See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/356971933
Safety culture, safety climate, and safety performance in healthcare facilities:
A systematic review
Article in Safety Science · March 2022
DOI: 10.1016/j.ssci.2021.105624
CITATION
READS
1
508
3 authors:
Intan Suraya Noor Arzahan
Zaliha Ismail
Universiti Teknologi MARA
Universiti Teknologi MARA
9 PUBLICATIONS 3 CITATIONS
90 PUBLICATIONS 445 CITATIONS
SEE PROFILE
SEE PROFILE
Siti Munira Yasin
Universiti Teknologi MARA
40 PUBLICATIONS 135 CITATIONS
SEE PROFILE
Some of the authors of this publication are also working on these related projects:
Determinants of Treatment Success Among Children with Tuberculosis Using MyTB Database Version 2.1 and Their Parents' Perspectives on Successful Treatment View
project
Safety Culture in Paramedics Training Institute View project
All content following this page was uploaded by Intan Suraya Noor Arzahan on 13 December 2021.
The user has requested enhancement of the downloaded file.
Safety Science 147 (2022) 105624
Contents lists available at ScienceDirect
Safety Science
journal homepage: www.elsevier.com/locate/safety
Review
Safety culture, safety climate, and safety performance in healthcare
facilities: A systematic review
Intan Suraya Noor Arzahan a, b, Zaliha Ismail a, *, Siti Munira Yasin a
a
b
Dept. of Public Health Medicine, Faculty of Medicine, Universiti Teknologi Mara Malaysia, 47000 Sungai Buloh, Selangor, Malaysia
Ministry of Health Training Institute (ILKKM), Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia
A R T I C L E I N F O
A B S T R A C T
Keywords:
Systematic Review
Safety culture or climate
Safety Performance
Health Professional
Healthcare Facilities
Numerous studies, especially in high-risk industries, have looked into how safety culture might help a company
improve its safety performance. However, healthcare facilities are still in their early stages of safety performance
development. A systematic review (SR) of Scopus, Web of Science, Dimensions, ScienceDirect, and Google
Scholar, was conducted using the Preferred Reporting Items for Systematic Reviews (PRISMA) technique. The
purpose is to look into the link involving safety culture or climate and safety performance in healthcare facilities.
A number of keywords ‘safety culture’, ‘safety climate’, ‘safety performance’, ‘injury’, ‘incident’, ‘healthcare’,
‘hospital’, ‘clinic’, ‘health office’, ‘health division’, and ‘health authority’ were chosen by researchers in this SR.
The inclusion criteria were (1) studies in healthcare facilities involving safety culture or safety climate-linked
with safety performance, (2) English language, and (3) research published in peer-reviewed journals within
five years (2016 to 2020). The EPHPP-Quality Assessment Tool was used to assess the quality of the studies. The
influence of safety culture, climate, and safety performance in 11 research was reviewed by researchers in the
current paper. Only one study was rated as strong quality, six of the studies were rated as moderate quality, and
the rest were rated as weak quality. The EPHPP quality assessment tool dictionary aided evaluation of article
bias. The proactive measure is favored among researchers in healthcare and has a significant relationship with
safety culture or safety climate. Despite the importance of this field, quality research is still insufficient, ac­
cording to our evaluation. Additional research is needed to explain the link between the variables evaluated,
particularly in healthcare facilities and other low-risk industries.
1. Introduction
The terms “safety culture” and “safety climate” are often used in the
literature to refer to the nature of an organization’s policies and the
attitudes of its employees regarding safety issues. In certain studies, the
words “safety culture” and “safety climate” have been used inter­
changeably. Researchers found numerous definitions in the literature,
but researchers have agreed upon no one description. Some indicators’
explanations are preferred over others in this regard. Safety culture is
most commonly referred to as “the result of individuals and groups’
beliefs, attitudes, competencies, and behavior patterns. It defines the
commitment to and the style and efficiency of an organization’s safety
and health (S&H) management” (International Atomic Energy Agency,
1991). Safety climate, on the other hand, is a more superficial
perspective. It has also been considered the measurement of safety
culture and how the people in one’s organization perceive safety in their
work environment (Zohar, 1980) Later, safety climate was defined as
how individuals view workplace safety rules, procedures, and practices
(Griffin and Neal, 2000) There is currently no consensus on the di­
mensions of the safety climate. It may vary from one industry to another
(Alruqi et al., 2018) The difference between safety culture and safety
climate is that safety culture relates to an organization’s set of values. In
contrast, safety climate refers to the effect of environmental and orga­
nizational factors on these values. Both (Guldenmund, 2000) and
(Zohar, 2010) said that safety culture is a fundamental concept in the
new strategy to enhancing the results of safety performance. Safety
culture aims to create a good environment where employees are aware
of hazards and accident prevention (He et al., 2012; Zin and Ismail,
2012).
However, there is no final consensus in the literature on the concept
of safety performance. The majority of academics determine the mean­
ing based on their own experiences (Yu-Jung et al., 2013; De Koster
* Corresponding author at: Dept. of Public Health Medicine, Faculty of Medicine, Universiti Teknologi Mara Malaysia, 47000 Sungai Buloh, Selangor, Malaysia.
E-mail address: zaliha78@uitm.edu.my (Z. Ismail).
https://doi.org/10.1016/j.ssci.2021.105624
Received 15 June 2021; Received in revised form 11 October 2021; Accepted 30 November 2021
Available online 11 December 2021
0925-7535/© 2021 The Authors.
Published by Elsevier Ltd.
This is an open
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
access
article
under
the
CC
BY-NC-ND
license
I.S. Noor Arzahan et al.
Safety Science 147 (2022) 105624
et al., 2011), for example, defined safety performance as an organiza­
tion’s capacity to avoid work-related accidents or injuries. Because of
their impact on organizational safety performance, safety culture and
climate have been influential in recent decades.
