A Narrative Synthesis of Qualitative Studies Conducted to Assess Patient Safety Culture in Hospital Settings *Hamad Alqattan,1 Zoe Morrison,2 Jennifer A. Cleland3 Sultan Qaboos University Med J, May 2019, Vol. 19, Iss. 2, pp. e91–98, Epub. 8 Sep 19 Submitted 11 Oct 18 Revision Req. 9 Dec 18; Revision Recd. 23 Dec 18 Accepted 10 Jan 19 1Department of Medical Education, University of Aberdeen, Aberdeen, Scotland; 2Department of Human Resources & Organisational Behaviour, University of Greenwich, London, UK; 3Centre for Healthcare Education Research and Innovation (CHERI), University of Aberdeen, Aberdeen, UK *Corresponding Author’s e-mail: r01haha@abdn.ac.uk In 1999, the institute of medicine’s to err is Human highlighted that a considerable number of patients die annually in the USA as a result of avoidable medical errors.1 Since this seminal publication, healthcare professionals and leaders have been more alert to the role of human factors in providing safe health- care services.1 Evidence suggests that organisational patient safety culture (PSC) plays a critical role in determining patient safety outcomes such as medication errors, hosp- ital-acquired infections and post-operative complications.2 Knowledge about the extent to which healthcare prov- iders perceive patient safety is an important initial step for improving PSC in healthcare organisations.3 PSC is an abstract concept and is difficult to measure; there is a need to develop an understanding of healthcare providers’ attitudes and behaviours related to patient safety. Furthermore, healthcare providers should use this understanding to form interventions addressing patient safety issues.4 The vast majority of studies examining PSC in healthcare organisations have adopted quantitative survey methods such as the Hospital Survey on Patient Safety Culture (HSOPSC), Safety Attitudes Questionnaire and Culture of Safety Survey.5 These tools were designed to evaluate healthcare providers’ perceptions of the diff- erent dimensions of PSC (e.g. leadership support, non- review نبذة وصفية من الدراسات النوعية اليت أجريت لتقييم ثقافة سالمة املرضى يف بيئة املستشفيات حمد القطان، زوي موري�شون، جينيفري كليالند abstract: This review aimed to identify methodological aspects of qualitative studies conducted to assess patient safety culture (PSC) in hospital settings. Searches of Google Scholar (Google LLC, Menlo Park, California, USA), MEDLINE® (National Library of Medicine, Bethesda, Maryland, USA), EMBASE (Elsevier, Amsterdam, Netherlands), PsycINFO (American Psychological Association, Washington, District of Columbia, USA) and Web of Science (Clarivate Analytics, Philadelphia, Pennsylvania, USA) databases were used to identify qualitative articles published between 2000 and 2017 that focused on PSC. A total of 22 studies were included in this review and analysis of methodological approaches showed that most researchers adopted purposive sampling, individual interviews, inductive content and thematic analysis. PSC was affected by factors related to staffing, communication, non- human resources, organisation and patient-related factors. Most studies lacked theoretical frameworks. However, many commonalities were found across studies. Therefore, it is recommended that future studies adopt a mixed methods approach to gain a better understanding of PSC. Keywords: Patient Safety; Culture; Needs Assessment; Qualitative Research. بيئة يف املر�شى �شالمة ثقافة لتقييم اأجريت التي النوعية للدرا�شات املنهجية اجلوانب حتديد اإىل املراجعة هذه تهدف امللخ�ص: امل�شت�شفيات. وقد اأجريت عملية املراجعة باإ�شتخدام قاعدة البيانات، مثقف البحث من جوجل )جوجل، مينلو بارك، كاليفورنيا، الواليات املتحدة االأمريكية(، ميدالين )املكتبة الوطنية للطب، بيثي�شدا، مرييالند، الواليات املتحدة االأمريكية(، اأم بي�س )اإل�شفري، اأم�شرتدام، هولندا(، كالرفيت، العلوم )حتليالت �شبكة االأمريكية(، املتحدة الواليات كولومبيا، مقاطعة وا�شنطن، االأمريكية، النف�س علم اأنفو )جمعية �شيكو على ركزت والتي 2017 و 2000 عامي بني املن�شورة النوعية املقاالت لتحديد االأمريكية(، املتحدة الواليات بن�شلفانيا، فيالدلفيا، ثقافة �شالمة املر�شى. مت ت�شمني ما جمموعه 22 درا�شة يف هذه املراجعة وحتليل االأ�شاليب املنهجية التي اأظهرت اأن معظم الباحثني اعتمد اأخذ العينات الهادفة، واملقابالت ال�شخ�شية، واملحتوى اال�شتقرائي والتحليل املو�شوعي. تاأثرت ثقافة �شالمة املر�شى بالعوامل املتعلقة باملوظفني والتوا�شل واملوارد غري الب�رشية والتنظيم والعوامل املتعلقة باملري�س. واخلال�شة اأن معظم الدرا�شات كانت تفتقر اإىل االأطر النظرية. ومع ذلك، مت العثور على العديد من القوا�شم امل�شرتكة بني الدرا�شات. لذلك، يو�شى باأن تتبنى الدرا�شات امل�شتقبلية منهج طرق خمتلطة للح�شول على فهم اأف�شل لـثقافة �شالمة املر�شى. الكلمات املفتاحية: �شالمة املر�شى؛ ثقافة؛ تقييم االحتياجات؛ بحث نوعي. This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License. https://doi.org/10.18295/squmj.2019.19.02.002 https://creativecommons.org/licenses/by-nd/4.0/ A Narrative Synthesis of Qualitative Studies Conducted to Assess Patient Safety Culture in Hospital Settings e92 | SQU Medical Journal, May 2019, Volume 19, Issue 2 punitive response to error, teamwork, job satisfaction, etc.).5 Surveys are useful as they are economical, time- efficient and allow for direct comparisons across various contexts.6 However, such questionnaires cannot provide an understanding of why certain responses are provided and fail to gather personal stories and experiences related to organisational safety culture.7 Qualitative research approaches are typically used to understand attitudes and behaviours and therefore, have a greater potential to document personal experiences, feelings about and