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IJHCQA
20,7
572
Received 10 May 2006
Revised 24 July 2006
Accepted 17 September
2006
Safety self-efficacy and safety
performance
Potential antecedents and the moderation
effect of standardization
Tal Katz-Navon
The Arison School of Business Administration, Interdisciplinary Center,
Herzliya, Israel
Eitan Naveh
Faculty of Industrial Engineering and Management,
Technion – Israel Institute of Technology, Haifa, Israel, and
Zvi Stern
Hadassah Hebrew University Medical Center, Jerusalem, Israel
Abstract
Purpose – The purpose of this paper is to suggest a new safety self-efficacy construct and to explore
its antecedents and interaction with standardization to influence in-patient safety.
Design/methodology/approach – The paper used a survey of 161 nurses using a self-administered
questionnaire over a 14-day period in two large Israeli general hospitals. Nurses answered questions
relating to four safety self-efficacy antecedents: enactive mastery experiences; managers as safety role
models; verbal persuasion; and safety priority, that relate to the perceived level of standardization and
safety self-efficacy. Confirmatory factor analysis was used to assess the scale’s construct validity.
Regression models were used to test hypotheses regarding the antecedents and influence of safety
self-efficacy.
Findings – Results indicate that: managers as safety role models; distributing safety information;
and priority given to safety, contributed to safety self-efficacy. Additionally, standardization
moderated the effects of safety self-efficacy and patient safety such that safety self-efficacy was
positively associated with patient safety when standardization was low rather than high. Hospital
managers should be aware of individual motivations as safety self-efficacy when evaluating the
potential influence of standardization on patient safety.
Originality/value – Theoretically, the study introduces a new safety self-efficacy concept, and
captures its antecedents and influence on safety performance. Also, the study suggests safety
self-efficacy as a boundary condition for the influence of standardization on safety performance.
Implementing standardization in healthcare is problematic because not all processes can be standardized.
In this case, self-efficacy plays an important role in securing patient safety. Hence, safety self-efficacy may
serve as a “substitute-for-standardization,” by promoting staff behaviors that affect patient safety.
Keywords Standardization, Safety, Israel
Paper type Research paper
International Journal of Health Care
Quality Assurance
Vol. 20 No. 7, 2007
pp. 572-584
q Emerald Group Publishing Limited
0952-6862
DOI 10.1108/09526860710822716
Introduction
It is estimated that 44,000 to 98,000 patients die each year as a result of treatment
errors in the US healthcare system. The total national annual cost of treatment errors is
estimated between $17 and $29 billion (Committee on Quality of Health Care in America
The authors would like to thank Anat Drach-Zehavi and Efrat Neter for their helpful comments.
and Institute of Medicine, 2000). The accuracy of these numbers has been challenged
(McDonald et al., 2000), but there is general agreement that patient safety problems, as
expressed by the number of treatment errors, is serious (Chassin and Galvin and
National Roundtable on Health Care Quality, 1998; Leape, 2002). Treatment errors are
increasingly viewed as organizational, not simply clinical outcomes. This emergent
interpretation emphasizes the importance of organizational psychology theories that
explain treatment error occurrence. Organization safety in general, is defined as
freedom from accidental injury (Perrow, 1984; Roberts, 1990), related to the employee
safety and other organizational stakeholders including customers. In healthcare, patient
safety refers to avoidance, prevention, and amelioration of adverse outcomes or injuries
stemming from healthcare processes (i.e. iatrogenic). These adverse outcomes include
errors and accidents caused by medical actions (in contrast to disease complications),
events that result from equipment failure, failure to complete a planned action as
intended (e.g. surgical events, events involving devices, patient protection, and care) or
the use of the wrong plan to achieve an aim (Gaba, 2000; Leape, 2002).
