Original Article

IJNHS
Importance of Nurse Workload
Management as the Main Factor Affecting
a Patient Safety Culture
Selamat1, Ratna Indrawati2, Anastina Tahjoo3
Department of Hospital Administration, Universitas Esa Unggul
Article information Abstract
Introduction: The implementation of patient safety goals is
Article history: the compliance behavior of health workers in implementing
Received; December 24th, 2021 the standards and targets set by the hospital concerning
Revised: January 22th, 2022 international patient safety goals to ensure safe services for
Accepted: February 15th, 2022 every patient. The international patient safety goals adopted
by the hospital accreditation committee (KARS) have 6 (six)
goals. Objective: The purpose of the study was to obtain
Corresponding author: empirical evidence of the effect of knowledge and workload
Ratna Indrawati on the implementation of patient safety goals mediated by
Address: Universitas Esa Unggul, Jl. patient safety culture. Method: This type of research is a
Arjuna Utara, Kebon Jeruk. Jakarta causative quantitative analytic study with a cross-sectional
Barat research design. The sample population of this study is 140
E-mail: [email protected] nurses with a saturated sampling technique. In this study,
measurements are done on primary data in a questionnaire
distributed by Google Form to 140 respondents, and all
respondents filled out the Google Form. In this study, the
International Journal of Nursing and
analysis was carried out using path analysis. Results: The
Health Services (IJNHS)
results showed that knowledge, workload, and patient
Volume 5, Issue 1, February 20th, 2022
safety culture simultaneously had a positive and significant
http://doi.org/10.35654/ijnhs.v5i1.561
effect on implementing patient safety goals. The research
E-ISSN: 2654-6310
findings show that patient safety culture can mediate patient
safety goals. The workload does not directly influence the
performance of patient safety goals. Recommendations: for
hospital management to be more attentive to nursing
workload management, the main factor affected patient
safety culture. For further research, data from other hospital
stakeholders can be added.

Keywords: knowledge, workload, safety culture, patient

safety goals implementation
This is an Open Access article distributed under the terms of the
Creative Commons Attribution 4.0 International License CC BY -
4.0

International Journal of Nursing and Health Services (IJNHS), Volume 5, Issue 1, February 20th, 2022 96
Introduction Those facts are confirmed by the Focus
The hospital is the place where people Group Discussion (FGD) result as the
go when they need health services. Those initial data collection at Hospital X in
who come to the hospital have the right Kota Tangerang. 58% of participants
to get quality and safe services. Events assumed that the patient safety culture
experienced by patients that can impact among nurses at Hospital X was still low,
patient safety are called Patient Safety 42% thought patient safety knowledge
Events. Patient Safety Events vary from among nurses was insufficient, and 50%
Hazardous Conditions, Near-miss of participants considered that nurses'
Events, No-harm Events to Adverse workload at Hospital X was well
Events. An adverse event that has a managed. More than 70% of reported
severe impact that causes disability and incidents, including Hazardous
even death is called a sentinel event (1). Conditions, Near-miss Events, No-harm
The success of preventing patient Events, and Adverse Events that
safety events is highly dependent on the occurred at Hospital X Kota Tangerang,
human factor. Therefore knowledge, involved nurses who directly served
workload, and patient safety culture are patients. This is not surprising
factors that need to be considered to considering the number of nurses as the
implement patient safety goals (2) (3). majority of human resources in hospitals.
At Hospital X Tangerang City, Reports from January to March 2020,
there were still patient safety incidents which are 1 Hazardous Conditions, 3
that should not have happened. Near-miss Events, 2 No-harm Events,
Therefore, it is necessary to examine the and 2 Adverse Events, all involve nurses.
factors that influence the implementation From simple investigations to Root
of patient safety goals. The primary Cause Analysis (RCA), the most
purpose of this study is to provide input common reasons are excessive workload
for the management of Hospital X and lack of knowledge about patient
Tangerang City to make improvements safety. This happens because of the high
that can reduce the incidence of patient turnover of nurses at Hospital X Kota
safety incidents. At Hospital X Kota Tangerang. For new nurses, who do not
Tangerang, there were still events where have the knowledge and experience of
superiors were angry with nurses who working in hospitals, incident reporting
reported patient safety events. This is an is a unique experience that requires
indication of a low patient safety culture. repetition to become a habit.
From the results of simple investigations The novelty of this study is placing
and RCA (Root Cause Analysis), from patient safety culture as a mediating
several incident reports, "forget" or "do variable and using path analysis as the
not know" are the most common reasons. data analysis method.
This shows a lack of patient safety
knowledge among the nurses. Another Literature Reviews
reason was "busy," which indicated the Patient safety is an essential
need to analyze the nurse's workload. component in the quality of hospital

International Journal of Nursing and Health Services (IJNHS), Volume 5, Issue 1, February 20th, 2022 97
services. The first dimension of the The design of this study used a
quality of hospital services is patient cross-sectional approach with
safety. Safety as the first domain of quantitative causality research, which
hospital service quality refers to aims to see the effect of knowledge and
"freedom from accidental injury"(3). workload on the implementation of
International Patient Safety Goals patient safety goals mediated by patient
(IPSGs) consist of 6 goals, namely: Goal safety culture.
1: Identify patients correctly; Goal 2:
Improve effective communication; Goal Sample, sample size & Sampling technique
3: Improve safety High Alert The sample in this study were
Medications; Goal 4: Ensure correct site, nurses with a total sample of 140
correct procedure, and correct patient respondents by total sampling, which are
surgery; Goal 5: Reduce the risk of the entire population. The inclusion
healthcare-associated infection; Goal 6: criteria were all nurses who directly
Reduce the risk of patient harm resulting served patients. The exclusion criteria
from falls (4). were nurses who had filed resignations
In this study, following the conditions and nurses who held managerial
of Hospital X Kota Tangerang, only positions.
target one, and target five will be
studied. Implementing patient safety Instrument for data collection
goals will serve as a layer of defense to The data collection instrument
prevent patient safety incidents from used a closed questionnaire. Each
occurring. Therefore, we can conclude statement item was provided with a
that patient safety is essential choice of answers in a rating scale using
continuously and consistently. a Likert scale, with the lowest score being
Safety culture is built by all one and the highest score being five. The
employees' attitudes, beliefs, knowledge variable consists of 3
perceptions, and values about safety (2). components with 3 question items each.
Patient safety culture defines our belief The workload variable consists of 4
system that will govern how we behave components with 3 question items each.
(1). The patient safety culture variable
consists of 7 components with 3 question
Study Model items each. The variable implementation
of patient safety goals consists of 2
components with 3 question items each.
The questionnaire that would be
distributed was in electronic form using
a google form to 140 respondents. The
collection was done directly without
intermediaries.
Data analysis was the validity test
using Pearson Product Moment
METHOD Correlation. It was said to be valid if the
Design

International Journal of Nursing and Health Services (IJNHS), Volume 5, Issue 1, February 20th, 2022 98
value of r count > r table. Data from 30 Characteristics Respondents Percentage

respondents were taken for validity Male 26 19%

testing. Questionnaire items that were Female 114 81%

not valid were not included in further TOTAL 140 100%

analysis. The reliability test used the 2 Age

17 - 25 years old 58 41%
Cronbach Alpha (α) > 0.6. The results 26 - 35 years old 72 51%
showed that all of the variables in this 36 - 45 years old 10 7%
study were reliable. All variables tested TOTAL 140 100%
for reliability were found to be valid and 3 Length of work
dependable. < 1 year old 30 21%
The Cronbach alpha scores of 1 - 5 years old 83 59%

instruments including 1) Knowledge 6 - 10 years old 21 15%

questionnaire (Cronbach alpha scores: 11 - 15 years old 5 4%

> 15 years old 1 1%
0.935); patient safety culture
TOTAL 140 100%
questionnaire (Cronbach alpha scores:
4 Work unit
0.951); and patient safety goal Hemodialysis 11 7.9%
implementation (Cronbach alpha scores: Emergency 15 10.7%
0.851) departments
Intensive Care Unit 8 5.7%
(ICU)
Statistically Analysis Operating room 8 5.7%

A normality test was carried out on Dental nurse 1 0.7%

all data, and it was found that all Sick baby ward 4 2.9%
Polyclinic 25 17.9%
variables had data that were normally
Isolation Inpatient 29 20.7%
distributed. An outlier test was also Room
carried out, and no outliers were found. Regular
Room
Inpatient 39 27.9%

Data analysis in this study used a path TOTAL 140 100%

analysis model by the AMOS program. 5 Last education
D3 104 74.3%

Ethical consideration D4 3 2.1%

This research has gone through an Strata 1 8 5.7%

Strata 1 NERS 25 17.9%
ethical review organized by Esa Unggul
TOTAL 140 100%
University. The ethical approval letter
number is
Table 2. Direct effect hypothesis testing
0341.21.341/DPKE.KEP/FINAL.EA/UE
among variables
U/IK/2021. Each respondent has signed
the informed consent. Variable Standard S.E. C.R. P
Estimate
Knowledge of Patient
RESULT safety goals 0.456 0.095 6.061 0.000
Characteristic of respondents implementation
Workload to Patient
Table 1. Characteristic of respondents safety goals -0.121 0.079 -1.261 0.207
implementation
Characteristics Respondents Percentage Knowledge of Safety
0.257 0.074 4.399 0.000
culture
1 Gender Workload to Safety
0.635 0.048 10.857 0.000
culture

International Journal of Nursing and Health Services (IJNHS), Volume 5, Issue 1, February 20th, 2022 99
 Safety culture to
Patient safety goals 0.367 0.102 3.588 0.000
implementation

The data above found that the correlation

between workload and the implementation
of patient safety goals has a p value> 0.05, so
H3 is rejected.

The goodness of Fit Model

Table 3 shows that the value of X2 Discussion
– Chi-Square is 0.629, and the probability
The effect of knowledge and workload
is p=0.428. A probability above 0.05
on implementing patient safety goals
indicates that Ho, which states no
with patient safety culture as an
difference between the sample
intervening variable.
covariance matrix and the estimated
Hypothesis testing conducted using
population covariance matrix, is
path analysis with the AMOS program's
acceptable. This means that the sample
help shows an influence between
covariance matrix and the estimated
knowledge, workload, and patient safety
population covariance matrix are the
culture on the implementation of patient
same, so the model has declared a good
safety goals. All variables have a
model (fit).
significant effect (p-value 0.000 – 0.012).
The estimated values of 11.9% and 19.2%
Table 3. Goodness of fit model
Mode indicate that although small, patient
Goodness of fit Cut–off Value safety culture as an intervening variable
l Results
positively influences knowledge
X2 – Chi-Square
Expected value is
small with DF=1 table 0.629
outcomes and workload to the
value = 3.815 implementation of patient safety goals.
Probability > 0.05 0.428
This can be interpreted that other factors
Cmin/DF <2 0.629
GFI > 0.90 0.998
influence the relationship between these
RMSEA < 0.079 0.000 variables, which were not examined in
AGFI > 0.90 0.978 this study.
TLI >0.90 1.010 From the results of the determination
CFI >0.90 1.000
analysis, the influence of knowledge,
workload, and patient safety culture on
Hypothesis test
the implementation of patient safety
The relationship between direct and
goals is 41.8%. In comparison, the
indirect variables was carried out using
remaining 58.2% is influenced by other
the AMOS program. The results can be
factors outside of this study.
seen in the image below:
Implementation of patient safety goals is
new behavior for health workers,
Figure 1. Research Construct Model
especially nurses who are just starting
their careers in the hospital. A new
behavior requires factors that support

International Journal of Nursing and Health Services (IJNHS), Volume 5, Issue 1, February 20th, 2022 100
the implementation of the behavior. safety incident reporting to improve the
Safety culture is one of the factors that implementation of patient safety goals.
have a strong influence on a person's Based on the discussion above, the
behavior (5), (6), study results support several studies
(7). According to Tylor (5), culture is a conducted in Indonesia, which also show
complex consisting of knowledge, belief, the relationship between nurses'
art, law, morals, habits, and abilities knowledge and the implementation of
acquired by a person as part of a patient safety goals. Sithi & Widyastuti
community, which is a hospital. (8) conducted a study on the factors that
Therefore, knowledge is also a factor that contribute to patient safety incidents in
influences a person's behavior. implementing patient safety goals for
inpatients at a hospital in the city of
Effect of knowledge on the Depok. In this study, it was found that
implementation of patient safety goals staff and knowledge factors are some of
There is a positive influence of the factors that contribute to patient
knowledge on implementing patient safety incidents. Research conducted by
safety goals (p-value <0.05) with an Soeryo Koesoemo et al. (9) shows the
estimated value of 0.456. This proves relationship between nurses' knowledge
that knowledge affects the and attitudes towards the application of
implementation of patient safety goals patient safety goals in the inpatient room
by 45.6%, and other variables outside this of Aulia Hospital, South Jakarta.
study influence the remaining 54.4%. The Syarianingsih Syam & Kurnia Widi
direct influence of knowledge on the Hastuti (10) researched the relationship
implementation of patient safety goals is between nurses' knowledge and
0.456, while if a patient safety culture attitudes towards implementing patient
mediates it, the estimated value is 0.119. safety goals in Yogyakarta Hospital.
It can be concluded that patient safety
culture has a role in improving the Effect of workload on the
implementation of patient safety goals. implementation of patient safety goals
Based on descriptive analysis using The result found no effect of
the three-box method on the knowledge workload on the implementation of
variable, the highest index value is found patient safety goals with a p-value of
in P7, an indicator of reducing the risk of 0.207 (>0.05) with an estimated value of -
infection related to health services, 0.121. This shows that the workload does
namely "I can explain five moments of not affect the implementation of patient
hand hygiene" with a score of 93.43. The safety goals. Based on these results, it can
lowest index value is found in P1 of the be concluded that the nurse's workload
incident reporting indicator, "I does not affect patient safety goals.
understand how to report patient safety Based on the analysis of the
incidents," 82.86. distribution of respondents using the
These results indicate that the three-box method, the average
hospital needs to pay attention to patient distribution of respondents with an
average index value of 73.77 lies in the

International Journal of Nursing and Health Services (IJNHS), Volume 5, Issue 1, February 20th, 2022 101
high category. The highest index value of patient safety, is still very weak. Nurse
80.71 is in BK4, the task level indicator, workload is the volume of work of
namely "I feel I can complete every task nurses in a hospital unit. At the same
given ."The lowest index value is found time, the work of nurses is the time
in the BK1 unit level indicator, namely "I needed to treat patients 24 hours per day.
feel that my unit's workload is balanced It is essential to know the workload as
between the number of patients and the the basis for knowing the work capacity
number of nurses," with an index value of nurses so that there is a balance
of 65.57. Employees feel that the between the nursing staff and the
workload of their unit is balanced workload.
between the number of patients and the
number of nurses. As much as 40% of Effect of knowledge on patient safety
employees think that there is a balance culture
between the number of patients and Through statistical calculations using
nurses. Amos V21, it is known that there is a
One of the factors that influence the positive and significant influence
risk of decreasing performance is between knowledge to patient safety
workload. An increase in workload can culture. Based on the coefficient of
occur if the number of nurses does not determination test (R2), the estimated
match the level of care needs of the value of the knowledge variable on
patient (11). For this reason, the hospital patient safety culture is 0.257. This means
can use various methods of calculating that the knowledge variable affects
the needs of nurses according to the patient safety culture by 25.7%, while
conditions and needs of the hospital. other variables outside this study
Hospital management can use the influence the remaining 74.3%.
formula from the Indonesian National Levett-Jones et al. (13) conducted a
Nurses Association (PPNI) workshop to study exploring nurses' knowledge
calculate the need for nurses if it takes about patient safety. According to him,
into account the number of visits and nurses' perception or confidence about
length of treatment per patient. It can their level of knowledge is more
also be used if the ability and resources influential than the actual level of
for personnel planning are limited, the knowledge. Perceptions of knowledge
type, type, and volume of health services and self-confidence affect the formation
are relatively stable and quite effective in of a patient safety culture.
overcoming the occurrence of spikes in According to the book Patient Safety
cases because it takes into account the Culture: Theory, Methods, and
full capacity of inpatient care (total used) Application – 1st edition, Waterson (14)
which can occur at any time. shows that patient safety culture is
The results of this study support the formed from the learning process so that
result of other research Sitanggang (12), there is a relationship between
which finds that the strength of the knowledge and culture. Thus, the higher
relations between the two variables, or deeper one's understanding of
namely the workload of nurses and something, the more likely that

International Journal of Nursing and Health Services (IJNHS), Volume 5, Issue 1, February 20th, 2022 102
knowledge becomes a culture within a of a patient safety culture can be
person. Previous research has linked hindered by things that are not liked or
knowledge and learning processes with become a negative factor for someone to
patient safety culture (13), (15), (16), (8), adopt a new culture. The excessive
(17), (18), (19), (20), (21), (14), (22), (23). workload can be a barrier to forming a
patient safety culture in a nurse. Other
Effect of workload on patient safety studies have also shown that for nurses
culture with undue burdens or organizations
Based on the results of statistical tests that place too much emphasis on labor
on the estimated value, it is known that efficiency, the formation of a patient
the workload has a positive and safety culture is also hampered (25), (26).
significant effect on patient safety
culture. Based on the estimated value of Effect of patient safety culture on the
the workload, it impacts 63.5% on patient implementation of patient safety goals
safety culture. Other variables outside The results of statistical testing
the study influence the remaining 36.5%. showed that patient safety culture had a
This variable appears to be the dominant positive and significant effect on the
or most significant variable influencing implementation of patient safety goals.
work safety culture. The average index value of 78.33 lies
Based on descriptive analysis using in the high category based on descriptive
the three-box method, the average index analysis using the three-box method. The
value of 73.77 lies in the high category. highest index value is found in the BPK4
The highest index value of 80.71 is in safety system indicator, namely "I feel
BK4, the task level indicator, namely "I the hospital has a good SOP in the
feel I can complete every task given ."The implementation of patient safety," with
second-lowest index value is found in an index value of 82.86. The lowest index
BK9, the patient level indicator, namely value is found in the BPK8 work pressure
"I feel that the distribution of patients is indicator with a value of 70.29, namely "I
quite evenly distributed among all health can always cope with work pressure in
workers," with an index value of 71. this hospital." there are 44% of
The results of this study are in employees who are doubtful if
accordance with Flin et al. (24) in his employees can overcome work pressure
book Measuring safety climate: problems in a hospital environment.
identifying the common features, The results of the study support
suggests that one of the factors that previous research, which has found that
influence patient safety culture is work culture is a decisive factor that influences
pressure, namely the work environment the implementation of patient safety
and workload. Previous research has goals (8,13-23).
also found a relationship between
workload and patient safety culture. In Study Limitations
the book Patient Safety Culture: Theory, This study has some limitations that
Methods, and Application – 1st edition, can be a source for future studies. The
Waterson (14) shows that the formation limitations found in this study: this study

International Journal of Nursing and Health Services (IJNHS), Volume 5, Issue 1, February 20th, 2022 103
was conducted on nurses who work in perceived imbalance between the
different areas, which means the number of nurses and patients. The
knowledge and perceived workload will competence of nurses as the ability to
be different. For example, nurses in the deal with workloads needs to be
inpatient and outpatient departments continuously improved through training
will be other in their workload and level and education so that there is no
of knowledge. excessive workload without having to
add too much human resource.
Conclusion Teamwork also needs to be formed and
Knowledge and workload mediated built through team-building activities so
by patient safety culture partially have a that nurses can work well together. In
positive and significant effect on the terms of patient safety culture, hospital
implementation of patient safety goals, leaders need to continue to pay attention
and learning has a direct impact on the to what makes up a safety culture
implementation of patient safety goals, starting from hospital management. A
but workload does not directly affect the no-blaming culture is formed, and
implementation of patient safety goals. finally, a patient safety culture.
If all these aspects can be met, it is
Managerial Implications hoped that knowledge, workload, and
This study proves the hypothesis of patient safety culture will be formed that
the influence of knowledge, workload, support the implementation of patient
and patient safety culture on safety goals.
implementing patient safety goals.
Hospitals, in this case, management Implication for further study
must be able to increase nurses' To obtain more representative
knowledge about patient safety and results, it is necessary to conduct
manage the workload of nurses well so research with a larger sample under
that the implementation of patient safety normal conditions.
goals can be carried out optimally.
It is necessary to periodically evaluate Recimmendation
the patient safety knowledge of Hospital management needs to form
employees, especially nurses. Patient systems and patterns that can improve
safety socialization and resocialization, knowledge of managing workloads well
both for incident reports and patient and form a patient safety culture by
safety goals, need to be a routine agenda. paying attention to the continuity of
This can be done effectively and patient safety socialization and
efficiently by using online meetings resocialization. It also evaluates and
regularly and continuously by adding enhances nurse schedule arrangements,
exciting elements such as competitions increasing nurse competence, and
and quizzes with prizes to avoid teamwork to establish a patient safety
boredom. Nurse workload management culture.
by managing a reasonable work schedule
needs to be considered to eliminate the Acknowledgments

International Journal of Nursing and Health Services (IJNHS), Volume 5, Issue 1, February 20th, 2022 104
 The authors express their highest 2(1). https://doi.org/10.9707/2307-
appreciation and gratitude to Dr. Rokiah 0919.1014
Kusumapradja, S.KM., M.HA, as the 8. Sithi DS, Widyastuti A. Contributing
head of the ESA Unggul University factor to incident of patient safety within
implementing patient safety goal in
Hospital Administration Masters study
inpatient Depok City Hospital Indonesia.
program. Dr. Rian Adi Pamungkas, S.
Annals of Tropical Medicine and Public
Kep, M.NS, PHN, have given a lot of Health. 2019; 22(11):316-324
support, assistance, and motivation since 9. Koesoemo S. Hubungan Antara
the lecture began until the writing of this Pengetahuan dan Sikap Terhadap Lama
journal. Thank you to the respondents Bekerja Perawat dalam Penerapan
who have participated and the hospital Sasaran Keselamatan Pasien di Ruang
for allowing this research to be carried Rawat Inap Rumah Sakit Aulia Jakarta
out. Selatan 2018. Seminar Nasional Pakar ke
2 Tahun 2019 Buku 1 : Sains dan
Teknologi; 2018.
10. Syam NS, Hastuti W, Kurnia S.
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