Hospital Safety Culture Shapes How Theatre Nurses Protect Patients and Themselves

Operating theatres are among the most unforgiving environments in modern medicine. Every procedure brings sharp instruments, blood-borne pathogens, and the constant possibility of human error, all compressed into a space where minutes can determine outcomes. A new multicentre cross-sectional study from China now offers a detailed statistical picture of how the culture of safety within hospitals relates to the everyday behaviours of the nurses who work in these high-stakes rooms, and the findings suggest that protecting patients and protecting staff may be two sides of the same cultural coin.

The research, led by Yan-Yan Zhu of Wenzhou Central Hospital, Affiliated to Wenzhou Medical University, together with colleagues from Taizhou Hospital of Zhejiang Province and Wenzhou Central Hospital, was published in BMC Nursing. The team set out to untangle the relationships among three constructs: patient safety culture, the organised set of values and practices that governs how hospital staff think about error; occupational exposure behaviours, the habits that determine whether nurses avoid needlestick injuries, splashes, and contact with hazardous fluids; and patient safety behaviours, the concrete actions nurses take to keep surgical patients from harm.

The study was conducted between March and June 2025 in the operating theatres of two tertiary general hospitals, facilities that sit at the top of the Chinese hospital hierarchy and handle the most complex surgical caseloads. Of 185 nurses invited to participate, 173 completed the questionnaire, a response rate of 93.5 percent that reflects the high level of engagement such surveys often achieve when delivered through institutional channels. After prespecified exclusions designed to remove incomplete or inconsistent responses, 130 questionnaires remained for analysis, corresponding to a data-retention rate of 75.1 percent. That attrition between collection and analysis is a routine but important detail in survey science, because the final analytical sample, not the initial pool, determines the statistical power and representativeness of the results.

Measurement was anchored by the Hospital Survey on Patient Safety Culture Version 2.0, a widely used instrument developed under the auspices of the Agency for Healthcare Research and Quality in the United States. HSOPSC 2.0 decomposes safety culture into composites such as hospital management support, supervisor expectations, handoffs and information exchange, and the perceived frequency of event reporting, allowing researchers to compute an overall positive response rate that summarises how favourably staff view the safety environment. For the two behavioural domains, the authors used self-developed scales assessing occupational exposure behaviours and patient safety behaviours. These instruments underwent preliminary psychometric evaluation within the sample itself, a step intended to confirm that the scales produced internally consistent and interpretable scores, although the researchers are careful to note that this evaluation was preliminary rather than a full validation program.

The headline numbers paint a moderately encouraging picture. The overall positive response rate for patient safety culture stood at 72.8 percent, meaning roughly three-quarters of survey items elicited responses favourable to safety. Mean scores were 39.8 plus or minus 5.6 for occupational exposure behaviours and 41.2 plus or minus 4.9 for patient safety behaviours, values that place the typical nurse above the midpoint of the scales but leave considerable room for improvement. In perioperative settings, where a single lapse in sharps handling or surgical site verification can cascade into serious harm, that residual gap is precisely what safety scientists worry about.

The correlational analysis revealed a consistent pattern of positive associations. Patient safety culture correlated with occupational exposure behaviours at r = 0.32 and with patient safety behaviours at r = 0.41, both statistically significant at p < 0.001. Occupational exposure behaviours, in turn, correlated with patient safety behaviours at r = 0.36, also highly significant. In practical terms, nurses working in units with stronger safety cultures reported both more careful protective practices against occupational hazards and more diligent safety behaviours directed at patients. The moderate size of these correlations, all in the range conventionally described as small to moderate, indicates real but partial overlap between organisational climate and individual conduct; culture matters, but it does not mechanically determine behaviour.

To move beyond simple bivariate associations, the researchers built a multivariable linear regression model predicting patient safety behaviours while adjusting for study centre and a set of prespecified demographic and work-related covariates. In this fully adjusted joint model, patient safety culture retained a significant association with patient safety behaviours, with a standardised coefficient of 0.29 and a 95 percent confidence interval of 0.15 to 0.43, p < 0.001. Occupational exposure behaviours also remained independently associated, with a coefficient of 0.24 and a 95 percent confidence interval of 0.08 to 0.40, p = 0.002. The persistence of both effects when entered simultaneously suggests that the two domains carry partly distinct information: a nurse’s protective habits against occupational exposures predict patient-directed safety behaviours even after accounting for the prevailing safety culture, implying that personal safety practice and organisational climate each contribute something the other does not capture.