Traditionally, when patient safety is compromised, the root cause is generally found
in inadequate safety rules and procedures. Our premise is that, in order to assure
patient safety and avoid treatment errors, hospitals should develop and implement
safety procedures (Perrow, 1984). Formal safety procedures are written organizational
rules and routines that are valuable to the organization because they define how safety
requirements will be met successfully. Research findings have inconsistently
determined the extent to which this emphasis on standardization leads to patient
safety improvement (Leape, 2002). Self-efficacy has been suggested as a necessary
condition for a wide range of individual performances (Bandura, 1997; Stajkovic and
Luthans, 1998). In this study, we use self-efficacy in the context of safety, identify its
antecedents, and demonstrate its moderating effect on patient safety in conjunction
with the standardization level.
Literature review
Safety self-efficacy
Self-efficacy perceptions influence one’s motivation to engage in specific behaviors
(Bandura, 1997). Thus, self-efficacy holds much promise for understanding safety
actions in organizational settings, specifically, patient safety in healthcare
organizations. Self-efficacy is defined as people’s judgment of their capabilities to
organize and execute courses of action required to attain designated performances. It is
concerned not with skills but one’s judgments of what one can do with one’s skills.
Hence, different people with similar skills, or the same person under different
circumstances, may perform differently, depending on variations in their beliefs of
personal efficacy (Bandura, 1997). Personal efficacy expectations determine whether an
individual initiates coping behavior, expends task-related efforts and sustains efforts
despite disconfirming evidence. Self-efficacy is a situation-specific cognition that is
highly focused on a particular task. Decades of empirical research generated a great
number of studies that demonstrated positive relationships between task-specific
self-efficacies and different motivational and behavioral outcomes in a variety of
settings (Stajkovic and Luthans, 1998). For example, Tierney and Farmer (2002)
developed a new concept, creative self-efficacy and demonstrated its influence on
creativity. Some researchers became interested in the more trait-like generality
self-efficacy dimension, termed general self-efficacy (Chen et al., 2001). In this article,
we follow Bandura’s state-like self-efficacy conceptualization.
Safety selfefficacy
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Despite self-efficacy’s potential influence on safety performance, little attention has
been directed toward the concept in a safety context. Thus, we use safety self-efficacy
and define it as one’s belief in one’s ability to assure patient safety. Safety self-efficacy
is qualitatively different than other related concepts, such as safety consciousness
(Barling et al., 2002), which have been used in the literature in order to explain
individual safety performance. Safety consciousness focuses on the individual’s
awareness of safety issues as well as more behavior-specific knowledge required to
ensure safety. Safety self-efficacy, on the other hand, focuses on one’s judgment of
one’s ability to assure patient safety.
Safety self-efficacy antecedents
We used Bandura’s (1997) self-efficacy conceptual framework to guide our
understanding and selection of safety self-efficacy determinants in the healthcare
setting. Self-efficacy beliefs are constructed from three principal information sources:
(1) Enactive mastery experiences that serve as capability indicators.
(2) Vicarious experiences that alter efficacy beliefs through comparison with
attaining other role models.
(3) Verbal persuasion (Bandura, 1997).
In the case of safety self-efficacy, we suggest one additional contextual self-efficacy
source, the perceived priority given to safety within the organizational unit
(Katz-Navon et al., 2005; Naveh et al., 2006). Thus, to develop a nomological net, specific
to safety self-efficacy, we considered four determinants:
(1) Enactive mastery experiences. The efficacy-performance relationship is cyclic
(Lindsley et al., 1995); that is, performance affects self-efficacy, which, in turn affects
performance and so on. The conviction that one can successfully execute the behavior
required has been shown to have a positive effect on performance (Bandura, 1997). Past
successes build a robust belief in one’s personal efficacy perception, while failures
undermine it. Bandura (1997) emphasized that after people gain experience performing
tasks, past performance should become the major explanatory factor of future
self-efficacy. Indeed, in Sexton et al.’s (1992) study, perceived self-efficacy accounted for
variance in the first performance stage, but after this initial “break-in” phase, earlier
behavior accounted for most of the variance in the succeeding task performance.
