Patient Safety Culture Perception among Moroccan Healthcare professionals: Cross-Sectional Study in Public Hospitals

Background There is a growing recognition of the need to establish a culture that focuses on patient safety in order to reduce the number of adverse events associated with care and improve health-care quality in Morocco. The aim of this research is to analyze results of the perception of health professionals working in two university hospitals concerning the concept of patient safety culture in Morocco. Methods This study evaluated the healthcare professional's perceptions of patient safety culture in two selected university hospitals centers in Morocco by using the validated French version of the Hospital Survey on Patient Safety Culture questionnaire (HSOPSC). A cross-sectional descriptive study was conducted in 2021. We randomly selected 10 health units of each hospital, to include up to 10 health professionals from each unit, regardless of length of experience. This self-administered questionnaire was distributed to a population of 204 Moroccan healthcare professionals who consisted predominately of available physicians and nurses across ten different health units. Result The overall grade of patient safety was deemed “good” for 52 % of the staff, “very good” for 17%, against “failing” for 2%. Out of the 10 dimensions explored. The “Teamwork within units” dimension had the highest score with 80%. The dimensions with the lowest positive response rates were “Staffing (23%)”, “non-punitive response to error” (31%) and “Teamwork across units' (47%). Seven dimensions were considered underdeveloped and three were undeveloped. Conclusion This work provides a better understanding of healthcare professional perception towards patient safety.


INTRODUCTION
The culture of patient safety is an important component of healthcare quality and an issue whose notoriety has been of high concern globally for the world health organization (WHO) (1). As it is an elementary factor forming the behaviors, perceptions and attitudes of health professionals (2). It can alter the process of providing care Adverse events are considered as damages emerging from errors or failures in the caregiving assistance provided by health professionals, whether intentionally or not, resulting in permanent or temporary harm injuries that incapacitate patients or even lead to death (4,5).
Several studies demonstrate that adverse events and medical errors are influenced by patient safety culture (6)(7)(8). Hence, interventions for the reduction of adverse events incorporate an enhancement of patient safety culture and the establishment of a reporting system that permit to learn from errors without blame. Therefore, the perception of health professionals concerning PSC is considered primary to insure the prevention and evaluation of patient safety in the hospital units (9,10).
In developing countries such as Morocco, the situation is more challenging, including higher risk of adverse events occurrence and underreporting, in consequence to the limitation in human resources, infrastructures, developed technologies, and lack of suitable measuring tools of the level and perception of safety in the health institutions (11)(12)(13)(14). To our knowledge, no studies have assessed healthcare professional's perception of patient safety culture in Morocco, specifically in hospitals related to the University hospital center in Casablanca and the University hospital center in Rabat.
Therefore, considering the importance of strategies for the assumption of a positive patient safety culture, in these primary health institutions in Morocco, this research is aiming to assess the results of analysis of the perception of health professionals who work in university hospitals of the patient safety culture, conducted in response to the gap of knowledge on the subject in Morocco (15).

