HE ALTH POLICY AND SYSTEMS

Patient Safety Culture Associated With Patient Safety Competencies

Among Registered Nurses
Seon Mi Cho, MSN, RN1 , & JiSun Choi, PhD, RN2
1 Doctoral Candidate, College of Nursing Science, Kyung Hee University, Seoul, Korea
2 Assistant Professor, College of Nursing Science, Kyung Hee University, Seoul, Korea

Key words Abstract

Patient safety, safety competency, safety
culture Purpose: To investigate the relationships between registered nurses’ (RNs’)
perceptions of the culture of patient safety in their workplace and their
Correspondence patient safety competency—attitudes, skills, and knowledge.
JiSun Choi, 26 Kyungheedae-ro, Dongdaemun- Design: A cross-­ sectional study design was used. Data were collected by
gu, Seoul, 02447, South Korea. using a self-­reported survey from 343 RNs working in a university hospital
E-mail: jchoi14@khu.ac.kr
in Seoul, South Korea.
Methods: Patient safety culture was measured using the Korean version
Accepted April 17, 2018
of the Agency for Healthcare Research and Quality’s Hospital Survey on
doi:10.1111/jnu.12413 Patient Safety Culture (Hospital SOPSTM). Patient safety competency was
measured using the Patient Safety Competency Self-­Evaluation tool. Mul-
tiple regression analysis was performed using Stata version 14 to examine
the relationships between patient safety culture and RNs’ patient safety
competency, while adjusting for the RNs nested in their units.
Findings: Of the 10 specific aspects of patient safety culture, only team-
work within units was significantly related to overall safety competency.
In relation to each of the three patient safety competencies, teamwork
within and across units and supervisor or manager expectations were sig-
nificantly related to attitudes, while teamwork within units and learning
were significantly related to skills. Only organizational learning was sig-
nificantly related to knowledge.
Conclusions: Although teamwork, leadership, and continuous learning in
the nursing unit were major factors influencing RNs’ safety competency,
the relationships of these factors to patient safety attitudes, skills, and
knowledge among RNs were varied.
Clinical Relevance: Creating a unit-­specific patient safety culture that is
tailored to the competencies of the unit’s RNs in patient safety practice
would be essential to enhance and maintain high levels of patient safety
attitudes, skills, and knowledge among the unit’s RNs, which would ulti-
mately affect patient safety.

Patient safety has been a high priority in healthcare
systems around the world over the past two decades.
Numerous initiatives and programs, including surveys
on patient safety culture, team strategies, and tools to
enhance patient safety performance, and international
accreditation and certification programs, have been
developed and implemented to promote patient safety
at the hospital and national levels (Agency for Healthcare
Research and Quality [AHRQ], 2017; Joint Commission
International, n.d.). More importantly, the role of nurses,
the largest group of healthcare professionals, has been
recognized as vital in providing safe and quality care
to patients (Institute of Medicine [IOM]; 2004). Likewise,
in South Korea, patient safety has become a major

