Influence of Perception of Patient Safety Culture, Job Stress, and Nursing Work Environment on Patient Safety Nursing Activities by Emergency Room Nurses

Eon Mi Lee; Jeong Hyun Cho; Seung Gyeong Jang

doi:10.7739/jkafn.2025.32.2.264

J Korean Acad Fundam Nurs > Volume 32(2); 2025 > Article

Lee, Cho, and Jang: Influence of Perception of Patient Safety Culture, Job Stress, and Nursing Work Environment on Patient Safety Nursing Activities by Emergency Room Nurses

Original Article

J Korean Acad Fundam Nurs 2025; 32(2): 264-274.

Published online: May 31, 2025

DOI: https://doi.org/10.7739/jkafn.2025.32.2.264

Influence of Perception of Patient Safety Culture, Job Stress, and Nursing Work Environment on Patient Safety Nursing Activities by Emergency Room Nurses

Eon Mi Lee¹⁾

, Jeong Hyun Cho²⁾

, Seung Gyeong Jang^3),

¹⁾Emergency Room Nurse, Dong-A University Hospital, Busan, Korea

²⁾Associate Professor, College of Nursing ‧ Institute for Health Science Research, Inje University, Busan, Korea

³⁾Assistant Professor, College of Nursing ‧ Institute for Health Science Research, Inje University, Busan, Korea

Corresponding author: Jang, Seung Gyeong College of Nursing, Institute for Health Science Research, Inje University 197 Inje-ro, Gimhae 50834, Korea Tel: +82-55-320-3103, Fax: +82-51-896-9840, E-mail: sgjang@inje.ac.kr

*This article is a condensed form of the first author's master's thesis from Inje University.

Received January 31, 2025 Revised May 13, 2025 Accepted May 19, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

This study aimed to investigate the influence of perceptions of patient safety culture, job stress, and nursing work environment on patient safety nursing activities among emergency room nurses.

Methods

This correlational study was conducted from June 5 to July 31, 2024, and targeted 114 emergency room nurses in Busan. A structured self-report questionnaire was used to collect data. Descriptive statistics, independent sample t-tests, one-way ANOVA, Pearson's correlation coefficients, and multiple regression analyses were employed for data analysis.

Results

Patient safety nursing activities significantly differed by age (F=6.17, p=.001) and total clinical experience (F=8.89, p<.001) among the participants' general characteristics. Positive correlations were identified with perceptions of patient safety culture (r=.70, p<.001) and nursing work environment (r=.27, p=.003). Multiple regression analysis indicated that perception of patient safety culture (β=.72, p<.001) and total clinical experience (β=-.32, p=.011) were significant predictors, accounting for 50.5% (F=20.24, p<.001) of the variance.

Conclusion

The findings indicated that perceptions of patient safety culture and total clinical experience are critical factors to be considered when designing interventions to enhance patient safety nursing activities among emergency room nurses.

Key words: Emergency nursing, Patient safety, Safety management

INTRODUCTION

Patient safety nursing activities include identifying, improving, and preventing healthcare issues [1]. In Korea, the Patient Safety Act was enacted in 2016, and the Korean Patient Safety Reporting and Learning System (KOPS) monitors safety incidents [2]. However, emergency departments are facing an increase in incidents due to high patient density, unpredictable conditions, and staff short-ages [3,4]. The fast-paced nature of emergency care increases risks such as medication errors, while procedural overload contributes to nurses’ workload and confusion [5,6]. Studies have shown that emergency care nurses have lower patient safety activity levels than nurses in other departments [7,8].

Patient safety culture refers to shared beliefs, values, and behaviors that minimize harm to patients by preventing healthcare errors [9]. Positive perceptions of patient safety culture reduce errors and improve safety [10]. As key professionals responsible for patient safety, nurses must be highly aware of and engaged in fostering a strong patient safety culture. Their interest and awareness significantly impact overall patient safety levels within healthcare institutions [11].

Job stress in nursing results from excessive workload, leading to physiological, psychological, and social strain [12]. Studies have identified job stress as a major factor influencing patient safety nursing behaviors [13]. Emergency room (ER) nurses experience high stress due to patient interactions, heavy workloads, and conflicts with caregivers and physicians [14,15].

The nursing work environment includes the physical setting, interpersonal interactions, and overall work atmosphere that supports effective nursing care [16]. A positive environment with adequate staffing enhances patient safety [17], whereas negative and unstable environments increase error rates and hinder error reporting, thereby negatively impacting patient safety nursing activities [18].

Although patient safety has been actively studied across various healthcare settings, research specifically focusing on ER nurses remains relatively limited. Most previous studies have been conducted on nurses working in general wards, operating rooms, or integrated nursing care service wards, while empirical research on ER nurses’ patient safety nursing activities has been scarce. However, ER presents a unique working environment, characterized by high patient turnover, unpredictable situations, and intense time pressure. In such settings, it is essential to comprehensively understand the factors that influence safe nursing practices. Previous research has examined individual factors such as perceptions of patient safety culture [19], awareness of patient safety risk factors [5], patient safety competencies [6], and emotional labor and job stress [13], in relation to patient safety nursing activities. However, integrated analyses that consider these factors together are rare. In particular, the perception of patient safety culture as an organizational factor, job stress as a personal factor, and the nursing work environment as an environmental factor have each been reported to independently influence patient safety nursing activities. Yet, there is a lack of empirical studies that investigate how these variables interact within the unique context of emergency nursing.