MATERIALS AND METHODS
Study setting and participants: This is a university hospital-based cross-sectional study in which the HSOPS French version questionnaire was used to assess patient safety culture from the healthcare professional perspective, conducted from January to March of 2021. The study was carried out in two university hospitals, one in Casablanca (Morocco) and another in Rabat (Morocco). Both institutions provide high-complexity care, teaching (undergraduate and graduate) and research functions in all medical specialties and has more than 3000 beds. We randomly selected 10 health units of each hospital, to include up to 10 health professionals from each unit, regardless of length of experience. The population (N =204) consisted of all staff (physicians, nurses, midwifes, and other health workers). The survey was administered to staff that interacted with the patients in the last 12 months. Participation in the study was voluntary.
Study instrument: The current research used as assessment tool the Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire, which was created and developed by the Agency for Healthcare Research and Quality (AHRQ) (16,17). The French version of the HSOPSC questionnaire explores the same constructs as the original version does, translated into French and validated by the Coordination Committee of the Clinical Evaluation and Quality in Aquitaine (CCCEQA) (18,19). The questionnaire has shown acceptable psychometric properties in this version. It also has a good feasibility and acceptability as it was observed in several psychometric studies like Occelli and al (20,21), reliability of the HSOPSC is reportedly high with a Cronbach alpha of 0.88 for the whole questionnaire and varies between 0.46 and 0.84 for the dimensions. Therefore, it was a valid and reliable tool to assess PSC.
The French version of the questionnaire is composed of Ten PSC dimensions explored through 45 items to assess the beliefs, skills and behaviors involved in the safety culture of the organization from hospital staff perspectives organized as follows: D1: Overall perception of patient safety, D2: Frequency of events reported, D3: Supervisor/manager expectations and actions promoting patient safety, D4: Organizational Learning-Continuous Improvement, D5: Teamwork within units, D6: Communication openness, D7: Non-punitive response to error, D8: Staffing, D9: Management support for patient safety, D10: Teamwork across units, each dimension is composed of three to four items constructed in a positive or negative manner.
For each item, the respondent may choose a score on a five-point Likert scale with the response options ranging from (5) strongly agreeing to (1) strongly disagreeing. Scores (4) agree and (5) strongly agree are considered 'positive' in relation to PSC, score (3) is 'neutral' and scores (1) strongly disagree and (2) disagree are considered 'negative' in relation to PSC. The primary outcome was the percentage of positive responses for each dimension of the HSOPS. Negatively worded items were reversecoded because an answer on a negatively worded item indicates a positive response.
Two other items assess individual assessments of patient safety: the "patient safety grade", with response options of excellent, good, very good, poor and failing, and the "number of events reported", with response options of no events reported, 1 to 2 events reported, 3 to 5 events reported, 6 to 10 events reported, 11 or more events reported. Data collection: In this study, we distributed a paper-based questionnaire to the participants after obtaining their verbal consent. They could freely and anonymously fill in the questionnaire and return their responses directly to the investigator. According to the user guide of the French version of HSOPSC questionnaire, if none of the dimensions' sections were entirely filled, the questionnaire would not be taken into account. In addition, if less than half of the items in the questionnaire have been completed, or the same answers were given to all the items, the questionnaire would be illegible and excluded (20). Data analysis: Data were entered and analyzed using the software Microsoft Excel. For general analysis of responses to different questions, we calculated the percentage of positive responses regarding the presence of patient safety culture in each dimension by dividing the number of positive responses ("strongly agree/agree") by the total number of responses (positive, neutral and negative) in the dimensions.
A percentage of positive responses above 75% was considered developed, a percentage of positive responses between 75% and 50% was considered underdeveloped and a percentage below 50% was undeveloped, showing that there were issues that needed improvement. For items with reverse wording with a negative connotation, disagreement indicated a positive response. Thus, to calculate the percentage of positive responses among the answers, we needed to consider the strongly disagree/disagree responses as positive answer.

RESULTS
Characteristics of the participants: From the 255-targeted healthcare professionals that provided survey feedback professionals, 51 illegible questionnaires were excluded and in total 204 questionnaires were approved and analyzed. Therefore, the response rate was of 80%, which is a required criterion for significant results.
The characteristics of health professionals including physicians, nurses, assistant, technicians and midwifes who responded to the questionnaire are summarized in (Table1). Healthcare professional's overall perception of patient safety quality ranked as good in 52% of cases (55% for physicians and 50% nurses) and poor in 23% of cases (20% for physicians and 29% for nurses). In addition, most professionals did not report any adverse events (62%) in the last 12 months (55% of physicians and 66% of nurses) as described in (Table 2) with the exception of professionals working for more than 10 years in the units or in a committee of management.

PSC dimensions:
The overall perception of patient safety had an average positive score of 55%. Most dimensions had scores between 50% and 70% or above they are all underdeveloped or developed with the exception of three dimensions that were undeveloped with less than 50% scores ( Table 3). The percentage of positive responses was highest for teamwork within units (80%) professionals felt that people supported each other, worked together as a team, and treated each other with respect. They had also the impression that in contact with their colleagues, they improved their care practice of safety. The lowest scores were (Table 3): D8 (Staffing (23%)): the professionals felt there were insufficient staff members to handle the workload. Furthermore, they had the feeling of constantly working in urgency mode. D7 (Non-punitive response to error (31%)): staff focusing on the fear of attribution of responsibility of error to a single person. D10 (Teamwork across units (47%)): the staff underlined the existence of dysfunctions during inter-departmental exchanges and communication.