A substantial amount of study has been conducted to examine the
relationship between safety culture and climate and their effect on safety
outcomes, including safety performance. Numerous studies, particularly
in high-risk sectors, have investigated how safety and safety culture may
assist an organization in improving its safety performance. (Cheyne and
Cox, 2000; Kasim, Hassan, Hamid, Emami, & Danaee, 2019). The
aviation sector started as a reactive industry and has thrived as a result
of positive underlying attitudes; the oil and gas industry has improved as
a result of being more systematic and calculative in its approach. Both
are convergent in that they are trying to fix their faults in order to
become more proactive. In light of this awareness, the healthcare system
is still in the early phases of growth regarding safety culture issues,
which is a good sign. Review studies in this area have also been pub­
lished in recent years, yet; there has been little review study on the in­
dicator metric of these three terms: safety culture, safety climate, and
safety performance, particularly in healthcare settings. As a result, this
paper summarizes all relevant studies conducted in healthcare in­
stitutions in order to evaluate the evidence demonstrating a connection
between safety culture, safety climate, and safety performance. The
organization of this systematic review is tailored to answer the critical
questions of interest as follows: (1) What is the dimension for safety
culture, safety climate, and safety performance in healthcare facilities?.
(2) What is the method of assessment that has been conducted?. (3)
What is the relationship between these variables?.The following is the
structure of the paper: Section 2 highlights the objectives of the review.
The methodologies utilized in the investigation are discussed in Section
3. Section 4 give the findings from the analysis. Section 5 has a discus­
sion, Section 6 highlights limitation, while Section 7 summarizes and
concludes the work.
translation, the search attempts eliminated non-English publications
and concentrated solely on English-language content. Finally, a fiveyear timeframe has been chosen (between 2016 and 2020).
3.2. Search strategy
The researcher used the PRISMA Statement to guide the review, and
it is often utilized in the safety and health field. The PRISMA Statement
also enables a thorough search of topics linked to the interaction be­
tween safety culture, climate, and performance. The researchers selected
five primary journal databases in this study – Scopus, Web of Science
(WoS), Science Direct, Google Scholar, and Dimensions. The keywords
‘safety’, ‘safety culture’, ‘safety climate’, ‘safety performance’, ‘injury’,
‘incident’, ‘healthcare’, ‘hospital’, ‘clinic’, ‘health office’, ‘health divi­
sion’, and ‘health authority’ were chosen in this systematic review. Since
the study focuses on healthcare facilities and only on health pro­
fessionals’ safety and health, the searching strategy did not include the
‘patient safety’ term. Provided below is a search strategy sample from
the Web of Science (WoS) online database:
(AB= ((“safety” OR “safety culture*” OR “safety climate*”) AND
(“safety performance*” OR “incident*” OR “injury*”) AND (“healthcare”
OR “hospital*” OR “clinic*” OR “health office*” OR “health division*”
OR “health authority*”) NOT (“patient safety”)))
Fig. 1 depicts the procedures for selecting relevant publications for
the study. The review involved a systematic review method, identifi­
cation of targeted variables, and content analysis. The systematic review
process, which took place in December 2020, included a database search
to discover similar papers. Based on past research and thesaurus, key­
words linked to safety culture, climate, safety performance, and
healthcare were included. After the meticulous screening, 12 duplicated
articles were excluded at this step. 4615 articles were matched based on
title and keywords set. After the screening process, we were left with 175
articles. After analyzing the publications, the researchers chose 11 ar­
ticles based on their conformity with the selection criteria. These last
few articles have been reviewed and discussed. The efforts were
concentrated on specific research that provided answers to the specified
questions. In order to collect information, researchers began by reading
the abstracts, followed by the articles (in detail) to identify relevant
themes.
In the next step, start to identify variables. We also identified the
article’s features, such as the authors’ names, origin, publication year,
method of assessment chosen for each variable, and the study popula­
tion. Table 1 summarises these characteristics. In the last step of content
analysis, we explored the relationships between safety culture, climate
dimensions, and safety performance metrics. The link between each
variable is provided in Table 3. This link is presented based on statistical
analysis that has been conducted in the papers. There are two methods
to describe these relationships: either a positive or negative relationship
between variables.
2. Objective
This systematic review aims to determine the indicator of safety
culture, climate, and performance in healthcare institutions, as well as
the evidence connecting safety culture, climate, and performance. The
solution needs to be broken down into feasible elements to form a model
that can produce better safety performance. Suppose we refer to previ­
ous studies and theories related to safety performance. In that case, the
safety culture or safety climate factor is one of the things that is often
given attention because of its role that helps a lot to improve safety
performance (De Koster et al., 2011; Fernández-Muñiz et al., 2014;
Lingard et al., 2012; Mellott, 2021; Nielsen et al., 2008; Rajabi et al.,
2020; Wachter and Yorio, 2014; Xu et al., 2020; Zwetsloot et al., 2017).
Researchers looked at the elements or variables that enhance safety
performance in the healthcare industry as part of this study, hoping that
this information will be useful to authorities (Public Services and Stat­
utory Authorities) in planning and identifying necessary safety culture
elements to improve safety performance. Besides that, it aims to meet
the objectives of the Malaysian Occupational Safety and Health Master
Plan 2016–2020 , to inculcate a safe and healthy work culture for the
well-being of employees, employers, and the country as a whole.