Therefore, this study aims to analyze the combined effects of perceptions of patient safety culture, job stress, and the nursing work environment on patient safety nursing activities among ER nurses. The findings are expected to provide foundational data for developing effective intervention strategies tailored to the distinct characteristics of the ER setting.

METHODS

1. Design

This descriptive correlational study examined the influence of ER nurses’ perceptions concerning patient safety culture, job stress, and the nursing work environment on patient safety nursing activities.

2. Participants and Data Collection

This study targeted ER nurses from five medical institutions in Busan City, including two tertiary hospitals and three general hospitals. Only nurses directly providing patient care were included, while those with < 1 year of ER experience or in managerial roles were excluded to avoid bias [20,21]. The required sample size was calculated using G*Power 3.1.9.7 based on a multiple linear regression analysis, with a statistical significance level of 0.05, power of 0.80, and an effect size of 0.15 assuming 8 predictor variables. These included perceptions of patient safety culture, job stress, nursing work environment, total emergency medical service experience (1 to <5 years, 5 to <10 years, 10 to <15 years), experience with patient safety-related activities, and experience with patient safety incidents within the past year. The estimated sample size was 109, including primary research variables and dummy variables such as clinical experience, safety-related activities, and incident occurrences. Considering a 10% dropout rate, 122 questionnaires were distributed and 114 completed responses were analyzed after excluding eight incomplete responses.

3. Research Tools

1) General characteristics

The general characteristics of the participants included eight items: gender, age, education level, total clinical total clinical experience, total emergency, medical service experience, type of emergency medical institution, experience of patient safety-related activities, and experience of patient safety accidents with a year.

2) Perception of patient safety culture

Perceptions of patient safety culture were assessed using the Korean version of the Patient Safety Culture Assessment Tool developed by Lee [9] for healthcare professionals. The tool consists of 35 items across three dimensions: organizational (patient safety systems, leadership, and policies), departmental (teamwork and non-punitive environment), and individual (knowledge/attitudes and priorities). Responses were recorded on a 5-point Likert scale, with higher scores indicating a stronger perception of patient safety culture. Seven items (items 25∼28 and 33∼35) were reverse-scored. In Lee's original study [9], the Cronbach's ⍺ for the tool was 0.93, and in the present study, it was 0.95.

3) Job stress

Job stress was measured using a nursing stress assessment tool developed by Kim and Gu [12] and subsequently revised by Lee and Ahn [22] to reflect the ER context. This tool consists of 71 items organized into 13 subdomains: excessive workload; conflict with physicians; professional conflict; inadequate treatment and compensation; work schedules and hours; conflicts with transport teams, other hospitals, and within the hospital; lack of professional knowledge and skills; interpersonal issues; relationships with supervisors; psychological burden related to medical limitations; inadequate physical environment in the emergency department; conflicts with patients and their families; and responsibilities beyond work duties. Responses were recorded on a 5-point Likert scale, with higher scores indicating greater job stress. The Cronbach's ⍺ for the tool was 0.94 in the original study by Kim and Gu [12], 0.97 in Lee and Ahn's study [22], and 0.97 in the present investigation.

4) Nursing work environment

The nursing work environment was assessed using the Korean version of the Nursing Work Environment Measurement Tool (Korean Practice Environment Scale of the Nursing Work Index, K-PES-NWI), which was originally developed by Lake [23] for nurses and subsequently adapted for Korean use by Cho et al [24]. This instrument consists of 29 items distributed across five subdomains. The subdomains included the foundation for quality nursing care, nursing manager support, staffing and physical resources, nurse-physician collaboration, and nurse participation in hospital management. Responses were recorded on a 4-point Likert scale, with higher scores indicating a more positive perception of the work environment. In terms of reliability, the original study by Lake [23] reported a Cronbach's ⍺ of .82, Cho et al. [24] found a Cronbach's ⍺ of .93, and the present study demonstrated a Cronbach's ⍺ of .89.

5) Patient safety nursing activities

Patient safety nursing activities were assessed using the Patient Safety Management Activity Tool originally developed by Lee [1]. In this study, a version of the tool adapted for emergency nursing contexts was used with prior permission from the modifying researcher. This tool consists of 34 items organized into nine subdomains. The subdomains include safe environment, emergency preparedness, medication administration, patient identification, verbal orders, infection control, pressure ulcer prevention, fall prevention, procedure/surgery. The responses were recorded on a 5-point Likert scale, with higher scores indicating a higher level of patient safety nursing activity. The reliability of the tool was reported as Cronbach's ⍺=.95 in Lee's original study [1] and ⍺=.92 in the present one.

