PATIENT SAFETY CULTURE IN SLOVENIAN OUT-OF-HOURS 
PRIMARY CARE CLINICS
Zalika KLEMENC-KETIŠ1,2,3*, Ellen TVETER DEILKÅS4, Dag HOFOSS5, Gunnar TSCHUDI BONDEVIK6,7
1University of Maribor, Faculty of Medicine, Department of Family Medicine, Taborska 8, 2000 Maribor, Slovenia
2University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Poljanski nasip 58, 1000 Ljubljana, Slovenia
3Community Health Centre Ljubljana, Metelkova 9, 1000 Ljubljana, Slovenia 
4Health Services Research Unit, Akershus University Hospital, Norway
5Institute of Health and Society, University of Oslo, Norway
6Department of Global Public Health and Primary Care, University of Bergen, Norway 
7National Centre for Emergency Primary Health Care, Uni Research Health, Bergen, Norway
Received: Apr 18, 2017
Accepted: Jun 23, 2017 
Original scientific article
Introduction. Patient safety culture is a concept which describes how leader and staff interaction, attitudes, 
routines and practices protect patients from adverse events in healthcare. We aimed to investigate patient 
safety culture in Slovenian out-of-hours health care (OOHC) clinics, and determine the possible factors that 
might be associated with it.
Methods. This was a cross-sectional study, which took place in Slovenian OOHC, as part of the international 
study entitled Patient Safety Culture in European Out-of-Hours Services (SAFE-EUR-OOH). All the OOHC clinics 
in Slovenia (N=60) were invited to participate, and 37 agreed to do so; 438 employees from these clinics were 
invited to participate. We used the Slovenian version of the Safety Attitudes Questionnaire – an ambulatory 
version (SAQAV) to measure the climate of safety.
Results. Out of 438 invited participants, 250 answered the questionnaire (57.1% response rate). The mean 
overall score ± standard deviation of the SAQ was 56.6±16.0 points, of Perceptions of Management 53.6±19.6 
points, of Job Satisfaction 48.5±18.3 points, of Safety Climate 59.1±22.1 points, of Teamwork Climate 72.7±16.6, 
and of Communication 51.5±23.4 points. Employees working in the Ravne na Koroškem region, employees with 
variable work shifts, and those with full-time jobs scored significantly higher on the SAQ-AV.
Conclusion. The safety culture in Slovenian OOHC clinics needs improvement. The variations in the safety 
culture factor scores in Slovenian OOHC clinics point to the need to eliminate variations and improve working 
conditions in Slovenian OOHC clinics.
Uvod. Kultura varnosti je koncept, ki opisuje, kako odnosi med vodstvom in osebjem, njihova stališča, 
postopki in praksa varujejo bolnike pred škodljivimi dogodki zaradi napake v zdravstvu. Z raziskavo smo želeli 
raziskati kulturo varnosti v slovenskih dežurnih ambulantah na primarni ravni zdravstvenega varstva in določiti 
dejavnike, ki so povezani z njo.
Metode. To je bila prečna opazovalna raziskava, ki je potekala v slovenskih dežurnih ambulantah na primarni 
zdravstveni ravni in je bila del mednarodne raziskave z naslovom Patient Safety Culture in European Out-of-
Hours services (SAFE-EUR OOH). K sodelovanju smo povabili vse dežurne ambulante v Sloveniji (N=60), 37 jih 
je sodelovanje potrdilo. V teh ambulantah je bilo k sodelovanju povabljenih 438 zaposlenih. Uporabili smo 
slovensko različico lestvice Safety Attitudes Questionnaire – ambulatory version (SAQ – AV), s katero smo merili 
raven kulture varnosti.