3.3. Quality assessment
The selected study’s quality was assessed using the Quality Assess­
ment System for Effective Public Health Practices Project (EPHPP)
quality for quantitative studies, which looks at selection bias, study
design, confounders, blinding, data collection techniques, and drop-out
rate. Evaluation of article bias was aided by the EPHPP quality assess­
ment tool dictionary. Based on the individual ratings provided to each
dimension, each article’s quality was evaluated as strong, moderate, or
weak, according to the dictionary. The findings from each domain were
then pooled to provide a global rating. The studies were assessed as
poor-quality (two or more aspects were deemed weak), moderatequality (one aspect was deemed weak), and high-quality (no aspect
was rated as weak). The study’s quality was evaluated by all of the au­
thors separately (ISNA, ZI, and SMY). Disagreements and questions that
occurred throughout the review process were resolved during
3. Method
3.1. Eligibility criteria
Particular inclusion and exclusion criteria are established to answer
the research question: What evidence exists to show safety culture or
climate link to safety performance in healthcare facilities?. First, only
article journals containing empirical data were chosen, which means
review articles, book series, books, book chapters, and conference pro­
ceedings are all omitted. Second, to prevent ambiguity or difficulty in
2
I.S. Noor Arzahan et al.
Safety Science 147 (2022) 105624
Fig. 1. Literature search strategy and selection for included studies (n = 11).
Table 1
Selected Journal Article.
Country
Iran
China
Studies
(Ghasemi, Aghaei, Askaripoor, &
Ghamari, 2020)
(Xu et al., 2020)
Canada
(McGhan, Ludlow, Rathert, &
McCaughey, 2020)
Egypt
(Alghalban et al., 2020)
USA
Turki
(Vogus, Ramanujam, Novikov,
Venkataramani, & Tangirala, 2020)
Uzuntarla et al. (2020))
USA
(Quach et al., 2020)
Indonesia
(Ismara, Husodo, Prabandari, &
Hariyono, 2019)
Nigeria
(Mashi, 2017)
USA
(Cook, Slade, Cantley, & Sakr, 2016)
Israel
(Isaak, Vashdi, Bar-noy, Kostisky, &
Hirschmann, 2016)
Type of Relationship
Method of Assessment
Respondent
Safety culture & Safety
Climate
Safety Performance
Safety Climate and
Safety Performance
Safety Climate and
Safety Performance
Safety Climate and
Safety Performance
Self-reported
Questionnaire
Self-reported
Questionnaire
Self-reported
Questionnaire
Hospital nurses
Safety Climate and
Safety Performance
Safety Climate and
Safety Performance
Safety Culture and
Safety Performance
Safety Climate and
Safety Performance
OSH Climate and OSH
Performance
Self-reported
Questionnaire
16 items Self-reported
Questionnaire
18 items Self-Reported
Questionnaire
Self-reported
Questionnaire
Self-reported
Questionnaire,
Interview & observation
Self-reported
Questionnaire
Self-reported
Questionnaire
Self-reported
Questionnaire
Safety compliance and
participation
Safety compliance and
participation
Number of injuries, job
satisfaction, stress & turnover
intent
Number of incidents-Sharps
Injuries
Experience on burnout
Safety behavior
Healthcare practitioners
Adverse events
Nurses, nursing assistants,
and clinicians/specialists
Hospital nurses
Safety Culture and
Safety Performance
Safety Climate and
Safety Performance
Safety Climate and
Safety Performance
3
Safety behavior
Healthcare employees
Healthcare practitioners
Healthcare workers
Hospital nurses
Safety compliance and
participation
Injury rates
Hospital nurses
Number of incidents
Healthcare practitioners
Healthcare practitioners
I.S. Noor Arzahan et al.
Safety Science 147 (2022) 105624
discussions.
performance.
4. Results
5. Discussion
4.1. Study selection
This systematic literature review provides new empirical evidence
about the safety culture, safety climate, and safety performance rela­
tionship in the healthcare industries. The quality evaluation of the ar­
ticles revealed that 64% (7 out of 11 research) of the included studies
were conducted moderately or strongly. This fact gives us confidence
that the conclusions of this literature study are less skeptical than in the
past assessments of the link between the safety culture, safety climate,
and safety performance (Aburumman et al., 2019; Kalteh et al., 2021; Vu
and Cieri, 2014).
After reviewing the abstracts and full papers, 11 suitable publica­
tions were chosen for inclusion in the review. We discovered that 27.2%
(n = 3) of the study were performed in the United States, 9.1% (n = 1) in
Egypt, 9.1% (n = 1) in Turkey, 9.1% (n = 1) in Canada, 9.1% (n = 1) in
Nigeria, 9.1% (n = 1) in Indonesia, 9.1% (n = 1) in Israel, 9.1% (n = 1)
in Iran, and 9.1% (n = 1) in China. Table 1 lists the features of the ar­
ticles that were chosen. The target respondent in healthcare facilities, as
well as the safety climate, safety culture, and safety performance eval­
uation methods, are among these features.
5.1. Safety culture or climate dimension
4.2. Study characteristics
The dimensions of the instrument in these surveys were established
depending on the aims of the study. However, the example of primary
aspects of the safety climate outlined by Xu et al. (2020) is such as
management commitment, organizational habits, safety engagement
and communication, safety equipment, housekeeping, safety training,
and rewards. Thus, in Table 4, we displayed the selection of the most
frequently recommended dimensions in assessing the safety climate or
culture. The most utilized dimensions for measuring healthcare facil­
ities’ safety culture were management commitment and safety resources
and availability of policies that reflect the organization’s commitment to
safety. This element is because safety resources such as allocated budget
from top management dedicated for safety-related is necessary espe­
cially organization under federal government (hospital etc.,) in ensuring
the progress and efforts to put towards safety in the healthcare facilities.
Furthermore, management commitments include designating at least
one competent member with safety training as secretary of the safety
committee and allowing workers to refuse to work in hazardous or un­
healthy conditions (Noor Arzahan et al., 2021) is vital to ensure the
organization is competent in handling safety-related issues and
problems.
