Healthcare organizations are struggling to cope with a growing global shortage of healthcare practitioners (Kroezen et al., 2015; Kuhlmann et al., 2013; Scheffler & Arnold, 2019; World Health Organization, 2016). In North America, as in other parts of the world, this shortage is most notable in nursing professions (American Association of Colleges of Nursing [AACN, 2019]; Canadian Nurses Association [CNA, 2014]; Snavely, 2016). A study projecting human resource shortages in healthcare among Organisation for Economic Co-operation and Development countries reports that Canada and the United States will see critical nursing shortages by 2030 (–26.3% and –42.4%, respectively; Scheffler & Arnold, 2019). In addition to existing nursing shortages, reduced retention also contributes to the burgeoning healthcare practitioner shortage (Austin et al., 2017).
Efforts to retain the existing workforce are negatively influenced by factors such as the aging nursing workforce, chronic staffing shortages, higher patient acuity, and increasing patient caseloads (AACN, 2019; CNA, 2014; Snavely, 2016; Unruh et al., 2016; Welton, 2017). An additional factor negatively affecting retention is the self-reported injury and illness rates of healthcare practitioners, which are among the highest of any occupational group in North America (Amaro et al., 2018; United States Department of Labor, 2016, 2019; Walton & Rogers, 2017).
Safety perceptions are crucial as workplace safety climate perceptions have been shown to have a relationship with care practitioner occupational self-reported injury rates as well as poor job satisfaction and turnover (McCaughey et al., 2013; Wagner et al., 2019; Walton & Rogers, 2017). Rates of occupational injury and illness for which sick time is taken vary for nurses in comparison to healthcare aides (United States Department of Labor, 2016, 2018), suggesting that these injury statistics may be related to position-specific job duties. However, little is known about the relationship between type of healthcare practitioner and their respective perceptions of safety (Flin, 2007). As such, the purpose of this study was to examine healthcare practitioner perspectives of workplace safety climate, job stress, and turnover intention to highlight potential differing perspectives by position (healthcare aides, nurses, allied health professionals).
Workplace Safety Climate
Workplace safety climate denotes employee perceptions of workplace safety and considers the relationship among variables (safety knowledge, safety policies, safety training) to work-related employee outcomes (work performance, injury rates, turnover, organizational commitment; Hofmann et al., 2017; Wagner et al., 2019). Outcomes in this study refer to observable behavioral or attitudinal effects that result from employee–workplace interaction. Workplace safety perceptions are influenced by many workplace factors (e.g., leadership, organizational culture, policy) and are linked to outcomes, including self-reported injury, accidents, and employee well-being (e.g., job satisfaction, engagement, turnover; Huang et al., 2016; Zohar et al., 2014). Previous research demonstrated a significant relationship between an individual’s safety perceptions and subsequent employee outcomes (Flin, 2007; Wagner et al., 2019). In addition, perceived positive workplace safety environments are related to positive work attitudes, willingness to participate in company programs, overall work performance, and organizational commitment as well as minimized negative employee outcomes such as poor job satisfaction, stress, and increased turnover intention (Hemmelgarn & Glisson, 2018). Conversely, poor safety climate perceptions have a negative relationship with key factors of healthcare practitioner retention such as stress, job satisfaction, and turnover intent (Kroezen et al., 2015; McCaughey et al., 2014; Sadatsafavi et al., 2015). This leads to the following hypotheses:
Hypothesis 1a (H1a): Healthcare practitioners who report a high level of safety climate perceptions will report lower stress levels, lower turnover intent, and greater job satisfaction than healthcare practitioners who report a negative/lower level of safety climate perceptions.
Hypothesis 1b (H1b): The odds ratio of reporting workplace injury will increase with poorer/lower safety climate perceptions.
Care Practitioner Position as a Workplace Safety Climate Antecedent
Workplace safety climate studies attempt to identify the antecedents that foster employee safety perceptions in order to positively influence the safety perceptions/employee outcomes relationship. Seminal studies of safety climate in healthcare (Flin, 2007; Flin et al., 2006; Neal & Griffin, 2004) have identified antecedents/safety climate/employee outcomes relationships; they have found that (1) safety antecedents are individual or environmental; (2) determinants of safe behavior include safety perceptions, knowledge, and motivation; and (3) employee and organizational outcomes are job performance and safety actions. In these relationships, antecedents influence generalized safety behavior determinants (i.e., safety climate perceptions), which then function as precursors to workplace performance, behavior, and outcomes. These robust relationships are well supported in the workplace safety climate literature (Flin, 2007; Flin et al., 2006), however, there is a need to examine the healthcare practitioner position as a safety antecedent.
