality of Quantitative Studies ......... 104
Appendix E – QualSyst Manual for Evaluating Quality of Qualitative Studies ........... 113
Appendix F – QualSyst Checklist for Evaluating Quality of Quantitative Studies ....... 117

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Appendix G – QualSyst Checklist for Evaluating Quality of Qualitative Studies ........ 118
Appendix H – Summary of QualSyst Quality Scores for Included Articles ................. 119

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List of Tables
Table 1 HSOPSC Supervisor/Manager Expectations and Actions Promoting Safety......

24

Table 2 SAQ Perception of Management..........................................................................

25

Table 3 SRS Perception of Unit Management...................................................................

26

Table 4 Results of Literature Search and Screening......................……………………….. 30
Table 5 Mean Scores for Supervisor/Manager Expectations and Actions Promoting Safety42

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List of Figures
Figure 1 Diagram illustrating search, screening, and inclusion/exclusion process............... 32

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Chapter One: Introduction and Background
Introduction
Safety culture is a concept that permeates many complex, highly technical work
environments including healthcare. Supervisory leadership for safety is an important dimension
of patient safety culture for, as recognized long ago, ‘‘(t)he supervisor or foreman is the key man
in industrial accident prevention. His application of the art of supervision to the control of
worker performance is the factor of greatest influence in successful accident prevention”
(Heinrich as cited in Flin & Yule, 2004, p. ii47). Of interest in the present thesis is the dimension
of nurses’ perceptions of supervisory leadership for safety in the context of patient safety culture.
The question underlying this thesis is whether trends can be found in studies that involve the use
of questionnaires for assessing nurses’ perceptions of supervisory leadership for safety in the
context of in patient safety culture.
Underlying this topic is the genesis of safety culture as a modern industrial concept. This
industrial perspective stems from the Chernobyl nuclear disaster (Cooper, 2000, p.113).
Evaluating the Chernobyl incident, the Nuclear Energy Agency concluded that its occurrence
was attributable to “a lack of ‘safety culture’” and referred to the indicators thereof as including
flaws in design, communication, and ultimately failure to “comply with established operational
procedures” (2002). Thereafter, safety culture was recognized and adopted into high risk
industries such as aviation, rail transportation, and off-shore petroleum production (Zhang,
Weidmann, von Thaden, Sharma & Mitchell, 2002). It now finds its place in healthcare, where
addressing and reducing the risk of harm and ensuring patient safety have become a “global
imperative” (Donaldson & Philip, 2004). The Institute of Medicine noted in 1999, “(h)ealth care
has much to learn from other industries about improving safety” (Kohn, Corrigan, & Donaldson,

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2000, p.71). The National Steering Committee on Patient Safety in Canada stated that “(t)o
improve safety, the healthcare system must develop and maintain a culture of safety” (2002,
p.10). As to fostering and maintaining a positive patient safety culture, it has been held that:
A culture of patient safety is created and maintained by two interdependent factors. The
first is an institutional or organizational framework that enables and sustains a culture of
patient safety. The second is the appropriate expertise, attitudes, behaviours and values of
those who work within that system. Both of these conditions are necessary to the safe
functioning of any health care institution. (Frank & Brien, 2009, p.5)
Concurrent with the growing awareness of patient safety culture has been the increased
recognition of the need to assess it (Nieva & Sorra, 2003, p.ii17). Assessment of patient safety
culture is undertaken with a view to addressing “weak safety culture as a causal factor” in
avoidable adverse events and deaths (Flin, 2007, p.655). Patient safety culture “has become an
important metric, because unlike many other safety measures, it is pertinent to all health care
facilities providing hands-on patient care” (Castle, Wagner, Perera, Ferguson & Handler, 2011,
p.23).
Patient safety culture is often evaluated through survey questionnaires that are completed
by those who work within healthcare systems. The purposes for assessing patient safety culture
may vary. As Nieva and Sorra state, such evaluations are important to “diagnose safety culture to
identify areas for improvement and raise awareness about patient safety” (2003, p.ii19) and the
outcomes serve as “patient safety improvement tools” (p.ii20). Prominent examples of survey
questionnaires in current use are the Manchester Patient Safety Framework (The University of
Manchester, 2006), the Hospital Survey on Patient Safety Culture (Agency for Health Care
Research and Quality, 2016a), the Safety Attitudes Questionnaire (SAQ) (Center for Healthcare

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Quality & Safety, 2016), and the Patient Safety Culture Survey Tool (PSCS) (Ginsburg,
Tregunno, Norton, Mitchell & Howley, 2014).
Patient safety culture survey questionnaires address many dimensions of patient safety
culture. One of them is the perception of supervisory leadership for safety. Perception of safety is
important as “(i)ncreasing empirical evidence supports the relationship between staff perceptions
of safety culture and safety behaviours and outcomes in healthcare and in other industries”
(Ginsburg et al., 2014, p.162). In this context, “(s)upervisor commitment to safety” found a place
in patient safety culture assessment (Flin, 2007, p.662). Why is this dimension of patient safety
important to measure? Supervisory leadership is seen “as one way to improve employees’ safety
behaviors and thereby reduce accident and injury rates” (Conchie, Moon, & Duncan, 2013,
p.109). The leadership aspect of “supervisory leadership” comes from the survey questionnaires
that measure participants’ perception through questions concerning their supervisors’ “values,
attitudes, perceptions, competencies, and patterns of behaviour” (Agency for Health Care
Research and Quality, 2016b, p.1). According to Flin, the measure of supervisory leadership in
the context of patient safety fundamentally represents “the perceptions of ... supervisor
prioritisation of safety” (2007, p.662). This is the dimension of patient safety culture assessment
that is of interest in this thesis.
Definitions
Patient safety
The Canadian Patient Safety Dictionary defines patient safety as “the reduction and
mitigation of unsafe acts within the healthcare system, as well as through the use of best
practices shown to lead to optimal patient outcomes” (2003, p.11). Simply stated an unsafe act is

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an “event/act/process that fail(s) to achieve the expected aim” (p.11) and in doing so
intentionally or unintentionally compromises patient safety.
Safety culture, safety climate, and patient safety culture
According to Cooper, “(c)ulture is something that is mutual and reciprocal” (2000,
p.223). Safety culture may be concisely defined as “those aspects of the organisational culture
which will impact on attitudes and behaviour related to increasing or decreasing risk”
(Guldenmund, 2000, p.251). In a healthcare context, some elaboration has been added. The
Agency for Health Care Research and Quality (AHRQ) cites the following definition, which was
originally framed by the Advisory Committee on the Safety of Nuclear Installations (ACSNI):
The safety culture of an organization is the product of individual and group values,
attitudes, perceptions, competencies, and patterns of behavior that determine the
commitment to, and the style and proficiency of, an organization's health and safety
management. Organizations with a positive safety culture are characterized by
communications founded on mutual trust, by shared perceptions of the importance of
safety, and by confidence in the efficacy of preventive measures. (as cited by AHRQ,
2016b, p.1)
According to Flin, the definition from ACSNI is “(t)he most widely accepted definition of safety
culture” (2007, p.656). The phrase “safety climate” is a regularly seen or used in the context of
safety culture. It is often used as the equivalent of “safety culture” (Halligan & Zecevic, 2011,
p.3). In one study, the authors stated that patient safety culture is the same as patient safety
climate (Nie, Mao, Cui, He, Li, & Zhang, 2013). More precisely, however, it is generally
accepted that safety climate “is the visible feature of a safety culture” (Ausserhofer, Schubert,
Desmedt, Blegen, De Geest, & Schwendimann, 2012, p.242), or “the surface features of the

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safety culture discerned from the workforce's attitudes and perceptions at a given point in time”
and “a snapshot of the state of safety providing an indicator of the underlying safety culture of a
work group, plant or organisation” (Flin, Mearns, O’Connor, & Bryden, 2000, p.178). This
distinction between safety climate and safety culture is important. Although “safety culture
surveys” are regularly administered to participants in a healthcare setting, applying these
definitions shows that surveying participants about their perceptions of patient safety culture is in
fact a survey of safety climate and as such it contributes to an understanding of institutional
safety culture (Flin, 2007, p.658). Safety climate is inextricably woven into safety culture. It is
important to this thesis as it is the outward measure of perception of safety culture.
The Canadian Patient Safety Institute (CPSI) integrates patient safety into the ACSNI
definition of safety culture and describes patient safety culture as one that:
... arises from attitudes, activities and enduring ethical values that are conducive to the
safe delivery of patient care. More precisely, it refers to the commitment of health care
practitioners and their institutions and organizations to minimize patient harm, promote
the well-being of patients and health care providers, reduce the likelihood of adverse
events, and communicate safety concerns – while at the same time learning from close
calls and other events. (CPSI, 2004, p.9)
In comparing the two definitions, it can be seen that the definition of the CPSI is
compatible with the earlier expression of safety culture given by ACSNI. If the CPSI definition
differs, it is to the extent that it particularizes the healthcare context. It nonetheless captures the
significance of shared values and attitudes, continuous improvement through learning, and the
importance of communication as a vehicle to achieve a positive safety culture.

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Supervisory leadership
Flin and Yule define “supervisors” in the following passage:
These are the first line managers, called supervisors, foremen, or team leaders in industry.
In health care, these would equate to leaders (at an operational level) of established
groups, such as ward sisters or leaders of more temporary groups such as an operating
theatre team. (2004, p.ii47)
To this definition, they add the dimension of leadership:
Supervisors have primary responsibilities for achieving the task and maintaining the
wellbeing of the team. As they structure, coordinate, and facilitate work activities, both
transactional and transformational leadership behaviours are very relevant at this level of
management. (Flin & Yule, 2004, p.ii47)
While it is relevant but not central to this thesis, it is useful to note that transactional
leadership is seen as “monitoring and reinforcing workers’ safe behaviours” whereas
transformational leadership is “(b)eing supportive” and “(e)ncouraging employee engagement in
safety initiatives (Flin & Yule, 2004, p.ii46). Accordingly, from the standpoint of this thesis,
perception of supervisory leadership for safety encompasses that dimension of patient safety
culture evaluation that measures an individual’s view of their direct supervisor’s leadership in
the area of patient safety, without distinction in the type of leadership demonstrated.
Problem and Study Purpose
Patient safety culture assessment results commonly are recorded as outcomes across a
participant population that is generally defined organizationally by, for example, a unit, or
institution. Missing from the literature is a broader analysis that compares results across and
between instruments that are used to assess patient safety culture. As indicated above, the

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perception of supervisory leadership for safety is an important dimension of patient safety
culture survey questionnaires. No studies appear to have been conducted to compare results
across different survey questionnaires to determine whether there are identifiable trends or
characteristics in the data. If they can be found, it is possible that the results in the literature
could serve use as a predictive tool for future surveys.
The purpose of this thesis was to examine reports of nurses’ perceptions of supervisory
leadership in relation to patient safety culture within and across different contexts of care. This
purpose was accomplished by means of a narrative synthesis that isolated data from the literature
on nurses as a participant group to which the patient safety culture instruments are administered
and then examined the results for nurses’ perceptions of supervisory leadership for safety. The
data were analyzed to identify whether there were trends in the data within or among the
instruments used, based on geographic location, type of institution, and nursing practice setting.
The result of this thesis may serve to strengthen the evaluation of the supervisory leadership
aspect of patient safety culture assessment and potentially may inform modification or
improvement to this dimension of patient safety culture and its assessment for the future.
Why is this a significant topic for exploration? Nurses’ perceptions of supervisory
leadership for safety as it is expressed in patient safety culture survey questionnaires has been
chosen based on several factors. Firstly, nurses represent the largest single group within the
larger community of healthcare professionals (Institute of Medicine, 2009, p.123). They are
present across the spectrum of healthcare contexts and practice areas. Secondly, leadership in
safety culture is important “from the boardroom to the frontline” (Sammer, Lykens, Singh,
Mains, & Lackan, 2010, p.157). The perception of “(s)upervisor commitment to safety” or
“supervisor prioritisation of safety” is a critical component (Flin, 2007, p.662). It is known that

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“first-line supervisors will provide the staff's primary point of contact with the management
structure, and therefore, supervisors' behaviour and expression of views will influence the
development of staff's opinions about management and their policies” (Clarke, 1999, p.187). It
has been proposed that “(i)ndividual safe behaviour is ... mainly related to organizational
involvement in safety, according to employees' perceptions” (Oliver, Cheyne, Tomás, & Cox,
2002, p.485). More pointedly, it has been stated that “(i)n the trenches of health care provision,
the issues that work group leaders pay attention to play a critical role in the priorities taken by
providers in their work” (Aarons, Farahnak, Ehrhart, & Sklar, 2014, p.8). This underscores the
importance of perception as it relates to patient safety. Given the link between perception of
supervisory leadership for safety and patient safety in practice, the significance of this indicator
cannot be underestimated.
Project Description, Purpose, and Objectives
This thesis involved a review of previous studies concerning nurses’ perception of
supervisory leadership based on their responses to patient safety culture survey questionnaires.
The purpose was to determine whether there were discernible similarities, differences or trends
across the different studies and whether they can be related to any specific factor, including
which survey questionnaire was used, differences in geographic location, and differences across
institutions or nursing practice settings. It is an important question, the answer to which may
assist in interpreting and evaluating the results of patient safety culture survey questionnaires and
potentially may support the development of strategies to support and improve the perception of
supervisory leadership for safety. Based on research conducted to prepare the thesis proposal, a
systematic review of this question had not been previously been undertaken. However, there was
a sufficient number of patient safety culture studies available that addressed the dimension of

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nurses’ perception of supervisory leadership for safety to allow for meaningful analysis to be
conducted.
This thesis explored the results of patient safety culture survey questionnaires that
recorded nurses’ perceptions of supervisory leadership within and across healthcare practice
settings. It was based primarily on quantitative studies. Qualitative research that met the
inclusion criteria was also retrieved. Irrespective of the design, the studies were evaluated for
their relevance to this thesis and the question of nurses’ perception of supervisory leadership for
safety. Some studies currently exist that examine and compare the results of patient safety
culture survey questionnaires. For example, Ginsberg, Tregunno, Fleming, Flemons, Gilin and
Norton (2008) compared perceptions of patient safety culture in six Canadian organizations. The
present thesis, however, sought to isolate data that addressed solely the safety culture dimension
of nurses’ perceptions of supervisory leadership for safety, and compare results for this
dimension across many studies that used different assessment tools in different of practice
settings. From this, it would be established whether conclusions concerning this dimension were
possible or further investigation was warranted. This analysis would also inform potential
avenues to support or improve nurses’ perceptions of supervisory leadership for safety. This
would add to the growing body of knowledge related to the assessment of patient safety culture
and the dimension of perception of supervisory leadership for safety.
The perception of supervisory leadership for patient safety is an important dimension of
safety culture in healthcare as “lack of leadership has been attributed as a barrier to safety
culture” (Sammer et al., 2010, p.158). The thesis drew data from literature reporting nurses’
responses to questionnaires for measuring their perceptions of supervisory leadership for safety
in the context of patient safety culture. These questionnaires’ results “focus on perceptions of

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what occurs in the daily life of the organization from the perspective of direct patient care
providers and other staff (in this case nurses) who have an impact on patient safety” (Nieva &
Sorra, 2003, p.ii18). While perception might ordinarily be thought to be of a qualitative nature,
by using survey questionnaires it is measured by obtaining numerical responses to standardized
questions. The results are then tabulated and reported as quantitative scores. Where research was
based on qualitative instruments, the perception of participants was recorded as a narrative and
emerging themes were identified.
Chapter Summary
This thesis is organized into five chapters. In Chapter 1, I have introduced the topic of
safety culture and its adoption into healthcare as patient safety culture. The thesis purpose has
been identified and I have stated the project description, purpose and objective, which focus on
identifying existing patient safety culture studies in the literature that assess nurses’ perception of
supervisory leadership for safety and examining the data to determine whether there are
discernible trends. Essential terms have been defined such as patient safety, patient safety culture
and climate, and supervisory leadership. Chapter 2 discusses the importance of supervisory
leadership in patient safety culture. Chapter 3 provides detail of the research design and
methodology. Chapter 4 gives the research results. Chapter 5 provides discussion of the results
and the conclusion of the thesis.

