Bondevik et al. BMC Health Services Research 2014, 14:139
http://www.biomedcentral.com/1472-6963/14/139
RESEARCH ARTICLE
Open Access
The safety attitudes questionnaire – ambulatory
version: psychometric properties of the Norwegian
translated version for the primary care setting
Gunnar Tschudi Bondevik1,2*, Dag Hofoss3, Elisabeth Holm Hansen4 and Ellen Catharina Tveter Deilkås5,6
Abstract
Background: Patient safety culture is how leader and staff interaction, attitudes, routines and practices protect
patients from adverse events in healthcare. The Safety Attitudes Questionnaire is the most widely used instrument
to measure safety attitudes among health care providers. The instrument may identify possible weaknesses in
clinical settings, and motivate and guide quality improvement interventions and reductions in medical errors. The
Safety Attitudes Questionnaire – Ambulatory Version was developed for measuring safety culture in the primary
care setting. The original version includes six major patient safety factors: Teamwork climate, Safety climate, Job
satisfaction, Perceptions of management, Working conditions and Stress recognition. We describe the results of a
validation study using the Norwegian translation of the questionnaire in the primary care setting, and present the
psychometric properties of this version.
Methods: The study was done in seven Out-of-hours casualty clinics and 17 regular GP practices employing a total
of 510 primary health care providers (194 nurses and 316 medical doctors). In October and November 2012, the
translated Safety Attitudes Questionnaire – Ambulatory Version was distributed by e-mail. Data were collected
electronically using the program QuestBack, whereby the participants responded anonymously. SPSS was used to
estimate the Cronbach’s alphas, item-to-own-factor correlations, intercorrelations of factors and item-descriptive
statistics. The confirmatory factor analysis was done by AMOS.
Results: Of the 510 invited health care providers, 266 (52%) answered the questionnaire - 72% of the registered
nurses (n = 139) and 39% of the medical doctors (n = 124). In the confirmatory factor analysis, the following five
factor model was shown to have acceptable goodness-of-fit values in the Norwegian primary care setting:
Teamwork climate, Safety climate, Job satisfaction, Working conditions and Perceptions of management.
Conclusions: The results of our study indicate that the Norwegian translated version of the Safety Attitudes
Questionnaire – Ambulatory Version, with the five confirmed factors, might be a useful tool for measuring several
aspects of patient safety culture in the primary care setting. Further research should investigate whether there is an
association between patient safety culture in primary care, as measured by the Safety Attitudes Questionnaire –
Ambulatory Version, and occurrence of medical errors and negative patient outcome.
Keywords: Adverse events, General practice, Medical errors, Out-of-hours, Patient safety culture, Primary care,
Quality improvement, Safety attitudes questionnaire
* Correspondence: gunnar.bondevik@igs.uib.no
1
Research Group for General Practice, Department of Global Public Health
and Primary Care, University of Bergen, Bergen, Norway
2
National Centre for Emergency Primary Health Care, Uni Health, Uni
Research, Bergen, Norway
Full list of author information is available at the end of the article
© 2014 Bondevik 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 credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Bondevik et al. BMC Health Services Research 2014, 14:139
http://www.biomedcentral.com/1472-6963/14/139
Background
Over the last years, there has been an increasing focus on
medical errors and patient safety. Until recently, patient
safety issues have mainly been addressed in the hospital
care setting [1-7]. However, adverse events are common
also in primary care, where the largest volume of health
care is delivered. For these reasons, there has been an increasing interest in factors related to patient safety also
outside the hospital setting.
Patient safety culture is how leader and staff interaction,
attitudes, routines and practices protect patients from
adverse events in healthcare [8]. The concept is developed
within the framework and research of organizational
psychology, and is regarded as a group phenomenon rather than that of an individual.
A number of instruments have been developed to measure safety attitudes of health care providers [1,9-13]. The
Safety Attitudes Questionnaire (SAQ) is most widely used,
and the original version includes six major patient safety
factors: Teamwork climate, Safety climate, Job satisfaction, Perceptions of management, Working conditions
and Stress recognition [14].
SAQ scores have been shown to correlate with patient
outcome in care giving units [12,15-17]. The instrument
may identify possible weaknesses in a clinical setting and
motivate quality improvement interventions and reductions in medical errors [18-20]. The SAQ has been translated and validated in a number of different countries,
including Norway [17].
The majority of the safety attitudes instruments are
adapted to different clinical settings within hospitals. It
has been shown that patient safety culture may vary
substantially across hospitals, departments and - in particular - wards, the level closest to the patients [21]. Interventions to improve patient safety should therefore
also include ward level.
In 2007, the first questionnaire for measuring safety
culture in the outpatient setting was described [1]. This
Safety Attitudes Questionnaire – Ambulatory Version
(SAQ-AV) was developed from the original SAQ, and
adjusted to the primary care setting. It has shown to be
a reliable tool for comparing attitudes across different
professional groups of health care providers outside
hospitals [1]. Further, SAQ-AV gives data that makes it
possible to focus on patient safety improvement activities, in addition to measuring change in attitudes over
time [22].