Healthcare practitioner position may have a significant relationship with safety perceptions and outcomes, as on-the-job injury and illness rates vary (United States Department of Labor, 2016, 2019). In the United States, healthcare practitioners in acute care settings experience an average of 7.7 nonfatal occupational injury and illness incidents per 100 workers, while those in nursing and residential care facilities experience an average of 10.9 incidents per 100 workers (United States Department of Labor, 2019). Variation in injury and illness statistics between nurses and healthcare aides suggests that injuries may be position related and result from role responsibilities. Divergence in roles and responsibilities and degree of patient interaction across the care practitioner spectrum may also affect variation in safety perceptions.
Anticipating the direction of the safety perception in the various roles can be a challenge, given the dearth of research comparing safety climate perceptions across healthcare practitioner positions. Significant differences in injury and illness rates (Occupational Safety and Health Administration, 2013; United States Department of Labor, 2016) suggest there may be differences in safety perceptions by care practitioner position, particularly when including allied health professionals (e.g., physical and occupational therapists) in the analysis, which leads to the following hypothesis:
Hypothesis 2 (H2): Workplace safety climate perceptions will vary by healthcare practitioner (nurses, healthcare aides, allied health professionals).
In summary, workplace safety climate perceptions are posited to have a direct relationship with core factors of care practitioner well-being (stress, turnover intent, job satisfaction) as well as rate of workplace injury (Danna & Griffin, 1999). Given the spectrum of roles and responsibilities of care practitioners, the position itself potentially functions as an antecedent to individual safety climate perceptions.
This research was a cross-sectional study using a nonexperimental survey design. The survey questionnaire was designed to examine workplace safety climate perceptions of care practitioners, specifically by position, as an antecedent to safety perceptions and outcomes, including injury rates. The study sampled a population of unionized healthcare practitioners working in a 298-bed community hospital in Western Canada. Participating hospital wards were selected in conjunction with the hospital’s chief nursing officer and the manager of education services. Wards were chosen to meet the inclusion criteria of employees providing acute and ambulatory patient care, as were multidisciplinary care teams. Written approval to conduct the study was obtained from the researchers’ university research ethics board and the ethics committee of the hospital in the study.
Survey packages were distributed to 788 healthcare practitioners, yielding a response rate of 221 (28%). This rate is similar to rates of previous studies (VanGeest & Johnson, 2011). The packages included details regarding privacy and confidentiality requirements; data collection, storage, and disposal; and data dissemination. Completion of the survey implied consent to participate in the study. At the hospital management’s request to protect the confidentiality of the employees completing the survey, no coding system was employed for survey follow-up. Data from three inpatient wards (medicine, surgery, geriatric rehabilitation) were examined. Each ward consisted of a multidisciplinary care team, including nurses, healthcare aides, and allied health professionals. Across these three inpatient wards, 144 usable surveys were collected.
Study variables included healthcare practitioner position, employee perceptions of their workplace safety climate, job stress, turnover intention, job satisfaction, and self-reported injury. Employee perception of safety, climate, job stress, and turnover used a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Job satisfaction used a 7-point Likert scale (1 = very strongly disagree to 7 = very strongly agree). Details of each variable follow.
- Healthcare practitioner position. Healthcare practitioner position was self-reported as either healthcare aide, nurse (registered nurse), or allied health professional.
- Individual workplace safety climate scale. A 10-item scale from Hayes et al. (1998) measured the dimension of individual workplace safety climate. Higher scores indicated the respondents believed their workplace had a higher level of safety, while lower scores indicated a perception of a less safe work environment (e.g., could get hurt, unsafe, risky). Cronbach alpha for individual workplace climate safety in this study (a = .91) was consistent with that found in previous research (Hayes et al., 1998).
- Job stress scale. A 13-item scale (Parker & DeCotiis, 1983) measured the dimension of job stress. Higher scores indicated that individuals felt higher levels of workplace stress, while lower scores indicated respondents reporting less stress. Cronbach alpha for the job stress scale in this study (a = .92) was consistent with that found in previous research (Jamal & Baba, 1992; Parker & DeCotiis, 1983).
- Turnover intentions scale. A four-item scale (Abrams et al., 1998) measured potential to leave current employment. High scores suggested a potentially high turnover intention, while lower scores suggested a low intention toward turnover. Cronbach alpha for the turnover intentions in this study (a = .87) was consistent with other studies (Abrams et al., 1998).
- Job satisfaction scale. A three-item overall job satisfaction scale (Cammann, 1983) measured employee job satisfaction. Higher scores equated with higher levels of job satisfaction, while lower scores indicated poor job satisfaction. Cronbach alpha for job satisfaction (a = .87) was consistent with that found in previous research (Cammann, 1983).
- Number of injuries. Respondents self-reported how many workplace injuries they had experienced in the previous year.
- Covariates. Professional characteristics of survey participants included education level and years of experience. Previous studies have shown these professional characteristics are related to healthcare practitioner injury and well-being (McCaughey et al., 2016; Walton & Rogers, 2017).
The demographics of the subjects were as follows: 88% (n = 127) were women, 28% (n = 40) were between the ages of 26 and 35 years, 26% (n = 37) were between the ages of 36 and 45 years, while 29% (n = 42) were between the ages of 46 and 55 years. Forty-five percent (n = 65) of the respondents held a university degree and 46% (n = 66) had professional training in a certificate program or some university. Twenty-four percent (n = 35) of the sample had 1–5 years of healthcare practitioner experience, 14% (n = 20) had 6–10 years of experience, 20% (n = 28) had 11–20 years of experience, and 37% (n = 53) had more than 20 years of experience. Of the survey respondents, 37% (n = 53) worked on surgery wards, 17% (n = 24) on geriatric rehabilitation wards, and 33% (n = 48) on medicine wards. Lastly, with respect to employee positions, 22% (n = 32) worked as healthcare aides, 51% (n = 74) were nurses, and 26% (n = 38) were in the allied health professions.
Table 1 shows descriptive statistics of the sample as well as correlations for the covariates with the key variables in which no multicollinearity issues were identified (Tabachnick & Fidell, 2019).
Hierarchal and Logistic Regression and ANOVA
Hierarchal and binary logistic regression and ANOVA data analyses were performed using the SPSS Statistics (Version 25) to examine H1a, H1b, and H2. In terms of the number of self-reported injuries, 60 of the respondents (41.7%) reported injuries in the previous 12 months (Table 2). The number of sick-time hours paid by position was approximately equivalent to the self-reported injuries (Table 2). Across the three care practitioner positions, nurses incurred 53.2% (n = 14,053 hours) of the paid sick time and reported 68.3% (n = 41) of all injuries, healthcare aides incurred 42.2% (n = 11,134 hours) of paid sick time and reported 23.3% (n = 14) of the total injuries, and allied health professionals incurred 4.6% (n = 1,225) of sick time and 8.3% (n = 5) of self-reported injuries. This comparison supports the accuracy of employee self-reported injury rates as being reasonable approximations of actual paid sick time (in hours) by care practitioner position.
Results for Model 1 (R2Δ = .324, p < .001) show that safety climate perceptions are negatively related to job stress (b = – .578, p < .001), while neither years of experience nor education level was found to be significant (Table 3). Results for Model 2 (R2Δ = .109, p < .001) show that both safety climate perceptions (b = –.335, p < .001) and years of experience (b = –.237, p < .001) are negatively related to turnover intention. Results for Model 3 (R2Δ = .180, p < .001) show that both safety climate perceptions (b = .431, p < .001) and years of experience (b = .174, p < .05) are positively related to job satisfaction. Models 1–3 show support for H1a.
With binary logistic regression, the results show workplace safety climate perceptions are significantly related to being injured at work (B = –0.796, exp b = .451, p = .001); that is, as individual safety perceptions decrease, the odds of being injured at work are 2.22 times greater than the odds for not being injured (Table 4). These results support H1b.
Healthcare position was found to have a significant relationship with healthcare practitioner safety climate (F [2,141] = 15.86, p < .001; Table 5). The Levene statistic is nonsignificant (1.48, p = .231), thus equal variances are assumed. As the sample sizes among the comparison groups are different, a Hochberg’s GT2 post hoc analysis was conducted to identify how the groups differed (Field, 2013). Post hoc tests indicated that nurses’ safety climate perceptions (M = 3.02, p < .05) are similar to the safety climate perceptions of healthcare aides (M = 3.03, p = N/S), and are significantly lower than allied health professionals’ perceptions (M = 3.91, p < .05). The safety climate perceptions of allied health professionals (M = 3.91, p < .05) are significantly higher than the safety climate perceptions of healthcare aides (M = 3.03, p = N/S). Allied healthcare professionals have the highest safety climate perceptions, while both nurses and healthcare aides show significantly lower perceptions, offering partial support for H2.