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Chapter Two: Patient Safety Culture and Perception of Supervisory Leadership
This chapter examines safety culture survey questionnaires as a reflection of climate
related to patient safety. Through the administration of these survey questionnaires, strengths and
deficits may be identified and mitigation strategies subsequently developed. As this thesis
examines supervisory leadership for patient safety culture, the discussion below focuses on these
factors.
Supervisory Leadership and its Relationship to Patient Safety Culture
The dimension of patient safety culture that is of interest in this thesis is supervisory
leadership for safety. It is an important aspect of the assessment of patient safety culture as it
reflects the participant’s perception of the prioritization of safety in the healthcare workplace.
Pertinent to the perception of supervisory leadership, and as stated by Flin (2007):
We tend to choose behaviours that will maximise reward and reduce the risk of
punishment. In the workplace, expectations of how supervisors, managers (and peers)
will respond to particular actions (e.g. prioritising safety over production targets) will to a
significant extent determine which behaviours are executed. (p.659)
Why Measure Safety Culture?
Safety culture is regularly measured in high risk industries including healthcare. In this
thesis, data were retrieved from the existing literature showing nurses’ perception of their
supervisory leadership for safety. As one study states, “it is important to investigate RN’s
experiences of their work setting as they are at the ‘sharp end’ of patient care and are an
instrumental part of patient safety work” (Smeds Alenius, Tishelman, Runesdotter, & Lindqvist,
2013, Introduction, para.1). Assessment of safety culture within an institution is commonly
accomplished using a questionnaire that asks participants to respond to a series of questions that

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in general are answered using a Likert scale (Guldenmund, 2007). The aim of patient safety
culture questionnaires is “to provide a metric by which implicit shared understandings about ‘the
way we do things around here’ can be made visible and available as input for change” (Nieva &
Sorra, 2003, p.ii21).
How Safety Culture is Measured
Patient safety culture questionnaires are a convenient tool for obtaining information from
a group of participants. Patient safety culture questionnaires are organized and designed to assess
specific dimensions. Some examples of those dimensions are teamwork, hospital management
support, and supervisory leadership for safety. One author suggests that “...healthcare
professionals are busy people undertaking critical tasks throughout their working day, which
makes it impractical to investigate safety climate using methods that are either complicated, time
consuming or expensive” (Smith, Zhao, Wang, & Ho, 2013, p.156). The administration of
questionnaires addresses this concern by providing a convenient instrument for participants to
complete.
To be precise, while the survey questionnaires conducted are commonly referred to as
patient safety culture surveys, it may be more accurate to consider them as safety climate surveys
(Ginsberg et al., 2014). As described by Flin, “(t)he assessment of the underlying safety culture
is normally conducted by measuring safety climate – namely by surveys of workforce
perceptions of the management of safety and the prioritisation of safety against other
organizational targets” (2007, p.658). Expressed another way, “(s)afety climate is a perceptual
measure that can serve as a window through which culture can be viewed” (Ginsberg et al.,
2014, p.162). Therefore, while it may popularly be considered that the survey questionnaires
evaluate the existing safety culture of an institution, by addressing participants’ perceptions of

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the particular dimensions assessed, they address the safety climate, which is nonetheless an
important aspect of safety culture. The distinction is important. The results may indicate areas of
strength and weakness, or suggest areas of opportunity for reinforcing safety culture, but they do
not definitively evaluate the safety culture of an institution. For some authors, this has been
considered a limitation. It has been noted that “surveys are limited by their methodology and can
only report on attitudes at the time that they are undertaken and perhaps also a little in the past”
(Glendon & Stanton, 2000, p.199). It has also been stated that “a safety climate survey only gives
an inkling of what a particular safety culture might be about” (Guldenmund, 2007, p.724). While
this may be the case, when safety culture survey questionnaires are properly situated and
understood, there can be an appreciation that resulting safety climate data supplies important
information that contributes to an appraisal of the safety culture of the institution from which
participants are drawn.
The Use of Patient Safety Culture Results
The implication of administering a patient safety culture survey is that the results will
require further investigation. The results of a safety culture survey questionnaire are a gateway
for further inquiry rather than a definitive answer to the state of an institutions safety culture. As
aptly stated by Nieva & Sorra, “(r)ather than viewing the assessment results as an end point, the
information should be considered the starting point from which action and patient safety changes
emerge” (2003, p.ii21). Further, it has been suggested that “(t)he deeper aspects of culture in
terms of underlying values, beliefs, and norms within an organization may be inadequately
captured with self-report quantitative instruments” (p.ii22). How, then, can safety culture survey
questionnaire results be usefully employed as a catalyst for sustainable change and
improvement? If the patient safety culture survey questionnaire results are only a starting point,

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it may be useful to clarify the results before moving forward. The results express the perception
of the participant group quantitatively. Ginsburg et al. suggest that using “quantitative and
qualitative approaches to obtain the breadth and depth of understanding afforded by these two
methods, respectively” (2014, p.162). Nieva and Sorra state that for the results to become useful
in improving institutional patient safety, there must be a means of “developing a shared
organizational understanding of the data” and “identifying the range of potential actions” (2003,
p.ii21). From a practical aspect, this may involve the delivery of “feedback and action planning
sessions” by trained facilitators before determining a precise strategy (p.ii21).
Patient Safety Culture Questionnaires
A number of questionnaires have been used to measure patient safety culture in nursing
care settings. Notable examples include the Hospital Survey on Patient Safety Culture
(HSOPSC), the Safety Attitudes questionnaire short form (SAQ), the Safety Climate Survey, the
Survey on Safety in Nursing Homes, and RN4CAST. They are described below.
Hospital Survey on Patient Safety Culture
The HSOPSC is a standardized instrument, available online, free of charge, selfadministered by participants, and supported by user guides to assist researchers in administering
the survey and interpreting the results (AHRQ, 2016b). It has been determined to be
“psychometrically sound” (Sorra & Dyer, 2010, Conclusions para. 1). The HSOPSC consists of
42 questions to assess 12 dimensions of patient safety culture and it includes four statements to
assess the dimension of interest to this thesis. In the HSOPSC, the dimension is entitled
“Supervisor/Manager Expectations and Actions Promoting Patient Safety”. Participants’
responses to the four statements assessing this dimension are given on a five-point Likert scale

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
24
that ranges from a score of 1 to indicate “strongly disagree” to 5 for “strongly agree.” (AHRQ,
2016a). The statements are given in Table 1.
Table 1
Hospital Survey on Patient Safety Culture
Supervisor/Manager Expectations and Actions Promoting Patient Safety
B1.

My supervisor/manager says a good word when he/she sees a job done according to
established patient safety procedures.

B2.

My supervisor/manager seriously considers staff suggestions for improving patient
safety.

B3.

Whenever pressure builds up, my supervisor/manager wants us to work faster, even
if it means taking shortcuts.

B4.

My supervisor/manager overlooks patient safety problems that happen over and
over.

(AHRQ, 2016a)

Statements B3 and B4 are reverse coded when the results are calculated. Scores of 4 or 5
on the Likert scale are considered positive for the purpose of scoring (Sorra, Gray, Streagle,
Famolaro, Young, & Behm, 2016, p.30). Often, only the percentage of positive responses (PPR)
is reported. PPR indicates the percentage of respondents who answered 4 or 5 to the statement
(except in the case of those statements that are reverse coded where the PPR is based on the
percentage of respondents who answered 1 or 2).
The HSOPSC provides two additional questions that ask respondents to give an overall
patient safety grade and to state the number of adverse events they have reported in the preceding
year. In addition, the HSOPSC includes questions that define the characteristics of the

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
25
respondent. These are work area or unit, length of employment at this hospital, length of
employment in work area or unit, working hours per week, position, and length of time working
in the profession or specialty (AHRQ, 2016a). The AHRQ reports that the HSOPSC is in use in
66 countries and has been translated into 31 languages, some of which were seen or referred to in
the studies used in this thesis (2016b).
Safety Attitudes Questionnaire
The Safety Attitudes Questionnaire short form (SAQ) is organized to assess teamwork
climate, safety climate, job satisfaction, stress recognition, perceptions of management at unit
and hospital level, and working conditions (Center for Healthcare Quality & Safety, 2016). The
SAQ is a self-administered questionnaire that is available online and free of charge to users. It
has been determined to have “generally good psychometric properties” (Sexton et al., 2006,
“Limitations,” para.1). The SAQ comprises 36 statements to measure six dimensions. Five of
those statements address “Perception of Management.” They are shown in Table 2.
Table 2
Safety Attitudes Questionnaire Perception of Management
24.

Management supports my daily efforts.

25.

Management doesn’t knowingly compromise patient safety.

26.

Management is doing a good job.

27.

Problem personnel are dealt with constructively by our (unit management).

28.

I get adequate, timely info about events that might affect my work, from (unit
management).

(Center for Healthcare Quality & Safety, 2016)

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
26
Participants provide two responses to each of these statements, one for unit management
and one for hospital management. The score for unit management corresponds to the dimension
of interest in this thesis. As with the HSOPSC, participants in the SAQ answer on a five-point
Likert scale ranging from 1 to indicate “strongly disagree” to 5 for “strongly agree.” Scoring
instructions for the SAQ indicate the method for the calculation and the conversion to a
percentage score for the measured dimensions, based on participants’ responses and reverse
scoring for negatively worded questions (Centre for Healthcare Quality & Safety, 2016).
Other instruments
The Safety Climate Survey (SCS) includes one statement that falls within the dimension
of nurses’ perceptions of supervisory leadership for patient safety. The statement is “The
physician and nurse leaders in my clinic area listen to me and care about my concerns”
(Almutairi, 2013, p.191; Di Benedetto, 2011, p.606). Responses are given on a five point Likert
scale where 1 indicates “strongly disagree” and 5 indicates “strongly agree” (Almutairi, 2013,
p.191).
The Survey on Resident Safety in Nursing Homes (SRS) comprises 53 statements that are
rated by participants on a 5 point Likert scale ranging from 1 for “strongly disagree” to 5 for
“strongly agree” (Singer, 2012, p.105). For the purpose of this thesis, three of the statements are
considered to bear a relationship to supervisory leadership for safety.
Table 3
Survey on Resident Safety in Nursing Homes Perception of Unit Management
Supervisor listens

Management in my unit (my managers and supervisors) listens to
CNAs (clinical nurse assistants).

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
27
Management in my unit (my managers and supervisors) listens to staff
ideas and suggestions about resident safety.
Supervisor

Management in my unit (my managers and supervisors) does not

priorities

knowingly compromise the safety of patients.

(Singer, 2012,
p.109)

The RN4CAST has been used in conjunction with aspects of the HSOPSC. The
RN4CAST was developed to provide an alternate to historic methods of human resources
planning. It provides a scientific basis for nursing workforce planning and forecasting and for
altering the focus from “simple projections in demand and supply of labour to impact on patient
safety and quality” (Sermeus et al., 2011, Discussion, Policy and scientific impact of the project,
para. 1).
Chapter Summary
In this chapter, I have reviewed the importance of supervisory leadership in patient safety
culture. Supervisory leadership for safety is one dimension of the assessment of safety culture. It
is a significant workplace influence on the perception of safety culture. I have also discussed
how patient safety culture is measured and the use that is made of the results of patient safety
culture questionnaires. A description of the HSOPSC, SAQ, and other data collection
instruments used in the included studies has been provided.

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
28
Chapter Three: Research Method, Design, and Procedures
The following chapter discusses the thesis methodology. Data collection, literature
review and search, inclusion and exclusion criteria are examined below. A detailed explanation
is given so that one may clearly understand how the findings were uncovered and this method
can be readily replicated. The purpose of the analysis was to “explore the relationships between
the individual studies” and assess what they reveal about perceptions of supervisory leadership in
relation to patient safety culture within and across different contexts of care the similarities and
differences across studies of nurses’ perceptions of supervisory leadership for safety (Pope,
Mays, & Popay, 2007, p.81). This exploration was used to demonstrate whether there are
similarities and differences in the data such that trends may be identified that are relevant to the
question asked in this thesis.
Method of Analysis
The thesis used the approach of narrative synthesis for the analysis of data. Narrative
synthesis “refers to an approach to the systematic review and synthesis of findings from multiple
studies that relies primarily on the use of words and text to summarise and explain the findings
of the synthesis” (Popay et al., 2006, p.5). Narrative synthesis was chosen because it is suited to
a project using both quantitative and qualitative studies and the individual survey questionnaires
used in those studies. Pope, Mays and Popay (2007) noted that the product of the synthesis
governs the approach undertaken. For example, the realist synthesis approach may result in “the
production of new knowledge and/or theory through a process of integration and/or reinterpretation of the original studies” (p.95). Alternatively, the narrative synthesis approach
“stops short of the formal integration or re-interpretation of different evidence sources, aiming
rather to juxtapose findings from multiple sources and highlight key messages from a body of

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
29
literature” (p.95). The purpose of this thesis more appropriately fits the latter statement and the
outcome may inform further avenues of research beyond the scope of this thesis. The narrative
synthesis approach is often used as the initial step in undertaking a systematic review. Other
methods of analysis, such as statistical analysis, may be employed if, as the narrative synthesis
progresses, they become relevant to answering the question posed by this thesis.
Literature Search and Screening
The foundation of this thesis is an analysis of the literature that addresses the patient
safety culture dimension of nurses’ perceptions of supervisory leadership for safety. Literature
searches were conducted using PubMed, CINAHL Complete, and Web of Science databases.
The search terms were “nurs*”, “patient safety culture”, and “survey.” The use of a wildcard “*”
was selected to generate results that included alternate terms such as “nursing”, “nurse”, or
“nurses.”
Identical search terms were used for each of the three databases. Results were limited to
the period of 2011 to 2016 as it was considered that this was sufficient to ensure that the
literature reflected current and recent results. It was expected that it would also yield a number of
results that was manageable and suitable for addressing the question. Initial screening of the
search results was conducted on the basis of the title of the article. Where necessary, the abstract
was also reviewed. Only full-text articles available in English were considered. Articles were
included in subsequent screening if the title and, where necessary, the abstract indicated that the
article would contain information addressing the question of nurses’ perceptions of supervisory
leadership in a patient safety context. Articles were sorted according to the database in which
they had been found. Using Microsoft Excel, a spreadsheet entry was made for each study. The
spreadsheet was organized alphabetically based on the surname of the lead author. Entries

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
30
recorded the database, assessment instrument used, whether the article measured patient safety
culture, whether the article contained data from nurses, whether that data included nurses’
perceptions of supervisory leadership for safety, the area of practice, and the geographic location
where the study was conducted. The results of the database searches and screening are shown in
Table 4.
Table 4
Results of literature search and screening
Database

Search Results

Selected for full
text screening

PubMed

197

38

CINAHL Complete

54

22

Web of Science

165

52

Total articles included

416

112*

for subsequent full-text

* Includes 5

screening

duplicate studies

Inclusion and Exclusion
After initial screening, the remaining articles were reviewed for inclusion and exclusion.
Articles were sorted into Microsoft Excel spreadsheets based on the instrument that had been
used to assess patient safety culture. Three separate spreadsheets were created, one each for
HSOPSC, SAQ, and other instruments. Articles were included if they reported frontline nurses’
perceptions of supervisory leadership for safety in the context of patient safety culture.
Conversely, if an article addressed an issue other than patient safety culture such as safety in

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
31
general, preventive safety interventions, or occupational health and did not report on perceptions
of supervisory leadership, it was excluded. In cases where an article reported on patient safety
culture and did not report results specific to nurses’ perceptions of supervisory leadership or
reported only an aggregate score for all professions, it was excluded. Studies aimed at validating
a patient safety survey questionnaire were included if they met the inclusion criteria provided the
study supported a conclusion that the survey questionnaire was a valid and reliable instrument.
To limit leadership to supervisory leadership for safety, articles were only included where they
reported on unit level hierarchical leadership. Therefore, where an article assessed leadership
among peers or at a level higher than the unit such as hospital management, it was excluded.
Where duplicate articles were found after the inclusion and exclusion criteria were applied, the
article was considered only once in the analysis. The searches were repeated October 30, 2016 to
ensure that they were up to date. Alerts in PubMed and Web of Science did not generate
additional studies subsequent to October 30, 2016 that met inclusion criteria. From the total of 40
articles identified for inclusion, five duplicate copies of studies were removed. This reduced the
number of articles included in this thesis to 35. An overview of the search, screening and
inclusion/exclusion process is shown in Figure 1 below.

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
32

Literature searches: 416 articles identified
PubMed, CINAHL Complete, Web of Science databases
Search terms: nurs*, patient safety culture, survey
Limited to 2011-2016, English language, peer-reviewed, full text,
English language

Screening: 112 articles included for subsequent full-text screening,
304 articles excluded
Screening based on title and abstract, articles suggesting dimension
of nurses' perception of supervisory leadership for safety assessed.