In this paper, we describe the results of a validation
study using the Norwegian translation of the SAQ-AV in
the primary care setting, both in out-of-hours (OOH)
casualty clinics and regular General Practitioner (GP) practices. We wanted to study whether the factor structure in
the translated version was the same as in the original questionnaire. We present the psychometric properties of the
Page 2 of 10
Norwegian translated version of the SAQ-AV. The study
is a part of the Norwegian patient safety campaign “In
Safe Hands”, which was launched in 2011 by the Ministry of Health.
Methods
Material
The present study was done both in OOH casualty clinics
and in regular GP practices. Seven OOH clinics in Norway
function as especially designated “Watchtower Clinics”,
established by the National Centre for Emergency Primary
Health Care to deliver research data [23,24]. The seven
Watchtowers were selected so as to be representative for
OOH casualty clinics in Norway, and serve 4,6% (226,000
inhabitants) of the nations population in a total of 18 municipalities. In addition, all regular GP practices in Sogn &
Fjordane County were invited to participate in the study.
This is one of 19 counties in Norway, with a population of
approximately 110,000 in 26 municipalities.
In order to protect the confidentiality of the respondents, we only included clinics and practices employing
at least five health professionals having clinical patient
contact. For this reason we replaced one of the seven
Watchtowers with the OOH clinic in the neighbouring
municipality. The seven OOH clinics participating in
our study employed a total of 337 health professionals,
of whom 231 medical doctors and 106 nurses. They
serve a total population of 251,000.
Seven of the total of 30 regular GP practices in Sogn
& Fjordane County were not included, as they had less
than five employees working clinically. Of the remaining
23 regular GP practices, 17 agreed to participate in the
study. These 17 regular GP practices employed a total of
173 health professionals, 85 medical doctors and 88
support medical staff. The professional background of
the support medical staff varied, and included registered
nurses, medical secretaries and bioengineers. In this
paper, we use the term “nurses” for this group of support medical staff. The participating GP clinics serve a
population of 70,000.
Translation procedures
The original SAQ-AV questionnaire was translated following modified principles adapted from Beaton et al.
[25]. Initially, the original English version was translated
into Norwegian using a professional translation bureau.
Next, an expert committee with clinicians and researchers
from the Research Group for General Practice (University
of Bergen), the National Centre for Emergency Primary
Health Care (Uni Research, Bergen) and the Norwegian
Knowledge Centre for the Health Services (Oslo) adapted
the initial translated version to the primary care setting in
Norway. This adapted version of the questionnaire was
Bondevik et al. BMC Health Services Research 2014, 14:139
http://www.biomedcentral.com/1472-6963/14/139
translated back into English by a second independent
translation bureau being blinded to the original version.
Based on this back-translated version, the expert committee made some adjustments in order to clarify misunderstandings. The prefinal Norwegian version was tested
in a group of primary health care providers. Based on
their feedback, the final version of the translated questionnaire was developed. Two Norwegian versions of the
questionnaire were made, one for OOH casualty clinics
and one for regular GP practices, with only minor modifications in a few of the questions – according to the setting. Pre-tests showed that it took approximately 15 min
to complete the SAQ-AV questionnaire.
Scoring
The SAQ-AV is a 62 item questionnaire where the respondents rate their agreement using a 5-point Likert
scale: 1 = disagree strongly, 2 = disagree slightly, 3 = neutral, 4 = agree slightly, 5 = agree strongly. For all questions,
“Not applicable” was included as a response category, and
combined with missing values in the data analyses. Scores
of negatively worded items were reversed, so that higher
scores in the data set always indicate a more positive
evaluation of the unit’s patient safety culture.
Data collection
The seven OOH clinics and 17 regular GP practices provided the e-mail addresses of all employees having direct
patient contact in their clinical work. In October and
November 2012, the SAQ-AV was distributed by e-mail
to all 510 primary health care providers in these 24
clinics/practices (316 medical doctors and 194 nurses).
Data were collected electronically using the program
QuestBack, whereby the participants responded anonymously. This program automatically sent a reminder to
those who had not responded after two weeks. After four
weeks, an additional reminder was sent to the administrative key persons in the OOH clinics and regular GP practices – asking them to motivate the clinical staff to
participate in the study.
After the study, each of the participating OOH clinics
and GP practices received a summary of the SAQ-AV
results for their own unit. In this way, the health care
providers were encouraged to focus on specific factors
related to patient safety, and to discuss possible strategies for improvement within their clinical setting.
Statistical analysis
The QuestBack file with anonymous SAQ-AV data was
converted into a SPSS file for further analysis. SPSS v.18
was used to estimate the Cronbach’s alphas, item-to-ownfactor correlations, intercorrelations of factors and itemdescriptive statistics. The confirmatory factor analysis was
done by AMOS.
Page 3 of 10
Internal consistency
Cronbach’s alpha is a measure of factor score consistency.
The test was done to demonstrate to which extent the
responses of items within a factor correlated pairwise.
Cronbach’s alpha scores above 0.7 were considered adequate. Item-to-own-factor correlations were checked to
see if the items correlated more with the factor they were
hypothesised to belong to, than to the other factors.
Hypothesised factor structure
The original SAQ, developed at the University of Texas
at Austin [14], described six factors: Teamwork climate,
Safety climate, Working conditions, Job satisfaction, Perceptions of management and Stress recognition (Table 1).