Perhaps the most conceptually interesting result came from the exploratory indirect-association analysis. Using statistical decomposition with bias-corrected and accelerated bootstrap confidence intervals, the team estimated an indirect association between patient safety culture and patient safety behaviours operating through occupational exposure behaviours, quantified at B = 0.74 with a 95 percent confidence interval of 0.21 to 1.60. In plain language, part of the reason nurses in strong safety cultures behave more safely toward patients appears to run through their safer handling of occupational hazards. The authors frame this explicitly as exploratory: the decomposition identifies a potential pathway but does not establish intervention effectiveness, and the confidence interval, while excluding zero, is wide enough to counsel caution about the precise magnitude of the mediated component.

Several limitations deserve emphasis, and the study itself acknowledges their weight. The cross-sectional design means all variables were measured at a single point in time, so the direction of influence cannot be established; it is equally plausible that nurses who habitually practise safely come to perceive their workplace culture more favourably, or that unmeasured third factors, such as staffing levels, workload, or training quality, drive both culture scores and behaviours. The sample of 130 nurses drawn from two tertiary hospitals in one Chinese province limits generalisability to other regions, hospital tiers, and health systems. The two behavioural scales were self-developed and only preliminarily evaluated within the sample, so their properties beyond this dataset remain uncertain. Self-reported behaviour is also vulnerable to social desirability bias, particularly around safety compliance, where respondents may feel pressure to report textbook practice. The researchers compensated for collinearity concerns by checking variance inflation factors and by adjusting for centre effects, but no statistical adjustment can fully repair the inferential limits of a cross-sectional design.

Even with those caveats, the findings carry practical significance for hospital administrators and perioperative nursing leaders. If occupational exposure behaviours constitute a behavioural domain that bridges organisational safety culture and frontline patient safety practice, then safety programs that treat staff protection and patient protection as separate silos may be missing a synergy. Training modules on sharps safety, personal protective equipment use, and exposure reporting could serve double duty, reinforcing the same habits of attention, communication, and error prevention that underpin safe surgical care. Conversely, investments in culture-building, such as non-punitive event reporting and visible management commitment, may yield dividends not only in staff morale and injury reduction but in measurable patient safety behaviour. The study’s authors stop short of prescribing interventions, and rightly so, since their data show associations rather than causal effects. But they note that the results identify potential areas for further safety assessment, and that framing is a reasonable roadmap: hospitals that want to understand their surgical safety risk profile would do well to measure occupational exposure behaviours alongside conventional culture surveys, treating the two as complementary lenses on the same underlying system. As perioperative medicine grows more complex and surgical volumes rise worldwide, evidence that the guardrails protecting nurses and the guardrails protecting patients are statistically entangled offers a simple, actionable insight: in the operating theatre, a culture of safety is not divisible, and the behaviours it produces tend to travel together.

Subject of Research: Associations among patient safety culture, occupational exposure behaviours, and patient safety behaviours in operating theatre nurses

Article Title: Associations between patient safety culture, occupational exposure behaviours and patient safety behaviours among operating theatre nurses: a multicentre cross-sectional study

Article References: Zhu, Y.-Y., Ma, Y.-J., Liu, X.-M., Li, L.-Y., & Yu, S.-M. (2026). Associations between patient safety culture, occupational exposure behaviours and patient safety behaviours among operating theatre nurses: a multicentre cross-sectional study. BMC Nursing. https://doi.org/10.1186/s12912-026-05408-y

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05408-y

Keywords: patient safety culture, operating theatre nurses, occupational exposure, perioperative nursing, cross-sectional study, HSOPSC 2.0, nurse safety behaviours, occupational health, hospital safety management, needlestick injury prevention, BMC Nursing, China