The clinician safety culture and leadership questionnaire: refinement and validation in Australian public hospitals

Abstract

Objective This study aimed to refine and validate a tool to measure safety culture and leadership in Australian hospitals. Design The clinician safety culture and leadership questionnaire was constructed by combining and refining the following two previously validated scales: Safety Attitudes Questionnaire and the Leadership Effectiveness Survey. Statistical processes were used to explore the factor structure, reliability, validity and descriptive statistics of the new instrument. Setting Thirty-two large Australian public hospitals. Participants 1382 clinicians (doctors, nurses and allied health professionals). Main Outcome Measure(s) Descriptive statistics, structure and validity of clinician safety culture and leadership scale. Results We received 1334 valid responses from participants. The distribution of ratings was left-skewed, with a small ceiling effect, meaning that scores were clustered toward the high end of the scale. Using confirmatory factor analysis, we confirmed the structure of the three scales as a combined measure of safety culture and leadership. The data were divided into equal calibration and validation datasets. For the calibration dataset, the Chi-square: df ratio was 4.4, the root mean square error of approximation RMSEA (a measure of spread of the data) was 0.071, the standardized root mean square residual SRMR (an absolute measure of the fit of the data) was 0.058 and the Confirmatory Fit Index (CFI) (another test confirming the fit of the data) was 0.82; while none of the indices suggested good fit, all but CFI fell within acceptable thresholds. All factors demonstrated adequate internal consistency and construct reliability, as desired. All three domains achieved discriminant validity through cross-loadings, meaning that the three domains were determined to be independent constructs. Results for the validation dataset were effectively identical to those found in the calibration dataset. Conclusions While the model may benefit from additional refinement, we have validated the tool for measuring clinician safety culture and leadership in our Australian sample. The DUQuA safety culture and leadership scale can be used by Australian hospitals to assess clinician safety culture and leadership, and is readily modifiable for other health systems depending on their needs.

Psychometric properties of leadership scales for health professionals: a systematic review

“… •103 items •Likert (7-point) •7 Domains: Self and Team Development; Staff and Care Delivery; Technology and Care Initiatives; Financial and Service Management; Leadership and Clinical Practice; Patient Safety and Risk Management; and Standards of Care Ireland n = 321 ~ 14.7% Female = 91% Registered Nurses Clinical Leadership Survey (CLS) [ 66 ] Self-evaluated clinical leader behaviours in staff nurses (basis in transformational leadership). • 41 items • Likert (5-point) • 5 Domains: Challenging the Process; Inspiring a Shared Vision; Enabling Others to Act; Modelling the Way; and Encouraging the Heart Canada n = 480 41% Female = 97% Registered Nurses Clinician Safety Culture and Leadership Questionnaire [ 67 ] Clinician report of safety culture in hospitals at organisational and departmental levels, across teamwork, safety climate and leadership in healthcare. • Clinician report • 35 items • Likert (5-point) • 3 Domains: Perceived Quality of Collaborating between Clinicians; Organisational Commitment to Patient Safety and Management Style; and Effectiveness of Healthcare Leaders in their Workplace Australia n = 1134 Not reported Female = 39% Physicians Nurses Allied Health Professionals Cotter Preceptor Selection Instrument (CPSI) [ 68 ] NPD practitioner perceptions of nurse attributes to assist nurse preceptor selection.…”

“…Of the two studies reporting on the MLQ, one reported adequate internal consistency of the whole scale [ 85 ] and one of the individual subscales [ 86 ]. Of the remaining 27 scales that reported internal consistency, 16 reported for the entire scale [ 43 , 60 – 64 , 66 , 70 – 73 , 75 , 78 , 80 , 83 , 84 , 87 , 89 ], and ten for individual subscales [ 65 , 67 – 69 , 74 , 81 , 82 , 93 , 95 , 96 ]. Three papers [ 64 , 66 , 72 ] reported only the range of Cronbach’s alpha values of the scale’s subscales, indicating one or more subscales with a Cronbach’s alpha of <.70, and thus did not satisfy our criteria for confirming the whole scale’s internal reliability.…”

“…Two further scales [ 82 , 92 ] were marked ‘U’ as, although mentioning factor analysis or construct validity, they did not report RMSEA or CFI values. Four scales [ 64 , 67 , 80 , 95 ] did not satisfy our criteria for adequate construct validity.…”

“…Eight of these scales (including the ILS, as convergent validity was tested and achieved in three of the five ILS studies) [ 60 , 63 , 66 , 68 , 74 – 76 , 93 ] were considered to have convergent validity ( r > .40) and two scales (the iLead and the ILS) [ 19 , 75 , 79 ] were considered to have both convergent and discriminant validity ( r < .30). Three studies [ 67 , 76 , 87 ] reported on convergent and/or discriminant validity that did not involve correlating the scales with other validated scales and thus, were marked unclear (‘U’). Only one scale (Survey of Transformational Leadership) [ 93 ] achieved acceptable construct, criterion, and convergent validity.…”

“…Of the 39 studies, only five reported on responsiveness, three of which included scales that satisfied our criteria for floor and ceiling effects of < 5% [ 62 , 71 , 90 ]. One scale [ 67 ] had a small ceiling effect with scores skewed toward the higher end of the scale (14–62% of people obtaining the highest possible score for each item). The three papers that reported on their scale’s acceptability [ 67 , 90 , 94 ] satisfied low proportions of missing items.…”