Similarly, self-efficacy correlated more with past performance than with future
performance. Self-efficacy significantly predicted future performance only when past
performance was held constant (Locke et al., 1984). There is also a body of literature
that emphasizes the importance of how humans learn by making mistakes. Thus,
analyzing performance allows the individual to make adjustments in future efforts
based on the previous decrease or increase in performance. Thus, in the context of
safety, one’s past experiences in successes or failures maintaining patient safety should
increase or decrease, respectively, one’s safety self-efficacy. The self-efficacy theory
locates performance with the individual. There is another line of thought in risk
management, however, suggesting that this is a phenomenon that is co-created within
the work group.
H1. Enactive mastery experiences will be positively associated with safety
self-efficacy.
(2) The manager as a role model. People also develop their self-efficacy from role model
vicarious experiences. Role modeling by supervisors is crucial for efficacy
development in complex challenging activities (Bandura, 1997) such as those that
confront healthcare personnel. Gist and Mitchell (1992) believed employees may lack
criteria by which to determine task success, while models demonstrating effective
performance strategies provide employees with data by which to assess their efficacy.
Supervisors may also engage in acts of verbal persuasion that are conducive to
self-efficacy formulation (Bandura, 1997). Healthcare personnel’s perceptions of their
supervisors’ safety-related activities and methods express the extent to which they
believe their supervisor is committed to patient safety (Zohar, 2002). Supervisors set
the tone and tempo for safety, for example, by emphasizing safety behaviors:
H2. Perceptions of managers’ safety role models will be positively associated with
safety self-efficacy.
(3) Verbal persuasion. Information and knowledge shape self-efficacy assessments
(Gist and Mitchell, 1992). Thus, we would expect to see an association between
safety-related knowledge and safety self-efficacy. The formal safety-information flow
within an organization deals with delivering several information types to employees;
such as unusual events, potential hazardous conditions and safety training sessions
(OHSAS 18001, 1999). Several safety-related knowledge sources usually exist in
healthcare systems: safety training; routine distribution of information about potential
hazards; learning from past experiences and errors. Safety information dissemination
to employees constitutes an organization’s planned effort to improve employees’
current and future safety performance by increasing their self-efficacy and redirecting
their attention toward safety (National Institute of Standards and Technology, 2003;
Ford et al., 1994). Information about safety provides staff members with guidelines for
performing their job in a safe manner, which shapes the belief one has in one’s ability
to assure patient safety:
H3. Safety information perceptions will be positively associated with safety
self-efficacy.
(4) Priority of safety. Safety priority refers to employee expectations and daily
behaviors regarding work-unit balance, workload and pressures for productivity and
safety (Zohar, 2000). Working in a safe manner often entails working at a slower pace,
investing extra effort, or operating under less-comfortable conditions. Consequently,
whenever work pressure increases, employees use a complex system of considerations
to set the relative priorities for safety versus speed or productivity. These
considerations include for example, organization evaluation, feedback, and reward
systems (Kerr, 1975). When safety priority is perceived as low, employees will focus on
productivity and will perceive they do not have the necessary resources for
maintaining patient safety. Thus, their safety self-efficacy will be low. On the other
hand, when safety priority is perceived high, employees will sense that the
organization supports and rewards their safety behaviors and thus, their safety
self-efficacy will be high:
H4. Safety priority will be positively associated with safety self-efficacy.
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Safety self-efficacy, standardization and patient safety
Numerous studies examined self-efficacy behavioral consequences in work
organizations (Bandura, 1997; Gist and Mitchell, 1992; Locke and Latham, 2002;
Stajkovic and Luthans, 1998). The majority found that self-efficacy ratings were
positively correlated with performance. Many healthcare studies established
relationships between patients’ self-efficacies and the success of their clinical
medical treatment (Bandura, 1997, pp. 279-286; Fries et al., 1998). Nevertheless, we
could not find any study that established the relationship with self-efficacy specifically
regarding patient safety. Traditionally, in the healthcare industry, the treatment errors
and lack of patient safety were related to disease complications (Leape et al., 1991) or
ergonomic factors (Donchin et al., 1995). Recently, however, most researchers agree
that staff cognition and motivation are also associated with safe patient care provision
(Committee on Quality of Health Care in America and Institute of Medicine, 2000;
Katz-Navon et al., 2005). Elevated self-efficacy leads to certain cognitive outcomes (e.g.
broader information searches, greater memory recall) and sustaining efforts linked to
performance (Bandura, 1997). Accordingly, high safety self-efficacy beliefs should
enhance persistence levels and coping efforts individuals need to demonstrate when
encountering challenging situations such as keeping a high level of patient safety:
H5. Safety self-efficacy will be positively associated with patient safety.
The healthcare environment is complex in terms of its task characteristics, since each
patient is unique. In order to control complexity and assure patient safety, healthcare
organizations place a strong emphasis on high standardization, i.e. the use of safety
procedures. Standardized work entails detailing how work should be performed to
reduce the variance associated with each task and thereby improve overall
performance (March, 1991). Procedures rigidly detail the sequence of steps that
should be taken for to complete tasks safely. Their aim is to assure safety performance
by reducing the risk of errors and managing the elements of uncertainty and risk
inherent in work methods (Brunsson and Jacobsson, 2000). Healthcare organizations
implement safety procedures even though research results regarding the extent to
which they lead to safety improvement are inconsistent (Leape, 2002). In healthcare,
strict adherence to safety procedures can only partially ensure good safety
performance, because uncertainty is high, and proper patient care necessitates
flexibility and constant decision-making. In uncertain situations, formal procedures
that should ensure safe employee behavior cannot encompass all possible daily work
situations (Gittell, 2002). We argue that safety self-efficacy suggests a possible solution
for the debate on the preferable level of standardization in the healthcare context.
Following Mischel et al.’s (1977, pp. 333-352) weak and strong situation’s theory, we
posit that low standardization represents a weak situation where there is no clear
structure that tells staff how to behave safely. On the other hand, high standardization
is a strong situation, in which there is a clear structure that specifically instructs staff
members how to behave safely. High safety self-efficacy should influence performance
in a weak situation more than in a strong one. Safety self-efficacy should be less
important for safe performance in a strong high standardization situation since, when
standardization is high, there is a clear structure that directs employees exactly how to
act. When employees perceive the level of standardization to be high, low and high
self-efficacious employees should perform relatively well since following the standard
assures safety performance. Perceived high standardization should help even the less
efficacious employees achieve good safety performance. On the other hand, in the
weak, low standardization situation, employees perceive that there are no rules to
follow, and good safety performance requires higher motivation. Thus, low
self-efficacious employees, who lack a structured environment, perform worse than
highly efficacious employees:
H6. Level of perceived standardization will moderate the effect of safety
self-efficacy on patient safety in such a way that safety self-efficacy will be
positively associated with patient safety when standardization is perceived as
low rather than high.
Methods
Participants
We surveyed 161 nurses using a self-administered questionnaire over a 14-day period in
two large private non-for-profit Israeli general hospitals. Each hospital treats more than
100,000 patients annually. We administered the questionnaires during working hours.
We randomly distributed questionnaires to 200 nurses in the different wards and asked
them to voluntarily participate in a study about patient safety. This constituted a
response rate of about 80 percent. Mean nurses’ seniority was 10.7 years (SD ¼ 8:6
years) with a minimum of 1 year to a maximum of 37 years in their profession.
Measures
.
Safety self-efficacy was assessed using six items (Alpha Cronbach Reliability
a ¼ 0:82 which measures inter-item consistency or agreement of values within
cases). Since self-efficacy is task-specific as we noted earlier, we constructed the
safety self-efficacy scale by focusing the questions from the general efficacy scale
to the safety domain. For example, “I can give my patients safe medical care”, “I
am confident in my ability to keep the safety procedures of my unit”. This and all
other independent measures were scored on a five-point Likert-type scale from
not at all or to a very slight extent (1) to a very large extent (5).
.
Enactive mastery experience was measured using the annual number of
treatment errors made by the unit members in the year before the questionnaire
was administered. Personal capabilities are easier to judge for activities that
produce independent objective indicators of adequacy (Bandura, 1997). In
healthcare, patient safety and treatment errors tend to have no absolute measure
of adequacy. Consequently, the staff must appraise their capabilities in
relationship to the others’ attainments. For example, a nurse may make a certain
number of treatment errors in a certain period of time. However, that nurse
would have no basis for judging whether this is acceptable or poor safety
performance without knowing how others have performed. Personal past
performance cannot always serve as a reference for what is good performance
since the employee would have no basis for judging without knowing how others
have performed. Thus, each employee can use the unit’s annual number of
treatment errors as a reference to assess her/his performance.
.
Manager as a role model was assessed using six items, e.g. “In my unit, the unit
head approaches team members during work to bring safety issues to their
attention”; “In my unit, the unit head ensures there are no hazards” (a ¼ 0:86).
.
Safety information was measured with four items, e.g. “in my unit, there are
many safety training programs” (a ¼ 0:077).
Safety selfefficacy
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.
.
578
.
.
Priority of safety was measured with seven items, e.g. “in my unit, in order to get
the work done, one must ignore some safety aspects” (a ¼ 0:85), and
standardization was measured using four items, e.g. “In my unit, there are
many written procedures” (a ¼ 0:82).
General self-efficacy was assessed using three items based on Chen et al. (2001):
“I am confident in my ability to perform my work”, I have confidence in my
ability to perform the different tasks required on my job’ and “I have the required
skills to perform my job” (a ¼ 0:69).
Safety consciousness was assessed using two items adapted from Barling et al.
(2002) applied to patient safety: “I always use the protective equipment needed in
my work (e.g. rubber gloves, robe)”, and “I am well aware of the safety risks of
my work” (a ¼ 0:56).
Patient safety was measured using nine questions that specified potential safety
failures. These potential failures were developed based on Committee on Quality
of Health Care in America and Institute of Medicine (2000). Since accidents are
rare events (Perrow, 1984).
We asked respondents to assess the number of near-misses in each of the nine potential
safety failures that happened to them in the last three months. For example, “How
many times in the last three months did you nearly give a patient the wrong medicine?”
or “How many times in the last three months have you nearly misidentified a patient?”
The measure was the sum of the numbers reported in response to all nine potential
safety failures.
Results
First, we conducted a confirmatory factor analysis (CFA) using SAS, version 9.1 to test
whether general self-efficacy, safety self-efficacy and safety consciousness are three
sufficiently distinct factors. The analysis was performed on variance-covariance
matrices with pair-wise deletion of missing values. The three-factor CFA yielded an
acceptable “fit” (Bollen, 1989) of x2 (46, N ¼ 157) ¼ 74:22, p , 0.01, NNFI ¼ 0:94,
CFI ¼ 0:95, and RMSEA ¼ 0:06. All the standardized factor loadings in the model
were above 0.6 (most loadings were around 0.7). The means, standard deviations, and
correlations among the variables are summarized in Table I.
Testing H1 to H4, potential safety self-efficacy antecedents, we regressed safety
self-efficacy on enactive mastery experiences, manager as a role model, verbal
persuasion and safety priority (see Table II). Results demonstrated significant effects
for: manager as a role model; verbal persuasion and priority of safety and a
non-significant effect for enactive mastery experiences. Thus, H2 to H4 were
supported.
Testing H5 and H6, we regressed patient safety on safety self-efficacy and
standardization, and their two-way interaction. We also included general self-efficacy
and safety consciousness in the analysis as control variables. To effectively partial-out
all hospital variance, thereby eliminating the potential lack of independence in the unit
level residual, we dummy coded the hospital and used it as a control variable. Because
the safety performance dependent variable was a count variable of infrequently
occurring events that had only non-negative integer values, we used a negative
binomial regression analysis (Gardner et al., 1995). In model 2, Table III, results
demonstrate that general self-efficacy, safety consciousness and hospital had near zero
magnitude insignificant effects. Hence, we regressed another model without these three
General self-efficacy
Safety self-efficacy
Safety consciousness
Enactive mastery experiences
Manager as a role model
Verbal persuasion
Priority of safetya
Standardization
Patient safety
4.57
4.02
4.6
15.74
3.82
3.47
2.31
3.73
3.5
0.48
0.52
0.51
0.84
0.70
0.72
0.76
0.67
5.47
SD
0.31 * * *
0.44 * * *
0.23
0.33 * * *
0.19 * *
20.26 * * *
0.41 * * *
20.18 * *
1
0.21 * * *
0.03
0.21 * * *
0.17 * *
20.30 * * *
0.38 * * *
20.28 * * *
2
0.06
0.27 * * *
0.28 * * *
2 0.15
0.30 * * *
2 0.21 * * *
3
2 0.01
0.08
0.05
0.22
0.09
4
0.40 * * *
20.09
0.40 * * *
20.01
5
6
0.04
0.40 * * *
20.13
Notes: a Note that a high score on priority of safety signifies a lack of priority: *p , 0.1; * *p , 0.05; * * *p , 0.01
1.
