Hospital Survey on Patient Safety Culture 2.0 – Brazilian version

Authors

Purpose

The primary objective of adapting the HSOPSC 2.0 for Brazil was to equip healthcare researchers and hospital administrators with an updated, culturally resonant tool to evaluate patient safety environments. While the first version of the scale was widely used, the evolution of patient safety science necessitated an instrument that better captures modern concepts, such as psychological safety and fair responses to clinical errors.

For psychometricians and clinical leaders, this scale fills a vital gap by providing a standardized metric to assess the efficacy of safety interventions over time. In the context of Brazil's National Patient Safety Programme, having a validated instrument allows institutions to move beyond merely counting adverse events to proactively measuring the underlying cultural factors that precipitate them. This proactive measurement is essential for fostering environments where continuous learning supersedes punitive actions.

Construct

patient safety culture is a multidimensional organizational construct reflecting the collective attitudes, values, and behaviors of hospital staff regarding the safety of the care they provide. It operates on the premise that systemic factors and interpersonal dynamics—rather than isolated individual failures—are the primary drivers of clinical errors. The HSOPSC 2.0 operationalizes this construct through ten distinct dimensions that span both unit-level and hospital-wide domains.

These dimensions capture a comprehensive picture of the workplace environment. For instance, interpersonal and team-based factors are measured through dimensions like Teamwork, Communication Openness, and Handoffs. Meanwhile, systemic and leadership factors are evaluated via dimensions such as Staffing and Work Pace, Hospital management Support, and Organizational Learning. By breaking down safety culture into these specific facets, the construct allows researchers to pinpoint exact areas of vulnerability within a healthcare organization's operational framework.

Validity

To establish validity, the researchers employed a rigorous universalist approach to Cross-cultural adaptation, ensuring semantic, conceptual, and operational equivalence before conducting empirical testing. This involved multiple translation phases, expert panel reviews, and pre-testing to resolve ambiguities, such as adapting the concept of 'temporary staff' to align with Brazil's specific third-party employment contracts.

Construct validity was subsequently evaluated using a large sample of hospital workers. The psychometric evaluation utilized an advanced modeling technique, demonstrating that the theoretical ten-factor structure of the original US version generally held up in the Brazilian context. However, it is noteworthy from a psychometric perspective that ten items exhibited factor loadings below the traditional 0.40 threshold. This suggests that while the overall construct translates well, certain specific indicators may function differently or carry less relevance in the Brazilian healthcare environment, highlighting the ongoing challenge of achieving perfect measurement equivalence across diverse cultures.

Reliability

The internal consistency of the Brazilian HSOPSC 2.0 presents a nuanced picture typical of translated organizational scales. Most of the ten dimensions demonstrated acceptable reliability, yielding Cronbach's alpha coefficients of 0.60 or higher. In the context of safety culture research, where subscales often contain only three or four items, these values are generally considered adequate for group-level analyses.

However, psychometricians must exercise caution when interpreting two specific dimensions: Handoffs and Information Exchange, which produced an alpha of 0.50, and Staffing and Work Pace, which yielded an alpha of 0.41. These attenuated reliability estimates suggest that the items within these subscales may not be covarying as strongly in the Brazilian sample as they do in the original US normative data. Such discrepancies could stem from the unique pressures of the Covid-19 pandemic during data collection or underlying cultural differences in how shift changes and workload are conceptualized.

Factor Analysis

To evaluate the latent structure of the instrument, the researchers utilized Exploratory Structural Equation Modeling within a Confirmatory Factor Analysis framework (ESEM-within-CFA). This sophisticated analytical approach is particularly well-suited for multidimensional psychological measures, as it allows for the estimation of cross-loadings that are typically constrained to zero in traditional CFA, thereby providing a more realistic representation of complex organizational constructs.

The ESEM model yielded excellent fit indices, indicating that the data aligned well with the proposed ten-factor structure. Specifically, the model produced a Comparative Fit Index (CFI) of 0.986 and a Tucker-Lewis Index (TLI) of 0.968, both well above the stringent 0.95 threshold for excellent fit. Additionally, the Root Mean Square Error of Approximation (RMSEA) was 0.045, further confirming a strong model fit. Despite these robust global fit statistics, the presence of several low factor loadings serves as a reminder that global fit does not always guarantee strong local item performance.

Subscales

Instrument

Scoring & Interpretation Guidelines

Sample

2,702 hospital staff members from a large general hospital in São Paulo, Brazil (56% response rate), collected during the Covid-19 pandemic.

Permissions & Test Year

The original instrument was developed by the AHRQ and is authorized to be used freely.

Test Year: 2023

Hospital Survey on Patient Safety Culture 2.0 – Brazilian version Items