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Safety Culture and RNs’ Competencies
focus in recent years, resulting in the initiation of a
hospital accreditation program surveyed by the Korea
Institute for Healthcare Accreditation (KOIHA) in 2010
to ensure patient safety and quality of care in Korean
healthcare settings (KOIHA, n.d.). Many Korean hos-
pitals have spent substantial funds and resources to
prepare for the KOIHA survey, which appears to be
effective in facilitating the improvement of patient
safety (Kim, Jung, Kim, & Lee, 2015; Park, Jung,
Park, Hwang, & Suk, 2017). Moreover, the KOIHA
accreditation brought into focus the need for the edu-
cation and training of nurses to enhance their patient
safety competencies in their work (Hwang, 2015).
The patient safety competency of registered nurses
(RNs) can be defined as the ability to integrate atti-
tudes, skills, and knowledge into nursing practices
(Campbell & Mackay, 2001; Lee, An, Song, Jang, &
Park, 2014) that are relevant for minimizing the risk
for harm to patients in their nursing units. Therefore,
RNs with patient safety competency understand basic
safety principles and system design, optimize human
and environmental factors, demonstrate effective com-
munication abilities, and use appropriate strategies,
safety resources, and error reporting systems (Canadian
Patient Safety Institute, 2009; Cronenwett et al., 2007).
To develop these competencies for RNs, transforming
nursing education and practice has been emphasized
as a major contributor (IOM, 2010). There have been
increasing efforts to provide a fundamental framework
for nursing safety education, such as the Quality and
Safety Education for Nurses project, which may lead
to changes in the roles and practices of nurses
(Cronenwett et al., 2007; Sherwood & Zomorodi, 2014).
In response to the need to evaluate the effects of
such efforts, most previous studies of patient safety
competency have focused on the development of meas-
urement tools to accurately capture patient safety atti-
tudes, skills, and knowledge of healthcare professionals
(Ginsburg, Castel, Tregunno, & Norton, 2012; Lee et al.,
2014; Okuyama, Martowirono, & Bijnen, 2011; Schnall
et  al., 2008). Self-­report tools, which were established
to be valid and reliable, are frequently used to measure
patient safety competency. Considering that a reliable
and valid tool to objectively measure overall patient
safety competency is not yet available, self-­report tools
are efficient and effective in assessing healthcare pro-
fessionals’ patient safety competency and enhancing
their own patient safety awareness (Ginsburg et  al.,
2012; Lee et  al., 2014).
Although the importance of the RNs’ competency
in relation to patient care quality and safety is well
recognized (Cronenwett et  al., 2007; IOM, 2010;
Sherwood & Zomorodi, 2014), few studies have
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Cho and Choi
examined the patient safety competency of RNs work-
ing in acute care hospitals (Dycus & McKeon, 2009;
Hwang, 2015). In a recent study of 459 RNs working
in acute care hospitals, a significant link between
patient safety competency among RNs and patient
safety culture was found (Hwang, 2015). Developing
a patient safety culture is an effective strategy to
promote patient safety in acute care settings (Morello
et  al., 2013; Ulrich & Kear, 2014; Weaver et  al.,
2013). Patient safety culture is defined as the shared
values, beliefs, and behavioral norms related to patient
safety among members of an organization, unit, or
team (Pronovost & Sexton, 2005; Weaver et al., 2013).
The major attributes of a safety culture have been
identified, including leadership, teamwork, evidence
based, communication, learning culture, a just culture,
and patient centered (Sammer, Lykens, Singh, Mains,
& Lackan, 2010). Leadership and teamwork have
been identified as key factors that were associated
with creating a culture of safety or improving patient
safety (Sammer et  al., 2010; Weaver et  al., 2013).
Therefore, it is reasonable to assume that these aspects
of safety culture affect patient safety competency
among RNs. More research is needed to identify
which specific aspects of patient safety culture are
significantly associated with safety competency among
RNs.
The purpose of this study was to investigate the
relationships between RNs’ perceptions of patient safety
culture in their workplace and their overall patient
safety competency, as well as each domain of their
patient safety competency—attitudes, skills, and knowl-
edge. In this study, the patient safety competency was
the individual RN’s competency—attitudes, skills, and
knowledge related to patient safety. With regard to
patient safety culture, 10 specific aspects of patient
safety culture were selected based on the dimensions
of the AHRQ’s Hospital Survey on Patient Safety Culture
(Hospital SOPSTM; AHRQ, 2017). Further, culture tends
to be embedded in various levels of workgroups, such
as care teams, nursing units, unit types, or organiza-
tions (Guldenmund, 2000). Each nursing unit is likely
to have its own culture of patient safety, which might
be different from the hospital-­ level culture of patient
safety. Thus, we examined the individual RNs’ percep-
tions on patient safety culture in their nursing units
as well as in the hospital as a whole. Patient safety
culture at the unit level included teamwork within
units, communication openness, feedback and com-
munication about error, organizational learning, non-
punitive response to error, supervisor/manager
expectations, and staffing; patient safety culture at the
hospital level included teamwork across units, handoffs
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Cho and Choi
and transitions, and management support for patient
safety.
Methods
Study Design
We employed a descriptive, correlational, and cross-­
sectional study design to investigate the relationship
between RNs’ perceptions of patient safety culture and
their patient safety competency—attitudes, skills, and
knowledge at one point in time.
Sample and Data Collection
The sample for this study was RNs working in a
university hospital with more than 800 inpatient beds
in Seoul, South Korea. To be eligible for this study,
RNs had to be a staff nurse or a charge nurse and
had to have worked more than 1 month, a minimum
period of orientation, in the current unit to suitably
capture their patient safety competency and the culture
in their unit. Of the 430 eligible RNs, a random sample
of 380 RNs that represented 75.5% of all RNs work-