Rezultati. Od 438 povabljenih je vprašalnike izpolnilo 250 zaposlenih (57,1%). Povprečna vrednost lestvice 
SAQ – AV je bila 56,6±16,0 točke. Povprečna vrednost faktorja dojemanje vodstva je bila 53,6±19,6 točke, 
faktorja zadovoljstvo z delom 48,5±18,3 točke, faktorja ozračje varnosti 59,1±22,1, faktorja ozračje timskega 
dela 72,7±16,6 in faktorja sporazumevanje 51,5±23,4 točke. Zaposleni v regiji Ravne na Koroškem, zaposleni 
z izmenskim delom in zaposleni s polnim delovnim časom so imeli statistično višji seštevek točk na lestvici 
SAQ – AV.
Zaključek. Kultura varnosti v slovenskih dežurnih ambulantah potrebuje izboljšave. Različni seštevki točk 
na lestvici SAQ – AV v različnih regijah Slovenije in v različnih dežurnih ambulantah kažejo na potrebo po 
zmanjšanju razlik in izboljšanju delovnih pogojev.
ABSTRACT
Keywords: 
safety culture, 
out-of-hours medical 
care, primary health 
care, Slovenia
IZVLEČEK
Ključne besede: 
kultura varnosti, 
dežurna služba, 
primarna zdravstvena 
raven, Slovenija
*Corresponding author: Tel: + 386 41 516 067; E-mail: zalika.klemenc-ketis@uni-mb.si
10.1515/sjph-2017-0028 Zdr Varst 2017; 56(4): 203-210
203
KULTURA VARNOSTI V SLOVENSKIH DEŽURNIH AMBULANTAH 
NA PRIMARNI RAVNI
Klemenc-Ketiš Z, Tveter Deilkås E, Hofoss D, Tschudi Bondevik G. Patient safety culture in Slovenian out-of-hours primary care clinics. Zdr Varst 2017; 56(4): 203-210.
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION
In the past two decades, quality in primary care has been 
extensively studied in Europe, including Slovenia (1-7). 
Several of these studies have dealt with patient safety 
issues, which is an important part of quality improvement 
(8-14). In Slovenia, patient safety features in primary 
health care have been investigated through the study on 
Quality and Costs of Primary Care in Europe (QUALICOPC), 
dealing with the organisation and accessibility of primary 
health care services (4, 15, 16). 
Out-of-hours health care (OOHC) at the primary health care 
level is a crucial part of the availability and accessibility 
of the provision of healthcare (17, 18). Several studies 
have already been published on patient safety issues in 
OOHC and primary care emergency settings (8, 13, 18-
21). Smits et al. reviewed patient records in OOHC clinics 
in the Netherlands, and determined that although patient 
safety incidents did occur in 2.4% of reviewed patients 
records in OOHC clinics, most did not harm the patients 
(8). A systematic review of the safety of telephone triage 
in OOHC clinics concluded that triage was safe in most 
cases. However, there was room for improvement in triage 
for patients who present with symptoms that indicate 
high risk (22). Patient safety culture in OOHC clinics as a 
concept, which describes how leader and staff interaction, 
attitudes, routines and practices protect patients from 
adverse events in healthcare, has been investigated in a 
few studies (13, 20, 21, 23). Bondevik et al. (13) found 
both demographic and professional differences in staff 
perception of patient safety in Norwegian OOHC clinics. 
In Slovenia, primary OOHC clinics are located in primary 
health care centres. Medical care is provided mainly by 
family physicians with their teams, who also carry out 
emergency services. Slovenian OOHC clinics are open 
24/7, enabling free access to patients on demand. In 
urgent cases, an emergency team with an ambulance is 
available. The team consists of a physician on call and two 
specialist nurses providing the emergency medical services 
(EMS). This is a major difference between Slovenian and 
most European OOHC clinics, as OOHC in the majority of 
the European countries is organised separately from the 
EMS (17). 
To date, only one paper has dealt with patient safety 
culture in Slovenian OOHC clinics (24). We therefore 
decided to study this issue further to get some insight into 
this area. We aimed to investigate patient safety culture 
in Slovenian OOHC clinics, and determine the possible 
factors that might be associated with it. 