DISCUSSION
The present study was conducted to analyze healthcare professional's perception of PSC in two Moroccan university healthcare centers. Analyzing the perceptions of professionals working in health institutions units of care using a questionnaire makes it possible to approach the unit's safety culture, to discuss with the professionals the issues covered through the dimensions and make them aware of important items that need developing. Improving the safety of care is conditioned by a shared vision of professionals on a culture of safety (22,23). The dimension of overall perception of safety had a score of (55%). This reflects the lack of safety standards and the implementation of strategic and corrective measures to increase awareness of this issue among health professionals in the two hospitals of this study.
Our study shows that one of the 10 dimensions explored, one was developed, six are considered underdeveloped and three undeveloped. The dimension of teamwork within units had the highest score, the staff communication within the units has proven to be of high quality in terms of coordination in care and supporting co-workers, freedom of expression is felt positively by the majority of staff interviewed. Most healthcare staff reported that they had shortage of staff to handle the workload, and that they worked longer hours than are recommended for patient care. This situation may have severe negative consequences for patient safety and quality of care (24). Furthermore, staff reported that they felt guilt about their mistakes, which were held against them, and the management focus was on their involvement in the AE rather than the AE itself. The issue of under-reporting AEs must become a priority to be taken into consideration and treated with vigilance; the staff should be encouraged to report AEs and rewarded for doing so (25,26). Patient safety culture in university hospital centers has been given increasing attention and many studies have shown a low level of safety and high level of AEs with negative consequences in similar setting (27)(28)(29)(30). In comparison with a study in 2020 of PSC in similar health institutions, the results of scores of the dimensions were similar to our study, the research of Fourar & al, in Algeria perceived that PSC was in overall underdeveloped. As well as comparable to our study non-developed dimensions were "non-punitive response to error" (31.9%), "Staffing" (26%), and "Teamwork across hospital units" with respective score of (39.5%). The dimension of teamwork within units had the highest score (78.5%) (31). In indication that the concept of patient safety culture and the perceptions and attitudes toward the improvement of this culture is a new concept that need more attention to create a safety environment in the health care institution in developing countries with similar sitting and sanitary challenges such as Algeria and Morocco.
According to healthcare organizations, for safety culture measurement to be useful, it must be accompanied by a return of the results at the same time in the units and at the institutional level (32). We recommend four major areas for improvement that have been identified and will be subject to specific training: 1. Improving analysis and management of risk and medical error by training and raising staff awareness of the culture of safety and the report of AE, by requesting resources of the institution of health management team and by evaluating the progress of teams in units; 2. Developing the scientific knowledge of the staff, to propose actions for improvement and to mitigate the feeling of personalization of the error and blame culture by encouraging collective responsibility for the care and making a multifactorial and multidisciplinary analysis. The evaluation of improvement actions must be ensured. 3. Involvement of administrative staff in the problems of the units and an improvement communication between administrators and caregivers in order to adapt human resources in number and availability. 4. The continuous improvement of teamwork across units and quality of life at work for professionals, by implementing a better communication system across units.
Several benefits are expected in the long term, within the increase in reporting of AEs and the use of a more professional vocabulary, building the spontaneity of the team to integrate in a risk management approach, the increase feedback and analysis and improved communication between professionals across units. The effect of these measures will have to be reassessed by resubmitting this questionnaire to the teams in units.
Therefore, it is important to create a culture in which health professionals are encouraged and supported to identify and report AEs without fear of punitive action or blame. Reporting of AEs is an essential component of effective strategies to improve patient safety that includes identification of error, reporting, analysis and corrective actions (33).
This work provides a better understanding of healthcare professional perception towards patient safety. In general, the level of patient safety culture in hospitals is good. With 6 out of 10 dimensions underdeveloped according to the results of the questionnaire, the culture safety of care seems to be an axis of work and a priority in our university hospital centers. The next step will be to continually evaluate and implement actions of improvement targeting these issues like blame culture regarding adverse events reporting and lack of staff during shifts in the units. A pertinent perception of culture of security should make it possible to obtain the adherence of health professionals to the systems of safety of care. In fact, narrowing the communication gap across hospital department units, and providing an equal chance to everybody to give their input about the patient safety. The evaluation and development of a culture safety of care, it is a question of making safety a priority for everyone, professionals in the field as well as managers.
This study has several limitations, such as assessment of perception of PSC, using a selfadministered questionnaire can be associated with a declaration bias. In addition, although we included two of the major university health centers of the targeted region, the chosen samples of professionals did not allow us to assume that these included settings were representative of the entire healthcare system in Morocco. Indeed, several respondents could not fill the questionnaire. In addition, we selected only one investigation tool to measure the patient safety culture, and hence the possibility of such biases cannot be completely dismissed.