2.
3.
4.
5.
6.
7.
8.
9.
Mean
8
20.30 * * *
7
20.22 * * *
0.35 * * *
Safety selfefficacy
579
Table I.
Mean, standard
deviation, and correlation
among the variables
(n ¼ 162)
IJHCQA
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variables (Cohen, 1988). Results demonstrated significant main effects and interaction
(see model 3, Table III).
To understand interaction, we followed the graphing method outlined by Aiken and
West (1991). Figure 1 shows that when standardization was perceived high, there was
no difference in the number of near-misses between high and low safety self-efficacy.
However, when standardization was perceived low, there were fewer near-misses for
580
Model 1 safety self-efficacy
Table II.
Regression analysis of
safety self-efficacy on its
antecedents
(standardized b
coefficients)
Table III.
Negative binomial
regression of safety
performance on
self-efficacy and
procedures suitability
(b coefficients with S.E.
in parentheses)
Figure 1.
The effect of safety
self-efficacy on patient
safety by levels of
standardization
Enactive mastery experiences
Role modeling
Verbal persuasion
Priority of safetya
R2
F
0.02
0.13 *
0.137 * *
20.295 * * *
0.14
6.34 * * *
Notes: a Note that a high score on priority of safety signifies a lack of priority; *p , 0.1; * *p , 0.05;
* * *p , 0.01
Intercept
Safety self-efficacy
Standardization
General self-efficacy
Safety consciousness
Safety self-efficacy £ standardization
Hospital
Dispersion estimate
Notes: *p , 0.1; * *p , 0.05; * * *p , 0.01
Model 2 patient safety
Model 3 patient safety
11.42 * * * (4.20)
2 2.11 * * (1.09)
2 1.84 * (1.13)
2 0.01 (0.22)
2 0.22 (0.20)
0.41 (0.28)
0.00 (0.2)
1.02 (0.16)
10.97 * * * (4.18)
22.22 * * (1.08)
21.97 * * (1.12)
0.43 * (0.28)
1.04 (0.16)
high safety self-efficacious staff members as compared to less self-efficacious staff
members.
Discussion
While other industries also have to deal with customer safety (for example, airlines and
nuclear power plants), healthcare safety demands specific care. Additionally, while
customer safety in other high reliability industries can be assured through
technological solutions, reliability analyses or expert systems and healthcare
customer safety depends greatly on personnel. Consequently, safety self-efficacy is
highly relevant to safety performance. Although hospital staff try to ensure patient
safety, they are not completely successful and treatment errors are still a major
problem. The present study adds theoretical and empirical tiers to our understanding
of treatment error origins. Theoretically, by introducing safety self-efficacy, the study
captures its antecedents and its influence on safety performance. Also, the study
suggests it as a boundary condition for the influence of standardization on safety
performance.
According to Bandura (1997), the first and most influential self-efficacy antecedent
is past experiences with the task at hand. However, in the present study, past
experiences with patient care were not significantly associated with safety
self-efficacy. This unexpected result may be explained by the hospital context. The
healthcare environment is complex in task characteristic terms, since each patient is
unique and each situation is different. Thus, knowledge of past results only partially
helps one’s ability to cope with different situations. One other possible explanation is a
measurement issue because past experiences were measured on the unit, while
self-efficacy was measured individually. In addition, Bandura (1997) suggested two
other self-efficacy antecedents: role modeling and verbal persuasion. Managers, who
emphasize safety, serve as safety role models. Thus, their employees have higher
safety self-efficacy. The healthcare system supplements employees with information
about safety that emphasizes the ultimate importance of keeping patients safe.