ing in the study hospital was invited to voluntarily
participate. Structured questionnaires were distributed
and collected by a researcher from June 12 to 25,
2015. Written consent was obtained from the partici-
pating RNs, and completed questionnaires were sealed
in envelopes to ensure the confidentiality of the
respondents. The final sample consisted of 343 RNs
working in various units in the study hospital, includ-
ing intensive care units, medical-­ surgical units, emer-
gency rooms, and outpatient clinics, with a response
rate of 90.5%. This study was approved by the insti-
tutional review board of the study hospital.
Measures
Patient safety competency was measured using the
Patient Safety Competency Self-­ Evaluation (PSCSE)
tool, originally developed by Lee and colleagues (2014)
to measure nursing students’ patient safety competency
in healthcare systems and nursing education environ-
ments in South Korea. The PSCSE tool used in this
study was a revised tool specifically for use with hos-
pital nurses. Reliability and validity were established
with a sample of 346 hospital nurses in metropolitan
areas in South Korea (Jang, 2013). The PSCSE tool
comprises 41 items in seven subscales, reflecting atti-
tudes, skills, and knowledge about patient safety. The
subscales are as follows: perception of patient safety
(8 items), patient safety promotion/prevention strategy
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Safety Culture and RNs’ Competencies
(4 items), and error reporting and disclosure (2 items)
for attitudes; communication related to error and
response to an error (7 items), evidence-­based practice
(11 items), and resource utilization (3 items) for skills;
and the concept of patient safety (6 items) for knowl-
edge. All items were rated on a 5-­ point Likert scale.
RNs were asked to rate their level of agreement with
each item of attitudes (1 = strongly disagree, 5 = strongly
agree), their level of comfort in performance on each
item of skills (1 = very uncomfortable, 5 = very comfort-
able), and their level of knowledge (1 = little knowl-
edgeable, 5 = very knowledgeable). We calculated mean
scores for each of the three domains of safety com-
petency (attitudes, skills, and knowledge). The total
score of the PSCSE (41 items) was calculated by aver-
aging the means for all three domains. Possible scores
range from 1 to 5; higher scores indicate greater patient
safety competency. Cronbach’s alpha was .95 for the
total score and ranged from .87 to .95 for each of
the three domains of safety competency in this study.
Patient safety culture was measured using the Korean
version of the AHRQ’s Hospital SOPSTM, translated
by Kim and colleagues with a forward-­backward trans-
lation method (Kim, Kang, An, & Sung, 2007). The
AHRQ’s Hospital SOPSTM, developed in the United
States, is a well-­ known tool for measuring hospital
staff perception of patient safety culture (Ulrich & Kear,
2014). Good reliability and validity have been estab-
lished, and the tool has been used internationally
(Fujita et al., 2013; Sorra & Dyer, 2010; Wagner, Smits,
Sorra, & Huang, 2013). The Hospital SOPSTM consists
of 42 items in 12 composites of patient safety culture.
For this study, we did not include two composites
(overall perceptions of patient safety and frequency
of reported events) that could be considered as patient
safety outcome variables (El-­ Jardali, Dimassi, Jamal,
Jaafar, & Hemadeh, 2011). Moreover, our main inter-
est was to identify specific aspects of patient safety
culture explicitly at the nursing unit and hospital levels
since the composite of overall perceptions of patient
safety was found to be highly correlated with some
of the AHRQ’s patient safety culture composites (Sorra
& Dyer, 2010). The seven composites included in this
study reflected the safety culture in the nursing unit
where participating RNs worked. Those are teamwork
within units (four items), supervisor or manager expec-
tations (four items), organizational learning–continuous
improvement (three items), feedback and communica-
tion about error (three items), communication openness
(three items), staffing (four items), and nonpunitive
response to errors (three items). The three other com-
posites reflected safety culture in the hospital, including
hospital management support for patient safety (three
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items), teamwork across units (four items), and hospital Table 1.  Characteristics of the Study Sample (N = 343)
handoffs and transitions (four items). Each item of
Characteristic Category n (%)
the 10 composites was rated on a 5-­point Likert scale
based on agreement (1 = strongly disagree, 5 = strongly Age (years) 20–29 176 (51.3)
agree) or frequency (1 = never, 5 = always). Possible 30–39 151 (44.0)
scores for each of the 10 composites range from 1 to ≥40 16 (4.7)
Gender Male 8 (2.4)
5, with higher scores indicating more positive percep-
Female 335 (97.6)
tions of patient safety culture. Cronbach’s alpha ranged
Education level Associate degree 77 (22.5)
from .74 to .80 for each of the 10 composites of the BSN or higher 266 (77.5)
Hospital SOPSTM in this study. Marital status Single 219 (63.8)
Demographic characteristics were age (in years), Married 124 (36.2)
education level (associate degree = 0, bachelor’s degree Unit type Intensive care unit 58 (16.9)
or higher = 1), marital status (single = 0, married = Medical unit 78 (22.7)
1), work shift rotation, and unit tenure, defined as Surgical unit 88 (25.7)
Outpatient clinic 39 (11.4)
the clinical experience of RNs in the current unit (in
Emergency room 15 (4.8)
years). In South Korea, hospital nurses usually work Perioperative unit 39 (11.4)
8-­hr shifts or a fixed shift (9 a.m. to 5 p.m.). Work Othera 26 (23.3)
shift rotation is a four-­category variable: day-­evening-­ Work (8-­hr) shift Day-­evening-­night shift 157 (45.8)
night rotation, day-­ evening rotation, night shift only, rotation rotation
and fixed 9 a.m. to 5 p.m. shift. Day-­evening shift 93 (27.1)
rotation
Night shift only 50 (14.6)
Data Analysis Fixed 9 a.m. to 5 p.m. 43 (12.5)
shift
Sample characteristics and study variables (patient Clinical experience in nursing, mean years (SD) 7.28 (5.12)
safety competency and patient safety culture) were Clinical experience in the current unit, mean years 3.91 (3.19)
summarized using descriptive statistics. Multiple regres- (SD)
sion analyses were performed at the individual RN
Note. BSN = bachelor of science in nursing.
level to examine the relationships of the 10 specific
Includes Oriental medicine unit, delivery room, and hemodialysis unit.
a