4. Data Collection Method

Data were collected from June 5 to July 31, 2024, using a self-administered questionnaire at two tertiary and three general hospitals in Busan, South Korea. Prior to data collection, the researchers obtained approval from the nursing departments and explained the study to

ER head nurses. Eligible nurses were provided with an information sheet and consent form to ensure voluntary participation. After providing written informed consent, participants completed the questionnaire independently. A small token of appreciation was given to all respondents.

5. Ethical Considerations

This study was approved by the Institutional Review Board (IRB) of Inje University (IRB No. 2024-02-023-007). Participants were informed of the aims, methodology, and ethical considerations of the study before providing written consent. The consent form guaranteed anonymity, voluntary participation, right to withdraw, and confidentiality. The completed questionnaires were collected in sealed opaque envelopes and stored securely. Data were anonymized by coding, stored on a password-protected computer, and stored for 3 years before being permanently deleted.

6. Data Analysis

Data were analyzed using IBM SPSS/WIN for Windows, v.27.0. Descriptive statistics, including means and standard deviations, were used to examine the participants’ general characteristics and perceptions of patient safety culture, job stress, nursing work environment, and patient safety nursing activities. Differences in patient safety nursing activities according to general characteristics were assessed using independent t-tests and one-way ANOVA with post hoc Scheffé tests. Pearson's correlation coefficient was used to analyze relationships among key variables, and multiple regression analysis was used to identify factors influencing patient safety nursing activities.

RESULTS

1. General Characteristics of Participants

A total of 114 ER nurses participated in this study. The majority were women (n=89, 78.1%), and the mean age was 30.18±5.85 years, with 67 participants (58.8%) aged under 30. Regarding education level, most participants held a bachelor's degree (n=98, 86.0%). In terms of total clinical experience, 60 nurses (52.6%) had 1 to less than 5 years of experience, followed by 33 (28.9%) with 5 to less than 10 years, 12 (10.5%) with 10 to less than 15 years, and 9 (7.9%) with 15 years or more. For total emergency medical service experience, 79 participants (69.3%) had 1 to less than 5 years, and 23 (20.2%) had 5 to less than 10 years. The most common type of emergency medical institution was a local emergency medical center (n=50, 43.9%), followed by regional emergency medical centers and local emergency medical institutions. More than half of the participants (n=62, 54.4%) had experience with patient safety-related activities, and 61 (53.5%) reported having experienced a patient safety incident within the past year. Among those who experienced such incidents, the most frequent type was medication error (n=38, 50.7%), and the most common frequency was a single occurrence (n=29, 47.5%). Additionally, 50 participants (82.0%) had experience reporting patient safety incidents (Table 1).

Table 1.

General Characteristics of Subjects (N=114)

Characteristic	Categories	n (%)	M± SD
Gender	Men	25 (21.9)
Gender	Women	89 (78.1)
Age (year)	＜30	67 (58.8)	30.18±5.85
	30∼35	24 (21.1)
	35∼40	13 (11.4)
	≥40	10 (8.7)
Education level	Diploma	10 (8.7)
	Bachelor	98 (86.0)
	≥ Master	6 (5.3)
Total clinical experience (year)	1∼5	60 (52.6)
	5∼10	33 (28.9)
	10∼15	12 (10.5)
	≥15	9 (7.9)
Total emergency medical service experience (year)	1∼5	79 (69.3)
	5∼10	23 (20.2)
	10∼15	10 (8.8)
	≥15	2 (1.8)
Type of emergency medical institution	Local emergency medical facility	0 (0.0)
	Local emergency medical institution	27 (23.7)
	Local emergency medical center	50 (43.9)
	Regional emergency medical center	37 (32.4)
Experience of patient safety-related activities	Yes	62 (54.4)
Experience of patient safety-related activities	No	52 (45.6)
Experience of patient safety accidents with a year	Yes	61 (53.5)
Experience of patient safety accidents with a year	No	53 (46.5)
Type of patient safety accidents within a year (n=61)^†	Medication error	38 (50.7)
	Fall down	34 (45.3)
	Others	3 (4.0)
Number of patient safety accidents experiences within a year (n=61)	1	29 (47.5)
	2	18 (29.5)
	3	5 (8.2)
	4	4 (6.6)
	≥5	5 (8.2)
Experiences of the incident reporting within a year (n=61)	Yes	50 (82.0)
Experiences of the incident reporting within a year (n=61)	No	11 (18.0)

M=mean; SD=standard deviation;

^† Multiple responses allowed.