Providing information about potential hazards can develop employees’ safety
self-efficacy since a definition of the problem is part of its solution.
Following Katz-Navon et al. (2005), who prioritized safety as a treatment error
explanation, we suggest that safety priority as safety self-efficacy is an antecedent.
This issue of priority has received special attention in the safety literature (Zohar,
2002). Our results demonstrate that safety priority was significantly associated with
safety self-efficacy over and above the other three antecedents. High safety priority
means that in the necessary tradeoff between safety and other organizational outcomes
(e.g., speed, productivity) priority is given to safety. Knowing this, the individual is
motivated to operate safely. Furthermore, we found a significant interaction between
self-efficacy and standardization and their influence on patient safety. Safety
self-efficacy has no effect on performance in highly standardized environments.
However, implementing standardization in healthcare is problematic (Leape, 2002), and
not all processes can be standardized. In these cases, self-efficacy plays an important
role securing patient safety. Hence, safety self-efficacy may serve as a
‘substitute-for-standardization,’ by promoting staff behaviors that affect patient
safety. Future research should address specific mechanisms by which safety
self-efficacy influence specific safety behaviors. Finally, in our study, safety
self-efficacy influenced patient safety while general self-efficacy and safety
consciousness did not. This is an important finding because the literature tends to
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582
underline general self-efficacy instead of the situation specific efficacies (Chen et al.,
2001). For example, in healthcare, a physician may have a high general self-efficacy
that s/he can treat his/her patients well, and at the same time has low safety
performance.
Limitations and future research
Our measure of enactive mastery experiences was at the unit analysis level while
self-efficacy was measured individually. Future research should develop alternative
measures of enactive mastery safety experiences. Second, the collection of safety data
in organizations in general, and in hospitals specifically, is subject to problems of
willingness to report because employees may tend to under-report errors (Leape, 2002).
Recently, Studdert et al. (2004) argued that transparency became the patient safety
movement leitmotif (Sage, 2003; Berwick and Leape, 1999). To learn from errors,
hospitals must first identify them; to identify them, they must foster an atmosphere
that is conducive to openness about reporting mistakes. Hospitals and physicians are
urged to be honest with patients about medical errors, and to report such events to one
another and to regulators. Finally, healthcare risk managers who collect data about
patient safety and treatment errors are limited if they have only partial information.
However, the present study used participants as self-informers about their own
near-misses. This may cause a potential same-source bias. However, we used two
different methods for measuring the independent variables (i.e. the Likert scales) and
the dependent variable (a count variable). Also, the correlations between the
independent and dependent variables were low, which decreases the possibility of
same-source bias (Kennedy, 1998, pp. 183-193). Nevertheless, future research on patient
safety should address measurement of patient safety and treatment error problems.
Management implications
Healthcare managers can count on standardization to assure patient safety. However,
because they operate in complicated healthcare settings, they must remember that
standardization is not always possible or desirable; especially in situations that require
individuals to improvise. In this case, safety self-efficacy should be developed and
increased in order to increase patient safety. Managers can increase safety self-efficacy
first by being safety role models (see further discussion in Katz-Navon et al., 2005).
They should point out potential hazards to staff, insist on implementing procedures
and guide employees’ safety behaviors. Additionally, employees should receive
information about safety through consistent safety training programs and safety
information flows. Finally, safety must be given priority over other organizational
outcomes such as speed and productivity. This should be done by, for example,
including safety as a criterion in employee evaluation processes and by rewarding
employee behavior, which add to patient safety. Previous research has supported the
importance of self-efficacy for effective performance. Our results suggest that such
influence extends to employees’ tendency to maintain patient safety in healthcare
organizations. This broadening is especially important in low standardization
situations.
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Corresponding author
Tal Katz-Navon can be contacted at: katzt@idc.ac.il
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