aspects of patient safety culture to overall patient safety

competency, as well as to each domain of safety com-
petency (attitudes, skills, and knowledge). In these
analyses using Stata version 14, the robust estimator
of variance was applied to obtain robust standard errors
while adjusting for nested data structure (i.e., the RNs
were nested in their nursing units). We also examined
the assumptions of multiple regression analysis, such
as multicollinearity. The results demonstrated that the
values of the variance inflation factor for all regression
models were <2.0, indicating no multicollinearity among
predictors.
Results
Sample RN characteristics are presented in Table  1.
The mean age was 31 years, and nearly all respond-
ents were female (97.4%). Most respondents (77.5%)
had a bachelor’s degree or higher in nursing. Almost
half the respondents (45.8%) reported working with
a rotation of three 8-­hr shifts, and the average tenure
on the current unit was 3.9 years.
Descriptive statistics for the individual RNs’ perceived
patient safety competency and patient safety culture
are presented in Table  2. The mean score for overall
patient safety competency was 3.9, and the scores for
the three domains of patient safety competency, atti-
tudes, skills, and knowledge were 4.2, 3.9, and 3.5,
respectively. The mean score for overall unit patient
safety culture was 3.3, ranging from 2.8 for staffing
to 3.9 for teamwork within units. The mean score
for overall hospital patient safety culture was 3.1,
ranging from 3.1 for hospital management support for
patient safety to 3.3 for teamwork across units.
The results of the models of the relationship between
patient safety culture and patient safety competency
are presented in Table  3. Of the 10 specific aspects
of patient safety culture included in the models, four
aspects of patient safety culture (teamwork within units,
organizational learning, supervisor or manager expecta-
tions, and teamwork across units) were found to be
significantly related to patient safety competency.
However, there were differences in the relationships
of each of those aspects of the patient safety culture
to overall patient safety culture, as well as to each
domain of patient safety competency (attitudes, skills,
and knowledge). Only teamwork within units was
significantly related to overall patient safety competency.