Inclusion and exclusion criteria applied: 35 articles included, 77
articles excluded
Full text review. Included if article reported data specific to front-line
nurses' perception of unit-level supervisory leadership for safety.
Excluded where this dimension was absent or where data reported
as an aggregate score for healthcare professions and not
differentiated for front-line nurses. 5 articles were duplicates and
were therefore excluded.

Figure 1: Diagram illustrating search, screening and inclusion/exclusion process
Data Extraction
The purpose of this thesis was to examine reports of nurses’ perceptions of supervisory
leadership in relation to patient safety culture within and across different contexts of care, to
determine whether there were discernible similarities, differences or trends across different
studies. It would also examine whether the results could be related to any specific factor,
including which survey questionnaire was used, differences in geographic location, and
differences across institutions or nursing practice settings. To accomplish this, data extracted
from each selected study were categorized and recorded in Microsoft Excel. Articles that were
included for full-text screening were sorted according to the database in which they had been

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
33
found. The full text of each screened-in study was read and an entry was made in the spreadsheet
for each study. The spreadsheet was organized alphabetically based on the surname of the lead
author. Entries recorded the database, instrument used, whether the article measured patient
safety culture, whether it contained data from nurses, whether that data included perceptions of
supervisory leadership for safety, the area of practice, and the geographic location where the
study was conducted. Only those articles that contained data recording nurses’ perceptions of
supervisory leadership for safety in the context of patient safety culture were included.
Studies that met inclusion criteria were then sorted in Microsoft Excel spreadsheets
according to the patient safety culture assessment tool that was used in the study. Data were
extracted to show the size of the participant group, the result for the perceptions of supervisory
leadership for safety, the result for individual questions or statements to which participants
responded if it was given in the study, and other pertinent information recorded by the authors
such as contextual influences on the study outcomes or limitations on the conclusions. This
allowed the characteristics of the included studies to be examined, and “patterns across the
studies” to be described.
Quality Assessment
Every included study was evaluated for quality using the QualSyst assessment tool
developed by Kmet, Lee, and Cook (2004). Quality is defined by Kmet et al. “in terms of the
internal validity of the studies, or the extent to which the design, conduct and analyses
minimized errors and biases” (p.2). The QualSyst tool, consisting of two questionnaires to be
used based on either a qualitative or quantitative study, was employed to assess quality for every
study used in this thesis. QualSyst was chosen as it was developed by the authors to provide
“standard criteria for simultaneously assessing the quality of diverse study designs” (p.2).

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
34
Extrapolating from “existing published tools, relying particularly upon the instruments
developed by Cho et al. (1994) and Timmer et al. (2003) for quantitative studies, and the
guidelines suggested by Mays and Pope (2000) and Popay et al. (1998) for qualitative studies,”
Kmet et al. developed a “pragmatic systematic review tool” in the form of the QualSyst
questionnaires for qualitative and quantitative studies (p.3). Accordingly, QualSyst was selected
for its versatility in application to the studies relied on in this thesis. The manuals and checklists
created by Kmet et al. are provided in Appendices D through G.
After evaluating the studies for quality, the QualSyst score was converted to a
percentage. Quality alone was not used to exclude studies from this thesis as “all studies have
weaknesses – the question is whether they matter and how much in the circumstances of the
review” (Pope, Mays, & Popay, 2007, p.32). Accordingly, a study that might have been
considered to be of low quality could be included and noted as such if it contained information
that was relevant to this systematic review although the results may not have been considered to
have as much weight as studies of higher quality (Mays, Pope, & Popay, 2005).
Ethical Considerations
This thesis was a systematic review of existing print and electronic publications that are
legally and publicly available. There were no living human subjects or human biological
materials involved. In the studies that were used, participants are not identified individually.
They are anonymous. Their responses were amalgamated and the data was reported as such. The
reports were directed at healthcare work settings and not at any specific cultural group although
in some reported results, researchers questioned the influence of culture on participant responses
and survey questionnaire outcomes. No grants or sponsorships were received to perform this
research study. As such, this thesis falls within the exemptions from ethical review (Canadian

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
35
Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada,
and Social Sciences and Humanities Research Council of Canada, 2014, p.15). Therefore,
Research Ethics Board approval is not required.
Chapter Summary
In this chapter I have discussed the methodology used in this thesis. I have described the
choice of narrative review and outlined the method of data collection using a literature search. I
have included a description of the inclusion and exclusion criteria and the results. A listing of the
included articles and their relevant features has been provided in Appendices A, B, and C. The
use of the QualSyst instrument for quality assessment of the included studies has been described.
I have provided details of the choice of narrative review to analyze the data extracted from the
studies. Ethical considerations were discussed and it was stated that this thesis falls within the
exemptions from ethical review.

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
36
Chapter Four: Findings
Introduction
The purpose of this thesis was to examine reports of nurses’ perceptions of supervisory
leadership in relation to patient safety culture within and across different contexts of care, to
determine whether there were discernible similarities, differences or trends across different
studies and whether they can be related to any specific factor, including which survey
questionnaire was used, differences in geographic location, and differences across institutions or
nursing practice settings. The thesis is based on the results of a systematic literature search,
which are set out in this chapter. The results are organized to first provide a general description
of the studies that were included, including the type and quality of study, the survey
questionnaire used and the geographic location of the study. Next, the results pertaining to each
survey questionnaire are organized by geographic region and the results are discussed. This is
followed by a summary of the results pertaining to nurses’ perceptions of supervisory leadership
as reported in the studies, and a conclusion.
Description of the Included Studies
Thirty-five studies were included in this thesis. The studies that met the inclusion criteria
are summarized in Appendices A, B, and C, which show the HSOPSC studies, SAQ studies, and
studies that used other instruments. Twenty-four studies used the HSOPSC questionnaire, six
studies used the SAQ, and five used other instruments. Of these latter five, two used the SCS,
one used the SRS, one used the HSOPSC in combination with the RN4CAST, and one study was
qualitative. The tables shown in Appendices A to C were useful for exploring “relationships in
the data,” and assessing whether conclusions could be drawn from the data relative to nurses’
perceptions of supervisory leadership for safety (Popay et al., 2006, p.12).

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
37
The included studies were evaluated for quality using the QualSyst instruments for
evaluating quality. A summary of the QualSyst scores for quality of the included articles is found
at Appendix H. As a rule, the included studies indicated a high degree of quality. The quality
scores are summarized in Appendix H. From the 35 studies that were included, 30 received a
quality score of 100% based on the QualSyst instrument for evaluating quality, two studies
received a score of 95%, one study received a score of 91%, one received a score of 85% and
one received a score of 80%. The lowest score of 80% was given to the study of Nie et al. (2013)
based on the manner in which the results were presented. Although a range of quality scores was
awarded to the studies, all of the studies were included irrespective of the QualSyst score.
Geographically, the study populations were widely dispersed, with some concentration of
studies in the Middle East and in Europe. The Middle Eastern countries of Egypt, Iran, Jordan,
Saudi Arabia, and Turkey accounted for 13 of the included studies. The European countries of
Albania, Croatia, Cyprus, Finland, Italy, Norway, and Sweden accounted for a further 13 studies.
Four studies emanated from Asia, specifically China and South Korea. Three studies were
conducted in the United States and one study was conducted in Brazil. One multinational study
with participants in Turkey, Japan, and the United States, was also included.
Hospitals were the practice setting for twenty-four of the included studies. As described,
multiple units within hospitals were surveyed. Only Ahmed et al. (2011) reported results for
nurses working in different practice areas within the hospital. ICUs were the subject of five
studies. Dialysis and nephrology were surveyed in three studies. Nursing homes, emergency and
the operating room were each the subject of one study.
Participants provided information concerning their characteristics in all of the studies that
were reviewed and it was reported. However, it was not often used in the analysis of data.

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
38
Practice areas were described with inconsistent levels of detail. Only Khater et al. (2015)
reported a multivariate regression analysis to determine the influence of years of experience,
practice area, age, weekly hours worked, and worksite on participants’ responses.
Data Collection Instruments
Two self-administered patient safety culture survey questionnaires predominate in the
studies included in this thesis. The HSOPSC appeared twenty-four times in the included studies
and the SAQ was used in six studies. Their wide use may be explained by their availability
online free of charge. Two studies used the SCS, one study used the RN4CAST, one study used
the SRS created by the authors to survey patient safety culture in nursing homes, and one study
used semi-structured interviews. All of these studies address nurses’ perceptions of leadership
for safety in the context of patient safety culture. The included studies were placed in three
groups based on the primary survey questionnaire used, whether HSOPSC, SAQ, or another
instrument. They are shown in Appendices A, B, and C.
Study Data: Hospital Survey on Patient Safety Culture
Twenty-four studies using the HSOPSC were included in this thesis. The studies are
organized below according to the geographic region in which the study was conducted. The
regions are the Middle East, the Far East, Europe and the United States.
Middle Eastern studies
The HSOPSC studies in this thesis included 10 articles from Middle Eastern countries.
Aboul-Fotouh et al. (2012) conducted a study of patient safety culture by using the HSOPSC in
medical, surgical, ICU, and paramedical departments in a university hospital in Egypt. The
participant group included nurses and other healthcare professionals. The study shows that
demographic and workplace information was collected from all participants. A result of 42.4%

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
39
positive responses (PPR), indicating the percentage of respondents who answered with a positive
score of 4 or 5 on the Likert scale, or 1 or 2 on those questions that are reverse coded, was given
for nurses’ perceptions of supervisor/manager expectations and actions promoting safety.
However, this result is not broken down by profession for individual practice areas. One of the
major findings of this study was that the hospital had a strong “learning culture” (p.375) and the
authors related this to disclosure of errors in the healthcare setting and corresponding opportunity
for knowledge creation. The authors expressed the limitation that this was a study limited to one
hospital with unique properties of a university setting.
Ahmed et al. (2011) studied patient safety culture at medical and pediatric university
hospitals in Egypt with the objective of developing an improvement plan. Two specific research
questions were “Are there any differences between nurses working in critical care units and
nurses working in general wards regarding their perceptions of patient safety culture?” and “Are
there any differences between staff nurses and head nurses regarding their perceptions of patient
safety culture?” (p.55). PPR for supervisor/manager expectations and actions promoting safety
was 28.9% for critical care nurses and 24.3% for general ward nurses. The authors suggest that
greater supervision is required in critical care, which this may account for the difference in
perception between the two staff nurse groups. PPR scores based on the responses by head
nurses were generally higher relative to those based on responses by staff nurses for patient
safety culture dimensions. In the case of supervisor/manager expectations and actions promoting
safety, head nurses had a PPR of 32.1%. The authors recommended supporting head nurses to
“establish non-punitive environment as well as a Teamwork spirit” (p.62).
Al-Awa et al. (2012) conducted a study to evaluate patient safety culture after a
university hospital in Saudi Arabia participated in a Canadian accreditation process. Survey

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
40
information was collected from 605 nurses and data were reported for each of the HSOPSC
questions addressing the dimension of supervisor/manager expectations and actions promoting
patient safety. The PPR for this dimension was 51%, and for the individual questions 58% for
B1, 61% for B2, B3 52% for B3, and 33% for B4 (see questions in Table 1, Chapter 2). These
scores indicate the number of nurses who gave a positive score of 4 or 5 (1 or 2 for the reverse
coded questions) for the questions addressing supervisor/manager expectations and actions
promoting patient safety. The authors state that hospital accreditation had a “positive impact” on
perception of patient safety culture (p.150). The influence of the presence of eight different
cultural backgrounds in the workplace is noted as an influence. The authors suggest that although
there are few Saudi Arabian nurses in the study group, “they might have a considerable effect on
the outcome of the study as they are deeply rooted in the local society and, consequently, might
have exerted dominant cultural effects” (p.148).
Al-Mandhari et al. (2014) conducted a study of healthcare workers at five government
hospitals in Oman using the HSOPSC. The HSOPSC was selected for the study based on
“culture free credentials” shown in prior use in Arabic speaking settings (p.269). The study
population included 237 nurses. Study results were compared to the United States, Lebanon, and
Taiwan because they were “socio-culturally different” from Oman (p.265). Although this study
does not provide a dimension score for nurses, the authors state that there were no significant
differences among professions (p.266). Based on this statement and as nurses were 237 of the
total of 390 participants, the study was included. The study result of 60% PPR for
supervisor/manager expectations and actions promoting patient safety was accepted for
inclusion. The authors note that paternalistic Omani management style and differences in cultural
backgrounds may influence participants’ perceptions of patient safety culture (p.268).

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
41
Ammouri et al. (2014) used the HSOPSC to investigate patient safety culture in four
government hospitals in Oman. The study population was 414 nurses and the PPR result for
supervisor/manager expectations and actions promoting patient safety was 60%. The authors
noted that a higher score in this dimension was related to nurses assigning a higher overall score
to their perception of patient safety (p.4).
Bahrami et al. (2014) conducted a study of 340 nurses using the HSOPSC to assess
patient safety culture at two educational hospitals in Iran. The nurses were employed in various
units and the results are recorded as mean scores and are given according to unit. These scores
are shown in Table 5. The authors note that based on this study, the perception of patient safety
culture in Iran is low. They recognize that this is a baseline study limited to one point in time. As
a result, the effect of any efforts to improve patient safety culture is not assessed. The authors
encourage longitudinal studies to evaluate changes in patient safety culture.
Table 5
Mean Scores for Supervisor/Manager Expectations and Actions Promoting Safety
Hospital unit

Mean score* and standard deviation (SD)

Internal

2.77 (SD = 0.78)

Surgery

2.38 (SD = 0.72)

Obstetrics and gynecology

3.09 (SD = 0.65)

Pediatrics

2.3

(SD = 0.63)

Mental health

2.0

(SD = 0.72)

Intensive care

2.5

(SD = 0.50)

Emergency

2.81 (SD = 0.56)

Laboratory

3.0

(SD = 0.25)

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
42
Radiology

3.75 (SD = 0.00)

Other

2.3 (SD = 0.68)

(Bahrami et al, 2014, p. 6)
Note: * The mean score is based on the 5 point Likert scale and a score of 4 or 5 is considered
positive.