2. Descriptive Statistics for Perception of Patient Safety Culture, Job Stress, Nursing Work Environment, and Patient Safety Nursing Activities

The perception of patient safety culture was 3.64±0.52 out of 5. Among the subscales, patient safety knowledge/attitude was the highest at 4.11±0.47, and prioritization of patient safety was the lowest at 2.89±0.96. Job stress scored 3.51±0.63 out of 5. Among the subscales, the highest score was 4.10±0.84 for conflict within hospitals and transport teams, and the lowest score was 2.99±1.13 for the inappropriate physical environment of wards. The nursing work environment score was 2.69±0.37 out of 4. Among the subscales, nurse manager's ability, leadership, and support of nurses was the highest at 2.94±0.47, and adequate staffing and resources was the lowest at 2.41± 0.54. Patient safety nursing activities scored 3.86±0.47 out of 5. Among the subdomains, infection control was the highest with 4.12±0.62, and safe environment was the lowest with 3.34±1.05 (Table 2).

Table 2.

Descriptive Statistics for Perception of Patient Safety Culture, Job Stress, Nursing Work Environment, Patient Safety Nursing Activities (N=114)

Variables	Range	Min	Max	M± SD
Perception of patient safety culture	1∼5	2	5	3.64±0.52
Leadership	1∼5	2	5	3.88±0.58
Policy of patient safety	1∼5	1	5	3.53±0.78
System for improvement of patient safety	1∼5	2	5	3.37±0.66
Team work	1∼5	2	5	3.79±0.61
Environment of non-punitive environment	1∼5	1	5	3.21±0.93
Knowledge and attitude of patient safety	1∼5	3	5	4.11±0.47
priority of patient safety	1∼5	1	5	2.89±0.96
Job stress	1∼5	2	5	3.51±0.63
Heavy workload	1∼5	2	5	3.69±0.69
Role conflict	1∼5	1	5	3.50±0.77
Lack of specialized skills and Knowledge	1∼5	2	5	3.46±0.81
Conflicts with doctors	1∼5	1	5	3.74±0.85
Conflicts among interpersonal relationship	1∼5	1	5	3.49±0.87
Psychological burden	1∼5	1	5	3.14±0.81
Inappropriate treat	1∼5	1	5	3.42±0.82
Conflict with supervising nurses	1∼5	1	5	3.30±1.11
Conflict related on-duty hours	1∼5	1	5	3.03±0.93
Responsibility without regard to work	1∼5	1	5	3.28±1.10
Inappropriate physical environment of wards	1∼5	1	5	2.99±1.13
Matters related the patient and the guardian	1∼5	1	5	4.06±0.96
Conflict within hospitals and transport teams	1∼5	1	5	4.10±0.84
Nursing work environment	1∼4	2	4	2.69±0.37
Staffing and resource adequacy	1∼4	1	4	2.41±0.54
Nursing foundations for quality of care	1∼4	2	4	2.79±0.39
Nurse participation in hospital affairs	1∼4	1	4	2.54±0.48
Collegial nurse-physician relations	1∼4	2	4	2.92±0.53
Nurse manager's ability, leadership, and support of nurses	1∼4	2	4	2.94±0.47
Patient safety nursing activities	1∼5	2	5	3.86±0.47
Patient identification	1∼5	3	5	3.99±0.48
Verbal orders	1∼5	2	5	4.03±0.69
Medication administration	1∼5	3	5	4.04±0.65
Procedure/Surgery	1∼5	1	5	3.86±0.91
Safety environment	1∼5	1	5	3.34±1.05
Infection control	1∼5	3	5	4.12±0.62
Fall prevention	1∼5	2	5	3.60±0.71
Pressure ulcer prevention	1∼5	2	5	3.49±0.63
Emergency preparedness	1∼5	2	5	3.86±0.59

M=mean; SD=standard deviation.

3. Differences in Patient Safety Nursing Activities by General Characteristics of Participants

There were significant differences in patient safety nursing activities according to age (F=6.17, p=.001) and total clinical experience (F=8.89, p<.001). Post hoc analyses showed that those aged ≥40 years had higher scores than those aged <40 years, and those with ≥15 years of total clinical experience had higher scores than those with ≥10 years and <15 years (Table 3).

Table 3.

Difference in Patient Safety Nursing Activities by the General Characteristics of Subjects (N=114)

Characteristics	Categories	M± SD	t or F (p)	Scheffé
Gender	Men	4.01±0.49	1.86
Gender	Women	3.82±0.45	(.066)
Age (year)	＜30^a	3.86±0.49	6.17	d＞ a, b, c
	30∼35^b	3.74±0.33	(.001)
	35∼40^c	3.68±0.46
	≥40^d	4.39±0.29
Education level	Diploma	3.80±0.39	2.14
	Bachelor	3.84±0.48	(.122)
	≥ Master	4.24±0.36
Total clinical experience (year)	1∼5^a	3.85±0.49	8.89	d＞ c
	5∼10^b	3.81±0.39	(＜.001)
	10∼15^c	3.76±0.61
	≥15^d	4.23±0.19
Total emergency medical service experience (year)	1∼5	3.86±0.49	0.44
	5∼10	3.84±0.37	(.726)
	10∼15	3.84±0.57
	≥15	4.17±0.09
Type of emergency medical institution	Local emergency medical facility	0.00±0.00	0.70
	Local emergency medical institution	3.93±0.46	(.497)
	Local emergency medical center	3.87±0.51
	Regional emergency medical center	3.79±0.41
Experience of patient safety-related activities	Yes	3.94±0.49	1.99
Experience of patient safety-related activities	No	3.77±0.43	(.050)
Experience of patient safety accidents within a year	Yes	3.81±0.48	-1.17
Experience of patient safety accidents within a year	No	3.92±0.45	(.246)

M=mean; SD=standard deviation.