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Cho and Choi Safety Culture and RNs’ Competencies

For each domain of the RNs’ patient safety competen- supervisor or manager expectations and teamwork across
cies, teamwork within unit was also found to be sig- units were significantly related to attitudes, while
nificantly related to attitudes and skills, but not related organizational learning was significantly related to skills.
to knowledge. In addition to teamwork within units, Organizational learning was only found to be significant
in relation to knowledge.
Table 2.  Descriptive Statistics for the Study Variables (N = 343) Among demographic characteristics included in the
model (age, education level, and unit tenure), all three
Variable M (SD) Range
characteristics were significantly related to overall patient
Patient safety competency 3.88 (0.42) 2.8–5.0 safety competency. In relation to the three domains
(overall) of patient safety competency, education level was found
Attitudes 4.23 (0.43) 2.6–5.0 to be significantly related only to knowledge, while
Skills 3.90 (0.51) 2.1–5.0 unit tenure was significantly related to both attitudes
Knowledge 3.52 (0.64) 1.3–5.0
and skills, but not to knowledge.
Unit patient safety culture 3.30 (0.36) 2.3–4.4
(overall)
Teamwork within units 3.91 (0.66) 1.0–5.0 Discussion
Communication openness 3.34 (0.61) 1.0–5.0
Feedback and communication 3.41 (0.63) 1.3–5.0 The importance of promoting patient safety culture
about error has been well established in relation to patient safety
Organizational learning–­ 3.49 (0.53) 1.7–5.0 (Ulrich & Kear, 2014; Weaver et  al., 2013). In the
continuous improvement
light of this positive relationship, this study extends
Nonpunitive response to error 2.88 (0.63) 1.0–5.0
the inquiry into the relationship between patient safety
Staffing 2.76 (0.54) 1.5–5.0
Supervisor/manager 3.63 (0.69) 1.0–5.0 culture and patient safety competency among RNs
expectations and actions working in acute care hospitals. Although RNs’ patient
promoting patient safety safety competency has been recognized as a vital fac-
Hospital patient safety culture 3.14 (0.45) 1.8–4.7 tor in improving patient safety (Canadian Patient Safety
(overall) Institute, 2017; Cronenwett et al., 2007), little is known
Hospital management support 3.06 (0.59) 1.0–5.0
about the patient safety competency of hospital RNs
for patient safety
due to the lack of sound competency assessment tools
Teamwork across units 3.25 (0.51) 1.8–5.0
Handoffs and transitions 3.12 (0.57) 1.0–5.0 that can be applied for general use in acute care
hospitals. In this study, we utilized a psychometrically

Table 3.  Coefficients (Standard Errors) for Predictors of Overall and Three Dimensions of Patient Safety Competency (Attitudes, Skills, and
Knowledge) Among Registered Nurses (N = 343)

Variable Attitudes Skills Knowledge Overall competency

Teamwork within units .137 (.043)* .185 (.047)** .092 (.074) .138 (.044)*
Communication openness −.018 (.053) −.058 (.075) .024 (.106) −.018 (.063)
Feedback and communication about .031 (.053) .079 (.063) .107 (.084) .072 (.052)
error
Organizational learning–continuous −.075 (.042) .128 (.062)* .205 (.096)* .086 (.052)
improvement
Nonpunitive response to error −.055 (.036) −.055 (.042) −.099 (.063) −.070 (.035)
Staffing .019 (.038) −.026 (.048) −.083 (.063) −.030 (.038)
Supervisor/manager expectations .096 (.038)* −.022 (.047) −.120 (.065) −.015 (.040)
Hospital management support for −.036 (.043) −.060 (.052) .118 (.077) .007 (.042)
patient safety
Teamwork across units .152 (.052)* .046 (.077) .032 (.113) .076 (.060)
Hospital handoffs and transitions −.004 (.044) −.010 (.057) −.006 (.084) −.007 (.047)
Age (years) .021 (.005)** .024 (.006)** .020 (.008)* .022 (.005)**
Education level (BSN or higher = 1 vs. .048 (.054) .104 (.054) .130 (.065)* .094 (.042)*
associate = 0)
Unit tenure (years) .026 (.008)* .020 (.009)* .024 (.013) .023 (.008)*

Note. BSN = bachelor of science in nursing.

*p < .05; **p < .001.

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Safety Culture and RNs’ Competencies
established tool to comprehensively evaluate all three
domains of individual hospital RNs’ patient safety com-
petency (attitudes, skills, and knowledge) in Korean
acute care settings where increased attention has recently
been focused by way of the hospital accreditation pro-
gram launched in 2010 for creating culture and systems
to improve patient safety. In particular, we focused
on investigating the associations between specific aspects
of patient safety culture and patient safety competency
overall, as well as each domain of patient safety com-
petency. Our findings reported here provide empirical
evidence of the association between specific aspects
of patient safety culture and patient safety competency
of RNs practicing in acute care hospitals.
In our RN sample, the levels of overall patient safety
competency were found to be generally moderate.
When examining each of the three domains of patient
safety competency separately, however, the mean scores
of their self-­reported skills and knowledge were lower
than those of attitudes, with the lowest score reported
for knowledge. In a previous study examining safety
attitudes, skills, and knowledge among experienced
pediatric oncology nurses (Dycus & McKeon, 2009),
findings showed that respondents had positive attitudes
and somewhat strong knowledge, but they were less
skillful in safety practice. Although the difference in
study findings is likely due to the use of different
measures and sampling variation, these findings indicate
that it is important to examine all three domains of
the patient safety competency using a reliable and
valid tool, which is able to provide more useful infor-
mation to enhance individual RNs’ patient safety com-
petency. Also, our findings indicate that there is room
to improve practical skills and knowledge in safety
practice among hospital RNs. It would be helpful to
develop training programs, such as problem-­or case-­
based learning tailored to the level of individual RNs’
patient safety skills and knowledge.
Unexpectedly, of the 10 specific aspects of patient
safety culture, based on the dimensions of the AHRQ’s
Hospital SOPSTM used in this study, only four aspects
of safety culture (teamwork within units, organizational
learning–continuous improvement, supervisor/manager
expectations, and teamwork across units) were found
to be significantly related to RNs’ patient safety com-
petency. Moreover, we found that the relationships
of each of those aspects of patient safety culture to
overall competency, as well as to patient safety atti-
tudes, skills, and knowledge, varied significantly. In
this study, teamwork that has been recognized fre-
quently as a major predictor of a positive safety culture
in previous studies (Sammer et al., 2010; Weaver et al.,
2013) was examined at both the nursing (within units)
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Cho and Choi
and hospital (across units) levels. We found that only
teamwork within units was significantly related to
overall patient safety competency. For each of the
patient safety competencies, teamwork within unit was
positively related to both attitudes and skills, whereas
teamwork across units was positively related to atti-
tudes only. Unit supervisor or manager expectation
was found to be positively related to attitudes only,
while unit organizational leaning–continuous improve-
ment was positively related to both skills and knowl-
edge, but not to attitudes. These findings may indicate
that an individual RN’s patient safety competency is
affected primarily by unit-­ level patient safety culture,
including unit teamwork, unit managers’ leadership,
and continuous learning, rather than hospital-­ level
patient safety culture. Thus, nursing administrators and
unit managers should pay more attention to build a
positive patient safety culture at the unit level. More
importantly, unit managers wishing to enhance RNs’
patient safety competency in their units should regu-
larly evaluate and monitor which areas of patient
safety  competency are weak, and develop strategies
in consideration of the unique impact of specific
aspects  of patient safety culture on RNs’ patient safety
competency.
Safety culture has been studied extensively, and
significant differences have been found at various levels,
such as individual, nursing unit, hospital, and country
levels (Fujita et  al., 2013; Sorra & Dyer, 2010; Yoo
& Kim, 2017). In our study, all aspects of the patient
safety culture included in the model were found to
be positive overall at the individual RN level. Findings
are similar to those from previous studies examining
patient safety culture using the same Hospital SOPSTM
in Asian countries, such as Japan and Taiwan (Fujita
et  al., 2013; Wagner et  al., 2013). Safety culture in
these Asian countries was generally reported as less
positive than in the United States (Fujita et  al., 2013).
This finding is likely due to traditional East Asian