Only 30 of the 62 items in the SAQ-AV are covered by
the original six factors. The rest of the items were considered useful for local improvement processes and discussion and included to provide additional information
regarding the work environment in the primary care setting. Since some of these items belonged thematically to
the Teamwork climate factor (Q37, Q39, Q45) we included the items in the hypothesized factor structure.
One item (Q18) had been moved from the factor
Perceptions of management to the factor Working conditions, in the validation of the Norwegian SAQ Short
form 2006 [17]. We replicated this since we also in the
present study found that the item (Q18) fitted the
Working condition factor better, indicating that respondents in primary care perceive that adequate staffing has
less to do with leadership, although it is strongly related
to working conditions. Since several studies find that the
factor Stress recognition does not vary significantly between organizational units [21,26], and also has problems
regarding construct validity [27], it cannot be considered a valid factor for measuring patient safety [28]. In
the present study, we based our analyses on the five
remaining factors, which were included in the hypothesised factor model.
Confirmatory factor analysis (CFA)
Among the 160 respondents answering each of the items
(no missing/not applicable), we tested the hypothesized
factors from the five factor model of the SAQ using
AMOS. The factors reflect the correlation structure in
the item responses. Valid factors should thus reflect a thematic logic that is coherent with the purpose of the questionnaire. CFA provides goodness-of-fit indices, which
show how the survey responses comply with the prehypothesised factor model.
The following goodness-of-fit indices were calculated:
P, Pclose, Adjusted Goodness-of-Fit Index (AGFI), Comparative Fit Index (CFI), Normed Fit Index (NFI), Root
Mean Square Error of Approximation (RMSEA) and
Hoelter 0.05. Acceptable goodness-of-fit values indicate
Bondevik et al. BMC Health Services Research 2014, 14:139
http://www.biomedcentral.com/1472-6963/14/139
Table 1 The six factors and corresponding items in the
original Safety Attitudes Questionnaire (SAQ) version
Teamwork
climate
Nurse input is well received in this office.
In this office, it is difficult to speak up if I perceive a
problem with patient care.
Disagreements in this office are resolved appropriately
(i.e., not who is right but what is best for the patient).
Page 4 of 10
that the SAQ-AV measures patient safety culture in the
hypothesised factors. The P and Pclose values should
exceed 0.05, the AGFI should be close to 1, and the
RMSEA should not exceed 0.10 [29]. The CFI should be
close to 1 and the NFI > 0.90 [30]. The Hoelter 0.05
should exceed 200, an estimate of the largest sample for
which a data set with these intercorrelations among the
variables would confirm the model [31].
I have the support I need from other personnel to care
for patients.
It is easy for personnel in this office to ask questions
when there is something that they do not understand.
The physicians and nurses here work together as a
well-coordinated team.
Safety climate I would feel safe being treated here as a patient.
Medical errors are handled appropriately in this office.
I receive appropriate feedback about my performance.
In this office, it is difficult to discuss errors.
I am encouraged by my colleagues to report any
patient safety concerns I may have.
The culture in this office makes it easy to learn from
the errors of others.
I know the proper channels to direct questions
regarding patient safety in this office.
Working
conditions
This office deals constructively with problem personnel.
Trainees in my discipline are adequately supervised.
I like my job.
Working in this office is like being part of a large family.
This office is a good place to work.
I am proud to work at this office.
Morale in this office is high.
Perceptions of The management of this office supports my daily
management efforts.
Office management does not knowingly compromise
the safety of patients.
The levels of staffing in this office are sufficient to
handle the number of patients.
I am provided with adequate, timely information about
events in the office that might affect my work.
Stress
recognition
This study was based on data regarding patient safety
culture among health care providers. It was conducted
in compliance with the ethical guidelines of the Helsinki
Declaration. All participants received written information about the purpose of the study, and that the data
would be collected anonymously and treated in confidence. As the study was not affected by the Norwegian
Health Research Act, approval from an ethics committee was not needed. The study was approved by the
Norwegian Social Science Data Services – the governmental agency for protecting survey research respondent privacy according to the Norwegian Personal Data
Act (Ref. No. 2012/30774).
This office does a good job of training new personnel.
All the necessary information for diagnostic and
therapeutic decisions is routinely available to me.
Job
satisfaction
Ethical considerations
When my workload becomes excessive, my
performance is impaired.
I am less effective at work when fatigued.
I am more likely to make errors in tense or hostile
situations.
Fatigue impairs my performance during emergency
situations (e.g. code or cardiac arrest).
Results
Of the 510 invited health care providers, 266 (52%) answered the questionnaire - 72% of the nurses (n = 139)
and 39% of the medical doctors (n = 124). Professional
status is not known for three of the respondents. The response rate was higher among doctors in GP practices
(55%) than doctors in OOH clinics (33%), while the corresponding rates for nurses were 73% and 71%, respectively.
Table 2 presents mean scores with standard deviations
for each of the 62 items, expressing the degree of agreement with the statements in the questionnaire (1 = disagree strongly, 2 = disagree slightly, 3 = neutral, 4 = agree
slightly, 5 = agree strongly). Missing values at item levels
are also shown in the table, and were on average 2.4%,
ranging from 0 to 8.3%. The strongest disagreement was
found in the statements “I feel burned out from my
work” and “Abnormal test results are frequently lost or
overlooked” (both mean scores 1.7). The highest mean
scores reflecting agreement were reported for the statements “I like my job” and “Attending physicians/primary
care providers in this office are doing a good job” (both
mean scores 4.7).