The authors also reported the PPR for four hospital sites used in their study. In this study,
the scores achieved for this dimension ranged from 36.12% to 42.17% for three hospitals in
2012, and 70% for a hospital in 2008 (Bahrami et al., 2014, p.4). According to the AHRQ, the
benchmark score indicating a positive safety culture for this dimension is 75%, which would
indicate that 75% of participants responded with a 4 or 5 on the Likert scale (1 or 2 for reverse
coded items) (p.4).
Gunes et al. (2016) conducted a study of 554 nurses working in three public hospitals and
one university hospital in Turkey. The units were indicated as medical, surgical, ICU, and
emergency. The PPR for supervisor/manager expectations and actions promoting safety was
reported in the ICU as 59.8%, in ‘general’ as 45.2%, and in surgical as 40.9%. No score was
reported for emergency and general was assumed to be the authors’ use of an alternate term for
medical. The authors acknowledge two limitations. The first is that the study population was
limited to nurses and is not generalizable to other healthcare professions and the second is that
recently graduated nurses with fewer than six months experience were excluded based on their
limited experience. In general, this study shows that there is a low positive perception of this
dimension and patient safety culture in general.
Khater et al. (2015) conducted a study in Jordan of 658 nurses employed in 21
government, private, and university hospitals to assess nurses’ perceptions of patient safety

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43
culture and factors influencing it. The score for supervisor/manager expectations and actions
promoting patient safety was 57.95%. For the individual questions on the HSOPSC that address
this dimension, the scores were 52.10% for B1, 54.60% for B2, 51.40% for B3, and 73.70% for
B4. It was not stated whether questions B3 and B4 were reverse scored as required and this
affects the reliability of the results for this dimension. Of note, the authors performed a
multivariate regression analysis to examine the influence of participant characteristics on the
dependent variable of nurses’ perceptions of patient safety culture. The characteristics included
years of experience, practice area, age, weekly hours worked, and whether the participant
worked in a government hospital or university hospital. All of these factors were stated to
influence participants’ responses although the authors did not state any finding specific to the
dimension of interest, namely supervisory leadership (p.86). The authors express the opinion that
nurses must exert leadership at the bedside, unit, and hospital management levels and that a
blame free environment is conducive to a positive patient safety culture.
Saleh et al. (2015) conducted a study in Jordan involving 242 nurses in 5 hospitals and
using the HSOPSC. For supervisor/manager expectations and actions promoting patient safety a
PPR of 43.3% was reported. Results were also given for the HSOPSC questions: 44.20% for B1,
41.3% for B2, 45% for B3, and 42.60% for B4. The result for this dimension was shown to be
related to overall patient safety perception. The authors note that a blame free, non-punitive work
environment removes barriers to error prevention and improves patient safety.
Ugurluoglu et al. (2012) conducted a study of healthcare professionals at a hospital in
Turkey using the HSOPSC. Nurses constituted 39 of the total of 108 participants. Nurses’
perceptions of supervisor/manager expectations and actions promoting patient safety was 60.9%
PPR. Individual HSOPSC question data was not given and although participant characteristics

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44
were gathered, they were not related to responses other than noting, with respect to the
dimension of interest, that nurses responded more positively than doctors did (p.466). The
authors state that this study is limited in its application as it surveyed only one hospital.
Yilmaz and Goris (2015) conducted a study of 316 nurses in Turkey using the HSOPSC.
They compared the responses of two groups of nurses working at intensive care units at two
hospitals, nurses who had received in-service patient safety training in hand-offs and transitions
as well as frequency of events reported, and those who had not received this training (p.599). A
Mann-Whitney test was used to analyze the data between the trained and untrained groups and
revealed that trained nurses performed higher than untrained nurses on those dimensions for
which training had been given (pp. 59-600). The authors argue for increased patient safety
training and more frequent assessments of patient safety culture. This study provides an
assessment of the impact of an intervention on perceptions of patient safety culture.
Far Eastern studies
Feng et al. (2011) conducted a study at a university hospital in China using the HSOPSC.
The participants were 228 staff nurses and 20 nurse managers. They also used a survey
questionnaire to assess perceptions of managers’ commitment to safety and they collected
demographic information from participants. The Managers’ Commitment to Safety scale is a 10
point scale and the mean score and standard deviation (SD) given by staff nurses was 8.32 (SD =
1.26). The mean of the nurse managers’ scores was 8.85 (SD = 0.69). Concerning the HSOPSC
dimension of supervisor/manager expectations and actions promoting patient safety, a score was
not given, but the authors stated that “safety commitment from management was closely related
to the culture of patient safety and was a significant predictor of patient safety culture” (p.254).

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45
Nie et al. (2013) conducted a study of 32 hospitals in 15 cities in China to assess the
perception of patient safety culture and describe factors that influence it in Chinese healthcare.
Nurses comprised 722 of 1160 participants. The study used 10 of the 12 HSOPSC dimensions.
Results are reported as number of positive responses. For the dimension of supervisor/manager
expectations and actions promoting patient safety, nurses’ positive responses are reported by the
authors in whole numbers and percentage conversions are provided here in parentheses: 540
(74.8%) for B1, 458 (63.4%) for B3, 559 (77.4%) for B4. Question B1 was incorrectly numbered
in the study as B2. The study shows no data for HSOPSC question B2. No overall score for
nurses for the dimension of supervisor/manager expectations and actions promoting patient
safety is given. The study shows generally a positive attitude toward patient safety culture.
Wang et al. (2014) conducted a study in seven Chinese hospitals using the HSOPSC. The
study focused on nurses’ perceptions of patient safety culture and adverse events. From each
hospital, they selected a medical unit, surgical unit, ICU unit, and emergency department. The
PPR for the dimension of interest was 73.8%. The mean score was 3.81 (SD = 0.52). The authors
expressed several limitations. They noted the sample bias and suggested that this study could not
be generalized to the entire nurse population of the area. They also suggested “a possibility that
unmeasured variables could confound” the survey questionnaire results (p.1121).
European studies
Brborovic et al. (2014) used the HSOPSC in a general hospital in Croatia. The participant
group was 148 nurses and the study explored the relationship between nurse “presenteeism” and
patient safety. Presenteeism reflected the influence of overtime, night shift hours and working
while sick. The practice areas were surgery, pediatrics, obstetrics, psychiatry, anaesthesiology
and ICU. The score for the dimension of supervisor/manager expectations and actions promoting

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46
patient safety was shown on a bar graph. Although no numerical score was given, it appeared to
be 55% PPR. The authors acknowledged that the HSOPSC may not be an effective tool to
explore individual nurse presenteeism as it is intended to measure department or hospital patient
safety culture (p.154).
Ballangrud et al. (2012) used the HSOPSC in 10 ICUs in six hospitals in Norway. In
total 220 nurses responded and for the dimension of supervisor/manager expectations and actions
promoting patient safety the PPR was 73.1%. Through regression analysis, it was found that this
dimension and the HSOPSC dimension of feedback and communication about error were related
to low participant scores for frequency of incident reporting. The authors discussed elements of
supervisory leadership that may improve incident reporting and noted the need for further study.
Concerning organizational culture, the authors noted that “(h)ospitals and type of units may
represent different cultures with specific professions and disciplinary traditions” (p.347). The
data from this study were utilized by Vifladt et al. (2016a) in a study of restructured ICUs. This
study is discussed below.
Vifladt et al. (2016a) are authors of a longitudinal study of ICUs in Norway. The study
uses the HSOPSC to measure changes in patient safety culture in six ICUs from 2008/2009 to
2012/2013. The 2008/2009 baseline data was previously published by Ballangrud, Hedelin, and
Hall-Lord (2012). In 2008/2009, a total of 217 nurses responded to the survey questionnaire and
in 2012/2013 145 nurses responded. By 2012/2013, three of the ICUs had been restructured by
merging general and medical intensive care and three had not been restructured. Using the Likert
scale, the mean scores for the restructured units were 3.92 (SD = 0.58) in 2008/2009 and 3.76
(SD = 0.50) in 2012/2013. The mean scores for ICUs that were not restructured were 3.71 (SD =
0.72) and 4.15 (SD = 0.65) over the same study period. The authors found that HSOPSC unit

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47
level dimensions were “vulnerable to the restructuring” (p.63) and suggested that “increased
stress and additional responsibilities for the manager during the restructuring” were influences on
some of the reduced dimension scores (p.64). This is an important study because it uses the
HSOPSC as an instrument to measure the impact on patient safety culture of an action like
workplace restructuring.
Vifladt et al. (2016b) used the HSOPSC in a study of the relationship between patient
safety culture and the results of the administration of a burnout scale. This study took place in the
structured and non restructured units used in Vifladt et al. (2016a). However, it took place in
2012/2013 and it is not part of a longitudinal study. In total, 143 nurses participated and the
mean score for the dimension of supervisor/manager expectations and actions promoting patient
safety was 3.94 (SD = 0.6). The authors found that “positive safety culture was statistically
significantly correlated with a low score for burnout and a strong sense of coherence” (p.29).
There were no statistically significant differences in burnout and sense of coherence between
restructured and non-restructured ICUs. The authors noted that small sample size as a limitation
of the study (p.33).
Kvist et al. (2013) used the HSOPSC to establish baseline data for four Finnish hospitals
in the context of Magnet accreditation, which, according to the authors, is “the highest
international recognition of nursing excellence” (p.153). The mean score for the dimension of
supervisor/manager expectations and actions promoting patient safety was 3.60 (SD = .80). This
was considered a moderate score (p.160). This study reviews aspects of the Magnet model and
focuses on the importance of developing and assessing transformational leadership in Finnish
hospitals. The authors stated that the response rate was low and may have reflected an absence of
awareness of patient safety culture and transformational leadership (p.162).

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Mantynen et al. (2014) is a study in a Finnish university hospital and it is related to Kvist
et al. (2013). It is a longitudinal study reflecting data from 2008/2009 and 2010/2011. For the
HSOPSC dimension of supervisor/manager expectations and actions promoting patient safety,
the mean score of the 234 nurses surveyed in 2008/2009 was 3.69 (SD = 0.73). In 2010/2011, the
mean score of 512 nurses was 3.68 (SD = 0.74). Two interventions with respect to
transformational leadership occurred prior to the second survey questionnaire. Training was
offered to nurse leaders and a mechanism was established to support nurse leaders with research
and evidence-based learning materials (Mantynen et al., 2014, p.2). The authors noted a
limitation in the manner of selecting and implementing the interventions. The importance of this
study is that it provides data over time and compares the results before and after interventions.
Turunen et al. (2013) surveyed 723 nurses and 109 nurse managers in four Finnish acute
care hospitals using the HSOPSC. The study reports results for supervisor/manager expectations
and actions promoting patient safety by question and does not provide an overall score for the
dimension. For nurses the PPRs were 43% for B1, 69% for B2, 64% for B3, and 70% for B4. For
nurse managers the PPRs were: 56% for B1, 84% for B2, 83% for B3, and 90% for B4. Authors
note that “it is important to narrow the gap” between staff nurse and manager perceptions of
patient safety culture (p.615).
Verbeek-van Noord et al. (2014) used the HSOPSC to study safety culture and compare
physicians and nurses in 33 Dutch emergency departments. Nurse respondents totalled 480 and
the result for supervisor/manager expectations and actions promoting patient safety was a mean
score of 3.5 (SD = 0.68). There was little discussion of this dimension score. The study noted
that patient safety culture scores differ among countries and recommended further research to
inquire into these dissimilarities (p.68). The authors used a multivariate analysis to show that

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49
other dimensions of the HSOPSC – teamwork within units, frequency of events reported,
feedback and communication about errors, and learning from errors – are predictors of patient
safety scores (p.68). Limitations are indicated as non-response bias, clustering, and the fact that
this was a survey of one emergency department only.
United States studies
Davis et al. (2016) used a modified HSOPSC to investigate patient safety culture in 55
free standing hemodialysis units in eight states in the United States. The nursing participants
totalled 134 nurses and 47 charge nurses. Participants were asked only questions B1 and B2
pertaining to the dimension of supervisor/manager expectations and actions promoting safety.
The PPR for nurses was 75.0% for B1 and 78.0% for B2, and for charge nurses it was 83% for
B1 and 85% for B2 (p.124). Among the limitations, the authors noted that the results were
limited in their application to the areas where the hemodialysis units were located. They
recommended the use of “safety culture assessments” to identify areas of concern for patient
safety and recommended that the assessments should be used “for quality assurance and
performance improvement” (p.126).
Ulrich and Kear (2014) used a modified HSOPSC and Medical Office Survey of Patient
Safety Culture (AHRQ, 2016c) in a study of 929 nurses and 249 nurse managers working in
hospital and outpatient nephrology in the United States. Two open-ended questions were also
asked and this allowed participants to provide personal comments on patient safety in
nephrology. In the presentation of results, the data are shown in graphs that do not distinguish
responses of nurses from nurse managers. However, the authors note that staff nurses’ ratings
were uniformly lower than those of nurse managers. The limitation in the presentation of the data
does not allow an evaluation of the authors’ analysis. The authors suggest that nephrology nurses

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50
need to engage in patient safety culture assessment in their individual practice settings. To that
end, they have developed a short assessment tool (p.471).
Summary of HSOPSC studies
Based on the results of the literature search that was conducted, the HSOPSC appears to
be the most commonly used patient safety culture survey instrument. The 24 studies that were
included in this thesis were drawn from the Middle East, Far East, Europe, and the United States.
The surveys were predominantly conducted in hospital settings and covered a wide variety of
practice areas. The results for the dimension of interest were varied. The importance of
supervisory leadership in achieving and maintaining a positive patient safety culture was an
evident theme across the studies. A number of studies identified the culture or ethnicity and
gender of the nurse respondents as influences on survey results. A blame free, non punitive
response to error reporting was identified as an important component of patient safety culture.
The studies identified the usefulness of the HSOPSC to measure the effects of change such as
reorganization or educational initiatives on patient safety culture in the healthcare workplace.
SAQ Studies
The Safety Attitudes Questionnaire short form (SAQ) was used in six studies included in
this thesis. The studies are organized below according to the geographic region in which the
study was conducted. The regions are the Middle East, Europe, and Brazil.
Middle Eastern studies
Abdi et al. (2015) used the SAQ and semi-structured individual interviews to assess
safety culture which was defined as patient safety and staff well-being (p.334). This study was
conducted in an ICU in an Iranian hospital. A total of 18 nurses responded. In the SAQ,
perception of management is divided into unit management and hospital management. This

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51
breakdown is not reflected in the results of this study, which show only a mean score for the
perception of management of 69.5% (SD = 12.2). This is less than the benchmark score of 75%
that would indicate a positive patient safety culture with respect to the perception of management
dimension. The semi-structured interviews that were also conducted with nurses supplemented
these scores by illustrating aspects of perception of unit level management. For example, one
nurse responded that nurses’ adherence to procedures was never confirmed by supervisors. The
nurse stated, “Without adequate supervision, you can not expect the nurses to follow all the rules
and regulations” (p.340). The semi-structured interviews revealed differences in the perception
of physicians and nurses. For example, in the area of teamwork, physicians believed they had a
good working relationship with nurses. On the other hand, nurses perceived a good relationship
with other nurses and less so with physicians and attending physicians. Another theme that
emerged from the qualitative results is that when reporting errors, nurses preferred “to report the
incidents informally to the head nurse” and some “were not willing to report errors committed by
their colleagues” (p.340). These responses suggest that the perception of the hierarchy within the
hospital is an influence on patient safety culture and unit level management plays a critical role.
The closer that supervisors are to direct-care nurses, the greater their potential to contribute to a
positive patient safety culture. The study demonstrates that supplementing a survey questionnaire
with qualitative interviews may reveal responses that enhance the survey questionnaire results.
This may provide a more complete picture of the state of patient safety culture.
Zakari (2011) administered a survey questionnaire to 203 nurses and 18 nurse managers
in ambulatory care in a hospital in Saudi Arabia using the SAQ. A limitation of this study is that
it does not provide a breakdown in the scores for nurses and nurse managers or hospital
management and unit management (p.234). The score for the dimension of perception of

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52
management was 20% PPR and a mean score of 63% (SD = 12.7). However, in a statistical
analysis the author found significant differences in the responses of nurses and nurse managers.
It was indicated that “perception of management dimension attitudes was higher among nurse
managers than registered nurses” (p.234). One of the recommendations of this study is that “to
improve safety culture, nurse leaders must include interventions aimed at breaking down barriers
between managers and nursing staff” (p.235). Zakari acknowledged that the nurse employees in
Saudi Arabia represent diverse cultural backgrounds and suggested further qualitative research to
explore whether this is an influence on patient safety culture (p.236).
European studies
Gabrani et al. (2015) conducted a study in four regional hospitals in Albania using the
SAQ. Nurses totalled 132 of the participants in the study. The authors did not distinguish
hospital management and unit level management in the data and indicated 44.8% (SD = 13.1)
was the mean score for perception of management among nurses. They noted that the survey
questionnaire results were intended as a “baseline” for further investigation (p.8) and suggested
that Albanian organizational culture may be an influence on patient safety culture (p.7).
Haerkens et al. (2016) conducted a study in teaching hospitals in the Netherlands to
validate the Dutch version of the SAQ. The study provided baseline information prior to
implementing Crew Resource Management training in select units (p.2-3). The responses of 623
nurses were received. The result was expressed as the mean score of all responses on the five
point Likert scale rather than as a percentage. This result was given as 2.89 (SD = 0.6) for
perception of management (p.5). The study did not distinguish unit and hospital level
management. The study validated the translation and use of the Dutch language version of the

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53
SAQ. A limitation on this study may be that the surveyed units were already enrolled to take
Crew Resource Management training.
Nguyen et al. (2015) conducted a study in two Italian hospitals to validate the Italian
language version of the SAQ. As a validation study, it provided baseline data on patient safety
culture in those hospitals. The nurses participating in the study totalled 134 and the response for
perception of management was 49.3% PPR (SD = 25.0). The authors noted a number of missing
responses to questions dealing with perception of management at the hospital and unit level.
They suggest that this may be due to a hierarchical organizational culture that contributed to a
“code of silence” (p.6).
Brazilian study
Carvalho et al. (2015) administered a survey questionnaire to healthcare professionals
working in the operating room of a hospital. They used the SAQ. This hospital was undergoing
an accreditation review. Nurses totalled 13 of the respondents and their mean score for
perception of management was 63.4% for unit management as compared with 46.9% for hospital
management. The authors commented on a “detachment” from management (p.1047). They
noted that 75% is the desired score according to international standards (p.1045).
Summary of SAQ studies
The six included studies used the SAQ in the Middle East, Europe, and Brazil. All of the
surveys were conducted in hospital settings. The results were varied and their usefulness for the
purpose of this thesis was limited in some cases by the manner of reporting the results. Four of
the six surveys were conducted to provide baseline data concerning patient safety culture in the
workplace and one involved an accreditation process. Two of these also involved validation of
the SAQ in a language other than English. The small sample size of one study limited its

