A Structural Equation Model of the Relationship among Safety Leadership, Safety Management, Safety Culture and Safety Performance of Head Nurses at Regional Hospitals under the Ministry of Public Health

Main Article Content

Sudthicharat Jantiya
Phechnoy Singchongchai
Patcharaporn Aree


Introduction: Safety performances are an important factor for health organizations, especially nursing organizations aiming to ensure the safety of both providers and customers. Research objectives: This study aimed to: (a) assess perceived safety leadership, safety management, safety culture, and safety performance of head nurses working at regional hospitals under the jurisdiction of the Ministry of Public Health; and (b) construct a structural equation model of the structural relationships among these four variables and test model fit of an empirical data. Research methodology: This is a quantitative study. Data were collected from 331 head nurses using a five-point rating scale questionnaire consisting of four domains, namely, perceived safety leadership, safety management, safety culture, and safety performance. Results: Finding showed that the average scores of all four dimensions of perceived safety were at a high level. The structural equation model of safety performance of head nurses was well fit with an empirical data (CMIN/DF= 1.96, GFI= 0.93, AGFI= 0.91, CFI= 0.99, RMSEA = 0.05). Safety leadership, safety management, and safety culture together explained 65% of the variation in safety performance. Safety leadership had positive direct effects on both safety management (β= .90, p< .01) and safety culture (β= .34, p< .01). On the other hand, safety management had a positive direct effect on safety culture (β= .57, p< .01). On one hand, safety culture had a positive direct effect on safety performance (TE = 0.81, p<0.01), while safety leadership and safety management had a statistically significant indirect effect on safety performance (TE= .69, p< .01). Conclusions: The structural equation model of the structural relationship of safety performance can be well applied in the real situation. Implication: It is recommended that the administrators of nursing organizations include the results of this study as one of the criteria for recruitment of head nurses who must demonstrate safety leadership. The results can be used to guide the development of training programs in safety leadership and safety management of nursing administrators. Promotion of safety culture must be put in place to make effective safety practices under the management of head nurses. Consequently, the better nursing care quality would be attained.


Download data is not yet available.

Article Details

How to Cite
Jantiya, S., Singchongchai, P., & Aree, P. (2021). A Structural Equation Model of the Relationship among Safety Leadership, Safety Management, Safety Culture and Safety Performance of Head Nurses at Regional Hospitals under the Ministry of Public Health. Journal of Health and Nursing Research (Journal of Boromarajonani College of Nursing, Bangkok), 37(2), 36-49. Retrieved from https://he01.tci-thaijo.org/index.php/bcnbangkok/article/view/251171
Research articles


1. Office of Strategy and planning Division Strategy Office of the Public Health Department Ministry of Public Health. 20 Year National Strategic Plan (Public Health). Nonthaburi: Office of Policy and Strategy Office of the Permanent Secretary 2010. (in Thai)
2. World Health Organization Patient safety. 2016. [cited 2018 July 25] Available from http://www. who.int/ patientsafety/en/

3. Nursing Division, Office of the Permanent Secretary, Ministry of Public Health A Guide to Collecting
Important Nursing Information 2017, Nonthaburi: Nursing Division, Office of the Permanent Secretary, Ministry of Public Health. 2017. (in Thai).

4. Nursing Council. Standard of nursing service and midwife at secondary and tertiary level. Nonthaburi: Nursing Council. 2005. (in Thai).

5. Institute for Hospital Quality Assurance (Public organization). Hospital and Health Service Standards, Issue 4. Nonthaburi: Good Day Books. 2018. (in Thai).

6. Announcement of Nursing Council on Nursing Standards, 2019, Nursing Council, 2019) Announcement of the Nursing Council on Nursing Standards, B.E. 2562 (2019, 20 February). Government Gazette. Volume 136, Special episode 97 d; 30-6. (in Thai)

7. Griffin MA, Neal A. Perceptions of safety at work: a framework for linking safety climate to safety performance, knowledge, and motivation. J Occup Health Psychol 2000;5(3):347-58.