4. Correlations among Perception of Patient Safety Culture, Job Stress, Nursing Work Environment, and Patient Safety Nursing Activities of Participants

Patient safety nursing activities were significantly positively correlated with perceived patient safety culture (r=.70, p<.001) and nursing work environment (r=.27, p=.003), but not significantly correlated with job stress (r=-.10, p=.277) (Table 4).

Table 4.

Correlations among Perception of Patient Safety Culture, Job Stress, Nursing Work Environment, Patient Safety Nursing Activities of Subjects (N=114)

Variables	Perception of patient safety culture	Job stress	Nursing work environment	Patient safety nursing activity
Variables	r (p)	r (p)	r (p)	r (p)
Perception of patient safety culture	1
Job stress	-.26 (.005)	1
Nursing work environment	.41 (＜.001)	-.02 (.847)	1
Patient safety nursing activity	.70 (＜.001)	-.10 (.277)	.27 (.003)	1

5. Influence of Perception of Patient Safety Culture, Job Stress, and Nursing Work Environment on Patient Safety Nursing Activities of Participants

To analyze factors influencing patient safety nursing activities among ER nurses, a multiple regression analysis was conducted using the enter method. Independent variables included total clinical experience, perception of patient safety culture, job stress, and nursing work environment as independent variables among the general characteristics of participants that showed a significant relationship with patient safety nursing activities. Total clinical experience, a categorical item among the independent variables, was analyzed as a dummy variable. Age was a variable that showed a significant difference in patient safety nursing activities but was excluded from the model due to multicollinearity with total clinical experience.

The Durbin-Watson statistic was used to test the independence of the residuals, and the value of 2.14 was between 1 and 3, indicating no autocorrelation between the error terms. Multicollinearity between the independent variables was checked, and the tolerance was 0.28∼0.91, which was >0.10 and <1.0, and the Variance Inflation Factor (VIF) was 1.11∼3.51, which was <10. Therefore, there were no issues of multicollinearity between independent variables.

The analysis showed that the factors that significantly influenced the participants’ patient safety nursing activities were perception of patient safety culture (β=.72, p< .001) and total clinical experience of ≥1 year but <5 years (criterion: >15 years) (β=-.32, p =.011). The explanatory power of these variables for patient safety nursing behavior was 50.5% (F=20.24, p<.001) (Table 5).

Table 5.

Influence of Perception of Patient Safety Culture, Job Stress, Nursing Work Environment on Patient Safety Nursing Activities of Subjects (N=114)

Variables	B	SE	β	t	p
(Constant)	1.56	0.38		4.10	＜.001
Perception of patient safety culture	0.65	0.07	.72	9.26	＜.001
Job stress	0.04	0.05	.06	0.80	.425
Nursing work environment	0.01	0.10	.01	0.08	.937
Total clinical experience (year)^†
1∼5	-0.30	0.12	-.32	-2.58	.011
5∼10	-0.19	0.12	-.19	-1.57	.120
10∼15	-0.26	0.14	-.17	-1.81	.073
	R²=.532, Adjusted R²=.505, F=20.24, p＜.001 Durbin-Watson=2.14, Tolerance=.28∼.91, VIF=3.51∼1.11

SE=standard error; VIF=variance inflation factor;

^† Dummy variable: Total clinical career (reference: ≥15).

DISCUSSION

This study aimed to analyze the impact of perceptions of patient safety culture, job stress, and the nursing work environment on ER nurses’ patient safety activities and to provide a foundation for effective interventions.

In this study, the mean perception of patient safety culture was 3.64±0.52, which was higher than 3.51±0.3 as reported in Kim and Kim's study involving ER nurses [6]. This suggests that the healthcare accreditation system implemented in 2010 and the enactment of the Patient Safety Act in 2016 may have contributed to improving ER nurses’ perception. However, ER nurses showed lower perception levels than those in other departments. For example, a study involving ward nurses reported a perception score of 3.88±0.43 [25], while a study on hemodialysis nurses reported a score of 3.81±0.42 [26]. Among the subdomains, knowledge and attitude toward patient safety scored the highest, whereas prioritization of patient safety scored the lowest, which is consistent with the results of previous studies [6]. This suggests that although ER nurses possess knowledge and a positive attitude toward patient safety, a culture that prioritizes safety in actual emergency situations may be lacking. Therefore, continuous efforts to enhance nurses’ perception of patient safety culture-along with institutional improvements-are necessary to ensure that patient safety remains a top priority, even in urgent and rapidly changing clinical situations, and to support the delivery of prompt and accurate nursing care.

The job stress was 3.51±0.63, which was similar to the findings of Lee and Kim's study involving ER nurses [13], but lower than 4.00±0.57 reported in Lee and Ahn's study, which also targeted ER nurses [22]. Consistent with previous studies, the most common stressors included conflicts within the hospitals and with external facilities, followed by conflicts with patients and caregivers [13,22]. In particular, when critically ill patients are transferred without confirming the ER's capacity, or when non-emergency patients are sent to wait for admission due to bed short-ages, the number and severity of patients can exceed available nursing resources, significantly increasing nurses’ workload and stress [27]. The 24-hour nature of ER exposes nurses to a wide variety of patients, including those who are violent or intoxicated, thereby intensifying workplace challenges [28]. These issues should be addressed through systemic interventions rather than being seen as individual burdens. Enhancing bed management, triage systems, and transfer coordination can ease nurses’ workload, while institutional support-such as resilience training, emotional labor management, and counseling services-can help mitigate psychological stress in emergency settings.

The nursing work environment score was 2.69±0.37, which was similar to the findings of Kim and Ji's study involving ER nurses [29]. In both studies, the subdomain of adequate staffing and material support received the lowest score. An appropriate nurse-to-patient ratio plays an important role in reducing patient safety incidents by enabling nurses to perform patient monitoring more effectively [17]. As this is difficult to address through individual effort alone, these findings underscore the need to establish and implement nurse staffing standards at both the hospital and government levels.

The patient safety nursing activity score was 3.86±0.47, which was consistent with the finding of previous studies involving ER nurses [6,13]. Among the subdomains, infection prevention received the highest score, which may reflect the impact of government-led infection control policies following the MERS and COVID-19 [6]. In contrast, the subdomain with the lowest score was maintaining a safe environment with previous studies [6]. In this study, the items under the maintaining a safe environment subdomain included statements such as “ I am aware of the locations of alarm systems in the ward” and “ I regularly inspect various alarm systems (e.g., call bells, fire alarms), immediately report any malfunctions, and conduct preventive checks”. The low average scores on these items suggest that ER nurses may lack clear information or awareness regarding the location, operation, inspection, and repair procedures of alarm systems [30]. The implies that the absence of structured education on the operation and maintenance of alarm systems may have contributed to low performance in this area. Additionally, the characteristics of ER settings-such as frequent patient movement and heavy workloads-may lead to deprioritization of environmental safety management tasks or a perception that such activities are outside the core scope of nursing practice. Therefore, in order to enhance patient safety nursing activities among ER nurses, it is essential to provide practice-based education and accessible information on alarm systems and safety management procedures. Institutional support is also needed to ensure that these activities are recognized and implemented as an integral part of routine nursing care.

In this study, patient safety nursing activities varied significantly based on participants’ age and total clinical experience. ER nurses aged ≥40 years showed higher activity levels than those aged <40 years, and those with ≥15 years of total clinical experience scored higher than those with 10 to <15 years of experience. These results are consistent with previous studies involving ER nurses [5,13,19], suggesting that clinical adaptation, proficiency, and coping strategies are acquired over time, contributing to safer practices [31].

The correlation analysis revealed a significant positive relationship between the perception of patient safety culture and patient safety nursing activities, consistent with previous findings involving ER nurses [6,19]. In contrast, job stress was not significantly associated with patient safety nursing activities. Lee and Kim's study [13], also involving ER nurses, reported a positive correlation, while Yang's study [32] with nurses in integrated nursing care service wards found a negative correlation. These conflicting results highlight the need for further research to clarify this relationship. Although the nursing work environment showed a significant correlation with patient safety nursing activities, it was not a significant predictor in the regression analysis. This may be due to the low variability in scores (2.69±0.37), indicating responses clustered within a narrow range. A moderate correlation between the nursing work environment and patient safety culture (r=.41, p<.001) also suggests potential overlap in explanatory power. Moreover, the nursing work environment was measured subjectively, which may not adequately reflect objective factors such as staffing levels, resource availability, or physical layout. Future studies should utilize objective tools tailored to emergency settings and explore indirect pathways through which the nursing work environment may affect patient safety nursing activities.

This study identified perception of patient safety culture as the most influential factor affecting patient safety nursing activities, followed by the total clinical experience. In fast-paced ER settings, it is essential to strengthen the safety culture through continuous education and organizational support. In particular, nurses with 1 to <5 years of clinical experience exhibited lower levels of patient safety nursing activity compared to those with ≥15 years of experience, highlighting the importance of retaining experienced nurses who can lead safety practices and serve as role models in clinical settings. Less experienced nurses should be provided with structured education and repeated opportunities for hands-on practice based on realistic clinical scenarios. Developing tailored educational content and practical programs based on clinical experience is essential for systematically enhancing patient safety nursing activities among ER nurses.

This study had several limitations. First, data were collected from two tertiary and three general hospitals, which may limit generalizability of findings. Second, the use of self-reported questionnaires may have resulted in over- or underestimation of patient safety nursing activities. Future research should expand the study sample size and use objective assessments such as observational evaluations. Despite these limitations, this study provides meaningful insights into how perception of patient safety culture, job stress, and the nursing work environment influence ER nurses’ safety activities. These findings provide a foundation for the development of effective intervention programs to improve patient safety practices in emergency care settings.

CONCLUSION

This study identified perception of patient safety culture and total clinical experience as the most influential factors affecting patient safety nursing activities among ER nurses. These findings emphasize that, beyond individual competence, a strong and sustained organizational culture of safety is essential to improve nursing practices in emergency settings. In particular, less experienced nurses demonstrated lower levels of safety activity, highlighting the need for differentiated education and support strategies that reflect various levels of clinical experience.

From a practical perspective, healthcare institutions should prioritize the development and implementation of experience-based training programs, along with structured support systems that embed safety protocols into daily nursing routines. Efforts should also be made to shift the perception of safety-related tasks-such as alarm system management and environmental checks-from optional responsibilities to core components of emergency nursing practice.

While this study contributes valuable insights into the dynamics of safety culture, work stress, and environmental context in ER, its findings are limited by the regional scope and reliance on self-reported data. Future research should broaden the study population across diverse institutional and geographical contexts, and incorporate objective assessment tools-such as observational evaluations-to more accurately measure actual safety performance.

Ultimately, strengthening the safety performance of ER nurses requires a multifaceted approach that combines individualized training, organizational culture development, and systemic policy support. These findings serve as a foundation for designing comprehensive, evidence-based interventions that can effectively advance patient safety in high-risk clinical environments.

Notes

CONFLICTS OF INTEREST

The authors declared no conflict of interest.

AUTHORSHIP

Study conception and design acquisition - Lee EM and Jang SG; Data collection - Lee EM; Data analysis & Interpretation - Lee EM; Drafting & Revision of the manuscript - Lee EM, Cho JH and Jang SG.

DATA AVAILABILITY

The data that support the findings of this study are available from the corresponding author upon reasonable request.

REFERENCES

1. Lee GO. The study on nursing manager leadership and patient safety-related nursing activities [master's thesis]. Seoul: Kyung Hee University; 2009. p. 1-50.

2. Ministry of Health and Welfare, Korea Institute for Healthcare Accreditation. Korean patient safety incident report 2022 [Internet]. Seoul: Korea Institute for Healthcare Accreditation; 2023. [cited 2025 May 16]. Available from:. https://www.kops.or.kr/portal/board/statAnlrpt/boardDetail.do

3. Hong EY. Analysis of patient safety incidents in the emergency department in Korea (2017-2021). The Journal of Humanities and Social Science. 2023; 14(3):939-954. https://doi.org/10.22143/HSS21.14.3.66

4. Yun JM, Park HS. Perception of the patient safety risk factors and safety management by nurses in emergency service, hospitals. The Korean Journal of Fundamentals of Nursing. 2014; 21(4):380-391. https://doi.org/10.7739/jkafn.2014.21.4.380

5. Kim MJ, Kim JK. A study on the relationships among perception about patient safety culture, patient safety competence and safety nursing activities of emergency room nurses. The Journal of the Korea Contents Association. 2017; 17(10):268-279. https://doi.org/10.5392/JKCA.2017.17.10.268

6. Sklar DP, Crandall CS, Zola T, Cunningham R. Emergency physician perceptions of patient safety risks. Annals of Emergency Medicine. 2010; 55(4):336-340. https://doi.org/10.1016/j.annemergmed.2009.08.020

7. Kim HJ, Kim HJ. Influences of nursing workplace spirituality, organizational citizenship behavior, and perception of patient safety management on the patient safety nursing activities among a tertiary hospital nurses. Journal of Korean Academy of Nursing Administration. 2022; 28(3):179-189. https://doi.org/10.11111/jkana.2022.28.3.179

8. Son YS, Lee YW, Kim YS, Song EJ, Lee HR, Lee JH. Perception of patient safety risk factors and performance level of safety care activities among hospital nurses. The Journal of Korean Academic Society of Nursing Education. 2018; 24(2):190-200. https://doi.org/10.5977/jkasne.2018.24.2.190

9. Lee SG. Development and psychometric evaluation of the Korean patient safety culture survey instrument for hospitals [dissertation]. Seoul: Chung Ang University; 2015. p. 1-142.

10. Lee KH, Lee YS, Park HK, Rhu JO, Byun IS. The influences of the awareness of patient safety culture on safety care activities among operating room nurses. Journal of Korean Clinical Nursing Research. 2011; 17(2):204-214. https://doi.org/10.22650/JKCNR.2011.17.2.7

11. Park SJ, Kang JY, Lee YO. Hospital nurses' perception of patient safety culture and safety care activity. Journal of Korean Critical Care Nursing. 2012; 5(1):44-55.

