Association between the Nursing Practice Environment and Safety Perception with Patient Safety Culture during COVID-19

The COVID-19 pandemic reshaped healthcare work environments, increasing workload, stress, and exposure to risk for nurses, particularly due to staff shortages and limited PPE. Given that unsafe care is a major global cause of death and disability, understanding patient safety culture (PSC)—the collective values, attitudes, and behaviors toward safety—is essential. Prior to COVID-19, studies reported generally good PSC, though heavier patient loads per nurse were linked to poorer safety ratings. During the pandemic, multiple studies found moderately unfavorable PSC, especially in high-acuity units, and associations with poorer working conditions and increased patient loads. Work environment characteristics—leadership, staffing, collaboration, and organizational support—have been associated with PSC and safety outcomes, but evidence on which specific subcomponents of the nursing practice environment (NPE) best predict PSC is mixed. This study sought to identify the association between NPE and safety perception with PSC among Peruvian nurses during COVID-19, addressing a gap in pandemic-era evidence and informing organizational strategies to improve safety.

Evidence links healthier nursing work environments to improved nurse satisfaction, performance, well-being, and patient outcomes, including safety event reporting. Cross-sectional and longitudinal studies show NPE predicts PSC and safety climate, though findings on which NPE subscales are predictive are inconsistent across countries (e.g., leadership and support vs. staffing adequacy vs. participation and collegial relations). Pre-pandemic studies generally reported higher PSC than those during COVID-19, when neutral to low PSC levels were common. Factors associated with lower PSC include long shifts, more night shifts, overtime, fewer days off, and higher patient loads; conversely, leadership support, higher experience, and university hospital employment relate to better PSC. Safety perception itself has been associated with both the work environment and PSC, and interprofessional collaboration and managerial expectations/support have been tied to adverse event reporting. These mixed findings underscore the need to disentangle which NPE elements and perceptions most strongly predict PSC in pandemic contexts.

Design: Quantitative, non-experimental, correlational, cross-sectional study conducted during the second wave of COVID-19 in Peru. Ethics: Approved by the Institutional Research Ethics Committee of Universidad Norbert Wiener (File No. 352-2021); informed consent obtained online. Settings and participants: Nurses working in Lima and Callao across primary healthcare facilities, public hospitals, private clinics, and military hospitals. Non-probability snowball sampling yielded N=211. Majority female (91.5%), most aged 25–44 years. Workplaces: hospitals 54.0%, health centers 25.1%, clinics 17.1%, military hospitals 2.4%. Measures: - Nursing Practice Environment (NPE): 31-item PES-NWI with five subscales (nurse participation; foundations for quality; nurse manager ability/leadership/support; staffing/resource adequacy; collegial nurse-physician relations). 4-point Likert. Favorability classified by number of subscale means >2.5. Reliability: prior α≈0.89; current ω=0.95. - Patient Safety Culture (PSC): AHRQ HSOPSC v2.0, 32 items, 10 dimensions (teamwork; staffing/work pace; organizational learning; response to error; supervisor/manager/clinical leader support; communication about error; communication openness; event reporting; hospital management support; handoffs/information exchange). Scored via percent positive responses; categorized as negative <50%, neutral 50–60%, positive ≥70%. Cross-culturally adapted/validated for Peru; current ω=0.94. - Safety perception: single item rating patient safety in the unit (poor, fair, good, very good, excellent), ordered from worst to best per AHRQ guidance. - Demographics/work variables: gender, age, workplace, hours, tenure, critical area assignment, COVID-19 patient contact. Analysis: Descriptive statistics; Shapiro–Wilk to assess normality (all key variables non-normal). Spearman correlations between NPE subscales and PSC dimensions. Two multiple regression models with stepwise selection by AIC to predict PSC: (1) predictors included NPE subscales plus sociodemographics; (2) predictors included total NPE score, safety perception, and workplace. PSC transformed using Tukey’s ladder of power to approximate normality. Diagnostics showed no outliers and assumptions met. Standardized coefficients reported. Analyses in R 4.2.1.

- Descriptives: Of 211 nurses, 91.5% female; 79.6% aged 25–44. Workplaces: hospitals 54.0%, health centers 25.1%, clinics 17.1%, military hospitals 2.4%. - NPE level: Favorable in 45.5% of participants (per PES-NWI classification). - PSC level: Neutral in 61.1%, positive in 31.8%, negative in 7.1%. - Correlations: All NPE subscales positively correlated with PSC (all p<0.001): • Nurse participation in hospital affairs: rho=0.466 • Nursing foundations for quality of care: rho=0.500 • Nurse manager ability, leadership, and support: rho=0.497 • Staffing and resource adequacy: rho=0.409 • Collegial nurse-physician relations: rho=0.430 • Total NPE with PSC: rho=0.570 - Regression Model 1 (subscales + covariates): Significant predictors were safety perception and the NPE subscale “nurse manager ability, leadership, and support.” Compared to “poor” safety perception, higher ratings were associated with higher PSC (standardized B approximately 0.36 for good, 0.52 for very good, 0.32 for excellent). Higher scores on the manager ability/leadership/support subscale predicted higher PSC (B≈0.23). Model R²≈0.50. - Regression Model 2 (total NPE + covariates): Total NPE strongly predicted PSC (B=0.40, p<0.001). Compared to “poor,” “very good” (B=0.47, p<0.001) and “excellent” (B=0.31, p<0.001) safety perception predicted higher PSC; “good” was not statistically significant in this model (B=0.29, p=0.07). Workplace also mattered: military hospital employment associated with slightly higher PSC (B=0.11, p=0.03). Model R²=0.51.

Findings show that nurses’ safety perception, workplace, and the nursing practice environment are significant determinants of PSC during the COVID-19 pandemic. The strong correlation between total NPE and PSC and the predictive value of NPE align with prior international evidence that healthier work environments foster better safety climate and culture. Notably, among NPE subscales, nurse manager ability, leadership, and support emerged as a key predictor, consistent with theories emphasizing leader–member exchanges and prior research linking managerial expectations, support, and interprofessional collaboration to improved safety outcomes and event reporting. Differences across contexts regarding which NPE elements predict PSC may reflect collinearity with safety perception and contextual variations in staffing and resources. The higher PSC reported in military hospitals suggests organizational context can influence safety culture, though evidence across settings remains mixed. The predominantly neutral PSC observed echoes other pandemic-era studies in Latin America and Europe, indicating a decline from pre-pandemic levels likely due to strained working conditions. Practically, the results underscore the importance of leadership that prioritizes safety, fosters teamwork, and integrates nurses’ feedback to strengthen PSC, even in resource-constrained settings.

Safety perception, workplace, and the nursing practice environment predict patient safety culture, together explaining about 51% of its variance. While all NPE subscales correlated with PSC, only the nurse manager’s ability, leadership, and support subscale—along with safety perception—predicted PSC in the subscale-based model. Peruvian nurses reported a predominantly neutral PSC and a generally favorable NPE. To build a safer work culture, healthcare institutions—especially in low- and middle-income countries—should develop nursing leadership focused on patient safety, strengthen managerial competencies, promote interprofessional collaboration, and incorporate nurses’ input and safety reports for continuous improvement. Future research should examine causal pathways longitudinally and explore contextual differences across healthcare settings.

- Cross-sectional, correlational design precludes causal inference; results identify predictors but not causation. - Self-administered online survey may introduce response biases; although privacy may reduce social desirability, self-report limitations remain. - Non-probability snowball sampling limits generalizability. - Conducted during the COVID-19 pandemic in specific Peruvian settings; findings may not generalize to other periods or contexts. - Although models explained about 50–51% of PSC variance, unmeasured factors likely contribute to PSC.