Person-centered care competence and patient safety competence in relation to patient safety culture: Mediating effects of patient safety management activities among nurses in central Vietnam

This multicenter cross-sectional study of 1,036 nurses in central Vietnam reveals that higher levels of person-centered care and patient safety competence are significantly associated with a stronger patient safety culture, partly mediated by increased engagement in patient safety management activities.

The Gist

Imagine a hospital not as a building, but as a massive, high-speed orchestra. The goal is to play a perfect symphony of healing without a single wrong note (a medical error).

This research paper is like a deep dive into the minds and habits of the musicians (the nurses) in Vietnam to understand what makes the orchestra sound safe and harmonious.

Here is the story of the study, broken down into simple parts:

1. The Three Key Ingredients

The researchers were looking at three specific things that make up a "safe" hospital:

• The Musician's Skill (Competence): This is how well the nurse knows their job. It includes two types of skills:
  • Person-Centered Care: The ability to treat the patient like a human being, listening to them and caring for their unique needs (like a musician listening to the conductor).
  • Patient Safety Skills: The technical know-how to prevent mistakes, like knowing how to handle dangerous medicines or stop infections (like a musician knowing their instrument perfectly).
• The Daily Practice (Management Activities): This is what the nurses actually do every day. It's the routine checking of wristbands, washing hands, and double-checking meds. It's the act of playing the notes correctly, over and over.
• The Orchestra's Vibe (Safety Culture): This is the "feeling" in the room. Does everyone feel safe admitting a mistake? Do they trust each other? Is the environment supportive? This is the overall sound of the orchestra.

2. The Big Question

The researchers wanted to know: Does having skilled musicians automatically make the orchestra sound good?

They suspected that just being smart and skilled isn't enough. They thought there was a "middleman" connecting the skill to the vibe. They hypothesized that doing the daily safety routines (the practice) is the bridge that turns individual skill into a safe culture.

3. The Study: A Snapshot of 1,000 Nurses

The team asked 1,036 nurses in five big hospitals in central Vietnam to fill out surveys. They asked:

• "How good are you at caring for patients?"
• "How good are you at safety skills?"
• "How often do you do safety checks?"
• "How safe does your workplace feel?"

4. What They Found (The Results)

• The Musicians are Talented: The nurses scored high on their skills. They knew their stuff and cared deeply about their patients.
• The Daily Practice is Strong: The nurses were very good at doing the routine safety checks (like checking IDs and preventing falls).
• The Vibe is "Okay," but not Great: Even though the nurses were skilled and did their routines well, the overall "safety culture" (the feeling of safety) was only moderate. It wasn't terrible, but it wasn't perfect either.

The "Aha!" Moment:
The study found that skill alone doesn't create a safe culture.
Think of it like this: You can have a world-class violinist (high skill), but if they don't practice the scales every day (safety activities), the orchestra still sounds off.

The research showed that skilled nurses lead to a safer culture, BUT mostly because they are the ones who consistently perform the daily safety routines.

• The Path: High Skill $\rightarrow$ Doing the Daily Safety Routines $\rightarrow$ A Stronger Safety Culture.

The "Daily Routines" acted as a bridge. Without that bridge, the skill didn't fully translate into a feeling of safety for the whole team.

5. The Takeaway for Everyone

If you want a hospital (or any team) to be safer, you can't just hire the smartest people or give them a one-time training seminar.

The Analogy:
Imagine you want a garden to be beautiful.

• Competence is having the best seeds and the best gardening knowledge.
• Management Activities are the daily watering and weeding.
• Safety Culture is the lush, green garden you see at the end.

This paper says: You can have the best seeds in the world, but if you don't water them every single day, you won't get a beautiful garden.

The Conclusion

To make hospitals safer, leaders need to do two things at once:

1. Train the nurses to be excellent and caring (improve the seeds).
2. Support the daily routines so nurses have the time, tools, and encouragement to do their safety checks every day (water the plants).

When you combine great skills with consistent daily action, that's when the whole hospital starts to feel truly safe.

Technical Summary

Title

Person-centered care competence and patient safety competence in relation to patient safety culture: Mediating effects of patient safety management activities among nurses in central Vietnam.

1. Problem Statement and Research Gap

• Context: Patient Safety Culture (PSC) is a critical determinant of healthcare quality. While individual competencies—specifically Person-Centered Care (PCC) competence and Patient Safety Competence (PSCp)—are known to influence safety outcomes, the mechanisms linking these individual attributes to the broader organizational PSC remain under-explored, particularly in low- and middle-income countries (LMICs).
• Gap: Previous studies have often examined these factors in isolation. There is a lack of integrated empirical models that test how frontline safety behaviors (Patient Safety Management Activities or PSMA) mediate the relationship between professional competencies and organizational safety culture.
• Objective: This study aimed to:
  1. Describe the levels of PCC competence, PSCp, PSMA, and PSC among nurses in central Vietnam.
  2. Examine the direct and indirect relationships among these factors using a mediation model where PSMA acts as the mediator between competencies and PSC.