12. Kim MJ, Gu MO. The development of the stresses measurement tool for staff nurses working in the hospital. Journal of Korean Academy of Nursing. 1984; 14(2):28-37. https://doi.org/10.4040/jnas.1984.14.2.28

13. Lee SN, Kim SH. The impact of emotional labor and job stress on the patient safety management activities among emergency room nurses in small-medium sized general hospitals. The Journal of the Korea Contents Association. 2022; 22(3):222-235. https://doi.org/10.5392/JKCA.2022.22.03.222

14. Oh YJ, Choi YH. Effects of emotional labor, job stress and burnout on somatization in nurses: in convergence era. Journal of Digital Convergence. 2015; 13(10):415-424. https://doi.org/10.14400/JDC.2015.13.10.415

15. Choi KL, Heo SE, Moon DH. Convergence study on the influence of job stress of shift work nurses on nursing performance. Journal of the Korea Convergence Society. 2016; 7(4):107-121. https://doi.org/10.15207/JKCS.2016.7.4.107

16. Friese CR, Lake ET, Aiken LH, Silber JH, Sochalski J. Hospital nurse practice environments and outcomes for surgical oncology patient. Health Services Research. 2008; 43(4):1145-1163. https://doi.org/10.1111/j.1475-6773.2007.00825.x

17. Liu X, Zheng J, Liu K, Baggs JG, Liu J, Wu Y, et al. Hospital nursing organizational factors, nursing care left undone, and nurse burnout as predictors of patient safety: a structural equation modeling analysis. International Journal of Nursing Studies. 2018; 86: 82-89. https://doi.org/10.1016/j.ijnurstu.2018.05.005

18. Cho E, Sloane DM, Kim EY, Kim S, Choi M, Yoo IY, et al. Effects of nurse staffing, work environments, and education on patient mortality: an observational study. International Journal of Nursing Studies. 2015; 52(2):535-542. https://doi.org/10.1016/j.ijnurstu.2014.08.006

19. Lee JE, Lee EN. Emergency room nurses' recognition of patient safety culture and their safety management activity. Journal of Korean Critical Care Nursing. 2013; 6(1):44-56.

20. Byeon YS, Lim NY, Kang KS, Sung MS, Won JS, Ko IS, et al. Clinical nursing competency for new graduate nurses. Journal of Korean Academy of Fundamentals of Nursing. 2003; 10(1):47-56.

21. Kim HW, Kim HS. Effects of perceived patient safety culture on safety nursing activities in the general hospital nurse's. Journal of Korean Academy of Nursing Administration. 2011; 17(4):413-422. https://doi.org/10.11111/jkana.2011.17.4.413

22. Lee YL, Ahn SH. Impact of job stress on turnover intention among emergency room nurses. Journal of Muscle and Joint Health. 2015; 22(1):30-39. https://doi.org/10.5953/JMJH.2015.22.1.30

23. Lake ET. Development of the practice environment scale of the nursing work index. Research in Nursing & Health. 2002; 25(3):176-188. https://doi.org/10.1002/nur.10032

24. Cho E, Choi M, Kim EY, Yoo IY, Lee NJ. Construct validity and reliability of the Korean version of the practice environment scale of nursing work index for Korean nurses. Journal of Korean Academy of Nursing. 2011; 41(3):325-332. https://doi.org/10.4040/jkan.2011.41.3.325

25. Kim SB, Kim YH. Associations of perceptions of patient safety culture, job crafting, and perceptions of patient rounding with patient safety management activities among tertiary hospital nurses. Journal of Korean Biological Nursing Science. 2024; 26(3):259-269. https://doi.org/10.7586/jkbns.24.020

26. Jung SJ, Jeong JH. Influence of professionalism and organizational communication on patient safety culture of nurses in hemodialysis units. Journal of Korean Clinical Nursing Research. 2019; 25(1):98-105. https://doi.org/10.22650/JKCNR.2019.25.1.98

27. Kim BJ, Lee EN, Kang KH, Kim SS, Kim SA, Sung YH, et al. A study of job analysis of the emergency room nurse. Journal of Korean Clinical Nursing Research. 2006; 12(1):81-95.

28. Kim MJ, Kim JM, Lee JH, Cho JH, Chung SP. Causes, effect and coping skills of stress in physicians and nurses of an emergency department. Journal of the Korean Society of Emergency Medicine. 2008; 19(4):428-433.

29. Kim JY, Ji EJ. Comparison of factor influencing turnover intention between ward and emergency room nurses: resilience, practice environment of nursing and burnout. Korean Journal of Health Communication. 2024; 19(1):19-29. https://doi.org/10.15715/kjhcom.2024.19.1.19

30. Kim MS. Perception and influencing factors for patient safety among emergency room nurses [master's thesis]. Ulsan: University of Ulsan; 2012. p. 1-64.

31. Lee NJ, Kim JH. Perception of patient safety culture and safety care activity among nurses in small-medium sized general hospital. Journal of Korean Academy of Nursing Administration. 2011; 17(4):462-473. https://doi.org/10.11111/jkana.2011.17.4.462

32. Yang HM. Effects of the comprehensive nursing care service ward nurses occupational stress on safety control and patient safety-related nursing activities. The Journal of the Korea Contents Association. 2019; 19(7):444-455. https://doi.org/10.5392/JKCA.2019.19.07.444