Workplace injury and illness statistics have highlighted the need to understand more about antecedent factors to develop strategies to reduce injuries and their subsequent negative impact on the healthcare workforce (Amaro et al., 2018; McCaughey et al., 2014; Walton & Rogers, 2017). This study examined the relationships among healthcare practitioner position; workplace safety climate perceptions; and the employee outcomes of job stress, turnover intention, self-reported injuries, and job satisfaction. Three major findings emerged (Figure 1).
The first major finding was the relationship between healthcare practitioner position and employee safety climate perceptions. Nurses were found to have the poorest safety climate perceptions of their workplace, followed by healthcare aides, and allied healthcare professionals have significantly higher safety perceptions. The distinction between different types of care practitioners may serve either as a safety facilitator or a barrier. For example, allied health professionals functioning in a consultative role with greater independence and autonomy may have more positive workplace perceptions (Skinner et al., 2015) of safety. Alternatively, more direct, hands-on care (e.g., patient transfers) that nurses and healthcare aides provide is a common source of care practitioner injury (Amaro et al., 2018; Walton & Rogers, 2017).
The second finding in the study confirmed the importance of a positive workplace safety climate. Practitioners with high levels of safety climate perceptions reported lower job stress, less turnover intent, and higher job satisfaction. These findings aligned well with the safety climate literature, in which safety climate has been found to have a positive relationship with a wide variety of employee and organizational outcomes beyond safety-related factors (Hemmelgarn & Glisson, 2018; Hofmann et al., 2017; Shea et al., 2016). With the critical shortage of healthcare practitioners compounded by existing retention problems (Lanctôt & Guay, 2014; Lartey et al., 2014; Trépanier et al., 2016), identifying climate perceptions that have a positive relationship with employee well-being will help organizations improve their culture for all types of healthcare workers.
Further, the third finding supported and emphasized the importance of safety climate perceptions. Care practitioners who reported lower safety climate perceptions were more than twice as likely to report an injury at work. These findings aligned with other studies that have examined the safety climate/injury relationship linking injuries to poor individual and organizational outcomes (McCaughey et al., 2016; Walton & Rogers, 2017).
Combined, these results suggest an intertwined relationship of experience, perceptions, and outcomes that supports seminal studies to identify antecedents to safety climate (Flin, 2007; Neal & Griffin, 2004). Workplace experiences may drive safety climate perceptions contributing to employee outcomes, and these perceptions vary by position. This suggests practitioner position or type has a larger role in workplace perceptions than previously identified in the safety climate literature (Flin, 2007; Flin et al., 2006). Further research is necessary to explore the experience/perception/outcomes relationship to identify variance by position, position-specific responsibilities, and the specific factors that influence care practitioners’ safety perceptions. Additional studies could examine if other positions such as physicians and nurse practitioners have varying safety perceptions across the care continuum.
The study has limitations that affect interpretation and generalizability. For example, the sample was a small group from a single hospital in Canada. The study was cross-sectional, which prohibited strong causal analyses. Common-method bias could also be a concern resulting from the single-source data (Vishwanath, 2017). However, the differentiated relationships between the variables reduce the possibility of common-method bias. Longitudinal designs with multisource data would provide stronger tests of the hypotheses. As the shortage of healthcare practitioners is a global issue, it would be beneficial to replicate studies examining healthcare practitioners’ safety perceptions in different countries as well as unionized versus nonunionized environments. Future studies also should incorporate mixed methodologies, combining quantitative and qualitative data to provide the opportunity for richer exploration of the relationships among antecedent factors, perceptions, and outcomes.
The study provides an emerging picture that healthcare practitioner position is a key factor in perceptions and outcomes related to the workplace safety climate. Given the high rates of care practitioner injury (AACN, 2019; CNA, 2014; CNA & Canadian Medical Association, 2005; Snavely, 2016), the findings are pertinent to healthcare leaders. The lower safety perceptions of nurses and healthcare aides indicate that leaders may need to examine their safety processes and training structure and then tailor them to match position-specific duties. Safety process teams could be formed to analyze core job components of the various positions to identify the responsibilities influenced by workplace safety issues. Also, strategies to improve the organization’s overall safety climate may positively influence employee satisfaction and decrease turnover intention. Senior healthcare leaders need to demonstratively support strategies to improve the workplace safety climate for employees (Flin, 2007; Kaplan et al., 2017).
Healthcare leaders can use the findings from this study to identify innovative approaches to increase positive perceptions of the workplace environment. By focusing on position, role, and perceptions of safety climate, healthcare leaders can provide safety processes and training to improve how employees perceive the safety of their workplace.
The authors thank the nurses, aides, and allied health professionals at the study hospital for their participation. We also thank Erin Walsh for her help in preparing this article.
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