culture, which emphasizes saving face, collectivism,
authority, and hierarchy (Fujita et  al., 2013; Wagner
et  al., 2013; Yoo & Kim, 2017). Moreover, it may be
related to the lack of effective systems to assess, evalu-
ate, and report patient safety issues. It is important
to continue ongoing efforts to improve current hospital
accreditation programs or surveillance systems and to
develop data-­driven healthcare policies in these Asian
countries.
Considering each aspect of patient safety culture sepa-
rately, however, we cannot state clearly that the United
States has a more positive safety culture than other
countries for each aspect of safety culture. For example,
nonpunitive response to error, which is one of the
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Cho and Choi
most important contributors to improve safety culture
(Sammer et  al., 2010), was the least positive aspect of
safety culture in our study, which is consistent with
findings from a previous study of safety culture in Japan,
Taiwan, and the United States (Fujita et  al., 2013),
where the lowest score was reported for nonpunitive
response to error, and ranged from 8.78 in Taiwan to
9.42 in the United States. In response to a great effort
to improve safety culture in acute care settings, patient
safety culture has been markedly developed. However,
findings indicate that there is a need to put more effort
into building a blame-­ free error-­
reporting atmosphere
at both the nursing unit and hospital levels. More
research is also needed to better understand differences
in patient safety culture across different countries and
to ensure that we are equipped to develop strategies
tailored to specific aspects of patient safety culture, as
well as nursing unit and hospital environments, in the
context of the unique culture of each country.
This study has several limitations. First, findings can-
not be generalized to all RNs working in acute care
settings because we used data from a single university
hospital in South Korea, and we restricted our inves-
tigation to RNs who were staff nurses or charge nurses.
Additionally, our RN sample participated voluntarily
so there might be differences in the levels of perceived
patient safety culture and competency between respond-
ents and nonrespondents in this study, although a
random sample of RNs who represented 75.5% of all
RNs working in the study hospital and the response
rate to the survey was very high. Second, this study
used data from a cross-­ sectional survey. Therefore,
findings demonstrate the association between patient
safety culture and RNs’ patient safety competency, but
not their causality. Third, other factors that may affect
RNs’ patient safety competency, such as accreditation
status, safety education or training, and nursing lead-
ership, were not included in the model. Lastly, it
should be noted that patient safety competency was
measured from RNs’ perspectives, although we used
a competency tool with strong reliability and validity.
To validate the accuracy of RN self-­ reported safety
competency, its relationship to patient safety outcomes
must be examined. Further research on the develop-
ment of an evaluation tool to objectively measure
patient safety competency among practicing RNs in
healthcare settings should be conducted. In addition,
further studies with a strong methodological study
design (e.g., large sample size, objective measure of
patient safety competency, longitudinal design) are
needed to explore RNs’ patient safety competency in
relation to patient safety culture at various levels, such
as nursing unit, unit type, and country.
Journal of Nursing Scholarship, 2018; 50:5, 549–557.
© 2018 Sigma Theta Tau International. 
Safety Culture and RNs’ Competencies
Conclusions
This study provides empirical evidence that a posi-
tive safety culture is significantly related to patient
safety competency among practicing RNs. Of the 10
specific aspects of patient safety culture that we exam-
ined, our findings demonstrate that teamwork, leader-
ship, and continuous learning at the nursing unit levels
are essential for enhancing RNs’ patient safety com-
petency. Moreover, our findings indicate that there
are significant variations in the relationships between
each of these aspects of patient safety culture and
each of the three domains of RNs’ patient safety
­competency—attitudes, skills, and knowledge. Strategies
to enhance and maintain RNs’ patient safety compe-
tency should be developed at the unit level for the
targeted areas of patient safety attitudes, skills, and
knowledge. These should be accompanied by hospi-
talwide initiatives to improve the overall safety culture
of the organization.
Clinical Resources
• Agency for Healthcare Research and Quality.
Surveys on patient safety culture. https://www.
ahrq.gov/professionals/quality-patient-safety/
patientsafetyculture/index.html
• Agency for Healthcare Research and Quality.
TeamSTEPPS. https://www.ahrq.gov/teamstepps/
index.html
• Quality and Safety Education for Nurses.
http://qsen.org/
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