opinions of organisational safety culture than responses to pre-determined survey questions.5,8–10 This type of research uses either inductive or deductive reasoning.11 Inductive approaches use patterns derived from data related to a particular phenomenon under study to construct theories, while deductive approaches use pre-existing theories in the literature as an analytical tool to gain insight into certain aspects of the data.11 In addition to the presence of different approaches in this field, a wide range of methods can be adopted for qualitative data collection (e.g. surveys, individual inter- views and focus group discussions) and analysis (e.g. con- tent analysis, thematic analysis and discourse analysis).12 This review aimed to evaluate the methodological aspects of existing qualitative studies which focused on PSC in hospital settings. The objective was to provide an overview of study quality and identify gaps in knowledge which could then be addressed in future research. Methods In this narrative synthesis of published studies, content analysis was used to describe the most commonly adopted qualitative methods in the included studies, and findings were quantified via frequency counts.13,14 Thematic syntheses was used to explain the different factors underpinning patient safety in the included studies.15 The specific research questions for this review were: “What are the most widespread methods used in previous qualitative studies of PSC in hospital settings?” and “What commonalities are there, if any, across studies, regarding factors affecting patient safety?”. To address these research questions, independent searches of Google Scholar (Google LLC, Menlo Park, California, USA), MEDLINE® (National Library of Med- icine, Bethesda, Maryland, USA), EMBASE (Elsevier, Amsterdam, Netherlands), PsycINFO (American Psych- ological Association, Washington, District of Columbia, USA) and Web of Science (Clarivate Analytics, Phila- delphia, Pennsylvania, USA) databases were conducted to identify studies on PSC. To be included in this review, studies had to be: 1) published original articles that focused on healthcare providers’ perception of PSC; 2) qualitative or mixed methods studies conducted in hospital settings; 3) published in English; and 4) published from January 2000 to December 2017 to focus on studies conducted between the publication of To Err is Human in 1999 and December 2017. Studies were excluded if they only assessed a subset of PSC, they did not have a methods section, they were opinion papers including anecdotal and discussion papers, editorials, letters to the editor, short communications, positions and expert opinion papers or theoretical literature reviews. The following search terms were collectively used when searching the databases: “patient safety culture” OR “patient safety climate” OR “perception of patient safety” OR “safety culture” OR “safety climate” OR “patient safety AND hospital”. Abstracts of the identified articles were used to determine relevance of the study based on this review’s inclusion criteria. If a study’s relevance could not be determined from the abstract, the article was read in its entirety. Five questions from the Critical Appraisal Skills Programme (CASP) checklist were used to guide and standardise data extraction from the included articles.16 These questions were selected as they focus on the methodological aspects of qualitative studies such as appropriateness of research design, recruitment strategy, data collection and analysis and clarity of findings. Answers to the selected question from the CASP were coded and then thematically sorted into tables. Sorted data relating to the identified methods were quant- ified using Microsoft Excel, Version 2013 (Microsoft Corporation, Redmond, Washington, USA). Further thematic synthesis was carried out to identify factors affecting patient safety, develop descriptive sub-themes and generate analytical themes.17 Results An initial database search revealed 390 articles relevant to PSC assessment. Duplicates (n = 139) were excluded and abstracts of the remaining 251 titles were used to decide relevance of the study based on the inclusion criteria. A summary of the search process is shown in Figure 1. A total of 22 studies carried out between 2006–2017 were included in this review. Of these, four studies were conducted in Sweden, three studies each were conducted in the USA, China and Iran and one study each was conducted in the UK, Canada, Finland, Australia, Brazil, Uruguay, Congo, Ethiopia and Bhutan. Most studies (72.7%) were purely qualitative, while six studies used mixed methods approaches. The majority (81.8%) did not state an epistemological basis or tradition (foundation for the study design). Of the four studies Hamad Alqattan, Zoe Morrison and Jennifer A. Cleland Review | e93 which did report an epistemological basis, two used case studies, one used dialectic hermeneutics and one used social constructivism. The latter represents an overarching epistemological basis, whereas case studies and dialectic hermeneutics may be more accurately categorised as methods.18 Most participants (59.1%) were selected using purposive or criterion sampling. Individual face-to- face interviews was the most frequent data collection technique (54.5%) followed by focus groups (18.2%). The majority of studies adopted content (50%) or thematic (22.7%) or both (9.1%) approaches to qualit- ative data analysis as well as grounded theory, frame- work analysis and template analysis (4.5% each). Frame- work analysis and template analysis are, broadly speaking, sub-branches of thematic approach.19,20 Inductive, or data-driven, analysis was the preferred approach (72.7%) where as deductive data analysis using pre-established PSC models was used only in six studies [Table 1]. Models differed in terms of numbers of PSC dimensions, ranging from 6–12 dimensions in each model. They also differed by the labels given for each dimension; however, some dimensions shared similar meaning regarding teamwork, communication, leadership and other organisational and environmental characteristics [Table 2]. Despite being conducted in diverse contexts, many common factors were identified that related to facil- itating or compromising patient safety. These factors were related to staffing, communication, non-human resources, organisational factors and patient-related factors. The number of available staff was commonly perceived as a determinant of patient safety.21–31 In general, participants believed that adequate staff numbers would help minimise workload and burnout and would sub- sequently help them work more accurately and safely. In addition, staff attitudes were perceived as important. Commitment to patient safety and compliance with clinical practice and patient safety standards were thought to play a vital role in determining the level of patient safety in the workplace.23–26,29,31–35 Job satisfaction and staff turnover rate were also identified as key determinants of patient safety.25,32 Communication factors commonly perceived as determinants of patient safety were teamwork, health- care provider-patient relationships, handovers and tran- sitions.22–29,32,33,35–37 For example, Zhu et al.’s study found that feedback and communication concerning errors were seen as important determinants of patient safety.22 There was widespread agreement among the diff- erent studies’ participants that the availability and appro- priateness of non-human resources, including policies, procedures, equipment, supplies, the physical environ- ment, technology and medical records in healthcare organisations were key factors for providing safe ser- vices.21–25,27–35,37–39 Study participants emphasised the importance of organisational factors, including staff training and cont- inuous education, in improving patient safety.22,25–27,29,34 They also emphasised the role of leadership in creating a permissive and open working atmosphere which facilitates reporting and learning from mistakes.22–24,27,34,38 Emphasis was also placed on the role of leadership in mentoring staff toward safe practices.22,25,30,32,37 Patient-related factors were less frequently raised in the reviewed studies. However, patient numbers, under- lying conditions, awareness of their condition and health literacy were all thought to contribute to patient safety [Table 3].29,36,37 Discussion Theoretically, PSC consists of objective aspects, like healthcare providers’ behaviours and practices related to patient safety, and subjective aspects such as their beliefs, values and attitudes about patient safety.40 These subjective aspects cannot be captured by quantitative survey-based methods, which only determine aspects about PSC in a healthcare organisation at a particular period.41 Qualitative methods can provide a more detailed understanding of PSC in healthcare settings; however, this review showed that only a few studies adopted quali- tative methods to explore this issue.9 Most studies lacked clear conceptual or theoretical frameworks and used relatively direct approaches to data collection and analysis. These studies were carried out in diverse contexts and countries and showed variations between the groups under study. Despite these differences, study findings shared commonalities regarding factors facilitating or compromising patient safety—such as Figure 1: Flow chart of the search process for articles on patient safety culture. A Narrative Synthesis of Qualitative Studies Conducted to Assess Patient Safety Culture in Hospital Settings e94 | SQU Medical Journal, May 2019, Volume 19, Issue 2 Table 1: Summary of the methods adopted in 22 studies on patient safety culture Author and year of publication Study design Tradition Sampling Data collection technique Data saturation Form of data Data analysis approach Analytical model(s) used Rathert et al.21 (2006) Mixed methods Not adopted Whole population Survey Not applicable Electronic data Not stated Not adopted Zhu et al.22 (2012) Qualitative Not adopted Purposive or criterion sampling Focus group Clarified Audio records Thematic analysis HSOPSC framework Lui et al.23 (2014) Mixed methods Not adopted Opportunity and purposive sampling Interview Clarified Audio records Thematic analysis SSC Model and HSOPSC framework Vaismoradi et al.24 (2014) Qualitative Not adopted Purposive or criterion sampling Interview and observation Clarified Audio records and field notes Content analysis Not adopted Abdi et al.25 (2015) Mixed methods Case study Critical case Interview Not clarified Audio records Framework analysis SAQ framework Umpiérrez et al.26 (2015) Qualitative Dialectic hermeneutic Purposive or criterion sampling Interview Clarified Audio records Content analysis Not adopted Wang et al.27 (2017) Qualitative Not adopted Stratified sampling Interview Clarified Audio records Grounded theory HSOPSC framework Wami et al.28 (2016) Mixed methods Not adopted Purposive or criterion sampling Interview Not clarified Audio records Content analysis Not adopted Pazokian et al.29 (2017) Qualitative Not adopted Critical case Interview Clarified Audio records Content analysis Not adopted Tarling et al.30 (2017) Mixed methods Not adopted Convenience sampling Focus group Not clarified Audio records Thematic analysis Not adopted Källberg et al.31 (2017) Qualitative Not adopted Purposive or criterion sampling Telephone interview Not clarified Audio records Content analysis Not adopted Danielsson et al.32 (2014) Qualitative Not adopted Purposive or criterion sampling Interview and focus group Not clarified Audio records Content analysis Not adopted Ridelberg et al.33 (2014) Qualitative Not adopted Purposive or criterion sampling Interview Not clarified Audio records Content analysis Vincent’s framework Kanerva et al.34 (2016) Qualitative Not adopted Purposive or criterion sampling Interview Not clarified Audio records Content analysis Not adopted Labat and Sharma35 (2016) Qualitative Social constructivism Purposive or criterion sampling Interview Not clarified Audio records Content analysis Not adopted Bishop and Cregan36 (2015) Qualitative Not adopted Purposive or criterion sampling Interview Not applicable Video records Thematic analysis Not adopted Jones37 (2014) Qualitative Not adopted Purposive or criterion sampling Focus group Not clarified Audio records Content analysis Not adopted dos Reis et al.38 (2017) Qualitative Not adopted Purposive or criterion sampling Interview Not clarified Audio records Content and thematic analysis Not adopted Pelzang et al.39 (2017) Qualitative Not adopted Purposive or criterion sampling Interview Not clarified Audio records Content and thematic analysis Not adopted Elder et al.52 (2008) Qualitative Not adopted Convenience sampling Focus group Not clarified Audio records Thematic analysis Not adopted Karlsson et al.53 (2011) Qualitative Not adopted Whole population Survey Not applicable Written data Content analysis Not adopted Allen et al.54 (2010) Mixed methods Case study Critical case Interview and document audit Not clarified Audio records Template analysis SAQ framework HSOPSC = hospital survey on patient safety culture; SSC = sammer’s safety culture; SAQ = safety attitude questionnaire. Hamad Alqattan, Zoe Morrison and Jennifer A. Cleland Review | e95 staffing, communication, non-human resources, organi- sational factors and patient-related factors. Most frontline staff (e.g. doctors, nurses and pharmacists) generally linked patient safety with the availability of appropriate systems and procedures to support patient safety in the workplace. Managers embraced more proactive approaches for risk identification and management. This difference is reflected in the findings of surveys on PSC conducted in different contexts.42–45 In addition, PSC was not uniform across healthcare providers working even in a single hospital.41 Evidence suggests that different patient safety sub- cultures within the same hospital are likely related to individual factors such as diverse healthcare providers that have different national, religious, educational and occupational backgrounds.40 This factor must be consid- ered when exploring PSC in hospital settings; however, further research is needed to examine this area. As previously mentioned, few studies have used theoretical models or categories offered by popular survey tools to categorise their data (deductive analysis). The benefits of using theoretical models or conceptual frameworks for qualitative data analysis can establish links between different concepts in the data and aid conceptual generalisability by illustrating how findings from one context are transferable to other contexts.12,46,47 Theoretical models were adopted in the included studies for two purposes. First, researchers of some studies int- ended to develop a context-specific PSC survey quest- ionnaire based on the PSC dimensions of an already established one. For example, both Zhu et al. and Wang et al. mentioned that the HSOPSC was widely used in China to evaluate PSC; however, they thought that the PSC dimensions of this tool should be indigenised.22,27 Therefore, they used the HSOPSC model as an analyt- ical tool in their qualitative inquiry in order to create a model applicable to the Chinese setting.22,27 Second, theo- retical models were adopted when data could fit in a particular pre-existing theoretical model. For example, Ridelberg et al. conducted a qualitative study to identify facilitators and barriers for patient safety in a Swedish hospital setting and adopted Vincent’s model after data analysis since the data aligned with this model.33 Another limitation noted in this review’s studies is that they were highly dependent on interviews and focus groups for data collection. While these techniques are good for exploring individual thoughts, experiences and shared idea, they have been criticised for being subjective—where participants can filter information before sharing it with the researchers. Other qualitative approaches, such as an observational approach, may be useful in exploring actions and verbal communication and for gathering useful contextual data.12 For example, Vaismoradi et al. used observations to gain a better under- standing and interpretation of nursing leadership in medical and surgical wards.24 Interestingly, qualitative studies seemed less prevalent in some contexts. For example, no qualitative or mixed methods studies were identified from the Gulf Corp- oration Council countries. However, Elmontsri et al. reported that the HSOPSC survey tool was adopted in 18 studies conducted in different Arabic countries from 2005–2015.48 They also found that non-punitive response to errors and communication openness were problematic and impacted negatively on adverse events.48 Qualitative approaches would be appropriate to explore the reasons behind these obstacles.49 These findings suggest that the focus of PSC research is on the healthcare providers and managers and not Table 2: Comparison between the characteristics of four safety culture models55–57 Characteristic HSOPSC model55 SAQ model55 CSS model56 Vincent’s model57 1 Teamwork within units Teamwork climate Teamwork Institutional context 2 Teamwork across units Perception of management Leadership Organisational and management factors 3 Supervisor/manager expectations and actions promoting safety Stress recognition Learning Work environment 4 Management support for patient safety Working conditions Evidence-based Team factors 5 Staffing Job satisfaction Fair culture Individual staff factors 6 Overall perception of patient safety Safety climate Patient-centred care Task factors 7 Organisational learning which continues improvement - Communication Patient characteristics 8 Non-punitive response to error - - - 9 Handovers and transitions - - - 10 Open communication - - - 11 Feedback and communication about error - - - 12 Frequency of events reported - - - HSOPSC = hospital survey on patient safety culture; SAQ = safety attitudes questionnaire; CSS = culture of safety survey. A Narrative Synthesis of Qualitative Studies Conducted to Assess Patient Safety Culture in Hospital Settings e96 | SQU Medical Journal, May 2019, Volume 19, Issue 2 on the patient. When patients were included in studies, they demanded that healthcare providers create a closer relationship and communicate better; these concerns were not indicated by healthcare providers in the same studies. Thus, patients appear to have a different pers- pective on PSC compared to providers. For example, Davis et al.’s study evaluated the reporting of adverse event and medical errors that occurred during hospital stays.50 They found that patients’ (n = 80) reports of medical errors were not found in medical records.50 Table 3: Factors influencing patient safety culture22,24–33,35–38 Categories Quotation (speaker) Staffing Staff number “It is difficult to practice safely and take care of every detail of your work, when you deliver care to many patients.”(Nurse)24 Staff awareness and commitment to patient safety “I have undertaken education in patient safety. It was a course that I requested when I resigned as manager three years ago because I wanted to know a bit more about it.” (Nurse)33 Staff competency “The fact is that I just did not know what to do. These things are quite rare in your career.” (Nurse)26 Job satisfaction “A worker who is not well paid, at times he will say ‘but why I have to spend all my time at work and it doesn’t change anything in my monthly salary?” (Provider)35 Staff turnover “Recently, many registered nurses have left because they have felt that there is too much pressure.” (Nurse)32 Staff compliance with policies and procedures “We [nurses] are supposed to double-check for high-alert medications, but it is not always done.” (Nurse)25 Communication Teamwork “In my opinion patient safety is improved by teamwork/collaboration between healthcare prof- essionals.” (Nurse)28 Healthcare provider- Patient relation ship “I hope doctors or nurses alleviate my anxieties and doubts with their professional answers and psychological support.” (Patient)27 Handover “The first doctor that had seen Vance had gone away for the weekend and we assumed erroneously that a handover had been done, that this doctor would be taking over Vance’s care, but he didn’t even know Vance was there. There was no handover.” (Patient)36 Feedback about error “In this unit, we discuss ways to prevent errors from happening again.” (Nurse)22 Power conflict “You will never be able to manage [the senior nurses].” (Nurse)35 Non-human resources Availability of process and policies supporting patient safety “We have a checklist now and we check every single patient on the ward is safe.” (medical surgical ward group)30 Equipment availability “Sometimes gloves and syringes which seems simple were not found when we try to give medic- ation.” (Nurse)28 Safety of physical environment “We have a laminated grip flooring. They can still have a fall but it is much better for them.” (Medical ward group)30 Availability of supporting technology “This computer system that we now have here makes it easier to find information, I think, and that is also part of patient safety.” (Nurse)33 Appropriateness of medical records “Major security problems with complicated electronic health systems.” (Doctor)31 Organisational factors Staff training and continuous education “I just did not know what to do. These things are quite rare in your career, nobody tells you what to do when things go wrong.” (Nurse)26 Openness “Safety things are still seen as a burden, and it is not cool to speak up about them.” (General surgery resident)37 Leadership supervision and inpatient safety process engagement “They (supervisors) have just ordered us to follow the protocols, but no one checks on us to see if we are doing so.” (Nurse)25 Non-punitive response to errors “A person who makes mistakes often is incompetent and should be fired.” (Manager)27 Staff participation in decision making “You have to listen to the people involved in the process. We have to raise issues and this can only happen if we listen to people who provide direct care.” (Nurse)38 Competing interest between public health and clinical services “The government usually emphasises the importance of public health in words but not in actions.” (Manager)27 Patient-related factors Patient volume “Services where volume is the highest, that is where things will fall through the cracks.” (General surgery resident)37 Underlying illness “In my opinion, I have to look at the conditions of all the patients; separate rooms should be consid- ered for patients who have the potential to disturb others.” (Nurse)29 Patient awareness and literacy “Now young parents are well educated and usually learn relevant information on the Internet before seeking care for their babies.” (Provider)27 Hamad Alqattan, Zoe Morrison and Jennifer A. Cleland Review | e97 Following the example of King and Coldham, the current authors tentatively propose that patients should be included in future PSC studies to provide a broader perspective on the issue.51 Quantitative and qualitative methods seek to address different questions and, therefore, one method cannot be superior to the other. However, a vast body of liter- ature highlights the utility of mixed methods research in healthcare. Future studies of PSC should consider using both qualitative and quantitative approaches simultan- eously or sequentially to gain a comprehensive underst- anding of PSC in a particular healthcare organisation.21,23,25 While narrative synthesis helped to answer the current research questions, it had two limitations. First, only empirical studies written in English were included. Relevant data from non-English articles could provide valid input to this narrative synthesis. However, English is common in the scientific field and is nowadays used in the vast majority of published studies. Second, the search was limited to electronic databases. Literature was not searched by hand and authors were not contacted to seek out unpublished works. Although this approach may have limited the number of studies included in this review, yet all included studies have been published in peer-reviewed journals. Conclusion This review focused on a relatively small number of studies using qualitative approaches to explore PSC in hospital settings. Most studies lacked conceptual or theo- retical frameworks. Despite this finding, there were many commonalities across diverse studies. Future studies should adopt a mixed methods approach to help gain knowledge of PSC in everyday workplaces. Such an approach would improve understanding of staff knowl- edge, attitude toward patient safety and help identify strategies to enhance patient safety. References 1. Leape LL, Berwick DM. Five years after to err is human: What have we learned? JAMA 2005; 293:2384–90. https://doi. org/10.1001/jama.293.19.2384. 2. The Health Foundation. Evidence scan: Does improving safety culture affect patient outcomes? From: www.health.org.uk/sit e s/def ault/file s/D o e sImprov ingSafe tyCultureAffe ctPati entOutcomes.pdf. Accessed: Dec 2018. 3. Martin WF. Is your hospital safe? Disruptive behavior and work- place bullying. Hosp Top 2008; 86:21–8. https://doi.org/10.320 0/HTPS.86.3.21-28. 4. Talati Z, Griffin M. Patient safety culture and organizational beh- aviour: Intergrating error, leadership and the working environ- ment. In: Waterson P, Ed. Patient safety culture theory, method and application. 1st ed. Boca Raton, USA: CRC Press, 2017. Pp. 43–6. 5. Colla JB, Bracken AC, Kinney LM, Weeks WB. Measuring patient safety climate: A review of surveys. Qual Saf Health Care 2005; 14:364–6. https://doi.org/10.1136/qshc.2005.014217. 6. Nieva VF, Sorra J. Safety culture assessment: A tool for improving patient safety in healthcare organizations. Qual Saf Health Care 2003; 12:ii17–23. https://doi.org/10.1136/qhc.12.suppl_2.ii17. 7. McLeod SA. Questionnaire. From: www.simplypsychology.org/ questionnaires.html Accessed: Dec 2018. 8. Cleland J. Exploring versus measuring: Considering the funda- mental differences between qualitative and quantitative research. In: Cleland J, Durning SJ, Ed. Researching Medical Education. New Jersey, USA: Wiley, 2015. Pp. 1–14. https://doi.org/10.10 02/9781118838983.ch1. 9. Pumar-Méndez MJ, Attree M, Wakefield A. Methodological aspects in the assessment of safety culture in the hospital setting: A review of the literature. Nurse Educ Today 2014; 34:162–70. https://doi.org/10.1016/j.nedt.2013.08.008. 10. Rahman MS. The advantages and disadvantages of using qual- itative and quantitative approaches and methods in language “Testing and assessment” research: A literature review. J Edu Learn 2017; 6:102–12. https://doi.org/10.5539/jel.v6n1p102. 11. Ormston R, Spencer L, Barnard M, Snape D. The Foundations of Qualitative Research. In: Ritchie J, Lewis J, Nicholls C, Ormston R, Eds. Qualitative Research Practice. 2nd ed. Thousand Oaks, California, USA: SAGE Publications Ltd, 2014. Pp. 1–26. 12. Hays DG, Singh AA. Qualitative Inquiry in Clinical and Educ- ational Settings. 1st ed. New York, USA: The Guilford Press, 2011. 13. Thomas J, Harden A, Newman M. Synthesis: Combining results systematically and appropriately. In: Gough D, Oliver S, Thomas J, Eds. An introduction to systematic reviews. Thousand Oaks, USA: SAGE Publications Ltd, 2012. Pp. 179–227. 14. Mays N, Pope C, Popay J. Systematically reviewing qualitative and quantitative evidence to inform management and policy- making in the health field. J Health Serv Res Policy 2005; 1:6–20. https://doi.org/10.1258/1355819054308576. 15. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008; 8:45. https://doi.org/10.1186/1471-2288-8-45. 16. Critical Appraisal Skills Programme. CASP checklist. From: casp-uk.net/wp-content/uploads/2018/03/CASP-Qualitative- Checklist-2018_fillable_form.pdf Accessed: Dec 2018. 17. Snilstveit B, Oliver S, Vojtkova M. Narrative approaches to systematic review and synthesis of evidence for international development policy and practice. J Dev Effect 2012; 4:409–29. https://doi.org/10.1080/19439342.2012.710641. 18. Crotty M. The foundations of social research: Meaning and perspective in social research. 1st ed. Thousand Oaks, California, USA: SAGE Publications Ltd, 1998. 19. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi- disciplinary health research. BMC Med Res Methodol 2013; 13:117. https://doi.org/10.1186/1471-2288-13-117. 20. Brooks J, McCluskey S, Turley E, King N. The utility of template analysis in qualitative psychology research. Qual Res Psychol 2015; 12:202–22. https://doi.org/10.1080/14780887.2014.955224. 21 Rathert C, Fleig-Palmer MM, Palmer DK. Minimizing medical errors: A qualitative analysis of health care providers' views on improving patient safety. J Appl Manag Entrep 2006; 11:5. 22. Zhu J, Li L, Li Y, Shi M, Lu H, Garnick DW, et al. What const- itutes patient safety culture in Chinese hospitals? Int J Qual Health Care 2012; 24:250–7. https://doi.org/10.1093/intqhc/mzs010. 23. Liu C, Liu W, Wang Y, Zhang Z, Wang P. Patient safety culture in China: A case study in an outpatient setting in Beijing. BMJ Qual Saf 2014; 23:556–64. https://doi.org/10.1136/bmjqs-2 013-002172. https://doi.org/10.1001/jama.293.19.2384 https://doi.org/10.1001/jama.293.19.2384 https://doi.org/10.3200/HTPS.86.3.21-28 https://doi.org/10.3200/HTPS.86.3.21-28 https://doi.org/10.1136/qshc.2005.014217 https://doi.org/10.1136/qhc.12.suppl_2.ii17 https://doi.org/10.1002/9781118838983.ch1 https://doi.org/10.1002/9781118838983.ch1 https://doi.org/10.1016/j.nedt.2013.08.008 https://doi.org/10.5539/jel.v6n1p102 https://doi.org/10.1258/1355819054308576 https://doi.org/10.1186/1471-2288-8-45 https://doi.org/10.1080/19439342.2012.710641 https://doi.org/10.1186/1471-2288-13-117 https://doi.org/10.1080/14780887.2014.955224 https://doi.org/10.1093/intqhc/mzs010 https://doi.org/10.1136/bmjqs-2013-002172 https://doi.org/10.1136/bmjqs-2013-002172 A Narrative Synthesis of Qualitative Studies Conducted to Assess Patient Safety Culture in Hospital Settings e98 | SQU Medical Journal, May 2019, Volume 19, Issue 2 24. Vaismoradi M, Bondas T, Salsali M, Jasper M, Turunen H. Facilitating safe care: A qualitative study of Iranian nurse leaders. J Nurs Manag 2014; 22:106–16. https://doi.org/10.1111/j.1365- 2834.2012.01439.x. 25. Abdi Z, Delgoshaei B, Ravaghi H, Abbasi M, Heyrani A. The culture of patient safety in an Iranian intensive care unit. J Nurs Manag 2015; 23:333–45. https://doi.org/10.1111/jonm.12135. 26. Umpiérrez AF, Fort ZF, Tomás VC. Adverse events in health and nursing care: Patient safety from the standpoint of the professional's experience. Text Context Nurs 2015; 24:310–15. https://doi.org/10.1590/0104-07072015000122014. 27. Wang Y, Liu W, Shi H, Liu C, Wang Y. Measuring patient safety culture in maternal and child health institutions in China: A qualitative study. BMJ Open 2017; 7:e015458. https://doi.org/10.1 136/bmjopen-2016-015458. 28. Wami SD, Demssie AF, Wassie MM, Ahmed AN. Patient safety culture and associated factors: A quantitative and qualitative study of healthcare workers’ view in Jimma zone hospitals, South- west Ethiopia. BMC Health Serv Res 2016; 16:495. https://doi. org/10.1186/s12913-016-1757-z. 29. Pazokian M, Borhani F. Nurses’ perspectives on factors affecting patient safety: A qualitative study. Evid Based Care J 2017; 7:76–81. https://doi.org/10.22038/EBCJ.2017.24174.1520. 30. Tarling M, Jones A, Murrells T, McCutcheon H. Comparing safety climate for nurses working in operating theatres, critical care and ward areas in the UK: A mixed methods study. BMJ Open 2017; 7:e016977. https://doi.org/10.1136/bmjopen-2017-0 16977. 31. Källberg AS, Ehrenberg A, Florin J, Östergren J, Göransson KE. Physicians' and nurses' perceptions of patient safety risks in the emergency department. Int Emerg Nurs 2017; 33:14–19. https://doi.org/10.1016/j.ienj.2017.01.002. 32. Danielsson M, Nilsen P, Ohrn A, Rutberg H, Fock J, Carlfjord S. Patient safety subcultures among registered nurses and nurse assistants in Swedish hospital care: A qualitative study. BMC Nurs 2014; 13:39. https://doi.org/10.1186/s12912-014-0039-5. 33. Ridelberg M, Roback K, Nilsen P. Facilitators and barriers infl- uencing patient safety in Swedish hospitals: A qualitative study of nurses’ perceptions. BMC Nurs 2014; 13:23. https://doi.org/10. 1186/1472-6955-13-23. 34. Kanerva A, Lammintakanen J, Kivinen T. Nursing staff 's perc- eptions of patient safety in psychiatric inpatient care. Perspect Psychiatr Care 2016; 52:25–31. https://doi.org/10.1111/ppc.12098. 35. Labat F, Sharma A. Qualitative study exploring surgical team members' perception of patient safety in conflict-ridden Eastern Democratic Republic of Congo. BMJ Open 2016; 6:e009379. https://doi.org/10.1136/bmjopen-2015-009379. 36. Bishop AC, Cregan BR. Patient safety culture: Finding meaning in patient experiences. Int J Health Care Qual Assur 2015; 28:595–610. https://doi.org/10.1108/IJHCQA-03-2014-0029. 37. Jones DL. Residents' perspectives on patient safety in university and community teaching hospitals. J Grad Med Educ 2014; 6:603–7. https://doi.org/10.4300/JGME-D-14-00350.1. 38. dos Reis GAX, Hayakawa LY, Murassaki ACY, Matsuda LM, Gabriel CS, de Oliveira MLF. Nurse manager perceptions of patient safety strategy implementation. Text Context Nurs 2017; 26:e00340016. https://doi.org/10.1590/0104-07072017000340016. 39. Pelzang R, Johnstone M, Hutchinson AM. Culture matters: Indigenizing patient safety in Bhutan. Health Policy Plan 2017; 32:1042–8. https://doi.org/10.1093/heapol/czx042. 40. Guldenmund F. Organizational Safety Culture Principles. In: Waterson P, Ed. Patient safety culture: Theory, methods and appl- ication. 1st ed. Boca Raton, USA: CRC Press, 2014. Pp. 15–36. 41. Lardner R. Safety Culture Application Guide. From: http://epsc. be/PRISM/_/FG1Safety_Culture_Guide.doc Accessed: Dec 2018. 42. Gershon RR, Karkashian CD, Grosch JW, Murphy LR, Escamilla- Cejudo A, Flanagan PA, et al. Hospital safety climate and its relationship with safe work practices and workplace exposure incidents. Am J Infect Control 2000; 28:211–21. https://doi.org/10.1 067/mic.2000.105288. 43. Alharbi W, Cleland J, Morrison Z. Assessment of patient safety culture in an adult oncology department in Saudi Arabia. Oman Med J 2018; 33:200–8. https://doi.org/10.5001/omj.2018.38. 44. Huang CH, Wu HH, Lee YC. The perceptions of patient safety culture: A difference between physicians and nurses in Taiwan. Appl Nurs Res 2018; 40:39–44. https://doi.org/10.1016/j.apnr.2 017.12.010. 45. Alqattan H, Cleland J, Morrison Z. An evaluation of patient safety culture in a secondary care setting in Kuwait. J Taibah Univ Sci 2018; 13:272–80. https://doi.org/10.1016/j.jtumed.201 8.02.002. 46. Davidoff F, Dixon-Woods M, Leviton L, Michie S. Demystifying theory and its use in improvement. BMJ Qual Saf 2015; 24:228–38. https://doi.org/10.1136/bmjqs-2014-003627. 47. O'Donnell CA, Mair FS, Dowrick C, Brún MO, Brún T, Burns N, et al. Supporting the use of theory in cross-country health ser- vices research: A participatory qualitative approach using Nor- malisation Process Theory as an example. BMJ Open 2017; 7:e014289. https://doi.org/10.1136/bmjopen-2016-014289. 48. Elmontsri M, Almashrafi A, Banarsee R, Majeed A. Status of patient safety culture in Arab countries: A systematic review. BMJ Open 2017; 7:e013487. https://doi.org/10.1136/bmjopen-2 016-013487. 49. Savin-Baden M, Major CH. Qualitative Research: The essential guide to theory and practice. Abingdon-on-Thames, UK: Rout- ledge, 2013. 50. Davis RE, Sevdalis N, Neale G, Massey R, Vincent CA. Hospital patients' reports of medical errors and undesirable events in their health care. J Eval Clin Pract 2013; 19:875–81. https://doi. org/10.1111/j.1365-2753.2012.01867.x. 51. King E, Coldham T. Patients and carers can be our service design consultants. From: www.england.nhs.uk/blog/tina-cold ham/ Accessed: Dec 2018. 52. Elder NC, Brungs SM, Nagy M, Kudel I, Render ML. Intensive care unit nurses' perceptions of safety after a highly specific safety intervention. Qual Saf Health Care 2008; 17:25–30. https://doi.org/10.1136/qshc.2006.021949. 53. Karlsson G, Hedman K, Fridlund B. Views on patient safety by operations managers in somatic hospital care: A qualitative ana- lysis. Open J Nurs 2011; 1:33–42. https://doi.org/10.4236/ojn.20 11.13005. 54. Allen S, Chiarella M, Homer CS. Lessons learned from meas- uring safety culture: An Australian case study. Midwifery 2010; 26:497–503. https://doi.org/10.1016/j.midw.2010.07.002. 55. Itoh K, Anderson H, Milkkelsen K. Safety Culture Dimensions, Patient Safety Outcomes and their Correlations. In: Waterson P, Ed. Patient Safety Culture Theory, Method and Application. Boca Raton, USA: CRC Press, 2017. Pp. 67–71. 56. Sammer CE, Lykens K, Singh KP, Mains DA, Lackan NA. What is patient safety culture? A review of the literature. J Nurs Scholarsh 2010; 42:156–65. https://doi.org/10.1111/j.1547-506 9.2009.01330.x. 57. Vincent C, Taylor-Adams S, Stanhope N. Framework for ana- lysing risk and safety in clinical medicine. BMJ 1998; 316:1154–7. https://doi.org/10.1136/bmj.316.7138.1154. https://doi.org/10.1111/j.1365-2834.2012.01439.x https://doi.org/10.1111/j.1365-2834.2012.01439.x https://doi.org/10.1111/jonm.12135 https://doi.org/10.1590/0104-07072015000122014 https://doi.org/10.1136/bmjopen-2016-015458 https://doi.org/10.1136/bmjopen-2016-015458 https://doi.org/10.1186/s12913-016-1757-z https://doi.org/10.1186/s12913-016-1757-z https://doi.org/10.22038/EBCJ.2017.24174.1520 https://doi.org/10.1136/bmjopen-2017-016977 https://doi.org/10.1136/bmjopen-2017-016977 https://doi.org/10.1016/j.ienj.2017.01.002 https://doi.org/10.1186/s12912-014-0039-5 https://doi.org/10.1186/1472-6955-13-23 https://doi.org/10.1186/1472-6955-13-23 https://doi.org/10.1111/ppc.12098 https://doi.org/10.1136/bmjopen-2015-009379 https://doi.org/10.1108/IJHCQA-03-2014-0029 https://doi.org/10.4300/JGME-D-14-00350.1 https://doi.org/10.1590/0104-07072017000340016 https://doi.org/10.1093/heapol/czx042 https://doi.org/10.1067/mic.2000.105288 https://doi.org/10.1067/mic.2000.105288 https://doi.org/10.5001/omj.2018.38 https://doi.org/10.1016/j.apnr.2017.12.010 https://doi.org/10.1016/j.apnr.2017.12.010 https://doi.org/10.1016/j.jtumed.2018.02.002 https://doi.org/10.1016/j.jtumed.2018.02.002 https://doi.org/10.1136/bmjqs-2014-003627 https://doi.org/10.1136/bmjopen-2016-014289 https://doi.org/10.1136/bmjopen-2016-013487 https://doi.org/10.1136/bmjopen-2016-013487 https://doi.org/10.1111/j.1365-2753.2012.01867.x https://doi.org/10.1111/j.1365-2753.2012.01867.x https://doi.org/10.1136/qshc.2006.021949 https://doi.org/10.4236/ojn.2011.13005 https://doi.org/10.4236/ojn.2011.13005 https://doi.org/10.1016/j.midw.2010.07.002 https://doi.org/10.1111/j.1547-5069.2009.01330.x https://doi.org/10.1111/j.1547-5069.2009.01330.x https://doi.org/10.1136/bmj.316.7138.1154