The confirmatory factor analysis showed that each of
the five hypothesised factors (Teamwork climate, Safety
climate, Job satisfaction, Working conditions and Perceptions of management) fitted the data well. The goodnessof-fit indices for the five factors are presented in Table 3.
As the P was satisfactory for all factors (p > 0.05), Pclose is
not presented in the table.
Bondevik et al. BMC Health Services Research 2014, 14:139
http://www.biomedcentral.com/1472-6963/14/139
Page 5 of 10
Table 2 Mean score for the 62 items in the Safety Attitudes Questionnaire – Ambulatory Version (SAQ-AV)
Statement
1. High levels of workload are common in this office.
Missing/NAa n (%) Mean scoreb (SD c)
0 (0)
4.4 (0.9)
2. I like my job.
1 (0.4)
4.7 (0.7)
3. Nurse input is well received in this office.
6 (2.3)
4.3 (1.0)
4. I would feel safe being treated here as a patient.
3 (1.1)
4.5 (0.8)
5. Medical errors are handled appropriately in this office.
5 (1.9)
4.1 (0.9)
6. This office does a good job of training new personnel.
5 (1.9)
3.9 (1.1)
7. All the necessary information for diagnostic and therapeutic decisions is routinely available to me.
14 (5.3)
4.2 (0.9)
8. Working in this office is like being part of a large family.
3 (1.1)
3.8 (1.1)
9. Senior management of this office is doing a good job.
11 (4.1)
4.2 (1.0)
10. The management of this office supports my daily efforts.
15 (5.6)
4.1 (1.0)
11. I receive appropriate feedback about my performance.
2 (0.8)
3.5 (1.2)
12. In this office, it is difficult to discuss errors.
2 (0.8)
2.1 (1.1)
13. Briefing other personnel before a procedure (e.g., biopsy) is important for patient safety.
11 (4.1)
4.1 (1.1)
14. Briefings are common in this office.
7 (2.6)
3.2 (1.2)
15. This office is a good place to work.
2 (0.8)
4.6 (0.7)
16. Communication breakdowns which lead to delays in delivery of care are common.
1 (0.4)
2.1 (1.1)
17. Office management does not knowingly compromise the safety of patients.
13 (4.9)
4.2 (1.3)
18. The levels of staffing in this office are sufficient to handle the number of patients.
1 (0.4)
3.5 (1.4)
19. Decision making in this office utilizes input from relevant personnel.
9 (3.4)
4.1 (1.0)
20. I am encouraged by my colleagues to report any patient safety concerns I may have.
7 (2.6)
3.8 (1.2)
21. The culture in this office makes it easy to learn from the errors of others.
4 (1.5)
3.5 (1.2)
22. This office deals constructively with problem personnel.
7 (2.6)
3.6 (1.0)
23. The medical equipment in this office is adequate.
5 (1.9)
4.0 (1.1)
24. In this office, it is difficult to speak up if I perceive a problem with patient care.
3 (1.1)
2.0 (1.1)
25. When my workload becomes excessive, my performance is impaired.
4 (1.5)
3.6 (1.2)
26. I am provided with adequate, timely information about events in the office that might affect my work.
4 (1.5)
3.8 (1.2)
27. I have seen others make errors that had the potential to harm patients.
8 (3.0)
2.4 (1.3)
28. I know the proper channels to direct questions regarding patient safety in this office.
2 (0.8)
4.1 (1.2)
29. I am proud to work at this office.
1 (0.4)
4.4 (0.8)
30. Disagreements in this office are resolved appropriately (i.e., not who is right but what is best for
the patient).
2 (0.8)
4.0 (0.9)
0 (0)
4.4 (0.8)
32. I am more likely to make errors in tense or hostile situations.
9 (3.4)
4.2 (0.9)
33. Stress from personal problems adversely affects my performance.
9 (3.4)
3.5 (1.2)
34. I have the support I need from other personnel to care for patients.
5 (1.9)
4.5 (0.8)
0 (0)
4.6 (0.8)
36. Disruptions in the continuity of care can be detrimental to patient safety.
13 (4.9)
4.0 (1.1)
37. During emergencies, I can predict what other personnel are going to do next.
11 (4.1)
3.7 (0.9)
38. The physicians and nurses here work together as a well-coordinated team.
3 (1.1)
4.1 (1.0)
39. I am frequently unable to express disagreement with staff physicians/intensivists in this office.
11 (4.1)
2.5 (1.2)
40. Truly professional personnel can leave personal problems behind when working.
6 (2.3)
3.9 (1.1)
31. I am less effective at work when fatigued.
35. It is easy for personnel in this office to ask questions when there is something that they do not
understand.
