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J Korean Gerontol Nurs > Volume 26(4):2024 > Article
Jeong, Song, and Jung: The mediating effect of patient safety culture on the relationship between professionalism, self-leadership, and compliance with infection prevention activity against emerging respiratory infectious disease among nurses working in geriatric long-term care hospitals: A cross-sectional study

Abstract

Purpose

This study investigates the mediating effect of patient safety culture on the relationship between professionalism, self-leadership, and compliance with infection prevention activity against emerging respiratory infectious diseases among nurses working in geriatric long-term care hospitals.

Methods

In total, 136 nurses from eight geriatric long-term care hospitals were invited to participate. For the statistical analyses, descriptive statistics, t-test, ANOVA, and Pearson’s correlation coefficient analyses were employed. The mediating effect was analyzed using the three-step mediation procedure of Baron and Kenny in hierarchical regression, and the significance of the mediating effect was tested using the Sobel test.

Results

Patient safety culture had a full mediating effect on the relationship between professionalism and compliance with infection prevention activity (Z=3.14, p=.001) and a full mediating effect on the relationship between self-leadership and compliance with infection prevention activity (Z=3.37, p<.001).

Conclusion

The study findings indicate that a higher patient safety culture within the organization further enhances compliance with infection prevention activity. Therefore, it is crucial to develop strategies to enhance nurses’ professionalism and self-leadership, as well as to improve organizational patient safety culture for the infection control in geriatric long-term care hospitals.

INTRODUCTION

Emerging respiratory infectious diseases, such as coronavirus disease-19 (COVID-19), are predominantly transmitted through droplets generated by coughing, sneezing, or talking. Given the propensity of respiratory viruses to lead to cluster infections in healthcare settings, the implementation of infection prevention practices by nurses is of paramount importance [1]. Patients in geriatric long-term care (LTC) hospitals often have cognitive and physical chronic conditions that impede their ability to perform activities of daily living independently, which places them at high risk for healthcare-associated infections (HAIs) as they come into close contact with staff during nursing care [2]. In South Korea, the initial outbreak of COVID-19 was primarily concentrated in LTC facilities for older adults [3]. Furthermore, a large prospective observational study conducted in the United Kingdom (UK) reported that individuals aged 80 years or older had a COVID-19 mortality rate 11 times higher than those under 50 years of age, with age being the most significant factor associated with the progression to severe COVID-19 [4,5]. Therefore, it is imperative to determine and enhance the predictors of nurses’ compliance with infection prevention practices to reduce the morbidity and mortality rates of emerging respiratory infectious diseases among patients of geriatric LTC hospitals.
Previous studies have identified work experience and prior education, knowledge of infectious disease or prior experience in care of suspected or confirmed patients, perception of infection risk, hospital safety culture, patient safety culture, self-leadership, and nursing professionalism as predictors of nurses’ compliance with infection prevention practices [6-9]. Among these factors, nursing professionalism is defined as delivering individual care based on professionalism, caring, and altruism principles. Higher levels of professionalism can enhance nurses’ autonomy and empowerment and promote organizational citizenship behaviors [10]. Additionally, self-leadership is described as a comprehensive self-influence approach involving self-guidance for naturally motivating tasks and self-management for necessary but non-motivating tasks [11]. It is believed that self-leadership can significantly enhance nurses’ performance [9]. In other words, professionalism improves patient safety and well-being, enabling nurses to provide high-quality care for older adult patients [8,12], while self-leadership enhances nursing outcomes in geriatric care, potentially influencing nurses’ compliance with infection prevention practices [8,13,14]. Consequently, professionalism and self-leadership are especially important for nurses in geriatric LTC hospitals, where they often carry out nursing tasks independently due to the absence of on-duty physicians, unlike in acute care settings.
Patient safety culture, how safety is viewed and treated by the members in organizations, has emerged as a major predictor of infection prevention activity among nurses in geriatric LTC hospitals amid the growing need for the prevention of HAIs due to the increasing older adult population and emerging respiratory infectious disease pandemic [15]. Enhanced patient safety culture is correlated with heightened engagement in infection prevention activities and reduced occurrences of patient adverse effects and hospital mortality [16].
Previous studies on the relationships between nursing professionalism, patient safety culture, and compliance with infection prevention activity have shown that nursing professionalism impacts culture of ensuring patient safety and that patient safety culture is a key predictor of infection prevention activity [17]. Therefore, it can be predicted that nursing professionalism could have an even more positive impact on infection prevention activity through the mediating effect of patient safety culture. In terms of self-leadership, in a study targeting members of organizations, it was found that consciousness of safety culture exhibited a partial mediating effect in the relationship between self-leadership and the enhancement of safety culture [18]. Furthermore, safety culture demonstrated a complete mediating effect in the relationship between self-leadership of aviation maintenance technicians and organizational effectiveness [19]. The infection prevention activities of nurses can be associated with nursing and organizational outcomes. Therefore, it can be inferred that the self-leadership of hospital nurses, by mediating patient safety culture, may have a more positive impact on infection prevention behaviors.
The involvement of nurses in infection prevention activities is vital for reducing adverse events, especially HAIs, among patients in LTC hospitals. Therefore, it is crucial to examine various influencing factors affecting nurses’ infection prevention activities and to explore strategies for improvement in a constructive manner. However, only a small number of studies have elucidated the mediating impact of patient safety culture on the relationship between nursing professionalism, self-leadership, and compliance with infection prevention activity, and none have specifically targeted nurses in LTC hospitals.
Against this backdrop, this study aims to investigate how patient safety culture mediates the relationship between nursing professionalism, self-leadership, and compliance with infection prevention practices, especially regarding emerging respiratory communicable diseases, and explore strategies to enhance patient safety culture for better implementation of infection prevention activities among nurses in LTC hospitals.