2 METHODS
2.1 Type of Study and Settings
This was a cross-sectional study that took place in 
Slovenian OOHC clinics from 16 March to 1 May 2015. The 
study was part of an international study entitled Patient 
Safety Culture in European Out-of-Hours Services (SAFE-
EUR-OOH), which was led by a coordinating research group 
from Norway. The study was a project by the European 
research network for out-of-hours primary health care 
(EurOOHnet) (25).
In Slovenia, there are 60 OOHC clinics and all were invited 
to participate; 37 of them agreed to do so. There are 
10 health care regions in Slovenia, which correspond to 
geographical regions: Murska Sobota, Maribor, Ravne na 
Koroškem, Celje, Krško, Novo Mesto, Ljubljana, Kranj, 
Nova Gorica, and Koper. The participating OOHC clinics 
were grouped according to these regions: seven OOHC 
clinics from the Ljubljana region, five from the Kranj and 
Ravne na Koroškem regions, four from the Koper region, 
three from the Murska Sobota, Maribor, Celje, Krško, and 
Novo Mesto regions, and one from the Nova Gorica region.
2.2 Participants
In each OOHC clinic, the person in charge of data 
collection asked all the employees (physicians, nurse 
practitioners, nurse managers, trainees, practice 
nurses, radiology technicians, and office managers) to 
participate. Following this procedure, 438 people were 
invited to participate. The participation was voluntary 
and anonymous.
2.3 Data Collection
The key national researcher for Slovenia (ZKK) collected 
the e-mail addresses of all the invited employees of the 37 
participating OOHC clinics in Slovenia. An e-questionnaire 
was sent by the coordinating research group in Norway 
to these employees on 16 March 2015. After two weeks, 
an automatic reminder was sent to those who had not 
responded. The e-questionnaires were sent using the 
computer programme, Qualtrics.
We used the Slovenian version of the SAQ-AV (24), which 
has been translated from English according to standard 
procedures (26). The SAQ-AV is a 62-item questionnaire 
where the respondents rate their agreement using a 
5-point Likert scale: 1=disagree strongly, 2=disagree 
slightly, 3=neutral, 4=agree slightly, 5=agree strongly (27). 
“Not applicable” was included as a response category in 
all questions, and combined with missing values in the 
data analyses. The scores of negatively worded items 
were reversed, so that higher scores in the data set always 
indicated a more positive evaluation of the OOHC clinics’ 
patient safety culture. Additionally, there were also 
some demographic questions (sex, age, function, work 
10.1515/sjph-2017-0028 Zdr Varst 2017; 56(4): 203-210
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experience, shifts, and type of employment). “Variable 
shifts” describes the different types of possible working 
hours: days, evenings, nights, and variable/rotating shifts. 
The Slovenian version of the SAQ-AV has five safety climate 
factors: Perceptions of Management, Job Satisfaction, 
Safety Climate, Teamwork Climate, and Communication 
(24). The total score of the SAQ-AV was calculated 
according to the Baker and Hershaw equation (28): 
[(Σitems 1-62) * 100/(5 * 62)] * 1.25 – 25. 
Similarly, the scores of the individual factors were 
calculated as: 
[(Σitems) * 100/(5 * N of items)] * 1.25 – 25. 
So, the minimum score was 0 and the maximum score was 
100 for the overall SAQ-AV score, as well as for each of 
the factors.
2.4 Analysis
Statistical analysis was carried out using the SPSS 22.0 
programme. We performed bivariate analysis using the 
independent t-test and one-way ANOVA, and multivariate 
analysis using linear regression. The variables that proved 
significant in the bivariate analyses were entered into 
the multivariate analysis. We set the limit of statistical 
significance at p<0.05.
3 RESULTS
3.1 Demographic Characteristics
Out of 438 invited participants, 250 answered the 
questionnaire (57.1% response rate). There were 110 
(44.0%) women in the sample (Table 1). 
3.2 Attitudes to Patient Safety Culture
The mean overall score ± standard deviation of the SAQ 
was 56.6±16.0 points; of Perceptions of Management 
53.6±19.6 points; of Job Satisfaction 48.5±18.3 points; 
of Safety Climate 59.1±22.1 points; of Teamwork Climate 
72.7±16.6; and of Communication 51.5±23.4 points.
The highest climate scores of patient safety culture were 
reported in the Nova Gorica region and the lowest in 
Koper. Perceptions of Management was scored highest in 
the Krško region, and Job Satisfaction, Safety Climate, 
Teamwork Climate, and Communication were scored 
highest in the Nova Gorica region. There were significant 
differences across regions in terms of the overall total 
SAQ-AV score, and of the climate factors Perceptions of 
Management, Job Satisfaction, and Communication (Table 
2). 
Table 1. Demographic characteristics of the Slovenian 
out-of-hours primary health care clinics’ employees 
participating in the study (N=250).
Sex
Male
Female
Not given
Age (years)
30 and lower
31-40
41-50
51-60
61 and higher
Not given
Usual shift
Days
Evenings
Nights
Variable
Not given
Type of employment
Full-time
Part-time
Contract
Not given
Work experience (years)
5 or less
6-10
11-20
21-30
31-40
41 or more
Not given 
Function
Physicians
Nurse practitioners
Nurse managers
Trainees
Practice nurses
Radiology technicians
Office managers
Not given
Region of Slovenia
Murska Sobota
Maribor
Ravne na Koroškem
Celje
Krško
Novo Mesto
Ljubljana
Kranj region
Nova Gorica region
Koper region
Not given
91 (36.4)
110 (44.0)
49 (19.6)
41 (16.4)
74 (29.6)
49 (19.6)
33 (13.2)
4 (1.6)
49 (19.6)
3 (1.2)
2 (0.8)
4 (1.6)
192 (76.8)
49 (19.6)
191 (76.4)
7 (2.8)
3 (1.2)
49 (19.6)
46 (18.4)
39 (15.6)
65 (26.0)
41 (16.4)
9 (3.6)
1 (0.4)
40 (19.6)
93 (37.2)
43 (17.2)
3 (1.2)
15 (6.0)
40 (16.0)
1 (0.4)
7 (2.8)
48 (19.2)
7 (2.8)
45 (18.0)
34 (13.6)
15 (6.0)
15 (6.0)
21 (8.4)
33 (13.2)
28 (11.2)
2 (0.8)
18 (7.2)
32 (12.8)
Characteristic N (%)
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206
Table 2. The scores of SAQ-AV and its factors in the Slovenian out-of-hours primary health care clinics of different Slovenian regions.
Perceptions of Management
Job Satisfaction
Safety Climate
Teamwork Climate
Communication
Overall SAQ-AV score
60.7 
(27.5)
50.6 
(16.6)
54.5 
(24.1)
76.2 
(12.2)
47.6 
(26.6)
57.9 
(16.6)
62.8 
(11.0)
51.7 
(19.4)
56.7 
(31.2)
75.6 
(15.5)
52.8 
(10.8)
57.5 
(16.8)
48.0 
(22.1)
45.0 
(20.9)
63.1 
(22.7)
65.4 
(19.4)
48.2 
(26.3)
53.6 
(18.7)
49.6 
(20.7)
41.5 
(20.2)
51.8 
(22.7)
73.0 
(14.6)
49.2 
(23.7)
52.7 
(16.0)
62.5 
(11.8)
66.7 
(5.9)
71.9 
(4.4)
79.2 
(5.9)
87.5 
(17.7)
73.5 
(0.3)
60.5 
(13.5)
57.7 
(10.2)
67.4 
(14.6)
77.8 
(13.6)
59.3 
(17.9)
64.5 
(9.4)
50.3 
(18.9)
51.4 
(14.6)
59.6 
(21.3)
74.2 
(16.7)
60.1 
(22.5)
58.5 
(15.4)
41.9 
(25.6)
43.5 
(24.2)
55.5 
(24.7)
69.9 
(22.3)
44.9 
(25.4)
51.2 
(21.3)
53.9 
(16.4)
41.7 
(20.7)
55.8 
(16.1)
67.2 
(13.5)
41.1 
(22.3)
51.9 
(15.1)
60.8 
(12.5)
50.5 
(14.7)
60.3 
(19.6)
77.7 
(12.4)
51.0 
(23.5)
60.1 
(12.3)
0.005
0.018
0.309
0.055
0.033
0.035
Murska 
Sobota
Mean (SD)
KrskoMaribor Novo 
Mesto
Nova
Gorica
Ravne na 
Koroskem
Ljubljana KoperCelje Kranj P
Bivariate analyses for the overall total SAQ-AV score 
revealed that physicians (t=1.992, p<0.048), practice 
nurses (t=1.882, p=0.049), those working in variable shifts 
(t=4.842, p<0.001), those working full-time (t=5.581, 
p<0.001), and those working in the Ravne na Koroškem 
region (t=4.571, p<0.001) had significantly higher scores 
when compared to the other categories. 
For the factor Perceptions of Management, bivariate 
analyses showed that those working in variable shifts 
(t=2.139, p=0.046), full-time (t=2.930, p=0.004), in the 
Ravne na Koroškem region (t=2.918, p=0.005), in the 
Krško region (t=2.827, p=0.012), and in the Kranj region 
(t=2.835, p=0.007) had significantly higher scores when 
compared to the other categories. 
For the factor Job Satisfaction, bivariate analyses 
revealed that those working in variable shifts (t=4.022, 
p=0.001), full-time (t=4.550, p<0.001), and in the Ravne 
na Koroškem region (t=4.816, p<0.001) had significantly 
higher scores when compared to the other categories. 
Bivariate analyses for the factor Safety Climate showed 
that practice nurses (t=3.821, p<0.001), and those working 
in variable shifts (t=4.506, p<0.001), full-time (t=5.514, 
p<0.001), and in the Ravne na Koroškem region (t=3.230, 
p=0.002) had significantly higher scores when compared 
to the other categories.
For the factor Teamwork Climate, bivariate analyses 
revealed that physicians (t=3.106, p=0.002), those working 
in variable shifts (t=2.489, p<0.001) or full-time (t=4.052, 
p<0.001), and participants working in the Maribor region 
(t=-2.735, p=0.009) had significantly lower scores when 
compared to the other categories. 
Bivariate analyses for the factor Communication showed 
that physicians (t=2.075, p=0.039), those working in 
morning shifts (t=4.238, p<0.001), those not working in 
afternoon shifts (t=-6.064, p<0.001), those working in 
variable shifts (t=3.243, p=0.005), those working full-
time (t=3.328, p=0.003), and those working in the Ravne 
na Koroškem region (t=2.122, p=0.035), in the Ljubljana 
region (t=2.146, p=0.033), and in the Nova Gorica region 
(t=2.208, p=0.026) had significantly higher scores when 
compared to the other categories. Participants working 
in afternoon shifts had significantly lower scores when 
compared to those working in morning, afternoon, or 
variable shifts.
Variables significantly associated with higher SAQ-AV 
scores in the multivariate analysis were employees working 
in the Ravne na Koroškem region, those with variable 
shifts, and those with full-time jobs. Higher scores in the 
factor Job Satisfaction were significantly associated with 
variable shifts, a full-time job, and working in the Ravne 
na Koroškem region. Employees working in variable shifts 
and having a full-time job scored significantly higher on 
both the Safety Climate and Teamwork Climate factors. On 
the contrary, those working in the Maribor region scored 
significantly lower on these factors. Employees working in 
variable shifts, having a full-time job, and working in the 
Ravne na Koroškem, Ljubljana and Nova Gorica regions 
scored significantly higher in the factor Communication 
(Table 3).
10.1515/sjph-2017-0028 Zdr Varst 2017; 56(4): 203-210
207
Table 3. Multivariate analysis for the scores of SAQ-AV and its five factors in the Slovenian out-of-hours primary health care clinics.
1 F=19.445, df=5, p<0.001, adjusted R2=0.30
2 F=3.981, df=8, p<0.001, adjusted R2=0.10
3 F=36.790, df=3, p<0.001, adjusted R2=0.33
4 F=18.266, df=4, p<0.001, adjusted R2=0.24
5 F=11.419, df=5, p<0.001, adjusted R2=0.19
6 F=6.286, df=8, p<0.001, adjusted R2=0.16
Overall SAQ-AV score1
Perceptions of Management2
Job Satisfaction3
Safety Climate4
Teamwork Climate5
Communication6
Ravne na Koroskem region
Physicians
Practice nurses
Variable shifts
Full-time job
Afternoon shift
Variable shifts
Full-time job
Maribor region
Ravne na Koroškem region
Krsko region
Kranj region
Koper region
Variable shifts
Full-time job
Ravne na Koroskem region
Variable shifts
Full-time job
Ravne na Koroskem region
Practice nurses
Variable shifts
Full-time job
Practice nurses
Physicians
Maribor region
Variable shifts
Full-time job
Physicians
Morning shift
Afternoon shift
Ravne na Koroskem region
Ljubljana Region
Nova Gorica region
7.46
2.98
1.54
13.70
14.30
14.68
10.85
5.73
-4.60
6.62
9.19
6.93
-9.14
21.84
19.17
9.71
14.72
19.93
5.48
7.07
8.26
14.67
-3.19
2.27
-8.25
19.15
12.89
5.03
23.71
-0.82
10.70
9.39
34.03
2.82
1.43
0.56
3.63
3.93
1.00
1.88
1.07
-1.27
1.68
1.59
1.63
-1.88
5.15
4.61
3.42
2.80
3.83
1.45
1.98
1.98
3.65
-1,07
0.94
-3.03
2.44
1.98
1.64
1.39
-0.05
2.49
2.13
2.22
2.24-12.67
1.14-7.11
3.90-6.99
6.27-21.14
7.14-21.57
14.28-43.65
-0.53-22.23
-4.78-16.24
-11.72-2.51
-1.12-14.36
-2.15-20.55
-1.47-15.34
-18.72-0.43
13.48-30.20
10.98-27.36
4.11-15.32
4.37-25.07
9.67-30.19
-1.98-12.94
0.04-14.10
0.02-16.50
6.75-22.60
-9.08-2.70
-2.50-7.06
-13.62-2.87
3.65-34.65
0.06-25.73
-1.02-11.09
-9.95-57.38
-35.41-33.77
2.24-19.15
0.70-18.08
3.86-64.20
0.005
0.155
0.577
<0.001
<0.001
0.319
0.062
0.284
0.204
0.093
0.112
0.105
0.061
<0.001
<0.001
0.001
0.006
<0.001
0.149
0.049
0.049
<0.001
0.287
0.349
0.003
0.016
0.049
0.103
0.166
0.963
0.013
0.034
0.027
Independent variables B 95% CI T PDependent 
variable
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208
4 DISCUSSION
This was the first study investigating patient safety 
culture in Slovenian OOHC clinics (24). It showed that 
the Teamwork Climate scores were the highest and Job 
Satisfaction scores were the lowest among the employees.
The fact that Teamwork Climate scores were the highest 
correlates with the results of the Slovenian study on 
ethical dilemmas in family medicine, where teamwork 
also seemed to be functioning well (29, 30). Teamwork 
as part of safety culture also scored high in hospital 
settings in Slovenia (10). Teamwork is very important 
in primary care, as health care providers with different 
professional backgrounds are engaged in the management 
of patients (31). This is also true for the OOHC clinics. 
In this setting, close cooperation between different 
professions is required (17). In fact, teamwork climate 
has been recognised as a key patient safety issue in OOHC 
clinics (24, 27, 32), and quality of performance seems to 
be associated with teamwork quality (33, 34). 
Slovenian workers in OOHC clinics are, however, often 
not satisfied with their jobs, and this also seems to be 
reflected in their perceptions of patient safety culture. 
This finding was expected, as there is a big shortage of 
both physicians and nurses in Slovenia, and many are 
overburdened (35-37). In Slovenia, OOHC and emergency 
services are usually performed by the same team. 
Physicians often work in OOHC part-time, and in addition 
to their official working hours. In some regions, they work 
at two different job posts at the same time – in their own 
practice and in OOHC (17, 36). This is especially true for 
rural settings in Slovenia. Since the organisational domain 
is important in terms of safety culture (38), the varying 
organisational models in Slovenian OOHC clinics might 
be partly responsible for the observed differences in the 
SAQ-AV factor scores across the Slovenian regions.
Several factors contributed to the variation in climate 
scores across groups of employees in Slovenian OOHC 
clinics. Employees working as physicians or nurses, 
working in variable shifts and working full-time, had the 
highest scores. Working in variable shifts could contribute 
to a higher perception of patient safety, because the 
employees that work variable shifts may feel more 
competent to manage patients in different circumstances. 
The finding that working full-time possibly contributes to 
higher perception of patient safety is interesting. Studies 
have focused more on the impact of longer working hours 
and overtime working on patient safety (39), and we could 
not find any study on the associations between patient 
safety and part/full-time working hours. We anticipate 
that employees working part-time are not so confident in 
their performance (40), and thus perceive patient safety 
lower. 
The scores of some factors varied across different 
Slovenian regions. This was especially true for the 
factors Perceptions of Management and Communication. 
Communication about safety issues in teams is very 
important and affects patient safety (41). It is probably 
connected to Perceptions of Management, as here also 
communication plays an important role. 
It seems that the factors revealed to be important for a 
culture of safety in our study explained a large degree 
of the variation of the safety culture in Slovenian OOHC 
clinics, but according to the variances, the multivariate 
models explained are not the only ones. 
Safety culture in OOHC has also been studied in Norway 
(13), and safety culture in emergency departments has 
been studied in the USA (21). In Norway and in the USA, 
the factor Job Satisfaction scored highest (13, 21), while 
in our study, it scored lowest. In our study, physicians 
scored significantly higher than nurses in Communication 
and Teamwork Climate, and in Norway (13), nurses 
scored higher in Safety Climate and Job Satisfaction. In 
the study from the USA (21), there were no differences 
between full-time and part-time workers regarding safety 
climate scores, which is not in line with the results of 
our study. It seems that safety climate in OOHC differs 
across countries, and further studies are needed to gain 
a deeper insight into these differences and their causes. 
This study has some limitations. It aimed to include all 
OOHC clinics in Slovenia; however, only two-thirds of them 
were willing to participate. Similarly, only 250 respondents 
out of 438 invited employees filled in the questionnaire. 
Even though the proportion of participating clinics and the 
response rate of employees were moderately high, one 
still has to be careful about generalising the findings to 
the OOHC clinics of the entire country. On the other hand, 
the results of this study correlated with similar Slovenian 
studies, which gives us confidence in their reliability and 
validity. 
5 CONCLUSION
Safety culture in Slovenian OOHC clinics needs 
improvement. The variations in safety culture factor 
scores in Slovenian OOHC clinics point to the need to 
unify working conditions in all Slovenian OOHC clinics. 
When planning safety culture improvements, the factors 
that were shown to be important in this study should be 
considered. We suggest reducing workload, more full-
time employment, and educating communication and 
management skills. Further studies are needed to detect 
other possible factors important in safety culture in OOHC 
clinics, and to reveal the possible causes of the current 
situation.
10.1515/sjph-2017-0028 Zdr Varst 2017; 56(4): 203-210
209
ACKNOWLEDGEMENTS
We thank all the workers in OOHC in Slovenia for 
participating in the study.
CONFLICTS OF INTEREST
The authors declare that no conflicts of interest exist.
FUNDING
The National Centre for Emergency Primary Health 
Care, Uni Research Health, Bergen, Norway, covered 
the expenses regarding the translation/back-translation 
of the Safety Attitudes Questionnaire and the data 
collection. Further, the Norwegian coordinating research 
group covered the expenses for the statistical analyses.
This study was partially supported by an unrestricted 
programme grant from the National Research Agency, P3 
0339.
ETHICAL APPROVAL
The study was approved by the National Ethics Committee 
of the Republic of Slovenia (No. 25/11/14).
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