Table 1 summarizes the study characteristics of the 11 eligible
studies. The tables provide information on study locations, types of re­
lationships, method of assessment, and target respondents found in each
study.
4.3. Quality assessment
Table 2 summarizes the quality of the 11 studies. The overall score at
the bottom of the table reveals that all studies scored strongly in terms of
selection bias (100%), data collection method (100%), and moderate in
terms of participant blinding (100%). Most studies scored moderately in
confounders (55%) and weak in research design (82%). Meanwhile,
there is a similar percentage for drop-outs in the studies and a similar
percentage for weak and moderate (36%). In terms of overall quality,
9% of the studies were high quality, 55% were of moderate level, and
36% were of low quality.
4.4. The type of variables’ relationship
Based on these selected publications, two studies based on these
chosen publications demonstrated a link between safety culture and
safety performance. The remaining nine studies investigated the link
between safety climate and safety performance. Six of the eleven pub­
lications used proactive methods to assess safety performance. Proactive
methods included safety behavior, safety compliance, and safety
engagement. Meanwhile, four of the studies used reactive measures such
as incidence and injury rates. Only one research combined reactive and
proactive methods to assess safety performance. Table 3 shows the di­
mensions, aspects, elements, indicators, or subscales of safety culture or
safety climate utilized in the studies and their connection to safety
5.2. Safety culture and safety climate – Method of assessment
As shown in Table 1, the variables are evaluated using various
techniques, including surveys, interviews, and observation. However, a
regular method of assessment chosen in the studied publications uses
self-reporting questionnaires. Researchers in the studied publication
designed questionnaires that were tailored to the targeted working
environment and subjects. Although employing a questionnaire to
analyze an organization’s safety climate or culture is straightforward, it
does have certain limitations. Because there is no clear consensus among
academics on the definitions of these terminologies, the categories of
Table 2
Quality assessment result against the effective public health practice project quality assessment tool
References
Selection bias
Design
Confounders
Blinding
Data collection method
Withdrawal &
Drop-outs
Global ratings
(Ghasemi et al., 2020)
Xu et al. (2020)
McGhan et al. (2020)
(Alghalban et al., 2020)
Vogus et al. (2020)
Uzuntarla et al. (2020)
Quach et al. (2020)
Ismara et al. (2019)
Mashi (2017)
Cook et al. (2016)
Isaak et al. (2016)
Sum Weak (%)
Sum Moderate (%)
Sum Strong (%)
Strong
Strong
Strong
Strong
Strong
Strong
Strong
Strong
Strong
Strong
Strong
0
0
11(1 0 0)
Weak
Moderate
Weak
Weak
Weak
Weak
Weak
Weak
Weak
Weak
Moderate
9 (82)
2 (18)
0
Moderate
Strong
Strong
Moderate
Strong
Weak
Moderate
Moderate
Moderate
Moderate
Weak
2 (18)
6 (55)
3 (27)
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
0
11(00)
0
Strong
Strong
Strong
Strong
Strong
Strong
Strong
Strong
Strong
Strong
Strong
0
0
11(1 0 0)
Moderate
Strong
Weak
Weak
Strong
Weak
Moderate
Strong
Moderate
Weak
Moderate
4 (36)
4 (36)
3 (28)
Moderate
Strong
Weak
Weak
Moderate
Weak
Moderate
Moderate
Moderate
Weak
Moderate
4 (36)
6 (55)
1 (9)
4
I.S. Noor Arzahan et al.
Safety Science 147 (2022) 105624
Table 3
Relationship between safety culture and safety climate dimensions and safety
performance measures
Studies
Ghasemi
et al.
(2020)
Xu et al.
(2020)
McGhan
et al.
(2020)
(Alghalban
et al.,
2020)
Vogus et al.
(2020)
Uzuntarla
et al.
(2020)
Quach et al.
(2020)
Ismara et al.
(2019)
Mashi
(2017)
Cook et al.
(2016)
Isaak et al.
(2016)
Safety culture and
safety climate
dimension, aspect,
element, indicator, or
subscale
Moderator/Mediator
Relationship among
coworker
Communication
Management
supervision
Working condition
Reporting of errors
Safety training
Leaders’ commitment
to safety
Communication about
safety
Safety education
Worker safety
precautions
Safety equipment and
housekeeping
Safety participation
and incentives
Safety knowledge
Safety policies
Safety training
Communication
Management
supervision
Working environment
Reporting of errors
The safety system in
place
Top management
commitment
Safety Resources
Risk management
Communication with
worker
Safety awareness
None
Safety priorities
Management
commitment to safety
Supervisor
commitment
Personal attitudes
toward safety
Environmental safety
Coworker interactions
around safety
Attitude
Norm
Perceived behavioral
control
Management
commitment
SOPs & regulations
Pro-safety policies
Management/
Supervisory
contribution
Employee engagement
Activities for safety
Climate at work
Safety communication
Management
commitment to safety
Procedure and safety
report
Table 4
Prevailing dimensions of safety climate/culture in healthcare facilities.
Relationship
with safety
performance
Positive
None
Positive
None
Positive
None
Positive
Safety culture or safety climate dimension, aspect, element,
indicator, or subscale
Frequency
(%)
Management commitment/supervision/participation/involvement
Safety resources/policies/training
Risk management/communication
Safety rules/procedures/equipment/rewards
Worker’s involvement/participation
8 (73%)
9 (82%)
6 (55%)
5 (45%)
5 (45%)
dimensions seem different for each type of organization. Thus, evalua­
tion appears to be a formidable task. For example, the management
commitment indicator assessment is varied and classically determined
by whether or not the organization’s senior management is dedicated to
employee safety (Cook et al., 2016). Analyzing the common dimensions
is crucial as the benefit is that it provides an essential indicator of how
far the organization’s safety culture has progressed. In the healthcare
industry, a quantitative approach to evaluating safety culture is the most
often used method of investigation, with qualitative approaches being
employed by only a small number. Most researchers devised a quanti­
tative technique for measuring safety culture by examining workers’
perceptions using a five-point neutral mid-point Likert scale to indicate
their level of agreement or disagreement. This is a common technique
used by past studies in construction, aviation, and manufacturing in­
dustries to prove its importance and relevance (Siti Fatimah Bahari,
2011; Amirah et al., 2013; Abdullah et al., 2016).
5.3. Safety performance – The assessment indicators
None
Positive
None
Positive
None
Positive
Safety intention act as
the mediator of safety
climate and safety
behavior
Consideration of
future safety
consequence (CFSC)
moderate relationship
between safety SOPs
& regulations and
safety participation
None
Positive
None
Positive
The type of industry being researched has a significant influence on
the safety performance indicators used. Over time, conceptual models
for analyzing the organization’s safety performance have been pre­
sented. These models are based on industry type and records on acci­
dents, injuries, and risky practices. Related to this matter, Cooper and
Phillips (2004) have categorized reactive (action taken after incidents
happened) and proactive measures (action taken to prevent incidents) as
two groups of safety performance assessment. After that, it is up to the
researcher to decide which measures to use, and it is usually determined
by the assessment’s goal and the organization’s available resources.
Reactive measurements are preferable when assessing the influence of
earlier organizational efforts to perform safety-related activities or
comparing effects when the safety intervention is done (Sherratt and
(Fred), 2012). Based on a study by Glendon and Litherland (2001),
reactive measures were used widely in high-risk industries. However,
they highlighted the weakness of such measures as if ignoring risk ex­
posures, lack of sensitivity toward the studied organization, question­
able accuracy, and retrospection. On the other hand, most studies in
literature supported that proactive measures are commonly used to
evaluate the state of the organization’s effort or progress in inculcating
safety practices to enhance performance. Proactive measures have also
proven to boost employee motivation in safety and health (Zahoor et al.,
2017); thus, it is most suitable to be selected in healthcare industries and
other low-risk organizations.
The incident rate calculation is the method commonly used to
represent reactive criteria in the scientific literature. However, proven in
other studies in higher-risk industries, the reactive measure does not
appear to have sufficient accuracy. For instance, in the construction
industry, contractors usually underreport the number of incidents due to
feeling afraid of the legal consequences after any incidents (Lingard and
Rowlinson, 1994). In reality, the adequacy of this criterion depends on
how often employers record incidents of missed days due to accidents
and how well workers understand their job’s legal responsibilities
(Jaselskis et al., 1996). Besides that, incidents are also being modified
and underreported to influence the company’s experience modification
rating. The higher incident frequency will cause the contractor’s
Positive
Positive
Negative
Positive
5
I.S. Noor Arzahan et al.
Safety Science 147 (2022) 105624
connects to people’s drive to execute their jobs that impact safety be­
haviors and incidents. The justification of the pathway has been
described in a study by Lingard et al. (2012). Management commitment
to safety affects worker injury performance by fostering shared views of
their immediate superiors’ safety requirements. Supervisors serve as a
“conduit” for communicating corporate safety objectives to front-line
employees and offering critical feedback on their conduct’s appropri­
ateness (Niskanen, 1994) The relationship between safety commitment
at the top of the organization and the incidence of injuries in workgroups
was completely mediated by supervisors’ expectations for safety.
From the statistical test results, the link between variables is avail­
able in two options. First, a negative correlation exists between safety
culture or climate and reactive safety performance metrics. Second,
there is a significant correlation between safety culture or climate and
proactive safety performance metrics. Looking through the literature,
the kind of criteria to choose is determined by the industry standard.
According to the findings, the riskier organizations such as aviation,
construction, and oil and gas, would prefer reactive criteria and find it
more appropriate because of changing working conditions (Siti Fatimah
Bahari, 2011; Amirah et al., 2013; Abdullah , 2016), but proactive in­
terventions are more appropriate in low-risk industries, such as
healthcare, due to the consistency of conditions and habits across time.
Finally, none of the assessed articles included studies examining the
effect of safety interventions on changes in safety performance. Perhaps,
this is because safety culture involves human belief, intention, motiva­
tion, and competence, which is the effort in the long run. However, most
research has proposed that safety climate and safety culture elements
that are proven statistically work on safety improvements to be included
as interventional factors in future studies.
company to pay a higher insurance premium, so the recorded incidents
are less likely to be correct. Hence, calculating this incident number is
difficult and unreliable, and using this criterion to assess safety perfor­
mance is not advised for any organization as stated by (Hinze et al.,
1995; Everett and Thompson, 1995).
In high-reliability sectors nowadays, preventative techniques are
commonly implemented. They have progressed from reactive earlier
and reached the level where all safety measures were in place and
practicing an excellent safety management system (Morrow et al.,
2014). The preventative technique also was applied in an organization
where no significant high fatalities incidents were recorded. Thus, for
low-risk organizations such as education-based as schools, training in­
stitutes, and government agencies, proactive measures are beneficial to
be used over-reactive measures. In these industries, employee behavior
observation (Ismara et al., 2019; Uzuntarla et al., 2020) and employee
participation in safety-related activities are more routinely employed as
a metric for evaluating safety performance (Mearns et al., 2003). Pro­
active measures are a safety performance evaluation instrument that has
gotten much attention in recent years because of their reliable charac­
teristics and not much controversy.
Predictive and monitoring measures of this proactive criteria, ac­
cording to Körvers and Sonnemans (2008), including indications that
are assessed before incidents happen, and the outcomes of audits, per­
ceptions of employees as to the benefits from practicing safety, and also
the workplace safety observations. Most of the studies selected in this
review comprehend safety behaviors as an indication of safety perfor­
mance in light of these inadequacies in reactive techniques for
measuring safety performance. The behavior is described as employees’
actions at work to ensure their safety and others’ safety in the working
environment. Yet, some recent studies still preferred dual measurement
of safety performance by considering both accident rates and safety
behavior. Even more interesting, Fernández-Muñiz et al., 2014 also
introduced an additional safety performance indicator by also looking at
employee satisfaction. This beneficial addition is helpful for industries
that are still in the early stage of inculcating safety culture and lower
risk.
6. Limitation
First, we were only able to find a few research on the relationship
between the studied variables in the healthcare industry. As a result,
finding a larger number of high-quality research in this sector is chal­
lenging. Despite doing a thorough literature search across five online
databases and using broad keywords, we could not rule out the possi­
bility of missing some relevant papers.
5.4. Safety culture or climate and safety performance in healthcare – The
link
7. Conclusion
The relationship between the studied elements is shown in Table 3.
Researchers in healthcare facilities have analyzed the link between
variables in two ways. First, the fundamental analysis involved a
connection between each of the safety culture dimension elements and
safety performance metrics using correlation coefficients and bivariate
test analysis (the non-intermediate link between variables). Second,
the connection between safety culture or safety climate as a single
structure towards safety performance. This analysis is a higher-level
analysis involving structural equations and the presence of mediator
or moderator variables. This review also considers any other elements or
factors that might contribute to, influence, or enhance the organiza­
tion’s safety performance, thus conducting a more thorough examina­
tion of the reasons for the incident events. This review also contributes
to an additional finding in the mediators or moderators linking safety
culture to safety performance.
The second method looked at the link between safety climate or
culture and the proactive safety performance measures such as safety
compliance and involvement. These two criteria provide an assumption
on workplace accidents tendency based on individual perception or
psychosocial factors. Numerous researches have been conducted to
determine their effects and between these studied variables (Abdullah
et al., 2016; Ali et al., 2009; Kasim et al., 2019; Mat et al., 2016). Based
on the analysis, safety climate or culture may be recognized as a reliable
indicator of safety performance since it predicts safety behavior.
Workers’ perceptions of the organization’s safety rules, beliefs, and
values are indicators of the safety culture or climate. This perception
Finally, this review looks at papers on the effects of safety climate
and culture on safety performance. The relevance of analyzing safety
performance has been verified in recent years to compare the feasibility
of safety culture practice and the impact on the target organization. Two
types of safety performance evaluations available are reactive and pro­
active measures. Reactive and proactive measures are negatively and
positively related to safety culture and safety climate, respectively,
following statistical findings. However, determining such effects is
challenging due to societies’ varying features and studied organizations.
What’s more, researchers seem to prefer proactive approaches that
promote ease of use and a preventive strategy, particularly in healthcare
settings. The limited research that has been conducted on the connection
between reactive and proactive measures, with safety culture and safety
climate, has discovered that safety compliance is more dependable.
However, researchers support future studies to include safety satisfac­
tion as an additional safety measure. This measure will reflect positive
morale and higher safety awareness to comply with the excellent safety
management system. The findings also revealed that characteristics such
as safety competence that include good safety knowledge might mod­
erate the effects of safety culture and safety climate on safety
performance.
8. Statement on the accessibility of data
The article/supplementary material contains the study’s original
6
I.S. Noor Arzahan et al.
Safety Science 147 (2022) 105624
contributions. Additional questions should be addressed to the corre­
sponding author(s).
Hinze, Jimmie, Bren, Dave C., Piepho, Nancy, 1995. Experience Modification Rating As
Measure of Safety Performance. J. Construct. Eng. Manage. 121 (4), 455–458.
International Atomic Energy Agency, I. (1991). SAFETY SERIES No . 75-INSAG-4 Safety
Culture Report. In Atomic Energy.
Isaak, V., Vashdi, D., Bar-noy, D., Kostisky, H., & Hirschmann, S., 2016. Enhancing the
Safety Climate and Reducing Violence. 65(9), 409–416. https://doi.org/10.1177/
2165079916672478.
Ismara, K.I., Husodo, A., Prabandari, Y.S., Hariyono, W., 2019. Relationship model for
occupational safety and health climate to prevent needlestick injuries for nurses.
Kesmas 13 (3), 144–149. https://doi.org/10.21109/kesmas.v13i3.1989.
Jaselskis, Edward J., Anderson, Stuart D., Russell, Jeffrey S., 1996. Strategies for
Achieving Excellence in Construction Safety Performance. J. Construct. Eng.
Manage. 122 (1), 61–70.
Kalteh, H.O., Mortazavi, S.B., Mohammadi, E., Salesi, M., 2021. The relationship
between safety culture and safety climate and safety performance: a systematic
review. Int. J. Occupat. Safety Ergonomics 27 (1), 206–216. https://doi.org/
10.1080/10803548.2018.1556976.
Kasim, H., Hassan, C. R. C., Hamid, M. D., Emami, S. D., & Danaee, M. (2019). The
relationship of safety climate factors, decision making attitude, risk control, and risk
estimate in Malaysian radiation facilities. Safety Science, 113(December 2018),
180–191. https://doi.org/10.1016/j.ssci.2018.11.025.
Körvers, P.M.W., Sonnemans, P.J.M., 2008. Accidents: A discrepancy between indicators
and facts! Safety Science 46 (7), 1067–1077.
Lingard, Helen, Cooke, Tracy, Blismas, Nick, 2012. Do perceptions of supervisors ’ safety
responses mediate the relationship between perceptions of the organizational safety
climate and Incident rates in the construction supply chain ? J. Construct. Eng.
Manage. 138 (2), 234–241.
Lingard, Helen, Rowlinson, Steve, 1994. Construction site safety in Hong Kong.
