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The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research
John B Sexton*1, Robert L Helmreich1, Torsten B Neilands2, Kathy Rowan3, Keryn Vella3, James Boyden4, Peter R Roberts5 and Eric J Thomas1 Address: 1The University of Texas Center of Excellence for Patient Safety Research and Practice, The University of Texas – Houston Medical School, Houston, USA, 2Center for AIDS Prevention Studies, University of California, San Francisco, USA, 3Intensive Care National Audit & Research Centre, London, UK, 4Royal Cornwall Hospital, Truro, Cornwall, TR1 3LJ, UK and 5Medical Research Institute of New Zealand, Wellington, NZ; University of Texas – Houston Medical School, Division of General Medicine, Department of Medicine (EJT), USA Email: John B Sexton* - [email protected]; Robert L Helmreich - [email protected]; Torsten B Neilands - [email protected]; Kathy Rowan - [email protected]; Keryn Vella - [email protected]; James Boyden - [email protected]; Peter R Roberts - [email protected]; Eric J Thomas - [email protected] * Corresponding author

Published: 03 April 2006
BMC Health Services Research 2006, 6:44

doi:10.1186/1472-6963-6-44

Received: 20 August 2005
Accepted: 03 April 2006

This article is available from: http://www.biomedcentral.com/1472-6963/6/44 © 2006 Sexton et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: There is widespread interest in measuring healthcare provider attitudes about issues relevant to patient safety (often called safety climate or safety culture). Here we report the psychometric properties, establish benchmarking data, and discuss emerging areas of research with the University of Texas Safety Attitudes Questionnaire.

Methods: Six cross-sectional surveys of health care providers (n = 10,843) in 203 clinical areas (including critical care units, operating rooms, inpatient settings, and ambulatory clinics) in three countries (USA, UK, New Zealand). Multilevel factor analyses yielded results at the clinical area level and the respondent nested within clinical area level. We report scale reliability, floor/ceiling effects, item factor loadings, inter-factor correlations, and percentage of respondents who agree with each item and scale.

Results: A six factor model of provider attitudes fit to the data at both the clinical area and respondent nested within clinical area levels. The factors were: Teamwork Climate, Safety Climate, Perceptions of Management, Job Satisfaction, Working Conditions, and Stress Recognition. Scale reliability was 0.9. Provider attitudes varied greatly both within and among organizations. Results are presented to allow benchmarking among organizations and emerging research is discussed. Conclusion: The Safety Attitudes Questionnaire demonstrated good psychometric properties. Healthcare organizations can use the survey to measure caregiver attitudes about six patient safetyrelated domains, to compare themselves with other organizations, to prompt interventions to improve safety attitudes and to measure the effectiveness of these interventions.

Background
Experts believe that hhhealthcare quality and safety must
be investigated within the framework of systems and con-

textual factors in which errors and adverse events occur.
[1-8] Vincent and colleagues describe several factors that
influence clinical practice: organizational factors such as
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BMC Health Services Research 2006, 6:44

safety climate and morale, work environment factors such
as staffing levels and managerial support, team factors
such as teamwork and supervision, and staff factors such
as overconfidence and being overly self assured. [8]
Healthcare provider attitudes about these and related factors are one component of an organization's safety culture. Influential organizations such as the UK National Health Service, the Joint Commission for the Accreditation of Healthcare Organizations, the Agency for Healthcare Research and Quality, and the U.S. National Quality Forum are encouraging the measurement of safety culture.

This interest derives in part from the experience of other
industries (nuclear power, naval aircraft carriers, NASA)
that are known for their ability to reliably deal with risky processes. [9]
Despite considerable interest, there is limited psychometric and benchmarking data available for the surveys designed to measure these attitudes [10-13]. The aims of
this paper are to present our experience with the University of Texas Safety Attitudes Questionnaire. We describe the survey's background, psychometric characteristics,
provide benchmarking data, discuss how the survey can
be used, and note emerging areas of research.

