The relationship between job stress and patient safety culture among nurses: a systematic review

The level of healthcare quality is critically dependent on patient safety. To consistently improve the level of care, it is becoming more widely acknowledged that health organizations need to improve their safety cultures [1]. Patient safety has been viewed as one of the key elements of healthcare administration [2]. According to Kohn et al. [3], safety is an essential and fundamental component of research on patient care. Safety culture is the combination of individual and group beliefs, attitudes, competencies, and behavioral patterns that shape an organization's commitment to attitude and level of competency in managing the safety of patients [1, 4]. The Agency for Healthcare Research and Quality (AHRQ) also defines patient safety culture as the degree to which an organization's culture supports and promotes patient safety [5].

The health-work interface has been recognized as a topic that must be discussed in today's world, particularly in the hospital setting when it comes to patient safety. Workers' health and working conditions appear to be crucial factors to consider while seeking safe treatment [6].

Job stress is one of the leading reasons for physical and mental problems among healthcare staff and lower productivity in healthcare organizations. It may affect the quality of health services, especially among nurses [7, 8]. Job stress is a harmful physical and emotional response that can occur when an employee is confronted with job demands and pressures that are out of relation to their knowledge, capabilities, and abilities, making it difficult to cope with [9]. Nursing is a stressful and high-risk profession, and nurses face job stress at work with great frequency [10, 11]. In many nations, nurses account for 50% of all health care professionals. They play a critical role in the management and front-line implementation of health measures [12]. While personally caring for patients, nurses play a crucial role in maintaining patient safety, since they spend much of their time with patients [13]. However, shortage of staff, work pressure, under-reporting of adverse events, and professionals' lack of continuing education all have an impact on the emergence of stress and adverse events, which helps to foster an environment where mistakes can happen and patients can suffer harm [14].

The impact of health injuries from stress on healthcare personnel can jeopardize patient safety. The exhausted health care staff and their difficulty coping with job stress may negatively impact the safety culture [6]. Job-related stress affects organizational performance, staff, and service outcomes [15]. Nurses are responsible for maintaining patient safety while providing health care. Thus, following safety standards while serving everyday treatment could reduce adverse events and damages [7]. Previous studies have indicated a positive relationship between organizational learning, good teamwork, and communication about errors as factors for improving patient safety culture [16‐18]. However, few studies have examined the relationship between job stress and patient safety culture. To our knowledge, no systematic review has been conducted to address this relationship. Therefore, this literature review aims to find and analyze the studies to increase the available knowledge regarding the relationship between job stress and patient safety culture.

Our search resulted in seven related articles. We reviewed the full text of these articles to look for the relationship between job stress and patient safety culture among nurses. The reviewed articles were all cross-sectional studies. However, one study used a cross-sectional, multicenter, mixed-methods approach [25], and one used descriptive correlational [22]. The size of the samples ranged from 143 [24] to 1671 [21], with a response rate ranging from 54.4% [22] to 92% [7]. Most of the studies were conducted in Iran [7, 20, 24], and other studies were conducted in Turkey [22], China [21], Oman [23], and Germany [25]. Detailed characteristics of the studies can be viewed in Table 2.

Regarding the tools used to assess job stress among nurses, study researchers used different instruments, one of which was self-developed [20]. However, most studies used the Hospital Survey of Patient Safety Culture (HSOPSC) to assess the level of safety culture among nurses more frequently than any other [7, 21, 23, 25]. In addition, the Safety Attitudes Questionnaire (SAQ) was used in one study [22], the Nurses Safety Climate Assessment Questionnaire was also used in one study [24], and a self-developed questionnaire using a patient safety checklist with 44 items was used in the last study [20].

In this systematic review, 350 journal articles were screened, and only 29 selected articles contained quantitative information on the relationship between job stress or factors associated with job stress and patient safety culture within the nursing field. However, not all of these articles directly examined the relationship between job stress and patient safety culture. Only three articles discussed the relationship directly, which made it difficult to focus on this exact relationship. The rest of the related articles were four, and they examined the relationship between patient safety culture and factors related to job stress, such as fatigue, workload, workplace violence, and burnout.