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54
usefulness and one study reported results without differentiating the responses of nurses and
nurse managers. Culture was identified as a factor in studies from the Middle East and it was
suggested that further research was required to determine whether it was an influence on patient
safety culture. Studies from Albania and Italy referred to workplace hierarchical culture as a
factor.
Other Instruments
Five studies that were included in this thesis used instruments other than the HSOPSC or
SAQ. The Safety Climate Survey (SCS) was used in two studies. One study developed and used
a Survey on Resident Safety in Nursing Homes (SRS) (Singer, 2012). The RN4CAST was used
in one study in conjunction with aspects of the HSOPSC. One study used a qualitative method.
These studies are organized below according to the geographic region where the study was
conducted, in this case the Middle East and Europe.
Middle Eastern study
Almutairi et al. (2013) conducted a study of 319 nurses working in a teaching hospital in
Saudi Arabia using the Safety Climate Survey. The survey questionnaire was conducted in
medical, surgical, and gynecological units. The SCS was a precursor to the more detailed SAQ
(Di Benedetto et al, 2011, p.610). The important feature of the results of this study is the focus
on cultural backgrounds and discussion of nationality as an influence on perceptions of patient
safety culture. Noting that many participants did not reveal their ethnicity or nationality, the
authors suggested that the participants “might be disempowered in this multicultural
environment and might not be able to discuss the safety concerns or issues in their clinical
practice” (Almutairi et al., 2013, p.192). For those who did reveal that information, there was a
statistically significant difference among the nationalities (p.191). Deficiencies were found in the

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55
perception of patient safety cultural generally and the authors stated that “education is the tool to
enhance the sense of empowerment for the multicultural nursing workforce” (p.193).
European studies
Danielsson et al. (2014) conducted a qualitative study of nurses and nursing assistants
working in a university hospital and a country hospital in Sweden. Focus groups and individual
interviews were held and management emerged as a theme. The authors noted that the perception
of management is commonly used in established patient safety culture survey questionnaires
(p.7). Participants noted that the behaviour modeled by managers “might undermine the safety
culture among staff” when it does not adhere to established protocols (p.7). Themes of
responsibility and competence were also identified as important elements and they do not appear
in the most common quantitative survey questionnaires. This study supports the benefit of
qualitative data in the assessment of patient safety culture.
Smeds Alenius et al. (2013) also conducted a study in Sweden. The authors surveyed
9236 nurses using the RN4CAST and to a lesser extent, some parts of the HSOPSC. The
RN4CAST is a tool that relates “workforce planning in nursing and patient safety” (Sermeus et
al., 2011, Discussion, para.1). Two findings from the study are significant to this thesis. Firstly,
the authors observe that participants whose work was most closely aligned with direct patient
care gave higher patient safety culture scores (Smeds Alenius et al, 2013). Secondly, “visible and
competent nursing leadership” is connected with nurses giving a higher rating to patient safety
(Discussion, para.3).
Di Benedetto et al. (2011) conducted a survey of 201 nurses working in 33 private
dialysis centres in Italy using the Safety Climate Survey and the Universal Hygiene Precautions

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56
Questionnaire (p.605). The results show that participants rated their direct supervisors more
highly than hospital management, noting “a lack in the responsiveness of senior leaders” (p.610).
United States study
Singer et al. (2012) developed and administered a survey questionnaire to assess nursing
home patient safety culture in eight nursing homes (p.104). This is the only study of long term
care that was included in this thesis. Of 432 respondents, only 27 were nurses, suggesting that
nurses are a small percentage of the staff that is present in these nursing homes. The overall score
for nurses’ perception of management support was 66.7%. This was a preliminary study and the
authors note that the study had not yet been validated. The authors note that the results may have
been influenced by “a social desirability bias toward a positive response” (p.116).
Summary of studies using other instruments
Five included studies were conducted in Saudi Arabia, Europe, and the United States and
used instruments other than the HSOPSC or SAQ. The settings included nursing homes and
dialysis units as well as hospitals. One study was a qualitative study. Some of the studies used
parts of other survey instruments or adapted them for use in a specific nursing context. Culture
and nationality were cited as influences on perceptions of patient safety culture.
Analysis of Similarities and Differences across Studies and Contexts of Care
In this chapter, the included studies were analyzed from the perspective of the study
instrument used, the geographic location, the area of nursing practice, the sample size, and data
concerning nurses’ perceptions of supervisory leadership for safety.
All of the studies provided baseline data. Baseline data indicates that there is no prior
history of conducting patient safety culture survey questionnaires in the study setting. In some
cases, for example Al Awa et al. (2012) the survey questionnaire was administered as part of an

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57
accreditation process. Two studies produced longitudinal data, providing baseline data plus a
subsequent evaluation after an intervening event. Ballangrud et al. (2012) provided baseline data
on ICUs in Norway that was subsequently relied on when Vifladt et al. (2016a) evaluated the
impact of restructuring versus not restructuring in the same ICU units surveyed by Ballangrud.
This was an important measure of change and in this case showed that patient safety culture and
the perceptions of supervisor/manager expectations and actions promoting patient safety were
negatively affected by restructuring. In Norway, Kvist et al. (2013) and Mantynen et al. (2014) in
studies of transformational leadership relative to Magnet hospitals evaluated the impact of
providing training and support to nurse leaders. The value of the longitudinal studies was in
measuring change over time.
The manner of reporting results for supervisory leadership for patient safety was varied.
Using the example of the five ICUs that were the subject of included studies, Ballangrud et al.
(2012) found a PPR on the HSOPSC of 73.10%. In a follow-up to this study, Vifladt et al.
(2016a) reported mean scores on the HSOPSC of 3.71 to 4.15 on the Likert scale. This study
followed an exercise in unit restructuring. In the study of Yilmaz and Goris (2015), the PPR for
the HSOPSC was 40.8%. Abdi et al. found a mean score of 69.5% (SD = 12.2 on the SAQ.
These studies use different assessment tools and report results differently, as mean scores and
PPRs. The results appear to be divergent and cannot be explained on the basis of these two
studies without significant investigation of the contexts in which the survey questionnaires were
used together with additional data to allow the results to be analyzed and interpreted.
Many observations and limitations were expressed in the included studies. Diverse
cultural backgrounds were suggested as an influence in a number of Middle Eastern and
European studies irrespective of the survey instrument used. Al-Awa et al. (2012) noted the

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58
presence of eight cultural backgrounds in the workplace. Zakari (2011) suggested qualitative
research to investigate the impact of diversity on patient safety culture. Al-Mandari et al. (2014)
suggested paternalistic management style in addition to cultural diversity may have influenced
patient safety culture. Gabrani et al. (2015) noted that Albanian organizational culture may be a
factor in perceptions of patient safety culture. Singer et al. (2012) noted that “a social desirability
bias toward a positive response” may have been a factor influencing participants (p.116).
Nguyen et al. (2015) suggested that a high incidence of missing responses concerning perception
of management may indicate an unwillingness to address the subject. Almutairi et al. (2013)
addressed the reluctance of participants to reveal their ethnicity or nationality as a factor. Nie et
al. (2013) cautioned against using the HSOPSC “in a different cultural context” (Reliability and
Validity, para. 1).
Several studies discussed supervisors’ or managers’ perceptions relative to frontline
nurses’ perceptions. In these cases, it was generally observed that the nurses’ scores for
perception of supervisory or managerial leadership were lower than the mean score given by
their supervisors and managers for this dimension (Zakari, 2011; Turunen et al., 2013; Ulrich &
Kear, 2014).
It was also demonstrated that qualitative assessment of patient safety culture offers
perspectives that supplement the data typically emerging from survey questionnaire data. Using
qualitative interviews, Danielssonet al. (2014) found themes such as competence and
responsibility. Neither of these is assessed on the quantitative instruments used in studies that
were reviewed in this thesis but could be explored qualitatively. Abdi et al. (2015) used the SAQ
together with semi-structured interviews. This allowed the addition of narrative detail to the
survey questionnaire responses that would not have been revealed otherwise. Ulrich and Kear

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59
(2014) supplemented the HSOPSC with two open-ended questions that allowed nurses to expand
their responses beyond the numeric Likert scale and provide examples from their personal
experience in their practice area.
Chapter Summary
In this chapter, the included studies were analyzed from the perspective of the study
instrument used, the geographic location, the area of nursing practice, the sample size, and data
concerning nurses’ perceptions of supervisory leadership for safety. The HSOPSC was used in
twenty-four studies. One of the dimensions it measures is supervisor/manager expectations and
actions promoting patient safety. The SAQ was used in six studies and one dimension it assesses
is perception of management at the unit level. Three other instruments, the SCS, SRS, and
RN4CAST, and one qualitative study were also found in the included studies. Geographically the
studies were widely dispersed. The Middle East accounted for thirteen studies, Europe for
thirteen studies, Asia for four studies, the United States for three studies, and Brazil for one
study. Chapter 5 provides a discussion of these results and the conclusion of the thesis.

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60
Chapter Five: Discussion and Conclusion
The impetus for this thesis originated from the results of a patient safety culture survey
questionnaire that was administered by a Canadian health services agency throughout a number
of healthcare sectors under its authority. The results uniformly showed low ratings for
supervisory leadership for safety. This led to the question whether, from a more global
perspective, patient safety survey questionnaires might reveal some consistency in their results.
The purpose of this thesis was to examine reports of nurses’ perceptions of supervisory
leadership in relation to patient safety culture within and across different contexts of care to
identify whether, within or among the instruments used, there were trends in the data based on
geographic location, type of institution, and nursing practice setting. This chapter discusses the
results.
Safety culture and safety climate have been viewed as intertwined. The responses to a
patient safety culture survey questionnaire indicate the safety climate or “the visible feature of
safety culture” (Ausserhofer et al., 2012, p.242). “Measuring and monitoring the PSC (patient
safety climate) in healthcare organizations allows hospital and nurse leaders to detect
vulnerabilities and to implement and evaluate improvement interventions to strengthen the PSC”
(p.250).
A variety of different survey questionnaires was encountered in the literature but the
HSOPSC and SAQ were predominant and there was a wide geographic distribution of studies.
Most of the studies considered in this thesis provided data that was gathered from an institution,
often a hospital and sometimes several hospitals in a region. Although the studies often provided
details of the unit or practice setting from which participants were drawn, rarely did the analysis
of results relate the participants’ responses to their individual units or practice settings. The

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61
absence of this detail limited the outcome of this thesis and the narrative review. Where it was
originally anticipated that the literature search would yield studies that addressed distinct nursing
practice settings, these studies were few. Where they were found to exist, some authors
acknowledged that the nursing practice setting may have been an influence on the patient safety
culture survey results. However, the number of studies that detailed responses from individual
nursing practice settings was too few to generate any generalizable conclusion concerning
nurses’ perceptions of supervisory leadership for safety. Nonetheless, a review of the results
yielded three important themes emerging from the results of survey questionnaires: benchmarks,
culture, and interventions.
Benchmarks
The first emerging theme is that the results of a patient safety culture survey
questionnaire provide a benchmark at a given point in time that relates to the given participant
population. Because the results appear to be highly dependent on context, for example the
culture, age, and education of the participants, they are not generalizable and are unlikely to be
useful predictors for other populations. Still, the usefulness of the results can be enhanced. In
dynamistic healthcare environments, longitudinal studies that repeat the survey questionnaire at
intervals could provide illuminating data for further research. This is being undertaken in some
instances. For example, in one study the stated objective was to obtain “baseline measurements
for a longitudinal study” (Kvist et al., 2012, p.152). Most of the studies that were considered in
this thesis administered a survey questionnaire once and provided limited discussion of factors
that may have influenced the results. Approaching patient safety culture from a longitudinal
aspect will provide the opportunity to assess the variables that may influence participant
responses. For example, “capacity and capability” (Bevan, 2010, p.140) are powerful

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62
determinants of culture and climate and are rarely static and changes to either of them may alter
subsequent survey questionnaire results. Additional value may be added by repeating survey
questionnaires over time to assess the influence of such changes in the workplace and its impact
in a patient safety culture context (Visser, Krosnick, & Lavrakas, 2000, p.226).
Both the HSOPSC and the SAQ ask participants to provide information concerning their
profession, work unit, and experience. Other than profession, this information about participants’
characteristics inconsistently appears to have been related to their reported survey questionnaire
results. Perhaps this is attributable to the sample size or concerns for participant anonymity.
Nonetheless, it is arguably information which, where it is appropriate to report it, could be useful
and particularly where longitudinal studies are undertaken as it could reveal explanations for
changes within the participant group that may influence survey questionnaire outcomes.
It is important to recognize that patient safety culture survey questionnaires are not
diagnostic although Li does describe them as “a diagnostic indicator on the state of safety in a
hospital” (2012, p.60) but acknowledges that they do not measure “behaviour, values, and
competencies” (p.64) or “causality” (p.66). Patient safety culture survey questionnaires do not
explain strengths or weaknesses that are reported in the results. In order to create meaning, it is
necessary to conduct further inquiry with the potential of then applying initiatives to support or
enhance patient safety culture. This warrants significant investigation of the underpinnings of
participants’ reported perception. The survey questionnaire results must be confined to the
population and setting that they address for “(w)ithout the right safety culture, initiatives to
improve patient safety, such as blame-free incident reporting and root cause analysis, are far less
likely to succeed” (Poley, van der Starre, van den Bos, van Dijk, & Tibboel, 2011, p.e310). As
Hamdan states, effective intervention has “the need for a customized approach that builds on

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63
existing strengths and targets areas of opportunities for improvement” (2013, p.886.e13). The
existence of a positive patient safety culture is of paramount importance in a healthcare
workplace where “complexity, intense stress, time sensitivity, multiple players, a requirement for
teams functioning at a high level with precise and accurate information, and the high and often
irreversible cost of error” are constants (Oriol, 2006, p.403).
Culture
The second theme of the findings of this thesis that warrants comment and has potential
for further exploration is the impact of the cultural background of the participants in the survey
questionnaires. A number of studies identified cultural backgrounds of the individual study
participants and the “socio-cultural” geographic milieu of the workplace setting as factors (AlMandhari et al., 2014, p.265). Ballangrud et al. (2012) remarked on “cultural and organisational
differences regarding patient safety” between Norway and the United States (p.348). Zakari
(2011) referred to the large contingent of foreign nurses in Saudi Arabia and the “considerable
effects” the diverse workforce might reflect in patient safety culture survey questionnaire results
(p.233). Al-Mandhari et al. (2014) noted the “Oman is known to be characterized by ‘directive
and paternalistic’ management styles” which could impact perceptions of patient safety culture
(p.268). In a study of a hospital in Taiwan, Li observed that in “eastern Asia, the virtue of
obedience is highly valued among nurses. Therefore, they tend to be silent and reluctant to
express their safety concerns” (2013, p.65). As this thesis illustrates, culture of the participant
population and study site cannot be overlooked as influential factors in the assessment of patient
safety culture and perceptions of supervisory leadership for safety. To more fully understand the
data, these contextual features need to be explored.

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Interventions
The third theme that emerges is the use of baseline and longitudinal studies in assessing
the effects of interventions. Carvalho et al. (2015) and Al-Awa et al. (2012) are examples of
patient safety culture assessment in accreditation processes. Yilmaz and Goris (2015), a Turkish
study, illustrates the impact of training and measures its effect in comparing the results of nurses
who had been trained in aspects of patient safety culture with nurses who had not received
training. Ballangrud et al. (2012) together with Vifladt et al. (2016a) provide a longitudinal study
that analyzes the impact of unit restructuring on patient safety culture in Norwegian ICUs. Kvist
et al. (2013) and Mantynen et al. (2014) combine to examine the impact over time of training
given to nurse leaders and information for nurses on transformational leadership.
There is no single intervention that will enhance perception of supervisory leadership for
safety in every healthcare. Hamdan noted in assessing the results of a patient safety culture
survey questionnaire of neonatal intensive care units (NICU) that “most of the NICUs have
opportunities to improve domains of patient safety culture and that these opportunities differ by
NICU” (2013, p.886.e9). The culture, strengths, and weaknesses of the workplace will play a
large part in determining a useful intervention.
A number of studies suggest interventions that may enhance patient safety culture. Kvist
et al. (2012) and Halligan et al. (2014) state that nurse leaders should be visible in the workplace.
Kvist et al. (2012) add that nurse leaders “should pay attention to giving direct feedback about
work generally and patient safety issues particularly” (p.162). Ammouri et al. (2014) suggest
mentorship among senior and junior nurses with particular attention to patient safety culture.
Parker’s study (as cited by Kuosmanen, Tiihonen, Repo-Tiihonen, Eronen, & Turunen, 2013,
214) indicated that “(s)taff should be engaged in discussions about their responses to raise

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65
awareness of patient safety and provide opportunities to share concerns.” Kuosmanen et al. also
suggest that continuing education is an important component of patient safety culture, but
cautions that “cultural differences between professional groups should be taken into account
when constructing (patient safety) educational plans” (2013, p.215). Regarding educational
interventions, Taher et al. noted that improving patient safety culture “requires not only
education and awareness but also being able to carry the personnel with you in the safety attitude
and implementation” (2014, p.101). Marsteller encourages “frank discussions among team
members and leaders about fear of punishment, stigma or retaliation for raising concerns. In the
absence of conversations about hazards, errors will eventually reach the patient” (2015, p.2188).
The attributes of a nurse leader are strongly linked to patient safety culture and the
qualities of effective leadership must be developed and applied to support patient safety culture.
“A leader guides, directs, and fosters goal attainment, thus motivating followers to reach their
full potential” (Merrill, 2015, p.319). Merrill strongly advocates for transformational leaders who
“are proactive and convince followers to strive for high performance” (p.319). Mantynen et al.
suggest that the need for transformational nurse leadership is “urgent” (2014, Conclusions, para.
1). To “promote patient safety” a transformational leader looks to “increasing employee
involvement in decision making, developing a culture of trust, and looking at error as an
opportunity to improve processes rather than reprimand employees” (Merrill, 2015, p.323).
Improving the skills of a nurse leader is a logical component in strengthening nurses’ perceptions
of supervisory leadership as “(n)urse leaders have the ability to cause change and are therefore in
unique positions to help create an environment ... where safety is valued” (Wagner, Capezuti, &
Rice, 2009, p.190).

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66
More concrete tools were suggested in several studies. Aviation “shares many
characteristics with medicine, particularly in terms of the goal of risk reduction and the
importance of teamwork and interpersonal skills” (Zeltser & Nash, 2010, p.13). Several studies
in the literature suggest borrowing from aviation to use Crew Resource Management in a
healthcare context to enhance patient safety culture (Oriol, 2006; Poley et al., 2011; Zeltser &
Nash, 2010). The foundation for CRM was described by Nance (2004) in the following passage:
The new definition of what it takes to lead has been forged in the fires of airline
disasters and the extensive renaissance in teamwork and communication methods that
resulted from those accident investigations. No longer are dangerously impossible claims
of human infallibility acceptable. No longer is autocratic, noncommunicative leadership
tolerable. No longer are health care participants given the false luxury of silence, or the
challenge of using excessive diplomacy as a license to remain silent.
From the smallest clinic to the largest hospital, this massive change in the way we
view teamwork, communication, leadership, and human fallibility is the basic formula
needed to change the structure of health care’s approach to the very real patient safety
issues before it. The vast majority of human errors that metastasize into patient injury or
death, whether involving medication errors or otherwise, can be prevented by attacking
and improving bad systems, not assuming the presence of bad people. (p.203)
Kemper et al. (2014) explain that Crew Resource Management “is based on the premise that
human error is avoidable, but can never be eradicated (Background, para.4). As described by
Hatlestadt (in Oriol, 2006) the basic concept of Crew Resource Management involves the
acknowledgement of human fallibility and “the training of all personnel to develop basic skills
for understanding the extent and nature of actual and potential errors, for altering the precursors

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67
to the error, and for identification of interventions that can prevent or mitigate error” (p.404).
Consistent with the Crew Resource Management approach, Kear and Ulrich acknowledge that
“patient safety and patient safety culture rely on an interprofessional team approach and
transparency” (2015, p.121). Haerkens et al. (2016) is an example of a study that provides
baseline data that will be used to assess the effects of Crew Resource Management training.
Implications and Recommendations
At the conclusion, it is important to return to the question posed by this thesis, which was
to examine reports of nurses’ perceptions of supervisory leadership in relation to patient safety
culture within and across different contexts of care to identify whether, within or among the
instruments used, there were trends in the data based on geographic location, type of institution,
and nursing practice setting.
Generalizable information cannot be drawn from the data generated by the studies
included in this thesis. The different survey questionnaires and methods, and the manner of
presenting the data both placed limitations on the use of the data. Nonetheless, there were three
salient themes that emerged. Firstly, the survey questionnaires are useful tools to establish
benchmarks for the participant population. Secondly, the concept of culture, including the
cultural backgrounds of participants, the organizational culture of the workplace, and the cultural
milieu of the geographic setting, are influences on the perceptions of patient safety culture and
they are necessary avenues of further inquiry. Thirdly, there are useful studies in the literature
that propose and in some cases assess the use or deployment of interventions and their impact on
patient safety culture. A strong example comes from the study conducted by Vifladt et al. (2014),
which showed a decline in patient safety culture after restructuring work units. In the context of
interventions, it is also a finding of this thesis that the assessment of patient safety culture cannot

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68
be a single or isolated event. Baseline data must be given meaning and to give it meaning, the
patient safety culture assessment must be repeated at intervals and examined in the context of the
workplace at the time of each assessment. There is also benefit in combining assessment
methods, for example the HSOPSC or SAQ together with qualitative interviews. The addition of
a personal narrative adds value.
Conclusion
The result of this thesis shows that trends cannot presently be found in patient safety
culture results, it may be that this is attributable to the fact that safety culture is an emerging
field. With time, the volume of reported patient safety culture data, more standardized reporting
of results, and more detailed analysis of information such as the demographic data of the
participants, may allow synthesis of the results and the identification of patient safety culture.

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69
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Appendices
Appendix A – Included Studies Using Hospital Survey on Patient Safety Culture
*PPR as used in Appendix A indicates percent positive responses as reported in the study. It is
the percentage of respondents answering 4 or 5 on Likert scale. Unless otherwise indicated, the
result is for the dimension of supervisor/manager expectations and actions promoting patient
safety. Note that questions B3 and B4 are reverse scored for the dimension.
Citation: Aboul-Fotouh, A.M., Ismail, N.A., Ez Elarab, H.S., & Wassif, G.O. (2012).
Assessment of patient safety culture among health-care providers at a teaching hospital in
Cairo, Egypt. Eastern Mediterranean Health Journal, 18(4), 372-377.
Study tool: HSOPSC; Arabic language translation
Geographic region: Egypt
Sample: 165 nurses (32.4% of respondents) of 510 physicians, nurses, pharmacists,
technicians and labourers
Practice area: Hospital: medical, surgical, intensive care (ICU), paramedical and other units
Relevant findings: PPR for nurses 42.4%. PPR also presented in relation to background
characteristics of participants age, gender, position, work area, and experience. Not analyzed
by profession and characteristics.

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Citation: Ahmed, G.A., Adam, S.M., & Abd Al-Moniem, I.I. (2011). Patient safety:
Assessing nurses’ perception and developing an improvement plan. Life Science Journal, 8(2),
53-64.
Study tool: HSOPSC
Geographic region: Egypt
Sample: 148 nurses, 128 staff nurses and 20 head nurses.
Practice area: Medical and pediatric university hospitals.
Relevant findings: Staff nurses 27.5% PPR. By unit: critical care 28.9% PPR; general wards
24.3% PPR. Noted that staff nurses’ perception of patient safety culture is less positive than
head nurses’ perception. Sample characteristics reported but not related to HSOPSC responses.
Citation: Al-Awa, B., Al Mazrooa, A., Rayes, O., El Hati, T., Devreux, I., Al-Noury, K.,
Habib, H., El-Deek, B.S. (2012). Benchmarking the post-accreditation patient safety culture at
King Abdulaziz University Hospital. Annals of Saudi Medicine. 32(2), 143-150. doi:
10.5144/0256-4947.2012.143
Study tool: HSOPSC
Geographic region: Saudi Arabia
Sample: 605 nurses
Practice area: 22 units in a university hospital
Relevant findings: Longitudinal study pre and post accreditation showing overall
improvement in responses to questions about supervisor/manager expectations. Results
compared to international benchmarks. Respondents represented eight distinct cultural
backgrounds.

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Citation: Al-Mandhari, A., Al-Zakwani, I., Al-Kindi, M., Tawilah, J., Dorvlo, A., Al-Adawi,
S. (2014). Patient safety culture assessment in Oman. Oman Medical Journal 29(4), 264-270.
doi: 10.5001/omj.2014.70
Study tool: HSOPSC
Geographic region: Oman
Sample: 237 nurses of 398 healthcare professionals
Practice area: 5 secondary and tertiary care hospitals
Relevant findings: Authors note that mean scores not significantly different among
professions surveyed. PPR for supervisor/manager expectations 60%. Some dimension results
compared with USA, Taiwan, and Lebanon but supervisor/manager expectations not
mentioned. Omani culture suggested as an influence.
Citation: Ammouri, A.A., Tailakh, A.K., Muliira, J.K., Geethakrishnan, R., Al Kindi, S.N.
(2014). Patient safety culture among nurses. International Nursing Review, 62(1), 102-110.
doi: 10.1111/inr.12159
Study tool: HSOPSC
Geographic region: Oman
Sample: 414 nurses
Practice area: Hospital; surgery, medicine, ICU, obstetrics, pediatrics, other
Relevant findings: 60% PPR. Individual question responses were converted to PPR and
reported as a percentage score: B1 80.9%, B2 81.6%, B3 50.7%, B4 26.6%. Study shows that
B3 and B4 were reverse scored as required.

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Citation: Bahrami, M.A., Chalak, M., Montazeralfaraj, R., Tafti, A.D. (2014). Iranian nurses’
perception of patient safety culture. Iran Red Crescent Medical Journal 16(4). doi:
10.5812/ircmj.11894
Study tool: HSOPSC
Geographic region: Iran
Sample: 302 nurses
Practice area: Hospital: internal medicine , surgery, obstetrics and gynecology, neurology,
pediatrics, ICU, emergency, other
Relevant findings: Supervisor/manager expectations reported as mean score on Likert scale:
internal medicine: 2.77 (SD = 0.78); surgery 2.38 (SD = 0.72); obstetrics and gynecology 3.09
(SD = 0.65); pediatrics 2.3 (SD = 0.63); mental health 2 .0 (SD = 0.72); ICU 2.5 (SD = 0.5);
ER 2.81 (SD = 0.56); laboratory 3.0 (SD = 0.25); radiology 3.75 (SD = 0.0). Participant
characteristics reported but not related to HSOPSC responses.

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Citation: Ballangrud, R., Hedelin, B., Hall-Lord, M.L. (2012). Nurses’ perceptions of patient
safety climate in intensive care units: A cross-sectional study. Intensive and Critical Care
Nursing 28, 344-354. doi:10.1016/j.iccn.2012.01.001
Study tool: HSOPSC
Geographic region: Norway
Sample: 220 nurses
Practice area: 10 intensive care units in 6 hospitals
Relevant findings: 73.1% PPR. Not differentiated by unit or participant characteristics.
Supervisor/manager expectations found to be a predictor for other patient safety culture
dimensions. Suggests research required on organizational and participant factors as influences
on patient safety culture.
Citation: Brborovic, H., Brborovic, O., Brumen, V., Pavlekovic, G., Mustajbegovic, J. (2014).
Are nurse presenteeism and patient safety culture associated: A cross-sectional study. Archives
of Industrial Hygiene and Toxicology, 65, 149-156. doi:10.1016/j.iccn.2012.01.001
Study tool: HSOPSC translated into Croatian
Geographic region: Croatia
Sample: 148 nurses
Practice area: General hospital
Relevant findings: Focus was to see whether “presenteeism” affected patient safety, i.e.
overtime, night shifts, working while sick. Results reported on a bar graph and not stated as a
number. Appear to be approximately 55% mean score for supervisor/manager expectations.

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Citation: Davis, K.K., Harris, K.G., Mahishi, V., Bartholomew, E.G., & Kenward, K. (2016).
Perceptions of culture of safety in hemodialysis centers. Nephrology Nursing Journal,43(2),
119-126.
Study tool: HSOPSC, modified to ask only questions B1 and B2
Geographic region: United States
Sample: 134 nurses, 47 charge nurses
Practice area: Hemodialysis centres
Relevant findings: Score for nurses for B1 75%, B2 78%. For charge nurses, scores were
higher: B1 83%, B2 85%. Authors suggest caution in generalizing results due to multiple
factors.
Citation: Feng, X., Acord, L., Cheng, Y., Zeng, J. and Song, J. (2011). The relationship
between management safety commitment and patient safety culture. International Nursing
Review, 58, 249–254. doi: 10.1111/j.1466-7657.2011.00891.x
Study tool: HSOPSC, translated into Chinese
Geographic region: China
Sample: 228 staff nurses, 20 nurse managers
Practice area: Hospital
Relevant findings: Staff nurses score for patient safety culture was not given but stated to be
lower than score given by nurse managers. Participant characteristics given but not related to
data from HSOPSC. Study affirms that management commitment is closely related to
perception of patient safety culture.

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Citation: Gunes, U.Y., Gurlek, O., Sonmez, M. (2016). A survey of the patient safety culture
of hospital nurses in Turkey. Collegian, 23, 225-232.
http://dx.doi.org/10.1016/j.colegn.2015.02.005
Study tool: HSOPSC, Turkish version
Geographic region: Turkey
Sample: 554 nurses
Practice area: 3 public hospitals, 1 university hospital
Relevant findings: Benchmark 74% PPR (AHRQ 2012) and in this study participants
achieved 48% PPR. Study provides breakdown of PPR relative to participant characteristics.
Not analyzed by profession and characteristics.
Citation: Khater, W.A., Akhu-Zaheya, L.M., Al-Mahasneh, S.I., & Khater, R. (2015). Nurses’
perceptions patient safety culture in Jordanian hospitals. International Nursing Review. 62,
82–91. doi: 10.1111/inr.12155
Study tool: HSOPSC, Arabic version
Geographic region: Jordan
Sample: 658 nurses
Practice area: Hospitals
Relevant findings: PPR for supervisor/manager expectations 57.95%. Scores for individual
questions: B1 57.95%, B1 52.1%, B2 54.6%, B3 51.4%, B4 73.7%. Authors performed
multivariate regression analysis to examine influence of participant characteristics. Limitation
suggested but not shown that participants may have provided responses to meet approval of
others.

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Citation: Kvist, T., Mäntynen, R., Turunen, H., Partanen, P., Miettinen, M., Wolf, G. A., &
Vehviläinen-Julkunen, K. (2013). How magnetic are Finnish hospitals measured by
transformational leadership and empirical quality outcomes? Journal of Nursing Management,
21(1), 152-164. doi: 10.1111/j.1365-2834.2012.01456.x
Study tool: HSOPSC, translated to Finnish
Geographic region: Finland
Sample: 925 nurses
Practice area: 4 hospitals
Relevant findings: HSOPSC used as part of measurement of Magnet hospital standards.
Score indicated as “moderate” and below target level of “excellent.” Transformational
leadership discussed. Study discusses connection between nursing perception and
transformational leadership component of Magnet model.
Citation: Mantynen, R., Vehvilainen-Julkunen, K., Partanen, P., Turunen, H., Miettinen, M.,
Kvist, T. (2014). Changes in transformational leadership and empirical quality outcomes in a
Finnish hospital over a two-year period: A longitudinal study. Nursing Research and Practice,
2014. http://dx.doi.org/10.1155/2014/218069
Study tool: HSOPSC
Geographic region: Finland
Sample: 234 nurses in 2008, 512 nurses in 2011
Practice area: University hospital
Relevant findings: Longitudinal study. Interventions aimed at improving patient safety
culture and other workplace between studies. Mean score in 2008 for supervisor/manager

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expectations 3.69 (SD = 0.73), in 2011 3.68 (SD = 0.74). Importance of transformational
leadership discussed.
Citation: Nie, Y., Mao, X., Cui, H. He, S., Li, J., Zhang, M. (2013). Hospital survey on
patient safety culture in China. BMC Health Services Research, 13:228. doi:10.1186/14726963-13-228
Study tool: HSOPSC, translated into Chinese; modified re frequency of events reported and
transitions
Geographic region: China
Sample: 722
Practice area: 32 hospitals in 15 cities
Relevant findings: Scores for dimension: B1 76%, B3 76%, B4 78%. Question B2 omitted.
Chinese cultural dimension noted by authors as an influence and question reliability of using
HSOPSC scale in a Chinese context.
Citation: Saleh, A.M., Darawad, M.W., & Al-Hussami, M. (2015). The perception of hospital
safety culture and selected outcomes among nurses: An exploratory study. Nursing and Health
Sciences, 17, 339-346. doi: 10.1111/nhs.12196
Study tool: HSOPSC
Geographic region: Jordan
Sample:
Practice area:
Relevant findings: English version used as English is the language of teaching and the
language of Jordanian hospitals. PPR for supervisor/manager expectations: B1 44.2%, B2

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91
41.3%, B3 45%, B4 42.6%. Overall score 43.3% for this dimension. Describes participant
characteristics but does not relate them to this result.

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92
Citation: Turunen, H., Partanen, P., Kvist, T., Miettinen, M., Vehvilainen-Julkunen, K.
(2013). Patient safety culture in acute care: A web-based survey of nurse managers’ and
registered nurses’ views in four Finnish hospitals. International Journal of Nursing Practice,
19, 609-617. doi:10.1111/ijn.12112
Study tool: HSOPSC, translated into Finnish
Geographic region:
Sample: 723 nurses, 109 nurse managers
Practice area: 4 acute care hospitals
Relevant findings: Aim to explore differences between staff nurses and nurse managers. PPR
for nurses B1 43%, B2 69%, B3 64%, B4 70%. For nurse managers PPR B1 56%, B2 84%, B3
83%, B4 90%. Authors state that patient safety culture should be regularly reassessed.
Citation: Ugurluoglu, O., Ugurluoglu, E., Payziner, P.D., & Ozatkan, Y. Patient safety
culture: Sample of a university hospital in Turkey. Pakistan Journal of Medical Sciences,
28(3), 463-467.
Study tool: HSOPSC, translated into Turkish
Geographic region: Turkey
Sample: 39 nurses
Practice area: Hospitals
Relevant findings: 60.9% PPR for nurses for supervisor/manager expectations. Other than by
profession, participant characteristics not analyzed relative to result.

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
93
Citation: Ulrich, B., & Kear, T. (2014). Patient safety culture in nephrology nurse practice
settings: Initial findings. Nephrology Nursing Journal, 41(5), 459-475.
Study tool: HSOPSC, modified
Geographic region: United States
Sample: 929 nurses and 249 nurse managers
Practice area: Nephrology nurse practice settings.
Relevant findings: Nurse and nurse manager not readily distinguishable in presentation of all
results and study does not describe whether there is a difference between nurses and nurse
managers. 52.4% of the 929 nurses in this study were direct care nurses. Others performed in
other functions.
Citation: Verbeek-van Noord, I., Wagner, C., Van Dyck, C., Twisk, J.W., De Bruijne, M.C.
(2014). Is culture associated with patient safety in the emergency department? A study of staff
perspectives. International Journal for Quality in Health Care, 26(1), 64-70. doi:
10.1093/intqhc/mzt087
Study tool: HSOPSC, Dutch version
Geographic region: Netherlands
Sample: 480 nurses
Practice area: Emergency
Relevant findings: Likert scale score for supervisor/manager expectations 3.5 (SD = 0.68).
Authors discuss clustering and non-response bias as limitations on their study.

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94
Citation: Vifladt, A., Simonsen, B.O., Lydersen, S., Farup, P.G. (2016a). Changes in patient
safety culture after restructuring of intensive care units: Two cross-sectional studies. Intensive
and Critical Care Nursing 32, 58-65. http://dx.doi.org/10.1016/j.iccn.2015.06.004
Study tool: HSOPSC, Norwegian version
Geographic region: Norway
Sample: 217 nurses 2008/2009, 145 nurses 2012/2013
Practice area: ICUs in 6 hospitals
Relevant findings: Longitudinal study conducted in 2008/2009 and 2012/2013. Uses data
from Ballangrud study, above. Comparison of 3 restructured ICUs where general and medical
ICUs merged, and 3 non restructured ICUs. Study showed that restructured units had lower
patient safety culture scores than non restructured units. In the dimension of
supervisor/manager expectations, authors suggest this may be attributed to higher stress and
greater workload for supervisor/manager during the exercise of restructuring.
Citation: Vifladt, A., Simonsen, B.O., Lydersen, S., Farup, P.G. (2016b). The association
between patient safety culture and burnout and sense of coherence: A cross-sectional study in
restructured and not restructured intensive care units. Intensive and Critical Care Nursing, 36,
26-34. http://dx.doi.org/10.1016/j.iccn.2016.03.004
Study tool: HSOPSC, Norwegian version
Geographic region: Norway
Sample: 142 nurses
Practice area: ICU
Relevant findings: Compares HSOPSC to burnout assessment results. Refers to Ballangrud
study. Positive score for HSOPSC relates to a low score for Bergen Burnout Indicator.

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95
Citation: Wang, X., Liu, K., You, L., Xiang, J., Hu, H., Zhang, L.,..&Zhu, X. (2014). The
relationship between patient safety culture and adverse events: A questionnaire survey.
International Journal of Nursing Studies, 51, 1114-1122.
http://dx.doi.org/10.1016j.ijnurstu.2013.12.007
Study tool: HSOPSC
Geographic region: China
Sample: 463 nurses
Practice area: Inpatient and emergency at 7 hospitals
Relevant findings: PPR 73.8%, Likert scale score 3.81 (SD = 0.52). Authors state that
participant evaluation of patient safety culture was related to reporting of adverse events.
Sample bias was suggested and participants were not considered representative of the nurse
population in the city from which they were recruited. Study does not discuss the
supervisor/manager expectation dimension in the analysis and conclusion.
Citation: Yilmaz, Z, & Goris S. (2015). Determination of the patient safety culture among
nurses working at intensive care units. Pakistan Journal of Medical Sciences, 31(3), 597-601.
http://dx.doi.org/10.12669/pjms.313.7059
Study tool: HSOPSC, translated into Turkish
Geographic region: Turkey
Sample: 316 nurses
Practice area: ICU in 2 hospitals
Relevant findings: 40.8% PPR. Noted that 220 participants had received patient safety
training in handoffs and transitions as well as frequency of event reporting. This was found to
have a positive influence on patient safety culture scores.

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Appendix B – Included Studies Using Safety Attitudes Questionnaire
Citation: Abdi, Z., Delgoshaei, B., Ravaghi, H., Abbasi, M., & Heyrani, A. (2015). The
culture of patient safety in an Iranian intensive care unit. Journal of Nursing Management, 23,
333-345. doi: 10.1111/jonm.12135
Study tool: SAQ-ICU version, translated into Farsi; qualitative interviews
Geographic region: Iran
Sample: 18 nurses
Practice area: ICU
Relevant findings: Perception of unit level management on SAQ indicated as mean score
69.5% (SD = 12.2). Two themes emerged in qualitative interviews: approval of management
decisions and management support of staff. Authors note steps that can be taken by nurse
leaders to foster patient safety culture.
Citation: Carvalho, P.A., Gottems, L.B., Pires, M.R., & de Oliveira, M.L. (2015). Safety
culture in the operating room of a public hospital in the perception of healthcare professionals.
Revista Latino-americana de Enfermagem, 23(6), 1041-1048. doi: 10-1590/01041169.0669.2647
Study tool: SAQ, translated into Portuguese
Geographic region: Brazil
Sample: 13 nurses
Practice area: Operating room
Relevant findings: Mean score for nurses’ perception of unit management 63.4%. Cronbach’s
α for this domain is 0.63. This is a baseline study of operating room safety culture. Includes
discussion of internally recommended standard of 75% and indicates score below 60%

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suggests need for intervention. Dimension scores ranged from 34.4% to 74.8% for all
dimensions of SAQ.
Citation: Gabrani, A., Hoxha, A., Simaku, A., & Gabrani, J. (2015). Application of the Safety
Attitudes Questionnaire (SAQ) in Albanian hospitals: A cross-sectional study. BMJ Open, 5.
http://dx.doi.org/10.1136/bmjopen-2014-006528
Study tool: SAQ, translated into Albanian
Geographic region: Albania
Sample: 132 nurses
Practice area: 4 regional hospitals
Relevant findings: Study does not distinguish unit level from hospital management results.
Perception of management mean score 44.8% (SD = 13.1). Notes that there was no significant
difference in findings of perception of physicians and nurses. States that study serves as a
starting point for further research.
Citation: Haerkens, M., van Leeuwen, W., Sexton, J.B., Pickkers, P., & van der Hoeven, J.G.
(2016). Validation of the Dutch language version of the Safety Attitudes Questionnaire (SAQNL). BMC Health Services Research, 16:385. doi 10:1186/s12913-016-1648-3
Study tool: SAQ, Dutch version
Geographic region: Netherlands
Sample: 623 nurses
Practice area: 17 departments in 9 hospitals
Relevant findings: Mean score for perception of management 2.89%. Study does not
distinguish unit level from hospital level management. Purpose of this study was to provide a

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baseline evaluation before the use of Crew Resource Management (CRM) as a patient safety
culture intervention.

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Citation: Nguyen, G., Gambashidze, N., Ilyas, S.A., & Pascu, D. (2015). Validation of the
safety attitudes questionnaire (short form 2006) in Italian in hospitals in the northeast of Italy.
BMC Health Services Research, 15:284. doi: 10.1186/s12913-015-0951-8
Study tool: SAQ, translated into Italian
Geographic region: Italy
Sample: 134 nurses
Practice area:
Relevant findings: Perception of unit management mean score 49.3% (SD = 25). Assesses
Italian form of SAQ and its suitability for use.
Citation: Zakari, N.M. (2011). Attitude of academic ambulatory nurses toward patient safety
culture in Saudi Arabia. Life Science Journal, 8(3), 230-237.
Study tool: SAQ
Geographic region: Saudi Arabia
Sample: 203 nurses
Practice area: 4 departments in one hospital; outpatient care
Relevant findings: Mean score 63% (SD = 12.7).

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Appendix C – Included Studies Using a Method Other than HSOPSC or SAQ
Citation: Almutairi, A.F., Gardner, G., & McCarthy, A. (2013). Perceptions of clinical safety
climate of the multicultural nursing workforce in Saudi Arabia: A cross-sectional survey.
Collegian, 20, 187-194. http://dx.doi.org/10.1016/j.colegn.2012.08.002
Study tool: Safety Climate Survey
Geographic region: Saudi Arabia
Sample: 319 nurses
Practice area: Hospital; medical, surgical, pediatric, gynecology, medical rehabilitation
Relevant findings: 21 question survey developed at Centre for Healthcare Quality and Safety
just as SAQ was. 2 questions considered relevant to supervisory leadership for safety: (1) The
physician and nurse leaders in my areas listen to me and care about my concerns (3.68 (SD =
1.100)); (2) Management/leadership does not knowingly compromise safety concerns for
productivity (3.53 (SD = 1.193)). Diverse cultural backgrounds of respondents, South-East
Asian (30.7%), European (3.4%), South African (5.3%), Middle Eastern (4.7%).

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Citation: Danielsson, M., Nilsen, P., Ohm, A., Rutberg, H., Fock, J., & Carlfjord, S. (2014).
Patient safety subcultures among registered nurses and nurse assistants in Swedish hospital
care: A qualitative study. BMC Nursing, 13:39. doi:10.1186/s12912-014-0039-5
Study tool: Semi-structured interviews
Geographic region: Sweden
Sample: 28 nurses
Practice area: Medical and surgical wards in 2 hospitals
Relevant findings: Leadership engagement and support discussed as important to patient
safety. Failure of management to adhere to rules is problematic. This study confirms that
perception of supervisory leadership for safety is an important element of patient safety
culture.
Citation: Di Benedetto, A., Pelliccia, F., Moretti, M., d’Orsi, W., Starace, F., Scatizzi,
L....&Marcelli, D. (2011). What causes an improved safety climate among the staff of a
dialysis unit? Report of an evaluation in a large network. Journal of Nephrology, 24(5), 604612. doi: 10.5301/JN.2011.6306
Study tool: Safety Climate Survey
Geographic region: Italy
Sample: 201 nurses
Practice area: Free standing dialysis units
Relevant findings: 2 questions considered relevant to supervisory leadership for safety: (1)
The physician and nurse leaders in my areas listen to me and care about my concerns (bar
graph suggests 82%); (2) Management/leadership does not knowingly compromise safety
concerns for productivity (bar graph suggests 84%). This study confirms that the closer the

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supervisor is to the delivery of patient care, the higher the perception of supervisory
commitment to patient safety.
Citation: Smeds Alenius, L., Tishelman, C., Runesdotter, S., & Lindqvist, R. (2013). Staffing
and resource adequacy strongly related to RNs’ assessment of patient safety: A national study
of RNs working in acute-care hospitals in Sweden. BMJ Quality & Safety, 0, 1-8.
doi:10.1136/bmjqs-2012-001734
Study tool: RN4CAST and some items from HSOPSC
Geographic region: Sweden
Sample: 9236 nurses
Practice area: Acute care hospitals
Relevant findings: RNs providing direct patient care gave higher overall patient safety rating
than supervisors. Visibility of leadership seen as influential factor in perception of patient
safety. RN4CAST is part of a larger European Union survey on nurse retention, recruitment,
and patient safety. This article is important as it gives insight into the RN4CAST and relates it
to the HSOPSC.

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Citation: Singer, S., Kitch, B., Rao, S., Bonner, A., Gaudet, J., Bates, D....& Campbell, E.
(2012). Journal of Patient Safety, 8(3), 104-124.
Study tool: Survey on Resident Safety in Nursing Homes
Geographic region: United States
Sample: 27 nurses
Practice area: Nursing homes
Relevant findings: Registered nurses are a small portion of the staff delivering direct care in
this study. This study provides information on supervisory leadership for safety in nursing
home setting. Findings reported as percent positively agree. 3 questions: (1) Management in
my unit (my managers and supervisors) listens to CNAs (33.3%); (2) Management in my unit
(my managers and supervisors) listens to staff ideas and suggestions about resident safety
(55.6%); (3) Management in my unit (my managers and supervisors) does not knowingly
compromise the safety of patients (66.7%).

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Appendix D – QualSyst Manual for Evaluating Quality of Quantitative Studies
This Appendix is reproduced from Appendix “A” of Kmet, Lee, and Cook (2004, pp.14-19).
Definitions and instructions for quality assessment scoring
How to calculate the summary score
•

Total sum = (number of “yes” * 2) + (number of “partials” * 1)

•

Total possible sum = 28 – (number of “N/A” *2)

•

Summary score: total sum / total possible sum

Quality assessment
1.

Question or objective sufficiently described?
Yes: Is easily identified in the introductory section (or first paragraph of methods
section). Specifies (where applicable, depending on study design) all of the following:
purpose, subjects/target population, and the specific
intervention(s)/association(s)/descriptive parameter(s) under investigation. A study
purpose that only becomes apparent after studying other parts of the paper is not
considered sufficiently described.
Partial: Vaguely/incompletely reported (e.g. “describe the effect of” or “examine the
role of” or “assess opinion on many issues” or “explore the general attitudes” …); or
some information has to be gathered from parts of the paper other than the
introduction/background/objective section.
No: Question or objective is not reported, or is incomprehensible.
N/A: Should not be checked for this question.

2.

Design evident and appropriate to answer study question?
(If the study question is not given, infer from the conclusions).

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Yes: Design is easily identified and is appropriate to address the study question/objective.
Partial: Design and/or study question not clearly identified, but gross inappropriateness
is not evident; or design is easily identified but only partially addresses the study
question.
No: Design used does not answer study question (e.g., a comparison group is required to
answer the study question, but none was used); or design cannot be identified.
N/A: Should not be checked for this question.
3.