41. Morale in this office is high.
0 (0)
4.5 (0.7)
42. Trainees in my discipline are adequately supervised.
8 (3.0)
4.0 (1.0)
43. I know the first and last names of all the personnel I worked with during my last shift.
2 (0.8)
4.0 (1.5)
Bondevik et al. BMC Health Services Research 2014, 14:139
http://www.biomedcentral.com/1472-6963/14/139
Page 6 of 10
Table 2 Mean score for the 62 items in the Safety Attitudes Questionnaire – Ambulatory Version (SAQ-AV) (Continued)
44. I have made errors that had the potential to harm patients.
5 (1.9)
2.6 (1.4)
45. Attending physicians/primary care providers in this office are doing a good job.
1 (0.4)
4.7 (0.6)
46. All the personnel in this office take responsibility for patient safety.
2 (0.8)
4.4 (0.8)
47. I feel fatigued when I have to get up in the morning and face another day on the job.
9 (3.4)
2.1 (1.3)
48. Patient safety is constantly reinforced as the priority in this office.
5 (1.9)
4.1 (1.0)
49. I feel burned out from my work.
3 (1.1)
1.7 (1.1)
50. Important issues are well communicated at shift changes.
7 (2.6)
4.0 (1.1)
51. There is widespread adherence to clinical guidelines and evidence-based criteria in this office.
11 (4.1)
3.8 (0.9)
52. I feel frustrated by my job.
1 (0.4)
1.8 (1.1)
53. I feel I am working too hard on my job.
1 (0.4)
2.3 (1.3)
54. Information obtained through incident reports is used to make patient care safer in this office.
8 (3.0)
3.7 (1.3)
55. Personnel frequently disregard rules or guidelines (e.g., hand washing, treatment protocols/clinical
pathways, sterile fields, etc.) that are established for this office.
6 (2.3)
2.0 (1.1)
56. Fatigue impairs my performance during emergency situations (e.g. code or cardiac arrest).
16 (6.2)
2.4 (1.4)
57. Fatigue impairs my performance during routine care.
9 (3.4)
2.8 (1.4)
58. I am satisfied with the current referral process in this office.
15 (5.6)
4.0 (1.0)
59. There is adequate and timely transfer of patient information between the primary care physician
and the specialist.
12 (4.5)
4.0 (1.0)
60. Medications are refilled in a timely manner.
12 (4.5)
4.3 (0.9)
61. Medications are refilled correctly.
22 (8.3)
4.5 (0.8)
62. Abnormal test results are frequently lost or overlooked.
8 (3.0)
1.7 (1.0)
a
NA = Not applicable.
b
Scoring: 1 = disagree strongly, 2 = disagree slightly, 3 = neutral, 4 = agree slightly, 5 = agree strongly.
c
Standard deviation.
Results based on answers from 266 primary health care providers working in 7 OOH casualty clinics and 17 GP practices.
The goodness of fit of the entire five-factor model is
presented in Figure 1. It is not as clearcut as that of the
five single factor models: The CFI of the entire model
was 0.86, its NFI was 0.73 and its P-value (and its
Pclose-value) was < 0.001. However, its RMSEA was satisfactory (0.07), and the model’s chisquare-to-degrees-offreedom ratio was excellent: 1.82.
The Cronbach alphas ranged from 0.67 to 0.83 for
the factor scores Teamwork climate, Safety climate,
Working conditions, Job satisfaction and Perceptions
of management (Table 4). All items in the table correlated higher with the factor it has been related to
than with any other factor.
Discussion
We have described the results of a validation study using
the Norwegian translation of the SAQ-AV in the primary care setting, both in OOH clinics and regular GP
practices. As far as we know, this is the first systematic
study of patient safety culture in a representative sample
Table 3 Goodness of fit indices for patient safety culture factors among 160* primary health care providers
P
AGFI
CFI
NFI
RMSEA
Hoelter 05
Teamwork climate
0.41
0.94
1.00
Safety climate
0.66
0.96
1.00
0.93
0.02
228
0.95
< .001
334
Job satisfaction
0.17
0.95
Working conditions
0.12
0.94
0.99
0.98
0.06
259
0.98
0.96
0.06
235
Perceptions of management
0.18
0.95
0.99
0.96
0.05
268
P: should exceed 0.05.
AGFI: Adjusted Goodness-of-Fit Index, should be close to 1.
CFI: Comparative Fit Index, should be close to 1.
NFI: Normed Fit Index, should exceed 0.90.
RMSEA: Root Mean Square Error of Approximation, should not exceed 0.10.
Hoelter 0.05: should exceed 200.
*160 of the 266 primary health care providers working in the 7 OOH casualty clinics and 17 GP practices included in this study replied to each of the items (they
had no missing/not applicable in any of the items related to the five factors).
Bondevik et al. BMC Health Services Research 2014, 14:139
http://www.biomedcentral.com/1472-6963/14/139
Page 7 of 10
Figure 1 Factor structure model.
of OOH clinics in Norway. In addition, the SAQ has not
earlier been validated in a Norwegian GP setting.
Among those responding to the questionnaire, there
was a low degree of missing values. The overall response
rate was, however, not optimal. It was substantially higher,
almost twice as high, among nurses compared to medical
doctors. This difference is in accordance with findings
from a SAQ-study in a Norwegian hospital setting [17]. A
possible reason for this could be that nurses may feel
closer linked to the clinical units than the doctors, since
they spend a larger amount of their working time there.