METHODS

Ethic statements: This study received approval from the Institutional Review Board (IRB) of Konyang University (IRB No. KYU 2023-05-038). Informed consent was obtained from the participants.

1. Study Design

This was a cross-sectional, descriptive study in design. This study was performed according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Reporting Guidelines (http://www.strobe-statement.org/).

2. Participants

Participants were 136 nurses working in LTC hospitals with 30 or more beds in four different regions of South Korea (Seoul, Bucheon, Daejeon, and Gyeryong). They were selected through convenience sampling. The inclusion criteria required participants to be involved in direct patient car; thus nurse managers were excluded. The sample size was calculated using the G*power 3.1.9.4 program, considering a significance level (α) of .05, a medium effect size of .15, power (1-β) of .80, and ten predictors for regression analysis [20]. The calculated minimum sample size was 135. To account for insufficient responses and a dropout rate of 15%, 155 participants were initially recruited. However, data from only 136 participants were ultimately included in the final analysis.

3. Measures

1) General Characteristics

The participant characteristics were measured in terms of age, level of education, work experience in nursing, current department of employment, number of hospital beds, experience in caring for confirmed patients with emerging respiratory communicable diseases, and experience in education in infection control over the past year.

2) Professionalism

In this study, professionalism was evaluated using the Nursing Professionalism Scale, originally developed by Yeun et al. [17] and subsequently refined by Han et al. [21] through factor analysis. This 18-item tool consists of five factors: professional self-concept (six items), social perception (five items), specialty of nursing (three items), nursing role (two items), and autonomy of nursing (two items). Respondents rate each item on a 5-point Likert scale (1~5), with higher scores indicating greater professionalism. The Cronbach’s alpha coefficient was .94 in Han et al.’s study [21] and .90 in the present investigation.

3) Self-Leadership

Self-leadership was assessed using a tool originally developed by Manz [22] and modified and adapted by Kim [23]. This 18-item tool comprises six domains: self-expectations (three items), rehearsal (three items), goal setting (three items), self-compensation (three items), self-critique (three items), and constructive thinking (three items). Respondents rate each item on a 5-point Likert scale (1~5), in which a higher score indicates greater self-leadership. The Cronbach’s alpha coefficient was .87 in Kim’s study [23] and .86 in the present study.

4) Patient Safety Culture

Patient safety culture was assessed using the Korean Scale for Patient Safety Culture in Long-Term Care Facilities developed by Yoon et al. [24]. This 27-item tool comprises four domains: managers’ leadership (nine items), work attitude (six items), organizational system (seven items), and managerial activities (five items). Respondents rate each item on a 5-point Likert scale (1~5), in which a higher score indicates greater patient safety culture. The Cronbach’s alpha coefficient was .87 in Yoon et al.’s study [24] and .85 in the present study.

5) Compliance With Infection Prevention Activity Against Emerging Respiratory Infectious Disease

Adherence with infection prevention practice against emerging respiratory communicable diseases was assessed using a tool developed by Jeong et al. [25]. This 34-item tool comprises five domains: management of supplies and environment, education, hand hygiene and respiratory etiquette, assessment of infection risk and management of traffic flow, management upon entering and exiting the room of an infectious disease and donning and doffing of personal protective equipment. Respondents rate each item on a 5-point Likert scale (1~5), in which a higher score indicates greater compliance with infection prevention activity. The Cronbach’s alpha coefficient was .88 in the Jeong et al.’s study [25] and .85 in the present investigation.

4. Data Collection and Ethical Considerations

Data collection performed between July 10 and August 30, 2023. The authors contacted LTC hospitals selected via convenience sampling to elucidate the study’s objectives and request collaboration. After obtaining institutional consent from the eight LTC hospitals that agreed to participate in the survey, we visited each facility in person to conduct the survey. Prior to administering the survey, participants were briefed on the study’s objectives, the voluntary nature of participation and withdrawal, as well as the assurance of anonymity and confidentiality. Participants who voluntarily provided written consent were given the questionnaire to complete and instructed to place it in a collection box after completion.

5. Data analysis

The data underwent analysis using SPSS 25.0 software (IBM Corp.). The participants’ general characteristics, professionalism, self-leadership, patient safety culture, and compliance with infection prevention activity were analyzed using frequency and percentage or mean and standard deviation. Differences in professionalism, self-leadership, patient safety culture, and compliance with infection prevention activity were examined based on participants’ general characteristics through t-tests and ANOVA. The correlations between professionalism, self-leadership, patient safety culture, and compliance with infection prevention activity were analyzed using Pearson’s correlation coefficients. Baron and Kenny’s three-step mediation analysis was employed to investigate the mediating effect of patient safety culture in the association between professionalism, self-leadership, and compliance with infection prevention activity. Additionally, the Sobel test was conducted to assess the significance of the mediating effect.

RESULTS

1. Differences of Professionalism, Self-Leadership, Patient Safety Culture, and Compliance With Infection Prevention Activity by General Characteristics

The mean participant age was 47.37±11.92 years, with the highest percentage of participants being in the 50~59 years group (n=45, 33.1%). Participants’ education level included those with an associate degree (n=68, 50.0%), followed by those with a bachelor’s degree (n=61, 44.9%). The mean nursing career length was 14.26±9.18 years, with 48 (35.3%) having a career of 10~20 years. The mean employment length in the current department was 5.28±5.16 years, with 74 (54.4%) having less than 5 years of experience. The majority of nurses worked in a 50 to 99 bed hospital (n=127, 93.4%). A total of 123 participants (90.4%) had experience in caring for patients with novel communicable diseases, and 113 (83.1%) had received education on infection control.
There were no significant differences in professionalism, self-leadership, patient safety culture, and compliance with infection prevention activity according to participants’ general characteristics (Table 1).

2. Level of Professionalism, Self-Leadership, Patient Safety Culture, and Compliance With Infection Prevention Activity of Participants

The total average score for professionalism among participants was 66.46±7.36, with an average item rating of 3.69±0.41 out of 5 points. The total average score for self-leadership was 62.80±8.89, with an average item rating of 3.49±0.49 out of 5 points. The total average score for patient safety culture was 108.55±13.50, with an average item rating of 4.02±0.50 out of 5 points. The total average score for compliance with infection prevention activity among participants was 157.67±14.45, with an average item rating of 4.64±0.42 out of 5 points (Table 2).

3. Correlations Between Professionalism, Self-Leadership, Patient Safety Culture, and Compliance With Infection Prevention Activity

Participants’ compliance with infection prevention activity was positively correlated with professionalism (r=.28, p=.001), self-leadership (r=.27, p=.002), and patient safety culture (r=.40, p<.001) (Table 3).

4. Mediating Effect of Patient Safety Culture in the Relationship Between Professionalism and Compliance With Infection Prevention Activity

The regression model was statistically significant at step 1 (F=24.56, p<.001), step 2 (F=11.27, p<.001), and step 3 (F=14.47, p<.001). The percentage of explained variance was 14.9% in step 1, 7.1% in step 2, and 16.6% in step 3. The Durbin–Watson statistic was close to 2, at 1.685, confirming that the assumption of independence of residuals was met. Variance inflation factors (VIFs) were all below 10, confirming the absence of multicollinearity.
In step 1’s model, professionalism (β=.39, p<.001) had a significant positive effect on patient safety culture. In step 2, professionalism (β=.28, p<.001) had a positive effect on compliance with infection prevention activity. In step 3, patient safety culture (β=.35, p<.001) had a positive effect on compliance with infection prevention activity. However, in step 3, professionalism (β=.14, p=.098) did not have a significant effect on compliance with infection prevention activity, confirming that patient safety culture has a full mediating effect in the relationship between professionalism and compliance with infection prevention activity. The mediating effect of patient safety culture in the relationship between professionalism and compliance with infection prevention activity was significant in Sobel test (Z=3.14, p<.001) (Figure 1).

5. Mediating Effect of Patient Safety Culture in the Relationship Between Self-Leadership and Compliance With Infection Prevention Activity

The regression model was statistically significant at step 1 (F=46.21, p<.001), step 2 (F=10.43, p<.001), and step 3 (F=13.36, p<.001). The percentage of explained variance was 25.1% in step 1, 6.5% in step 2, and 15.5% in step 3. The Durbin–Watson statistic was close to 2, at 1.665, confirming that the assumption of independence of residuals was met. VIFs were all below 10, confirming the absence of multicollinearity.
In step 1’s model, self-leadership (β=.51, p<.001) had a significant positive effect on patient safety culture. In step 2, self-leadership (β=.27, p=.002) had a positive effect on compliance with infection prevention activity. In step 3, patient safety culture (β=.36, p<.001) had a positive effect on compliance with infection prevention activity. However, in step 3, self-leadership (β=.09, p=.341) did not have a significant effect on compliance with infection prevention activity, confirming that patient safety culture has a full mediating effect in relationship between self-leadership and compliance with infection prevention activity. The mediating effect of patient safety culture in the relationship between self-leadership and compliance with infection prevention activity was significant in Sobel test (Z=3.37, p<.001) (Figure 2).

DISCUSSION

This study aimed to examine how patient safety culture mediates the relationship between professionalism, self-leadership, and compliance with infection prevention activities. The mean of the participants’ compliance was 157.67±14.45, and they represented a score of 92.7 out of 100 based on a total score of 170 for compliance, indicating that the participants’ compliance was significantly high. In addition, the mean for each item of compliance was 4.64±0.42 out of 5. Despite not using the same scale, compliance with infection prevention activity in this study was slightly higher than in previous studies, compared to 4.58 out of 5 in a study of nurses working in LTC hospitals and 4.54 out of 5 in a study of paramedics [26,27]. The difference in findings could stem from the scale employed in this study, which assessed compliance to infection prevention activity specific to emerging respiratory communicable diseases, rather than overall compliance with infection prevention measures. This may also be due to the accumulation of experience and repetitive training in responding to novel respiratory communicable diseases, which has improved compliance with infection prevention activities among nurses working in geriatric LTC hospitals [5-7].
There were no significant differences in compliance according to general characteristics, and these findings are consistent with previous studies [7,26]. The participant characteristics were highly homogeneous in this study, as they were nurses working in LTC hospitals, approximately 75% of whom were in their 40s or older, with an average clinical experience of more than 14 years. Furthermore, 90% of the participants had cared for patients with novel respiratory communicable diseases, and more than 83% had received infection-related education, indicating a high level of compliance with infection prevention activity, which may explain the lack of differences in performance. As for the number of beds, previous studies of hospital nurses have shown a significant effect on infection prevention activity, but in this study, more than 93% of the participants were from LTC hospitals with more than 50 beds and less than 100 beds, thereby showing no difference in infection prevention activity based on the number of beds, and follow-up research on LTC hospitals with various numbers of beds would be required [28].
Furthermore, this study examined how patient safety culture mediated the relationship between professionalism and compliance with infection prevention activity. The results show that patient safety culture fully mediated the connection between professionalism and compliance with infection prevention activity. In other words, while the professionalism of nurses in LTC hospitals directly influences compliance with infection prevention activity, in the context of patient safety culture, its effect on compliance with infection prevention activity is only through patient safety culture. These factors explained for 16.6% of the variance. Therefore, this suggests improving patient safety culture in LTC hospitals to be of utmost importance for enhancing compliance with infection prevention activity against respiratory communicable diseases among nurses. Previous studies have primarily focused on the impact of nursing professionalism on compliance with infection prevention activities or the impact of patient safety culture on compliance with infection prevention activities [8,9,15]. However, even if nurses possess a strong sense of professionalism, their performance in infection prevention practices aimed at reducing HAIs may be insufficient if they lack awareness of patient safety culture. Therefore, elucidating the mediating effect of patient safety culture on the relationship between these variables is critically important.
Moreover, patient safety culture also fully mediated the relationship between self-leadership and compliance with infection prevention activity. In other words, while the self-leadership of nurses in LTC hospitals directly influences compliance with infection prevention activity, in the context of patient safety culture, its effect on compliance with infection prevention activity is only through patient safety culture. These factors explained for 15.5% of the variance. The finding aligns with a study that investigated the mediating effect of safety culture on the relationship between self-leadership and organizational effectiveness among aviation maintenance technicians [19]. However, patients in LTC hospitals are particularly vulnerable to HAIs, and nursing assistants are directly involved in their care. Consequently, nurses in these settings require a higher level of self-leadership and awareness of patient safety culture compared to workers in other fields. Therefore, this implies that ensuring a patient safety culture within LTC hospitals is of paramount importance for enhancing compliance with infection prevention activities, particularly concerning novel respiratory communicable diseases among nurses.
A limitation of this study is that the participants were nurses from eight LTC hospitals selected through convenience sampling. Therefore, caution is warranted when generalizing the research findings, and future studies should aim to broaden the study population.

CONCLUSION

The study findings indicate that a higher patient safety culture within the organization further enhances compliance with infection prevention activity. Therefore, it is crucial to develop strategies to enhance nurses’ professionalism and self-leadership, as well as to improve organizational patient safety culture for infection control in geriatric LTC hospitals. From the perspective of nursing practice, nurse managers in LTC hospitals should expand the application of educational programs to improve nurses’ awareness of patient safety culture. Additionally, the government should implement initiatives to measure and evaluate patient safety culture through dedicated programs and policies.

NOTES

Authors' contribution
Conceptualization - HJ; Data curation - SYJ and MSS; Funding acquisition - SYJ, MSS, and HJ; Investigation - HJ; Methodology - MSS; Project administration - SYJ, MSS, and HJ; Supervision - SYJ, MSS, and HJ; Writing–original draft - SYJ, MSS, and HJ; Writing–review & editing - HJ
Conflict of interest
No existing or potential conflict of interest relevant to this article was reported.
Funding
This paper was supported by the Konyang University Research Fund in 2023.
Data availability
Please contact the corresponding author for data availability.
Acknowledgements
None.

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Figure 1.
Mediating effect of patient safety culture in the relationship between professionalism and compliance with infection prevention activity.
jkgn-2024-00430f1.jpg
Figure 2.
Mediating effect of patient safety culture in the relationship between self-leadership and compliance with infection prevention activity.
jkgn-2024-00430f2.jpg
Table 1.
Differences of Professionalism, Self-Leadership, Patient Safety Culture, and Compliance With Infection Prevention Activity by General Characteristics (N=136)
Variable Categoy n (%) M±SD Professionalism Self-leadership Patient safety culture Compliance with infection prevention activity
M±SD t/F (p) M±SD t/F (p) M±SD t/F (p) M±SD t/F (p)
Age (year) <40 35 (25.7) 68.31±9.85 62.17±9.30 108.62±13.89 156.97±14.14
40 to 49 35 (25.7) 66.03±5.82 62.02±9.31 107.17±18.55 153.68±17.94
50 to 59 45 (33.1) 47.37±11.92 65.53±7.20 1.04 (.376) 64.17±8.77 0.53 (.660) 108.95±10.48 0.19 (.899) 159.84±10.52 1.60 (.191)
≥60 21 (15.4) 66.05±7.36 62.19±7.89 109.85±8.83 160.80±15.08
Level of education College 68 (50.0) 66.64±7.69 61.63±8.59 109.07±14.67 157.75±15.97
University 61 (44.9) 66.44±7.28 63.55±9.26 1.84 (.163) 107.78±12.95 0.19 (.824) 156.81±13.21 0.83 (.434)
Master or higher 7 (5.1) 64.71±4.68 0.22 (.805) 67.57±6.80 110.14±5.81 164.28±6.12
Work experience in nursing (year) <10 45 (33.1) 67.64±9.23 63.24±9.16 111.00±13.52 159.84±14.20
≥10 to <20 48 (35.3) 14.26±9.18 65.93±6.24 0.68 (.509) 62.14±8.44 0.20 (.816) 105.58±15.82 1.98 (.142) 155.64±15.54 0.98 (.378)
≥20 43 (31.6) 65.79±6.20 63.06±9.24 109.30±10.05 157.65±13.38
Work experience in current department (year) <5 74 (54.4) 66.71±8.09 62.41±9.72 108.63±15.94 0.17 (.837) 157.32±14.22
≥5 to <10 34 (25.0) 5.28±5.16 67.44±5.86 1.27 (.283) 64.29±5.85 0.65 (.519) 109.38±10.29 158.41±14.87 0.06 (.937)
≥10 28 (20.6) 64.57±6.80 62.00±9.68 107.32±9.91 157.67±14.98
Number of hospital beds ≥30 to <50 4 (2.9) 67.25±3.30 67.00±6.63 110.00±8.04 165.25±6.29
≥50 to <100 127 (93.4) 66.46±7.55 0.05 (.945) 62.65±9.06 0.46 (.629) 108.77±13.67 0.65 (.520) 157.37±14.64
≥100 5 (3.7) 65.60±4.21 63.20±5.35 101.80±13.98 159.20±14.02 0.60 (.549)
Experience in caring for ERID confirmed patients Yes 123 (90.4) 66.51±7.21 0.27 (.785) 62.82±9.21 0.11 (.911) 108.17±13.46 -.098 (.326) 157.87±14.53 0.51 (.606)
No 13 (9.6) 65.92±8.86 62.53±5.01 112.07±14.39 155.69±13.92
Experience in education of infection control Yes 113 (83.1) 65.90±6.60 -1.50 (.146) 62.34±9.19 -1.60 (.116) 107.79±13.66 -1.44 (.150) 157.43±14.77 -0.42 (.675)
No 23 (16.9) 69.17±10.02 65.04±6.91 112.26±12.62 158.82±12.91

ERID=Emerging respiratory infectious diseases; M=Mean; SD=Standard deviation.

Table 2.
Level of the Professionalism, Self-Leadership, Patient Safety Culture, and Compliance With Infection Prevention Activity (N=136)
Variable M±SD (total) Min~Max M±SD (item) Min~Max
Professionalism 66.46±7.36 47~87 3.69±0.41 2.61~4.83
Self-leadership 62.80±8.89 30~89 3.49±0.49 1.67~4.94
Patient safety culture 108.55±13.50 27~36 4.02±0.50 1.00~5.00
Compliance with infection prevention activity 157.67±14.45 102~170 4.64±0.42 3.00~5.00

M=Mean; Max=Maximim; Min=Minimum; SD=Standard deviation.

Table 3.
Correlations Between Major Variables (N=136)
Variables r (p)
Professionalism Self-leadership Patient safety culture Compliance with infection prevention activity
Professionalism 1
Self-leadership .38 (<.001) 1
Patient safety culture .39 (<.001) .51 (<.001) 1
Compliance with infection prevention activity .28 (.001) .27 (.002) .40 (<.001) 1
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