Method of subject selection (and comparison group selection, if applicable) or source of
information/input variables (e.g., for decision analysis) is described and appropriate.
Yes: Described and appropriate. Selection strategy designed (i.e., consider sampling
frame and strategy) to obtain an unbiased sample of the relevant target population or the
entire target population of interest (e.g., consecutive patients for clinical trials,
population-based random sample for case-control studies or surveys). Where applicable,
inclusion/exclusion criteria are described and defined (e.g., “cancer” – ICD code or
equivalent should be provided). Studies of volunteers: methods and setting of recruitment
reported. Surveys: sampling frame/strategy clearly described and appropriate.
No: No information provided. Or obviously inappropriate selection procedures (e.g.,
inappropriate comparison group if intervention in women is compared to intervention in
men). Or presence of selection bias which likely seriously distorted the results (e.g.,
obvious selection on “exposure” in a case-control study).
N/A: Descriptive case series/reports.

4.

Subject (and comparison group, if applicable) characteristics or input
variables/information (e.g.,

for decision analyses) sufficiently described?

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Yes: Sufficient relevant baseline/demographic information clearly characterizing the
participants is provided (or reference to previously published baseline data is provided).
Where applicable, reproducible criteria used to describe/categorize the participants are
clearly defined (e.g., ever-smokers, depression scores, systolic blood pressure >140). If
“healthy volunteers” are used, age and sex must be reported (at minimum). Decision
analyses: baseline estimates for input variables are clearly specified.
Partial: Poorly defined criteria (e.g. “hypertension”, “healthy volunteers”, “smoking”).
Or incomplete relevant baseline/demographic information (e.g., information on likely
confounders not reported). Decision analyses: incomplete reporting of baseline estimates
for input variables.
No: No baseline/demographic information provided. Decision analyses: baseline
estimates of input variables not given.
N/A: Should not be checked for this question.
5.

If random allocation to treatment group was possible, is it described?
Yes: True randomization done – requires a description of the method used (e.g., use of
random numbers).
Partial: Randomization is mentioned, but method is not (i.e. it may have been possible
that randomization was not true).
No: Random allocation not mentioned although it would have been feasible and
appropriate (and was possibly done).
N/A: Observational analytical studies. Uncontrolled experimental studies. Surveys.
Descriptive case series/reports. Decision analyses.

6.

If interventional and blinding of investigators to intervention was possible, is it reported?

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Yes: Blinding reported.
Partial: Blinding reported but it is not clear who was blinded.
No: Blinding would have been possible (and was possibly done) but is not reported.
N/A: Observational analytic studies. Uncontrolled experimental studies. Surveys.
Descriptive case series/reports. Decision analyses.
7.

If interventional and blinding of subjects to intervention was possible is it reported?
Yes: Blinding reported.
Partial: Blinding reported but it is not clear who was blinded.
No: Blinding would have been possible (and was possibly done) but is not reported.
N/A: Observational analytic studies. Uncontrolled experimental studies. Surveys.
Descriptive case series/reports. Decision analyses.

8.

Outcome and (if applicable) exposure measure(s) well defined and robust to
measurement/misclassification bias? Means of assessment reported?
Yes: Defined (or reference to complete definitions is provided) and measured according
to reproducible, “objective” criteria (e.g., death, test completion – yes/no, clinical scores).
Little or minimal potential for measurement/misclassification errors. Surveys: clear
description (or reference to clear description) of questionnaire/interview content and
response options. Decision analyses: sources of uncertainty are defined for all input
variables.
Partial: Definition of measures leaves room for subjectivity, or not sure (i.e. not reported
in detail, but probably acceptable). Or precise definition(s) are missing, but no evidence
or problems in the paper that would lead one to assume major problems. Or
instrument/mode of assessment(s) not reported. Or misclassification errors may have

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occurred, but they did not likely seriously distort the results (e.g., slight difficulty with
recall of long-ago events; exposure is measured only at baseline in a long cohort study).
Surveys: description of questionnaire/interview content incomplete; response options
unclear. Decision analyses: sources of uncertainty are defined only for some input
variables.
No: Measures not defined, or are inconsistent throughout the paper. Or measures employ
only ill-defined, subjective assessments, e.g. “anxiety” or “pain.” Or obvious
misclassification errors/measurement bias likely seriously distorted the results (e.g., a
prospective cohort relies on self-reported outcomes among the “unexposed” but requires
clinical assessment of the “exposed”). Surveys: no description of questionnaire/interview
content or response options. Decision analyses: sources of uncertainty are not defined for
input variables.
N/A: Descriptive case series/reports.
9.

Sample size appropriate?
Yes: Seems reasonable with respect to outcome under study and the study. When
statistically significant results are achieved for major outcomes, appropriate sample size
can usually be assumed, unless large standard errors (SE > ½ effect size) and/or problems
with multiple testing are evident. Decision analyses: size of modeled cohort/number of
iterations specified and justified.
Partial: Insufficient data to assess sample size (e.g., sample size seems “small” and there
is no mention of power/sample size/effect size of interest and/or variance estimates aren’t
provided). Or some statistically significant results with standard errors > ½ effect size
(i.e., imprecise results). Or some statistically significant results in the absence of variance

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estimates. Decision analyses: incomplete description or justification of size of modeled
cohort/number of iterations.
No: Obviously inadequate (e.g., statistically non-significant results and standard errors >
½ effect size; or standard deviations > _ of effect size; or statistically non-significant
results with no variance estimates and obviously inadequate sample size. Decision
analyses: size of modeled cohort/number of iterations not specified.
N/A: Most surveys (except surveys comparing responses between groups or change over
time). Descriptive case series/reports.
10.

Analysis described and appropriate?
Yes: Analytical methods are described (e.g. “chi square”/”t-tests”/”Kaplan-Meier with
log rank tests”, etc.) and appropriate.
Partial: Analytical methods are not reported and have to be guessed at, but are probably
appropriate. Or minor flaws or some tests appropriate, some not (e.g., parametric tests
used, but unsure whether appropriate; control group exists but is not used for statistical
analysis). Or multiple testing problems not addressed.
No: Analysis methods not described and cannot be determined. Or obviously
inappropriate analysis methods (e.g. chi-square tests for continuous data, SE given where
normality is highly unlikely, etc.). Or a study with a descriptive goal/objective is overanalyzed.
N/A: Descriptive case series/reports.

11.

Some estimate of variance (e.g., confidence intervals, standard errors) is reported for the
main results/outcomes (i.e., those directly addressing the study question/objective upon
which the conclusions are based)?

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Yes: Appropriate variances estimate(s) is/are provided (e.g., range, distribution,
confidence intervals, etc.). Decision analyses: sensitivity analysis includes all variables in
the model.
Partial: Undefined “+/-” expressions. Or no specific data given, but insufficient power
acknowledged as a problem. Or variance estimates not provided for all main
results/outcomes. Or inappropriate variance estimates (e.g., a study examining change
over time provides a variance around the parameter of interest at “time 1” or “time 2”,
but does not provide an estimate of the variance around the difference). Decision
analyses: sensitivity analysis is limited, including only some variables in the model.
No: No information regarding uncertainty of the estimates. Decision analyses: No
sensitivity analysis.
N/A: Descriptive case series/reports. Descriptive surveys collecting information using
open-ended questions.
12.

Controlled for confounding?
Yes: Randomized study, with comparability of baseline characteristics reported (or noncomparability controlled for in the analysis). Or appropriate control at the design or
analysis stage (e.g., matching, subgroup analysis, multivariate models, etc.). Decision
analyses: dependencies between variables fully accounted for (eg., joint variables are
considered).
Partial: Incomplete control of confounding. Or control of confounding reportedly done
but not completely described. Or randomized study without report of comparability of
baseline characteristics. Or confounding not considered, but not likely to have seriously

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distorted the results. Decision analyses: incomplete consideration of dependencies
between variables.
No: Confounding not considered, and may have seriously distorted the results. Decision
analyses: dependencies between variables not considered.
N/A: Cross-sectional surveys of a single group (i.e., surveys examining change over time
or surveys comparing different groups should address the potential for confounding).
Descriptive studies. Studies explicitly stating the analysis is strictly
descriptive/exploratory in nature.
13.

Results reported in sufficient detail?
Yes: Results include major outcomes and all mentioned secondary outcomes.
Partial: Quantitative results reported only for some outcomes. Or difficult to assess as
study question/objective not fully described (and is not made clear in the methods
section), but results seem appropriate.
No: Quantitative results are reported for a subsample only, or “n” changes continually
across the denominator (e.g., reported proportions do not account for the entire study
sample, but are reported only for those with complete data—i.e., the category of
“unknown” is not used where needed). Or results for some major or mentioned secondary
outcomes are only qualitatively reported when quantitative reporting would have been
possible (e.g., results include vague comments such as “more likely” without quantitative
report of actual numbers).
N/A: Should not be checked for this question.

14.

Do the results support the conclusions?

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Yes: All the conclusions are supported by the data (even if analysis was inappropriate).
Conclusions are based on all results relevant to the study question, negative as well as
positive ones (e.g., they aren’t based on the sole significant finding while ignoring the
negative results). Part of the conclusions may expand beyond the results, if made in
addition to rather than instead of those strictly supported by data, and if including
indicators of their interpretative nature (e.g., “suggesting,” “possibly”).
Partial: Some of the major conclusions are supported by the data, some are not. Or
speculative interpretations are not indicated as such. Or low (or unreported) response
rates call into question the validity of generalizing the results to the target population of
interest (i.e., the population defined by the sampling frame/strategy).
No: None or a very small minority of the major conclusions are supported by the data. Or
negative findings clearly due to low power are reported as definitive evidence against the
alternate hypothesis. Or conclusions are missing. Or extremely low response rates
invalidate generalizing the results to the target population of interest (i.e., the population
defined by the sampling frame/strategy).
N/A: Should not be checked for this question.

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Appendix E – QualSyst Manual for Evaluating Quality of Qualitative Studies
This Appendix is reproduced from Appendix “B” of Kmet, Lee, and Cook (2004, pp.20-22).
Definitions and instructions for quality assessment scoring
How to calculate the summary score
•

Total sum = (number of “yes” * 2) + (number of “partials” * 1)

•

Total possible sum = 20

•

Summary score: total sum / total possible sum

Quality assessment
1.

Question or objective sufficiently described?
Yes: Research question or objective is clear by the end of the research process (if not at
the outset).
Partial: Research question or objective is vaguely/incompletely reported.
No: Question or objective is not reported, or is incomprehensible.

2.

Design evident and appropriate to answer study question?
(If the study question is not given, infer appropriateness from results/conclusions).
Yes: Design is easily identified and is appropriate to address the study question.
Partial: Design is not clearly identified, but gross inappropriateness is not evident; or
design is easily identified but a different method would have been more appropriate.
No: Design used is not appropriate to the study question (e.g., a causal hypothesis is
tested using qualitative methods); or design cannot be identified.

3.

Context for study is clear?
Yes: The context/setting is adequately described, permitting the reader to relate the
findings to other settings.

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Partial: The context/setting is partially described.
No: The context/setting is not described.
4.

Connection to a theoretical framework/wider body of knowledge?
Yes: The theoretical framework/wider body of knowledge informing the study and the
methods used is sufficiently described and justified.
Partial: The theoretical framework/wider body of knowledge is not well described or
justified; link to the study methods is not clear.
No: Theoretical framework/wider body of knowledge is not discussed.

5.

Sampling strategy described, relevant and justified?
Yes: The sampling strategy is clearly described and justified. The sample includes the
full range of relevant, possible cases/settings (i.e., more than simple convenience
sampling), permitting conceptual (rather than statistical) generalizations.
Partial: The sampling strategy is not completely described, or is not fully justified. Or
the sample does not include the full range of relevant, possible cases/settings (i.e.,
includes a convenience sample only).
No: Sampling strategy is not described.

6.

Data collection methods clearly described and systematic?
Yes: The data collection procedures are systematic, and clearly described, permitting an
“audit trail” such that the procedures could be replicated.
Partial: Data collection procedures are not clearly described; difficult to determine if
systematic or replicable.
No: Data collection procedures are not described.

7.

Data analysis clearly described, complete and systematic?

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Yes: Systematic analytic methods are clearly described, permitting an “audit trail” such
that the procedures could be replicated. The iteration between the data and the
explanations for the data (i.e., the theory) is clear – it is apparent how early, simple
classifications evolved into more sophisticated coding structures which then evolved into
clearly defined concepts/explanations for the data). Sufficient data is provided to allow
the reader to judge whether the interpretation offered is adequately supported by the data.
Partial: Analytic methods are not fully described. Or the iterative link between data and
theory is not clear.
No: The analytic methods are not described. Or it is not apparent that a link to theory
informs the analysis.
8.

Use of verification procedure(s) to establish credibility of the study?
Yes: One or more verification procedures were used to help establish
credibility/trustworthiness of the study (e.g., prolonged engagement in the field,
triangulation, peer review or debriefing, negative case analysis, member checks, external
audits/inter-rater reliability, “batch” analysis).
No: Verification procedure(s) not evident.

9.

Conclusions supported by the results?
Yes: Sufficient original evidence supports the conclusions. A link to theory informs any
claims of generalizability.
Partial: The conclusions are only partly supported by the data. Or claims of
generalizability are not supported.
No: The conclusions are not supported by the data. Or conclusions are absent.

10.

Reflexivity of the account?

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Yes: The researcher explicitly assessed the likely impact of their own personal
characteristics (such as age, sex and professional status) and the methods used on the data
obtained.
Partial: Possible sources of influence on the data obtained were mentioned, but the likely
impact of the influence or influences was not discussed.
No: There is no evidence of reflexivity in the study report.

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Appendix F – QualSyst Checklist for Evaluating Quality of Quantitative Studies
This checklist is drawn from Kmet, Lee, and Cook (2004, p.4).

1

Criteria
Question/objective sufficiently described?

2

Study design evident and appropriate?

3

Method of subject/comparison group selection or
source of information/input variables described and
appropriate?

4

Subject (and comparison group, if applicable)
characteristics sufficiently described?

5

If interventional and random allocation was
possible, was it described?

6

If interventional and blinding of investigators was
possible, was it reported?

7

If interventional and blinding of subjects was
possible, was it reported?

8

Outcome and (if applicable) exposure measure(s)
well defined and robust to
measurement/misclassification bias? Means of
assessment reported?

9

Sample size appropriate?

10 Analytic methods described/justified and
appropriate?
11 Some estimate of variance is reported for the main
results?
12 Controlled for confounding?
13 Results reported in sufficient detail?
14 Conclusions supported by results?

YES
(2)

PARTIAL
(1)

NO
(0)

N/A

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Appendix G – QualSyst Checklist for Evaluating Quality of Qualitative Studies
This checklist is drawn from Kmet, Lee, and Cook (2004, p.5).

1

Criteria
Question/objective sufficiently described?

2

Study design evident and appropriate?

3
4

Context for the study clear?
Connection to a theoretical framework/wider body of
knowledge?
5 Sampling strategy described, relevant and justified?
6 Data collection methods clearly described and systematic?
7 Data analysis clearly described and systematic?
8 Use of verification procedure(s) to establish credibility?
9 Conclusions supported by the results?
10 Reflexivity of the account?

YES
(2)

PARTIAL
(1)

NO
(0)

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Appendix H – Summary of QualSyst Quality Scores for Included Articles
Quantitative studies

Lead author
Abdi
Aboul-Fotouh
Ahmed
Al-Awa
Al-Mandari
Almutairi
Ammouri
Bahrami
Ballangrud
Brborovic
Carvalho
Davis
Di Benedetto
Feng
Gabrani
Gunes
Haerkens
Khater
Kvist
Mantynen
Nguyen
Nie
Saleh
Singer
Smeds-Alenius
Turunen
Turunen
Ulrich
Verbeek-van
Noord
Vifladt (2016a)
Vifladt (2016b)
Wang
Yilmaz
Zakari

QualSyst
score
17/20
20/20
20/20
20/20
20/20
20/20
20/20
20/20
20/20
20/20
20/20
20/20
20/20
20/20
19/20
20/20
20/20
20/20
20/20
22/22
20/20
16/20
20/20
20/20
20/22
19/20
20/20
20/20
20/20

Percentage
score
85%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
95%
100%
100%
100%
100%
100%
100%
80%
100%
100%
91%
95%
100%
100%
100%

22/22
22/22
22/22
20/20
20/20

100%
100%
100%
100%
100%

NURSES’ PERCEPTIONS OF SUPERVISORY LEADERSHIP FOR PATIENT SAFETY
120
Qualitative studies

QualSyst score for included quantitative
studies
n = 34
Percentage
Number of studies
score
100
29
95
2
91
1
85
1
78
1
Lead author
QualSyst
Percentage
score
score
Danielsson

20/20

100%

QualSyst score for included qualitative
studies
n=1
Percentage score
Number of studies
100
1