8. Nevhage B, Lindahl H. A conceptual model, methodology and tool to evaluate safety performance in an organization (Master's Degree) Land University. 2008 [cited 2019 Jul 20] Available from: http://lup.lub.lu.se/ student-papers/record/178699332.

9. Cooper MD, The Safety Culture Construct: Theory and Practice. In: Gilbert C, Jurne B, Laroche H, Bieder C, editors. Safety Cultures, Safety Models Taking Stock and Moving Forward.The registered company Springer Nature Switzerland AG; 2018; 47-62.

10. Cooper MD. Improving safety culture: A practical guide. Wiley; 1998.

11. Cooper, MD. Safety leadership. 2010a. [cited 2018 Jul 21] Available from: http://www.behavioral-safety.
com/behavior-based-safety -solution-center/safety-coaching-and-training/safety–leadership.

12. Jantiya S, Singchongchai P, Aree P, Safety Leadership and Safety Performance in Health Organization: A Systematic Review. Boromarajonani College of Nursing, Uttaradit Journal 2019;2(11):1-15. (in Thai).

13. Clarke SR. Safety leadership: A met analytic review of transformational and transactional leadership styles as antecedents of safety behaviors. J of Occupational and Organizational Psychology 2013;86(1):22-49.

14. Tao J, Yang F, Qiu D, Reniers G. Analysis of safety leadership using a science mapping approach. J Process Safety and Environmental Protection 2020;(140):244-57

15. Cooper MD. Navigating the safety culture construct: A review of the evidence. B-Safe Management Solutions Inc. Franklin, IN, USA; 2016.p. 4-16.

16. Donovan SL, Salmon PM, Horberry T, Lenne MG. Ending on a positive: examining the role of safety leadership decisions, behaviors and actions in a safety critical situation. Appl. Ergon 2018;(66):139–50.

17. Cooper, M D. Towards a model of safety culture. J Safety science 2000;2(36):111-36.

18. Surienty L, Khoo TH, Daisy KM. Occupational safety and health (OSH) in SMEs in Malaysia: a preliminary investigation. J of Global Entrepreneurship 2011;1(1):65-75.

19. Seangon L, sritoomma N, Wongkhomthong J, Meehanpong P. The safety management modelof nursing organization at the tertiary-level hospitals in Thailand. J Christian University. 2018;24(4):516-29. (in Thai).

20. Yang CC, Wang YS, Chang ST, Guo SE, Huang, MF. A study on the leadership behavior, safety culture, and safety performance of the healthcare industry. J World Academy of Science, Engineering and Technology 2009;53(1):1148-55.

21. Tengilimoglu D , Celik E, Guzel A. The effect of safety culture on safety performance: Intermediary role of job satisfaction. BJEMT 2016;15(3):1-12.

22. Fernández-Muñiz B, José Manuel MP, Camilo José V-O. Safety culture: analysis of the causal relationships between its key dimensions. Journal of Safety Research 2007;(386);627-41.

23. Adjekum DK, Keller J, Walala M, Christensen C, DeMik RJ, Young JP, et al. An examination of the relationships between safety culture perceptions and safety reporting behavior among non-flight collegiate aviation majors. International Journal Aviation, Aeronautics, and Aerospace 2016;3(3):1-38.

24. Lun CJ, Shah RAW. The effects of safety leadership on safety performance in Malaysia. Saudi Journal of Business and Management 2011;2(1):12-8.

25. Dilaver D, Elif C, Alper G. The Effect of Safety Culture on Safety Performance: Intermediary Role of Job Satisfaction. British Journal of Economics, Management & Trade 2016;15(3);1-12.

26. International Civil Aviation Organization [ICAO]. Safety Management Manual (SMM) (2nded.) (Doc 9859 AN/474). Montreal, Canada 2009.

27. Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J. Thomas E.J. The safety attitudes questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Services Research 2006;6(1):44.

28. Krejcie RV, Daryle W. Determining sample size for research activities. Educational and Psychological Measurement 1970;30(3):607-10.