Three articles discussed the relationship between occupational stress or job stress and patient safety culture. The findings of these studies showed that a significant negative relationship was found between job stress and patient safety culture [7, 22, 24]. However, it was not within the same power in all studies. For example, Yalcin Akgul and Aksoy [22] explained that the relationship was weak. That could be because the study was conducted in one unit with a small number of nurses participating. Other studies showed that many factors such as fatigue, workload, burnout, and workplace violence impacted staff’s job stress and lowered patient safety culture [21, 23, 25]. That is because these factors could increase nurses' stress, making them more prone to mistakes and adverse events, which in turn has been associated with patient safety. Although Keykaleh et al. [20] have found factors that greatly impacted nurses' stress, no significant relationship between nurses' job stress and patient safety culture was found. That could be due to the differences in working conditions in the hospitals where this study was conducted.

It is wise to note that this review was based on the findings of seven studies with different results. There are many possible causes for the differences in the findings. The first might be the sample size and study population disparity. For example, in one study, the population was all OR staff including nurses, physicians, and technicians [22]. Another study focused on nurses and physicians [25]. However, other studies were conducted exclusively on nurses [7, 20, 21, 23, 24]. The second reason for the disparity could be differences in socioeconomic status and measurement instruments. For example, Sturm et al. [25] used the German version of the Hospital Survey on Patient Safety Culture, which had some differences in the number of components compared to other versions of the same tool. Other studies used different tools to measure patient safety culture, which had some variations in the components compared to other tools [20‐22, 24]. That also applies to measuring job stress, as different tools with variations in their components were used. Using different tools means that some studies assessed the relationship between job stress and some dimensions of patient safety culture with different approaches. For instance, Al Ma'mari et al. [23] assessed the relationship between job stress variables with an overall perception of the patient safety culture dimension. However, Asefzadeh et al. [7] assessed the relationship between job stress with each dimension of patient safety culture separately. In the rest of the studies reviewed, the lack of consistency among tools made it difficult to evaluate specific dimensions of other tools in comparison to others.

Another reason for the differences in the relationship found in this review might be the different working conditions for nurses, affecting job stress. For example, the type of hospitals (educational, private, or government), the number of patients, the number of staff, financial means [22], and other related conditions can affect the overall results of job-related stress and also the perception of the patient safety culture [20]. In addition, nurses' demographic characteristics could affect the overall level of stress at work. However, not all have a negative relationship, due to the differences between their living conditions and their work conditions [7, 20].

To our knowledge, this is the first conducted systematic review that investigates the relationship between job stress and patient safety culture. However, the studies included in this review have some limitations. The first limitation was that all of them were cross-sectional. While all articles in the review to examined the impact of job stress on patient safety culture, cross-sectional investigations do not exclude the possibility of a bidirectional relationship between the variables. The possibility of influence from patient safety culture on job stress merits future investigation. In addition, most were conducted at a single site or in a single unit in a hospital, limiting the generalizability of results. The next limitation was that this review did not include the gray literature. Finally, the last limitation could be attributed to the heterogeneity of the studies, which the readers should consider when applying this conclusion.

The finding of this review suggests that there is a negative relationship between job stress and patient safety culture. The cornerstone of promoting patient safety and quality of treatment in healthcare institutions is the patient safety culture. Building a strong patient safety culture is critical for healthcare institutions to promote patient safety while improving the quality of care. Job stress seems to be one of the barriers to improving the patient safety culture, which requires the development of effective stress management measures for nurses and other healthcare staff. Therefore, administrators and nursing managers should consider nursing stress in the workplace a safety issue. More research is needed to develop interventions to reduce nursing stress in the workplace and improve their work environment and provide safe patient care at an optimal level.