2. Methodology

• Study Design: A multicenter cross-sectional study conducted between June and December 2024.
• Setting & Participants:
  • Location: Five tertiary (Grade I) hospitals in central Vietnam.
  • Sample: 1,036 registered nurses providing direct patient care with at least six months of experience (Response rate: 99.6%).
  • Sampling: Stratified random sampling with proportional allocation based on hospital size, followed by systematic random sampling within departments.
• Measurement Instruments:
  • PCC Competence: Person-Centred Care Assessment Tool (P-CAT); 13 items, 5-point Likert scale. (Cronbach's $\alpha$ = 0.662).
  • Patient Safety Competence (PSCp): Health Professional Education in Patient Safety Survey (H-PEPSS); 23 items, 6 domains. (Cronbach's $\alpha$ = 0.898).
  • Patient Safety Management Activities (PSMA): 24-item scale covering identification, medication safety, infection prevention, etc. (Cronbach's $\alpha$ = 0.863).
  • Patient Safety Culture (PSC): Hospital Survey on Patient Safety Culture (HSOPSC); 42 items, 12 dimensions. (Cronbach's $\alpha$ = 0.889).
• Statistical Analysis:
  • Software: SPSS v20.0.
  • Descriptive & Correlational: Means, SDs, and Pearson correlations.
  • Regression: Multivariable linear regression to test predictors (Models 1–3).
  • Mediation: Bias-corrected bootstrapping with 5,000 resamples to estimate indirect effects and 95% Confidence Intervals (CIs).
  • Covariates: Age, gender, education, experience, job satisfaction, working hours, and safety incident history.

3. Key Results

• Descriptive Statistics:
  • Competence Levels: Nurses reported moderate-to-high levels of PCC competence ($3.77 \pm 0.36$) and PSCp ($4.23 \pm 0.36$).
  • Activities: Engagement in PSMA was high ($4.44 \pm 0.35$).
  • Culture: PSC was perceived as moderate ($3.93 \pm 0.35$), indicating a gap between individual capability and organizational climate.
• Correlations: All variables were positively correlated. The strongest association was between PCC competence and PSC ($r = 0.49, p < 0.001$).
• Regression Analysis:
  • Model 1: Both PCC competence ($\beta = 0.149$) and PSCp ($\beta = 0.274$) significantly predicted PSMA.
  • Model 2: Both competencies significantly predicted PSC directly.
  • Model 3 (Mediation): When PSMA was added, the coefficients for competencies decreased but remained significant, while PSMA significantly predicted PSC ($\beta = 0.102$). This indicates partial mediation.
• Mediation Effects (Bootstrapping):
  • PCC $\to$ PSMA $\to$ PSC: Significant indirect effect ($\beta = 0.0265$, 95% CI: 0.0143–0.0404).
  • PSCp $\to$ PSMA $\to$ PSC: Significant indirect effect ($\beta = 0.0497$, 95% CI: 0.0304–0.0711).
  • Conclusion: PSMA partially mediates the relationship between professional competencies and patient safety culture.

4. Key Contributions

• Theoretical Integration: The study successfully integrates the Theory of Planned Behavior, Safety Climate models, and Donabedian's Structure–Process–Outcome model into a unified framework. It validates that individual competencies (Structure) influence safety culture (Outcome) through safety behaviors (Process).
• Contextual Evidence: Provides rare, high-quality empirical data from a Vietnamese tertiary hospital setting, addressing the scarcity of LMIC-specific research on the interplay between nursing competencies and safety culture.
• Mechanism Clarification: Demonstrates that while competence is crucial, its impact on organizational culture is partially dependent on the consistent enactment of routine safety behaviors (PSMA). It highlights that competence alone is insufficient without behavioral translation.

5. Significance and Implications

• For Policy and Management: Improving patient safety culture requires a dual approach:
  1. Competence Development: Enhancing PCC and safety training for nurses.
  2. Systemic Support: Creating organizational environments that facilitate the translation of these competencies into daily safety practices (e.g., reliable workflows, non-punitive reporting, adequate staffing).
• For Practice: The findings suggest that interventions should not focus solely on training but must also address the "behavioral gap" by ensuring that safety management activities are embedded in daily workflows.
• Future Research: The authors call for longitudinal and interventional studies to establish causal pathways and test system-level strategies for sustaining safety culture improvements.

Conclusion: The study confirms that higher person-centered care and patient safety competencies are associated with a stronger patient safety culture, but this relationship is significantly mediated by the frequency and quality of patient safety management activities. Strengthening safety culture requires aligning individual professional development with supportive organizational structures.