Methods
Terminology
Safety culture has been be defined as "the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an

organization's health and safety management [13]." The
SAQ elicits a snapshot of the safety culture through surveys of frontline worker perceptions. When using questionnaires to study group-level perceptions, the most appropriate term to use is climate (e.g., safety climate, or teamwork climate). Climates are more readily measurable

aspects of safety culture (perceptions are part of both definitions) but surveys are generally not capable of measuring all other aspects of culture like behavior, values, and competencies. However, readers should be aware that

some papers, organizations, and opinion leaders use the
terms climate and culture interchangeably. We use the
term climate where some may expect to see the phrase culture of patient safety.

Here we use clinical areas (a.k.a., work units, patient care areas, nursing units) as the group-level of interest. By testing the psychometrics of the SAQ at the individual level and the clinical area level, we can test the appropriateness of conceptualizing patient safety issues at the clinical area level, because clinical areas are generally associated with

managers, geographical locations, and specific clinical
and operational outcomes.

http://www.biomedcentral.com/1472-6963/6/44

Lineage and conceptual background of the Safety
Attitudes Questionnaire (SAQ)
The Safety Attitudes Questionnaire (SAQ) is a refinement
of the Intensive Care Unit Management Attitudes Questionnaire, [14,15] which was derived from a questionnaire widely used in commercial aviation, the Flight Management Attitudes Questionnaire (FMAQ). [16,17]

The FMAQ was created after researchers found that most
airline accidents were due to breakdowns in interpersonal
aspects of crew performance such as teamwork, speaking
up, leadership, communication, and collaborative decision making. The FMAQ measures crew member attitudes about these topics.

Because 25% of the FMAQ items demonstrated utility in
medical settings in terms of the subject covered and factor
loadings, they were retained on the SAQ, The new SAQ
items were generated by discussions with healthcare providers and subject matter experts. In addition, we relied upon two conceptual models to decide which items to
include: Vincent's framework for analyzing risk and safety
[8] and Donabedian's conceptual model for assessing
quality [18] This generated a pool of over 100 new items
covering four themes: safety climate, teamwork climate,
stress recognition, and organizational climate. Items were
evaluated through pilot testing and exploratory factor
analyses. This phase of survey development consistently
yielded 6 factor-analytically derived attitudinal domains
containing 40 items from the survey (two, three, four, and
five factor structures were less robust). Three of the targeted themes, safety climate, teamwork climate, and stress recognition, emerged as factors. In particular, safety climate and stress recognition are conceptually quite similar to their counterparts in aviation. [19] The fourth targeted

theme, organizational climate, consistently emerged as
three distinct but related factors, perceptions of management, working conditions, and job satisfaction. Organizational climate plays a decisive role in setting the preconditions for success or failure in managing risks

[3,4,20] , and we therefore retained these three factors as
part of safety attitude assessment. An additional 20 items
were retained because they were deemed interesting and
valuable to the unit managers and senior hospital leadership to whom we reported the results of our pilot studies. The SAQ has been adapted for use in intensive care units
(ICU) [15,21] , operating rooms (OR), general inpatient
settings (medical ward, surgical ward, etc.), and ambulatory clinics. For each version of the SAQ, item content is the same, with minor modifications to reflect the clinical
area. For example, "In this ICU, it is difficult to discuss
mistakes," vs. "In the ORs here, it is difficult to discuss
mistakes." The SAQ elicits caregiver attitudes through the
6 factor analytically derived climate scales: teamwork climate; safety climate; job satisfaction; perceptions of man-

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BMC Health Services Research 2006, 6:44

Scale: Definition

Example items

Teamwork climate: perceived quality
of collaboration between personnel

–Disagreements are appropriately resolved (i.e., not
who is right, but what is best for the patient)
–Our doctors and nurses work together as a well
c...

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Keywords

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