Many primary care doctors do clinical work different
places (in GP practices, OOH clinics, nursing homes, well
baby clinics), while most nurses are employed only in one
clinical setting. This may imply an increased interest in
creating a positive and safe working environment.
The response rate was higher among doctors in GP practices (55%) than doctors in OOH clinics (33%). As GPs
commonly spend more working hours in GP practices than
most OOH-doctors do in casualty clinics, the higher response rate increases the validity of the patient safety
assessment in general practice. OOH-doctors commonly
work in casualty clinics for only a limited part of their total
working hours. This may lead to a poorer linkage to this
particular work place, meaning that the rather low response rate should not reduce the validity of the patient
safety assessment in OOH clinics very much. Nurses are
more often employed only in one clinic, and spend most
of their working time there. The high response rates
among nurses both in GP practices (73%) and OOH
clinics (71%), strengthen the validity of the patient
safety assessments.
Nurses might have had the opportunity to fill in the
questionnaire during their work time – whereas it was a
free time, and thereby an unpaid, activity for the majority of the doctors. This may explain the higher interest
among nurses for participating in a study of how their
working environment supports patient safety. There also
may be a gender difference in how to respond to the
reminders that were sent. A majority of the responses
tended to be skewed towards the favourable side of the
scale, reflecting a positive attitude to patient safety.
The Cronbach alphas were above the recommended limit
of 0.70 for four of the factors, and not much below for the
Bondevik et al. BMC Health Services Research 2014, 14:139
http://www.biomedcentral.com/1472-6963/14/139
Page 8 of 10
Table 4 Item variation and internal consistency of five factors based on 160a respondents
Teamwork climate: Cronbach’s alpha: 0.83
3. Nurse input is well received in this office.
d
Mean (SDb)
ITOFCc
4.23 (1.01)
0.62
24 . In this office it is difficult to speak up if I perceive a problem with patient care.
4.00 (1.15)
0.53
30. Disagreements in this office are resolved appropriately (i.e., not who is right but what is best for the patient).
3.97 (0.97)
0.62
34. I have the support I need from other personnel to care for patients.
4.45 (0.82)
0.65
35. It is easy for personnel in this office to ask questions when there is something that they do not understand.
4.56 (0.77)
0.61
37. During emergencies, I can predict what other personnel are going to do next.
3.69 (0.88)
0.36
38. The physicians and nurses here work together as a well-coordinated team.
4.02 (0.97)
0.62
d
39 . I am frequently unable to express disagreement with staff physician/ intensivists in this office.
3.50 (1.44)
0.41
45. Attending physicians/primary care providers in this office are doing a good job.
4.73 (0.49)
0.52
Mean (SDb)
ITOFCc
4.54 (0.74)
0.27
Safety climate: Cronbach’s alpha: 0.77
4. I would feel safe being treated here as a patient.
5. Medical errors are handled appropriately in this office.
4.12 (0.88)
0.60
11. I receive appropriate feedback about my performance.
3.39 (1.16)
0.56
12d. In this office, it is difficult to discuss errors.
3.84 (1.09)
0.58
20. I am encouraged by my colleagues to report any patient safety concerns I may have.
3.80 (1.21)
0.55
21. The culture in this office makes it easy to learn from the errors of others.
3.41 (1.18)
0.63
28. I know the proper channels to direct questions regarding patient safety in this office.
4.06 (1.19)
0.46
Mean (SDb)
ITOFCc
4.75 (0.61)
0.50
Job satisfaction: Cronbach’s alpha: 0.74
2. I like my job.
8. Working in this office is like being part of a large family.
3.75 (1.13)
0.49
15. This office is a good place to work.
4.61 (0.72)
0.72
29. I am proud to work at this office.
4.46 (0.80)
0.62
41. Morale in this office is high.
4.42 (0.76)
0.32
b
Mean (SD )
ITOFCc
6. This office does a good job at training new personnel.
3.85 (1.09)
0.64
7. All the necessary information for diagnostic and therapeutic decisions is routinely available to me.
4.18 (0.94)
0.55
18. The levels of staffing in this office are sufficient to handle the number of patients.
3.41 (1.45)
0.56
22. This office deals constructively with problem personnel.
3.50 (0.99)
0.55
42. Trainees in my discipline are adequately supervised.
3.91 (1.05)
0.63
Working conditions: Cronbach’s alpha: 0.71
b
Perceptions of management: Cronbach’s alpha: 0.67
Mean (SD )
ITOFCc
9. Senior management of this office is doing a good job.
4.16 (1.03)
0.59
10. The management of this office supports my daily efforts.
4.09 (1.00)
0.59
17. Office management does not knowingly compromise the safety of patients.
4.20 (1.29)
0.25
19. Decision making in this office utilizes input from relevant personnel.
4.06 (0.99)
0.36
26. I am provided with adequate, timely information about events in the office that might affect my work.
3.72 (1.12)
0.39
a
160 of the 266 health care providers included in this study replied to each of the items (they had no missing/not applicable in any of the items related to the
five factors).
b
Standard deviation.
c
ITOFC = Item-to-own-factor correlation.
d
Reverse-scored items.
fifth factor Perceptions of management (0.67). These values
demonstrate internal consistency of the factors.