Construct. Manage. Economics 12 (6), 501–510. https://doi.org/10.1080/
01446199400000061.
Mashi, M. S., 2017. The Effect of Management Commitment , Safety Rules and Procedure and
Safety Promotion Policies on Nurses Safety Performance : The Moderating Role of
Consideration of Future Safety Co ... (February 2018).
Mat Jusoh, N.H., Panatik, S.A., 2016. The Effects of Safety Climate on Safety
Performance: An Evidence in a Malaysian-Based Electric Electronic and
Manufacturing Plant. Sains Humanika 8 (4–2), 33–39. https://doi.org/10.11113/sh.
v8n4-2.1056.
McGhan, G. E., Ludlow, N. C., Rathert, C., & McCaughey, D., 2020. Variations in
Workplace Safety Climate Perceptions and Outcomes Across Healthcare Provider
Positions. Foundation of the American College of Healthcare Executives, 65(3).
https://doi.org/10.1097/JHM-D-19-00112.
Mearns, K., Whitaker, S.M., Flin, R., 2003. Safety climate, safety management practice
and safety performance in offshore environments. Safety Sci. 41 (8), 641–680.
https://doi.org/10.1016/S0925-7535(02)00011-5.
Mellott, Susan, 2021. Commentary: Safety culture and systems thinking for predicting
safety competence and safety performance among registered nurses in Saudi Arabia:
a cross-sectional study. J. Res. Nursing 26 (1-2), 33–34. https://doi.org/10.1177/
1744987120976440.
Morrow, S.L., Kenneth Koves, G., Barnes, V.E., 2014. Exploring the relationship between
safety culture and safety performance in U.S. nuclear power operations. Safety Sci.
69, 37–47. https://doi.org/10.1016/j.ssci.2014.02.022.
Nielsen, K.J., Rasmussen, K., Glasscock, D., Spangenberg, S., 2008. Changes in safety
climate and accidents at two identical manufacturing plants. Safety Sci. 46 (3),
440–449. https://doi.org/10.1016/j.ssci.2007.05.009.
Niskanen, T., 1994. Assessing the safety environment in work organization of road
maintenance jobs. Accident Analysis and Prevention (26), 27–39.
Noor Arzahan, I.S., Ismail, Z., Yasin, S.M., 2021. Content Validity Of A Self-Reported
Instrument For Safety And Health (S & H) Culture Practice In Paramedic Training
Institute Using A Heterogeneous Expert Panel. Turkish J. Comput. Mathematics
Educat. 12 (7), 2464–2472.
Quach, E.D., Kazis, L.E., Zhao, S., Ni, P., Mcdannold, S.E., Clark, V.A., Hartmann, C.W.,
2020. Safety Climate Associated With Adverse Events in Nursing Homes : A National
VA Study. J. American Med. Directors Assoc. 2–6 https://doi.org/10.1016/j.
jamda.2020.05.028.
Rajabi, F., Mokarami, H., Cousins, R., Jahangiri, M., 2020. Structural equation modeling
of safety performance based on personality traits, job and organizational related
factors. Int. J. Occupat. Safety Ergonomics. https://doi.org/10.1080/
10803548.2020.1814566.
Sherratt, F. S. (Fred)., 2012. Constructing Safety on Sites : The Social Construction of
Safety on Large UK Construction Sites. University of Bolton, (March), 567–576.
Siti Fatimah Bahari., 2011. An Investigation of Safety Training , Safety Climate and
Safety Outcomes : A Longitudinal Study in a Malaysian Manufacturing Plant.
Uzuntarla, Fatma, Kucukali, Serhat, Uzuntarla, Yasin, 2020. An analysis on the
relationship between safety awareness and safety behaviors of healthcare
professionals. Ankara/Turkey. (April) 62 (1). https://doi.org/10.1002/joh2.
v62.110.1002/1348-9585.12129.
Vogus, T. J., Ramanujam, R., Novikov, Z., Venkataramani, V., & Tangirala, S., 2020.
Adverse Events and Burnout The Moderating Effects of Workgroup Identification and
Safety Climate. Retrieved from www.lww-medicalcare.com.
Vu, T., Cieri, H. De., 2014. Safety culture and safety climate definitions suitable for a
regulator A systematic literature review. (April).
Wachter, J.K., Yorio, P.L., 2014. A system of safety management practices and worker
engagement for reducing and preventing accidents : An empirical and theoretical
investigation. Accident Anal. Prevent. 68, 117–130. https://doi.org/10.1016/j.
aap.2013.07.029.
9. Contributions of the authors
ISNA planned the research, conducted the literature review, evalu­
ated the quality of the literature, and wrote the paper. ZI and SMY
drafted an article outline, conducted a literature study, evaluated the
quality of the literature, then edited and polished the paper. Each author
contributed to the paper and approved the final version submitted for
publication.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgement
This study was supported by the Universiti Teknologi Mara Malaysia
(UiTM) under UiTM Grant No. 600-RMC/GPK 5/3 (205/2020).
References
Abdullah, M. S., Othman, Y. H., Osman, A., & Salahudin, S. N., 2016. Safety Culture
Behaviour in Electronics Manufacturing Sector (EMS) in Malaysia: The Case of
Flextronics. Procedia Economics and Finance, 35(October 2015), 454–461. https://
doi.org/10.1016/s2212-5671(16)00056-3.
Aburumman, M., Newnam, S., Fildes, B., 2019. Evaluating the effectiveness of workplace
interventions in improving safety culture : A systematic review. Safety Science 115
(January), 376–392. https://doi.org/10.1016/j.ssci.2019.02.027.
Ali, H., Azimah Chew Abdullah, nor, & Subramaniam, C., 2009. Management practice in
safety culture and its influence on workplace injury: An industrial study in Malaysia.