The five factor model (Teamwork climate, Safety climate, Job satisfaction, Working conditions and Perceptions of management) fitted the dataset from this
Norwegian primary health care setting, with acceptable
goodness-of-fit values. A model containing a sixth factor, Stress recognition – one of the original six SAQ
factors – could not be confirmed. As mentioned above,
several studies have found it to be invalid as an
Bondevik et al. BMC Health Services Research 2014, 14:139
http://www.biomedcentral.com/1472-6963/14/139
organizational climate scale, and that may explain our
result.
Conclusions
The results of our study indicate that the Norwegian
translated version of the Safety Attitudes Questionnaire –
Ambulatory Version, with the five confirmed factors,
might be a useful tool for measuring several aspects of patient safety culture in the primary care setting. Discussing
the results at unit level may facilitate strategies to reduce
risk of medical errors, by focusing on improvement of
quality and health care provider attitudes. In future studies, possible patient safety culture differences between
OOH clinics and GP practices should be investigated.
Likewise, it needs to be clarified whether different professional background may influence attitudes to patient
safety in the primary care setting. Further research should
also validate the questionnaire by correlating the scores
on the SAQ-AV domains to patient-associated outcomes,
not only medical errors and negative health outcomes, but
also patient satisfaction and employee-related outcomes,
such as staff satisfaction, retention and burnout.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
GTB was responsible for designing the study, developing the Norwegian
translated version of the SAQ-AV questionnaire, data collection, analysis and
interpretation of data, and writing the manuscript. DH participated in
developing the Norwegian SAQ-AV questionnaire, and was responsible for
the statistical analysis and interpretation of results, in addition to revising the
manuscript critically. EHH participated in designing the study, developing
the Norwegian SAQ-AV questionnaire, data collection and revising the
manuscript critically. ECTD participated in designing the study, developing
the Norwegian SAQ-AV questionnaire, data analyses and interpretation, and
writing the manuscript. All authors read and approved the final manuscript.
Authors’ information
GTB, MD and PhD, is Professor in General Practice at the University of Bergen
and Principal Researcher at the National Centre for Emergency Primary
Health Care, Bergen, Norway. He is specialist in Family Medicine, and works
clinically as General Practitioner in Bømlo, Norway.
DH is Professor at the Institute of Health and Society, Faculty of Medicine,
University of Oslo. He is a social scientist.
EHH, MPH and PhD, is Associate Professor at Haraldsplass Deaconess
University College of Bergen, Norway, and Research Adviser at The
Norwegian Nurses Organization in Norway. She is a registered nurse.
ECTD, MD and PhD, is a Senior Researcher at the Health Services Research
Unit at Akershus University Hospital and a Senior Advisor for the Norwegian
Knowledge Centre, secretariat of the Norwegian patient safety campaign.
She is a Consultant in internal medicine in an ambulatory clinic for
rehabilitation of stroke patients, at Akershus University Hospital.
Acknowledgements
We thank the health care providers in the 7 OOH casualty clinics and 17 GP
practices for participating in the study.
Author details
1
Research Group for General Practice, Department of Global Public Health
and Primary Care, University of Bergen, Bergen, Norway. 2National Centre for
Emergency Primary Health Care, Uni Health, Uni Research, Bergen, Norway.
3
Institute of Health and Society, University of Oslo, Oslo, Norway.
4
Haraldsplass Deaconess University College, Bergen, Norway. 5Norwegian
Page 9 of 10
Knowledge Centre for the Health Services, Olso, Norway. 6Health Services
Research Unit, Akershus University Hospital, Lørenskog, Norway.
Received: 11 November 2013 Accepted: 26 March 2014
Published: 29 March 2014
References
1. Modak I, Sexton JB, Lux TR, Helmreich RL, Thomas EJ: Measuring safety
culture in the ambulatory setting: the safety attitudes questionnaire–
ambulatory version. J Gen Intern Med 2007, 22:1–5.
2. Hammons T, Piland NF, Small SD, Hatlie MJ, Burstin HR: Ambulatory patient
safety. What we know and need to know. J Ambul Care Manage 2003,
26:63–82.
3. Gandhi TK, Sitting DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW:
Communication breakdown in the outpatient referral process. J Gen
Intern Med 2000, 15:626–631.
4. Gandhi TK, Weingart SN, Leape LL, Seger DL, Rothschild JM, Borus J,
Fleming J, Bates DW: Medication errors and potential adverse drug
events among out patients. J Gen Intern Med 2000, 15(Suppl):116.
5. Gandhi TK, Burstin HR, Cook EF, Puopolo AL, Haas JS, Brennan TA, Bates DW:
Drug complications in outpatients. J Gen Intern Med 2000, 15:149–154.
6. Weingart SN, Wilson RM, Gibberd RW, Harrison B: Epidemiology of medical
error. BMJ 2000, 320:774–777.
7. Gandhi TK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E, Seger DL,
Shu K, Federico F, Leape LL, Bates DW: Adverse drug events in ambulatory
care. N Engl J Med 2003, 348:1556–1564.
8. Deilkås ET: Patient safety culture - opportunities for healthcare management,
PhD thesis. Norway: University of Oslo; 2010.
9. Singer SJ, Gaba DM, Geppert JJ, Sinaiko AD, Howard SK, Park KC: The
culture of safety: results of an organization-wide survey in 15 California
hospitals. Qual Saf Health Care 2003, 12:112–118.