Disaster Prevention and Management: An International Journal, 18(5), 470–477.
https://doi.org/10.1108/09653560911003660.
Alghalban, Y., Badr, S., Salem, E., Kasemy, Z., Khooder, S., El-Bahnasy, R., 2020.
Epidemiology of Needlesticks and Sharps Injuries among Healthcare Workers and
Organizational Safety Climate By. Egyptian Journal of Occupational Medicine 44
(2), 679–696.
Alruqi, Wael, Hallowell, Matthew, Techera, Ulises, 2018. Safety climate dimensions and
their relationship to construction safety performance: A meta-analytic review. Safety
Science 109, 165–173. https://doi.org/10.1016/j.ssci.2018.05.019.
Amirah, N.A., Asma, W.I., Muda, S., Amin, A., 2013. Operationalisation of safety culture
to foster safety and health in the Malaysian manufacturing industries. Asian Social
Sci. 9 (7), 283–289. https://doi.org/10.5539/ass.v9n7p283.
Cox, S.J., Cheyne, A.J.T., 2000. Assessing safety culture in offshore environments. Safety
Sci. 34 (1-3), 111–129.
Cook, J.M., Slade, M.D., Cantley, L.F., Sakr, C.J., 2016. Evaluation of safety climate and
employee injury rates in healthcare. Occupat. Environ. Med. 73 (9), 595–599.
https://doi.org/10.1136/oemed-2015-103218.
Cooper, M.D., Phillips, R.A., 2004. Exploratory analysis of the safety climate and safety
behavior relationship. J. Safety Res. 35 (5), 497–512. https://doi.org/10.1016/j.
jsr.2004.08.004.
De Koster, R.B.M., Stam, D., Balk, B.M., 2011. Accidents happen: The influence of safetyspecific transformational leadership, safety consciousness, and hazard reducing
systems on warehouse accidents. J. Operat. Manage. 29 (7–8), 753–765. https://doi.
org/10.1016/j.jom.2011.06.005.
Everett, John G., Thompson, Willard S., 1995. Experience Modification Rating for
Workers’ Compensation Insurance. J. Construct. Eng. Manage.-Asce 121 (1), 66–79.
Fernández-Muñiz, B., Montes-Peón, J.M., Vázquez-Ordás, C.J., 2014. Safety leadership,
risk management and safety performance in Spanish firms. Safety Sci. 70, 295–307.
https://doi.org/10.1016/j.ssci.2014.07.010.
Ghasemi, F., Aghaei, H., Askaripoor, T., Ghamari, F., 2020. Analysis of occupational
accidents among nurses working in hospitals based on safety climate and safety
performance: a Bayesian network analysis. Int. J. Occupat. Safety Ergonomics 1–7.
https://doi.org/10.1080/10803548.2020.1768759.
Glendon, A.I., Litherland, D.K., 2001. Safety climate factors, group differences and safety
behaviour in road. Safety Sci. 39 (3).
Griffin, Mark, Neal, Andrew, 2000. Perceptions of safety at work: a framework for linking
safety climate to safety performance, knowledge, and motivation. Journal of
Occupational Health Psychology 5 (3), 347–358. https://doi.org/10.1037/10768998.5.3.347.
Guldenmund, F.W., 2000. The nature of safety culture : a review of theory and research.
Safety Science 34, 215–257. https://doi.org/10.1016/S0925-7535(00)00014-X.
He, Ahong, Xu, Surui, Fu, Gui, 2012. Study on the basic problems of safety culture.
Procedia Eng. 43, 245–249. https://doi.org/10.1016/j.proeng.2012.08.042.
7
I.S. Noor Arzahan et al.
Safety Science 147 (2022) 105624
Xu, X., Le, N., He, Y., Yao, X., 2020. Team Conscientiousness, Team Safety Climate, and
Individual Safety Performance: a Cross-Level Mediation Model. J. Business Psychol.
35 (4), 503–517. https://doi.org/10.1007/s10869-019-09637-8.
Yu-Jung, Liu, Jin-Luh, Chen, Shyh-Yueh, Cheng, Ming-Tsai, Hsu, Chen-Hua, Wang, 2013.
Evaluation of Safety Performance in Process Industries. Process Safety Progress 25
(4), 326–330. https://doi.org/10.1002/prs.
Zahoor, Hafiz, Chan, Albert, Utama, Wahyudi, Gao, Ran, Zafar, Irfan, 2017. Modeling the
relationship between safety climate and safety performance in a developing
construction industry: A cross-cultural validation study. Int. J. Environ. Res. Public
Health 14 (4), 351. https://doi.org/10.3390/ijerph14040351.
Zin, S. M., & Ismail, F. (2012). Employers’ Behavioural Safety Compliance Factors
toward Occupational, Safety and Health Improvement in the Construction Industry.
Procedia - Social and Behavioral Sciences, 36(June 2011), 742–751. https://doi.org/
10.1016/j.sbspro.2012.03.081.
Zohar, Dov, 1980. Safety climate in industrial organizations: Theoretical and applied
implications. Journal of Applied Psychology 65 (1), 96–102. https://doi.org/
10.1037/0021-9010.65.1.96.
Zohar, Dov, 2010. Thirty years of safety climate research: Reflections and future
directions. Accident Analysis and Prevention 42 (5), 1517–1522. https://doi.org/
10.1016/j.aap.2009.12.019.
Zwetsloot, G.I.J.M., Kines, P., Ruotsala, R., Drupsteen, L., Merivirta, M., Bezemer, R.A.,
2017. The importance of commitment, communication, culture and learning for the
implementation of the Zero Accident Vision in 27 companies in Europe. Safety Sci.
96, 22–32. https://doi.org/10.1016/j.ssci.2017.03.001.
8
View publication stats