10. Weingart SN, Farbstein K, Davis RB, Phillips RS: Using a multihospital survey
to examine the safety culture. Jt Comm J Qual Saf 2004, 30:125–132.
11. Sorra JS, Nieva VF: Hospital Survey on Patient Safety Culture, (Prepared by
Westat, Under Contract No. 290-96-0004). AHRQ Publication No. 04–0041.
Rockville, MD: Agency for Healthcare Research and Quality; 2004.
12. Colla JB, Bracken AC, Kinney LM, Weeks WB: Measuring patient safety
climate: a review of surveys. Qual Saf Health Care 2005, 14:364–366.
13. Flin R, Burns C, Mearns K, Yule S, Robertson EM: Measuring safety climate
in health care. Qual Saf Health Care 2006, 15:109–115.
14. Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J,
Roberts PR, Thomas EJ: The safety attitudes questionnaire: psychometric
properties, benchmarking data, and emerging research. BMC Health Serv
Res 2006, 6:44.
15. Sexton JB: A matter of life and death: social psychological and organizational
factors related to patient outcomes in the intensive care unit, PhD thesis.
University of Texas; 2002.
16. Sexton JB, Thomas EJ, Helmreich RL, Neilands TB, Rowan K, Vella K,
Boyden J, Roberts PR: Frontline assessments of healthcare culture: Safety
Attitudes Questionnaire norms and psychometric properties. Austin, TX:
The University of Texas Center of Excellence for Patient Safety Research and
Practice; 2004. Technical Report No. 04–01.
17. Deilkås ET, Hofoss D: Psychometric properties of the Norwegian version
of the Safety Attitudes Questionnaire (SAQ), generic version (short form
2006). BMC Health Serv Res 2008, 8:191.
18. Thomas EJ, Sexton JB, Neilands TB, Frankel A, Helmreich RL: The effect of
executive walk rounds on nurse safety climate attitudes. A randomized
trial of clinical units. BMC Health Serv Res 2005, 5:28.
19. Pronovost P, Weast B, Rosenstein BJ, Sexton B, Holzmueller CG, Paine L,
Davis R, Rubin HR: Implementing and validating a comprehensive
unit-based safety program. J Patient Saf 2005, 1:33–40.
20. Pronovost PJ, Berenholtz SM, Goeschel CA, Needham DM, Sexton JB,
Thompson DA, Lubomski LH, Marsteller JA, Makary MA, Hunt E: Creating high
reliability in health care organizations. Health Serv Res 2006, 41:1599–1617.
21. Deilkås ET, Hofoss D: Patient safety culture lives in departments and
wards: multilevel partitioning of variance in patient safety culture.
BMC Health Serv Res 2010, 10:85.
22. Sexton JB, Paine LA, Manfuso J, Holzmueller CG, Martinez EA, Moore D,
Hunt DG, Pronovost PJ: A check-up for safety culture in “my patient care
area”. Jt Comm J Qual Patient Saf 2007, 33:699–703.
Bondevik et al. BMC Health Services Research 2014, 14:139
http://www.biomedcentral.com/1472-6963/14/139
Page 10 of 10
23. Hansen EH, Hunskaar S: Development, implementation, and a pilot study
of a sentinel network (“The Watchtowers”) for monitoring emergency
primary health care activity in Norway. BMC Health Serv Res 2008, 8:62.
24. Hansen EH, Zakariassen E, Hunskaar S: Sentinal monitoring of activity of
out-of-hours services in Norway in 2007: an observational study.
BMC Health Serv Res 2009, 9:123.
25. Beaton DE, Bombardier C, Guillemin F, Ferraz MB: Guidelines for the
process of cross-cultural adaptation of self-report measures. Spine 2000,
25:3186–3191.
26. Schwendimann R, Zimmermann N, Küng K, Ausserhofer D, Sexton B:
Variation in safety culture dimensions within and between US and Swiss
Hospital Units: an exploratory study. BMJ Qual Saf 2013, 22:32–41.
27. Taylor JA, Pandian R: A dissonant scale: stress recognition in the SAQ.
BMC Res Notes 2013, 6:302.
28. Zohar D: Safety Climate: conceptual and Measurement Issues. In
Handbook of Occupational Health Psychology. Edited by Quick JC, Tetrick L.
Washington, D.C: American Psychological Association; 2003:123–142.
29. Browne M, Cudeck R: Alternative Ways of Assessing Model fit. In Testing
Structural Equation Models. Edited by Bollen KA, Long JS. Newbury Park,
California: Sage; 1993:136–162.
30. Hooper D, Coughlan J, Mullen M: Structural equation modelling:
guidelines for determining model fit. J Bus Res 2008, 6:53–60.
31. Hoelter JW: The analysis of covariance structures: goodness-of-fit indices.
Sociol Methods Res 1983, 11:325–344.
doi:10.1186/1472-6963-14-139
Cite this article as: Bondevik et al.: The safety attitudes questionnaire –
ambulatory version: psychometric properties of the Norwegian translated
version for the primary care setting. BMC Health Services Research
2014 14:139.
Submit your next manuscript to BioMed Central
and take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit