The Impact of Market Orientation on Patient Safety Climate Among Hospital Nurses

Abstract

Improving market orientation and patient safety have become the key concerns of nursing management. For nurses, establishing a patient safety climate is the key to enhancing nursing quality. This study explores how market orientation affects the climate of patient safety among hospital nurses. We proposed adopting a cross-sectional research design and using questionnaires to collect responses from nurses working in two Taiwanese hospitals. Three-hundred and forty-three valid samples were obtained. Multiple regression and path analyses were conducted to test the study. Market orientation was defined as the combination of customer orientation, competitor orientation, and interfunctional coordination. Customer orientation directly affects the climate of patient safety. Although the findings only supported Hypothesis 1, competitor orientation and interfunctional coordination positively affected the patient safety climate through the mediating effects of hospital support for staff. Health care managers could encourage nurses to adopt customer-oriented perspectives to enhance their nursing care. In addition, to enhance competitor orientation, interfunctional coordination, and the patient safety climate, hospital managers could strengthen their support for staff members.

Keywords

patient safety climate patient safety market orientation nursing care hospital nurse

Introduction

Patient safety has become the primary focus of health care reform; in 2001, the Joint Commission on the Accreditation of Healthcare Organizations cited patient safety as its evaluation focus for health care systems. The International Council of Nurses named patient safety the core theme of the 2005 International Nursing Conference. For health care organizations, the work environment is an important influencer of patient safety (Bae, 2011). Health care professionals should develop individual strategies suitable to the features of each unit to establish a safe patient climate and increase patient safety (Hughes, Chang, & Mark, 2009). Consequently, developing a strong patient safety climate has become a key component of medical quality in hospitals (Singer, Rosen, Zhao, Ciavarelli, & Gaba, 2010).

To address the considerable instability of health care markets, hospitals have begun to develop market orientation to improve their organizational performance (Wood, Bhuian, & Kiecker, 2000). Since the global budget program was implemented in Taiwan, market orientation has become the primary adaptive strategy used by hospitals in the Taiwanese health care market (Huang, Weng, Lai, & Hu, 2013). Market orientation can be divided into the dimensions of customer orientation, competitor orientation, and interfunctional coordination (Narver & Slater, 1990); for health care organizations, patients are considered the key customers. Developing a customer/patient orientation enables nurses to prioritize patient benefits and safety, prompting them to proactively search for methods to minimize risks; this decreases the chance of adverse events occurring during medical processes (Darby & Daniel, 1999; Hunt, 2010; Wolf et al., 2008). Furthermore, a competitor orientation enables hospital managers to elucidate the strengths, abilities, and actions of their competitors to improve health care quality and patient value (Huang, Hu, Lai, & Weng, 2011; Wood et al., 2000). When employees perceive customer satisfaction as a form of duty, they are willing to share their feelings with their colleagues (Kohli, Jaworski, & Kumar, 1993). Effective communication among frontline staff facilitates providing medical departments with the information required to reduce patient safety problems (Tucker, Singer, Hayes, & Falwell, 2008). If all departments can effectively cooperate and communicate with each other, patient safety value, awareness, and actions will be diffused among all levels of departments in a hospital (Dixon-Woods, 2010; Havens, Vasey, Gittell, & Lin, 2010).

Nurses are the primary providers of inpatient care in hospitals and their perceptions of the work environment affect patient safety; therefore, nurses are the key to improving patient safety (Stone et al., 2007). The level of focus that nurses exhibit when caring for patients determines patient safety (Norris, 2009). Nurses continually care for patients while simultaneously monitoring patient safety; this affects the patient safety climate and directly influences the patient safety outcome (Bae, 2011). For nurses, establishing a patient safety climate is important to enhancing nursing quality. Therefore, this study explores how market orientation affects the patient safety climate among hospital nurses in Taiwan.

Market Orientation

Market orientation is an important organizational climate that produces the behaviors necessary to generate superior customer value; this ensures the continued optimal performance of hospitals (Wood et al., 2000). Narver and Slater (1990) proposed that the organizational climate comprises three components: customer orientation, competitor orientation, and interfunctional coordination; however, according to Kohli and Jaworski (1990), market orientation can be considered a multistage process that involves generating market intelligence, disseminating information, and ensuring organizational responsiveness. Although these scholars used distinct theoretical bases to explain market orientation, a customer and competitor orientation typically involves acquiring target customer and competitor intelligence and disseminating this information throughout an organization. Interfunctional coordination reflects the level to which organizational members interact with and respond to the acquired information (Chen & Quester, 2009). Therefore, Narver and Slater offer the same argument as Kohli and Jaworski (Lee et al., 2010). In summary, numerous hospitals and health professionals value market orientation that comprises customer orientation, competitor orientation, and interfunctional coordination (Huang et al., 2013). Previous studies have proven that market orientation positively affects profitability, product development, service quality, sales growth, customer retention, and cost control (Lonial & Raju, 2001; Raju, Lonial, Gupta, & Ziegler, 2000; Wrenn, 2002); however, no studies have explored how market orientation affects patient safety.

Patient Safety Climate

The patient safety climate is relevant to shared perceptions of practices, policies, procedures, and routines regarding patient safety in an organization (Singer et al., 2009). The construct of patient safety includes multiple dimensions; however, previous research has attained no consensus regarding these dimensions (Flin, Burns, Mearns, Yule, & Robertson, 2006; Hughes et al., 2009). After reviewing relevant literature, Naveh, Katz-Navon, and Stern (2005) and Katz-Navon, Naveh, and Stern (2005) identified four key dimensions of a patient safety climate which correspond to employee perceptions regarding four initiatives: safety procedures, managerial safety practices, safety information flow, and safety priority. Safety procedures refer to the shared perceptions of employees regarding the level of detail in the safety procedures of an organization. Managerial safety practice refers to employee perceptions regarding the safety-related activities and methods of supervisors. Safety information flow refers to employee perceptions regarding the amount of information they receive through circulation of routine information and training. Safety priority is the degree of concern assigned to safety within an organizational unit. Naveh et al. and Katz-Navon et al. sampled American hospital employees, verifying that this type of four-dimensional measurement is suitable for all hospital employees. Weng, Huang, Huang, and Wang (2012) adopted the arguments of Naveh et al. and Katz-Navon et al. to define and measure the patient safety climate among hospital nurses. Compared with previous dimensions, the four dimensions provide a strong theoretical and empirical basis for measuring patient safety climate. Thus, we defined patient safety climate as the sum of the patient safety procedures, managerial patient safety practices, patient safety information flow, and patient safety priority perceived by nurses in the hospital workplace.

Relationship Between Market Orientation and Patient Safety Climate

Numerous hospitals consider customer orientation as an important business strategy (Dobni & Luffman, 2003), aiming to satisfy patient needs by providing medical care that meets customer expectations (Raju et al., 2000). Developing customer orientation improves the work satisfaction of nurses, subsequently satisfying the customers (Darby & Daniel, 1999; Singer, Gaba, & Geppert, 2003). Developing a customer/patient orientation enables nurses to prioritize patient benefits and safety, prompting them to proactively search for methods of minimizing risks; this decreases the chance of adverse events occurring during medical processes (Darby & Daniel, 1999; Hunt, 2010; Wolf et al., 2008). When the staff members highly value patient safety, safety information proliferates throughout the organization (Katz-Navon, Naveh, & Stern, 2005). In addition, the primary customers of hospitals are patients. Nurses who exhibit a high level of customer orientation work diligently to understand patient needs and actively perform patient-centered actions (e.g., patient safety), developing relevant procedures and rules based on their concerns (Berry, Seiders, & Wilder, 2003). Furthermore, nurses and managers proactively search for methods of decreasing risks during medical procedures, consequently decreasing the occurrence of adverse events; this enhances the overall patient safety climate (Berntsen, 2006; Squires, Tourangeau, Laschinger, & Doran, 2010). This indicates that patient-centered actions performed by hospital staff are beneficial for patient safety climate through the creation or improvement of patient care principles, rules, and procedures that hospital staff can realistically apply (Hunt, 2010; Wolf et al., 2008). Therefore, we propose Hypothesis 1: Customer orientation is positively associated with the patient safety climate.

Competitor orientation refers to the ability of the organizational staff members to monitor the strategies and actions of competitors, allowing competitive knowledge to be distributed and shared among departments (Grinstein, 2008; Narver & Slater, 1990). Understanding competitor actions and reactions and adjusting internal practices to optimize resources allow hospitals to establish competitive advantages and attain organizational objectives (Raju et al., 2000). In response to increasing market competition, numerous hospitals are actively improving their medical care quality to attain competitive advantages. Enhancing the patient safety climate is the key to improving medical quality (Hughes et al., 2009). Therefore, based on the argument of Narver and Slater (1990), when hospitals have a strong competitor orientation and consider strengthening the patient safety climate a crucial strategy, nurses actively collect information regarding the patient safety–related strategies and actions of competitors to learn relevant safety practices. In addition, numerous hospitals in the global health care market have begun to view patient safety as the key to improving medical quality (Tzeng & Yin, 2007); thus, a high level of competitor orientation enables hospital managers to focus on patient safety, elucidating the increasingly fierce safety-related competition. To achieve a stronger patient safety performance compared with competitors and improve the overall patient safety climate, hospital managers must provide support and resources, coordinating and integrating patient safety activities, procedures, and information (Devers, Pham, Liu, & Berenson, 2004; Stewart & Usher, 2010; Vlayen, Hellings, Claes, Peleman, & Schrooten, 2012). Therefore, we propose Hypothesis 2: Competitor orientation is positively associated with the patient safety climate.

If an organization exhibits a high level of interfunctional coordination, staff members are willing to share and communicate important information with other organizational members; thus, market intelligence is shared among all departments, ensuring that the provided services cater to customer needs (Grinstein, 2008). Sufficient communication and coordination is important to improving the quality of nursing care and the patient safety climate (Hughes et al., 2009). Cross-level and interdepartmental interaction and communication regarding patient safety information are the primary factors influencing how hospital staff members perceive patient safety (Havens et al., 2010; Matsubara, Hagihara, & Nobutomo, 2008). This indicates that the departments and specialists within hospitals must communicate and coordinate to promote patient safety, enabling safety-related values, awareness, and actions to be promulgated throughout the hospital; such cooperation enhances how nurses and managers view patient safety, enhancing relevant patient safety policies and procedures (Anthony & Preuss, 2002; Hughes et al., 2009; Leonard, Graham, & Bonacum, 2004; Tucker et al., 2008). Therefore, we propose Hypothesis 3: Interfunctional coordination is positively associated with the patient safety climate.

Materials and Methods

Data Source

The research participants comprised frontline nurses from two hospitals in Taiwan which were equal to or above the regional level. These hospitals provide similar clinical services and employ a combined 916 clinical and nonclinical nurses. Data were collected using questionnaires. The questionnaire survey was administered in the hospitals from April 11, 2010, to May 15, 2010. Hospital nurses provide nursing care in various departments and often cooperate with other medical staff members on project teams to deliver health services. Nurses who serve on distinct project teams express varying perceptions of the patient safety climate. Therefore, three to seven frontline nurses were randomly selected as respondents from each nursing team in each department. The selected teams were divided into two categories: departmental and project teams. Questionnaires were distributed to 393 nurses and 343 valid questionnaires were returned, yielding a valid response rate of 87.28%. The results of a Harman’s one-factor test indicated that the common method variance problem was not serious.

Measurement

The measurement method used in this study was a 5-point Likert-type scale, on which 1 = strongly disagree and 5 = strongly agree. The measurement items were translated from English to Chinese for the nurses in Taiwan and subsequently back-translated to English by a researcher who majored in market orientation and patient safety to confirm that the translation maintained the original meaning of each item. Market orientation was defined as the sum of customer orientation, competitor orientation, and interfunctional coordination as perceived by frontline nurses. The items referenced the Market Orientation (MKTOR) scales provided by Narver and Slater (1990) and 10 items, comprising 5 customer orientation items, 2 competitor orientation items, and 3 interfunctional coordination items. The range of each dimension of the Cronbach’s α demonstrated a reliability of .86 to .90. The patient safety climate was defined as the sum of patient safety procedures, managerial patient safety practices, patient safety information flow, and patient safety priority as perceived by frontline nurses. The items were generated by referencing the patient safety climate scales proposed by Naveh et al. (2005) and Katz-Navon et al. (2005), yielding 30 items: 8 items related to patient safety procedures, 8 items related to managerial patient safety practices, 7 items related to safety information flow, and 7 items related to the priority of patient safety. The range of each dimension of the Cronbach’s α demonstrated a reliability of .88 to .92. Table 1 lists the measurement items of market orientation and patient safety climate.

Table 1.

Construct Validity of Questionnaire Items.^a

Construct and item	Factor loading	Error variance	CR	AVE
Market orientation
Customer orientation			0.88	0.59
1. Our hospital effectively provides medical services so that the patients are willing to utilize our services over a long period of time	0.80***	0.36
2. Our hospital provides all patients with useful medical services continuously	0.84***	0.29
3. Our hospital is well aware of patients’ needs	0.80***	0.36
4. Our hospital attaches great importance to patient satisfaction	0.67***	0.55
5. Our hospital attaches great importance to after-treatment services that patients are provided with	0.73***	0.47
Competitor orientation			0.87	0.77
1. Our hospital responds rapidly to the new services and actions of other hospitals	0.90***	0.19
2. Our hospital is well aware of advantages and actions of other hospitals	0.86***	0.26
Interfunctional coordination			0.86	0.68
1. Departments of our hospital could effectively coordinate to satisfy patients’ needs	0.85***	0.28
2. Information on patients could be well disseminated among relative medical departments of our hospital	0.72***	0.48
3. Departments of our hospital would work together to provide excellent medical services	0.89***	0.21
Patient safety climate
Patient safety procedures			0.90	0.54
1. There are many written rules and procedures regarding patient safety in our team	0.71***	0.50
2. The rules and procedures regarding patient safety in our team are closely related to our jobs	0.73***	0.47
3. The rules and procedures regarding patient safety in our team are detailed and specific	0.82***	0.33
4. I am able to put the rules and procedures regarding patient safety in our team into practice	0.69***	0.53
5. The scope of the rules and procedures regarding patient safety in our team is extensive	0.61***	0.62
6. The rules and procedures regarding patient safety in our team enhance patient safety	0.78***	0.40
7. Our team has standard operating rules and procedures to deal with medical errors or adverse events	0.78***	0.40
8. I am aware that there are formal channels for responding to problems or information regarding patient safety	0.73***	0.46
Managerial patient safety practice			0.92	0.59
1. Our managers often remind employees to pay attention to issues of patient safety	0.83***	0.32
2. Our managers strictly obey the rules and procedures regarding patient safety	0.89***	0.22
3. When employees violate the rules and procedures regarding patient safety, our managers urge the employees to improve and follows up	0.81***	0.34
4. Our managers consider the employees’ effectiveness of implementing patient safety when evaluating employees’ performance and considering promotion	0.70***	0.50
5. Our managers are very unhappy when employees neglect patient safety	0.45***	0.80
6. Our managers try their best to avoid any risks that may threaten safety	0.81***	0.35
7. Our managers try their best to help me when there is a problem regarding patient safety	0.79***	0.38
8. Our mangers encourage employees to respond to any doubts regarding patient safety	0.79***	0.37
Patient safety information flow			0.91	0.59
1. Our team has fixed procedures to update the rules and procedures regarding patient safety	0.75***	0.44
2. The employees are regularly informed about the latest rules and procedures regarding patient safety	0.75***	0.44
3. Employees are often informed about the potential factors that risk patient safety	0.79***	0.38
4. There are many training opportunities to help employees to deal with problems regarding patient safety	0.80***	0.36
5. Our team regularly announces information regarding patient safety	0.83***	0.30
6. The rules and procedures regarding patient safety in our team are presented in a simple and understandable way	0.70***	0.52
7. Our team has a formal mechanism to provide assistance and consultation for patient safety	0.77***	0.41
Patient safety priority			0.89	0.54
1. Sometime I will neglect the issues related to patient safety to complete my tasks^b	0.77***	0.41
2. I finish my work as soon as possible when I am under pressure, even if patient safety is neglected^b	0.82***	0.33
3. There is a human resource shortage in our team, so we have to reduce patient safety standards^b	0.74***	0.46
4. I neglect rules and procedures regarding patient safety very often^b	0.86***	0.27
5. We are permitted to disobey obey the rules and procedures regarding patient safety^b	0.72***	0.49
6. The main purpose for the rules and procedure of the patient safety is to protect patients	0.53***	0.72
7. The ways to complete the tasks are not that important as long as no accidents occur	0.68***	0.53

Note. CR = composite reliability; AVE = average variance extracted.

^aFactor loadings were standardized. ^bThe scales were reversed for these items that make up patient safety priority.

***p < .01.

Regarding the control variables, we selected age, education, position (Singer et al., 2003), team type, nursing experience, hospital experience (Singer et al., 2009), the time the nurse joined the team, and hospital support for staff (Squires et al., 2010). Hospital support is the degree to which frontline nurses perceive the support of their managers when they are devoted to improving patient safety in the workplace. The construct measurement items were based on Katz-Navon et al. (2005) and Naveh et al. (2005); these 3 items attained a Cronbach’s α of .89.

Validity and Reliability

All of the questionnaire items were validated by three health care scholars and nine top nurse managers. Thirty frontline nurses were included to do pretests. Subsequently, construct validity was examined using confirmatory factor analysis (CFA). CFA results of market orientation indicated that χ²/df = 3.79; goodness-of-fit index (GFI) = .93; adjusted GFI (AGFI) = .88; root mean squared residual (RMR) = .02; root mean square error of approximation (RMSEA) = .09; normed fit index (NFI) = .95; incremental fit index (IFI) = .96; Tucker–Lewis index (TLI) = .94; comparative fit index (CFI) = .96. Table 1 indicated that the minimum of composite reliability (CR) was interfunctional coordination of .86, and the minimum of average variance extracted (AVE) was customer orientation of .59. The factor loadings of all items reached statistically significant levels. The CFA results also showed that, excluding customer orientation, the square roots of all the AVE values of every dimension were higher than the each pairwise correlation coefficient. The study further performed a χ² difference test (Anderson & Gerbing, 1988). The results showed that χ² differences were all greater than 3.84 (χ², p < .05).

The measurement model of patient safety climate also generated acceptable fit indices (χ²/df = 2.58; GFI = .83; AGFI = .81; RMR = .02; RMSEA = .07; NFI = .86; IFI = .91; TLI = .90; CFI = .91). Table 1 showed that the minimum of CR was patient safety priority of .89, and the minimum of AVE also was patient safety priority of .54. The factor loadings of all the items reached statistically significant levels. The CFA results also show, excluding patient safety procedures, the square roots of all the AVE values of every dimension are higher than each pairwise correlation coefficient. The study ran χ² difference test again. The χ² differences were also greater than 3.84 (p < .05). In sum, the measurement model had acceptable convergent and discriminate validity.

Ethical Considerations of the Study

After receiving approvals from the institutional review boards of the two hospitals (reference number: CLH-0115 and 980703), study data were collected via questionnaires. We sent out questionnaires with informed consent forms to the study subjects. All the valid subjects agreed with joining this study and signed the consent forms.

Analysis Methods

The analyses were conducted using Statistical Package for the Social Sciences (SPSS) 15.0 and AMOS 6.0. Descriptive and bivariate analyses were used to explore data and CFA was used to test the validity and reliability of data. In addition, multiple regression model and path analysis were used to analyze the impact of market orientation on patient safety climate.

Results

The sample comprised 77 nurses from various project teams and 266 nurses from various departments. Most of the participants were women, many of whom held undergraduate degrees or higher. Of the 77 nurses, 82.8% were specialists and 61.5% had more than 7 years of nursing experience, whereas 61.8% had been working in hospitals for more than 5 years. Of the sample, 35% had been on their current team for more than 5 years and 18.4% had been on their current team for 1.1 to 2 years. Factor scoring the CFA models indicated that customer orientation was the highest scoring dimension of market orientation (customer orientation = 7.75; competitor orientation = 5.81; interfunctional coordination = 6.71). Of all the patient safety climate dimensions, managerial practices scored the highest (patient safety procedures = 4.39; managerial patient safety practices = 4.43; patient safety information flow = 3.69; patient safety priority = 4.36).

The variance inflation factors of the independent variables were less than 10 and the Kolmogorov–Smirnov test indicated that the normal distribution of the residuals was acceptable. Regarding the control variables, the results of the multiple regression model indicated that only the position and hospital experience of the nurses, and hospital support for staff were significantly and positively correlated with the patient safety climate (Table 2).

Table 2.

Multiple Regression Analysis.^a

Variable	Patient safety procedures		Managerial patient safety practice		Patient safety information flow		The priority of patient safety		Overall patient safety climate		Hospital support for staffs
Variable	Model 1	Model 2	Model 3	Model 4	Model 5	Model 6	Model 7	Model 8	Model 9	Model 10	Model 11	Model 12
Control variables
Age	−0.04	−0.05	−0.05	−0.06	−0.06	−0.07	−0.06	−0.07	−0.05	−0.06	0.15**	0.11
Educational level^b	0.01	−0.00	−0.00	−0.02	0.04	0.02	−0.01	−0.01	0.01	−0.00	0.04	0.01
Team type^c	−0.03	−0.06	−0.03	−0.06	0.03	−0.01	−0.04	−0.05	−0.02	−0.06	−0.13	−0.13
Position^d
Nurse	−0.16	−0.10	−0.11	−0.04	−0.18**	−0.12	−0.17**	−0.13	−0.17**	−0.09	−0.05	0.00
Nurse specialist	−0.25***	−0.18**	−0.19**	−0.12	−0.27***	−0.20***	−0.16**	−0.13	−0.25***	−0.18**	−0.03	0.03
Nursing experience^e
≤2 years	−0.00	0.01	0.07	0.07	0.08	0.07	−0.05	−0.03	0.03	0.03	0.00	−0.02
2.1 to 3 years	−0.13	−0.07	−0.16	−0.10	−0.10	−0.06	−0.14	−0.08	−0.15	−0.08	0.09	0.08
3.1 to 4 years	−0.12	−0.10	−0.09	−0.08	−0.04	−0.02	0.03	0.04	−0.10	−0.08	0.09	0.08
4.1 to 5 years	−0.08	−0.05	−0.11	−0.09	−0.03	−0.01	−0.14	−0.12	−0.09	−0.06	0.06	0.05
5.1 to 6 years	0.00	−0.02	0.03	0.01	0.02	−0.00	−0.03	−0.04	0.01	−0.01	0.08	0.05
6.1 to 7 years	−0.05	−0.04	−0.01	−0.01	0.01	0.00	−0.09	−0.07	−0.03	−0.03	0.02	0.00
Hospital experience^f
≤1 year	−0.05	−0.03	−0.07	−0.04	−0.08	−0.05	0.00	0.00	−0.06	−0.04	−0.06	−0.02
1.1 to 2 years	0.00	−0.01	0.01	0.00	−0.06	−0.08	−0.01	−0.01	−0.01	−0.02	0.11	0.07
2.1 to 3 years	0.18**	0.11	0.23**	0.16**	0.18**	0.10	0.20**	0.14	0.21**	0.13	−0.04	−0.09
3.1 to 4 years	0.06	0.04	−0.01	−0.03	0.06	0.04	−0.09	−0.11	0.04	0.02	0.06	0.03
4.1 to 5 years	0.01	0.03	0.05	0.07	−0.11	−0.07	−0.02	−0.00	−0.01	0.02	0.01	0.05
The time the nurse joined the team^g
<6 months	−0.02	0.01	0.02	0.05	−0.02	0.01	−0.04	−0.00	−0.01	0.02	−0.06	−0.04
6 to 12 months	−0.07	−0.09	0.01	−0.01	−0.04	−0.06	−0.07	−0.09	−0.05	−0.07	−0.01	−0.02
1.1 to 2 years	−0.03	−0.03	−0.01	0.00	0.01	0.03	−0.02	−0.02	−0.02	−0.01	−0.08	−0.04
2.1 to 3 years	−0.13	−0.10	−0.10	−0.07	−0.14	−0.10	−0.14	−0.12	−0.13	−0.10	0.11	0.12
3.1 to 4 years	−0.06	−0.06	0.01	0.01	−0.08	−0.08	−0.00	−0.00	−0.05	−0.05	0.04	0.04
4.1 to 5 years	−0.05	−0.07	−0.01	−0.03	0.00	−0.03	0.03	0.01	−0.03	−0.05	−0.10	−0.11
Hospital support for staffs	0.37***	0.19***	0.33***	0.14***	0.43***	0.23***	0.10	0.08	0.39***	0.19***	—	—
Market orientation
Customer orientation		0.47***		0.41***		0.24**		0.45***		0.45***		−0.10
Competitor orientation		0.08		0.12		0.17		−0.16		0.10		0.29***
Interfunctional coordination		−0.05		−0.02		0.12		0.03		−0.01		0.24**
R ²	.21	.40	.17	.37	.26	.45	.07	.18	.22	.44	.08	.25
Adj. R ²	.15	.35	.11	.32	.20	.41	.01	.11	.16	.39	.01	.19
F value	3.57***	8.14***	2.83***	7.16***	4.74***	10.07***	1.10	2.59***	3.81***	9.36***	1.22	4.15***

Note. n = 343.

^aStandardized regression coefficients after controlling for other variables. ^bReference group is “BS or higher.” ^cReference group is “project team.” ^dReference group is “others.” ^eReference group is “over 7 years.” ^fReference group is “over 5 years.” ^gReference group is “over 5 years.”

**p < .05. ***p < .01.

Table 2 indicates that customer orientation is significantly and positively correlated with each dimension of and the overall patient safety climate (p < .05). Customer orientation exerted the greatest influence on patient safety procedures (β = .47). By contrast, competitor orientation and interfunctional coordination did not directly influence the patient safety climate. Therefore, these findings support only Hypothesis 1. Competitor orientation and interfunctional coordination did not demonstrate a significant direct influence on the patient safety climate; however, the results shown in Table 2 indicate that after considering market orientation, the β value of hospital support for staff in Models 2, 4, 6, 8, and 10 greatly decreased in comparison with values produced in Models 1, 3, 5, 7, and 9. In addition, the correlation matrix indicates that the hospital support for staff and market orientation dimensions were significantly correlated. Therefore, we evaluated whether hospital support for staff mediates the relationship between market orientation and the patient safety climate. Model 12 shows that the regression coefficients of competitor orientation and interfunctional coordination attained significance (p < .05).

The results of path analysis revealed that the path coefficient of customer orientation on the patient safety climate was .52, whereas interfunctional coordination and competitor orientation significantly and positively influenced the hospital support for staff. The path coefficient of hospital support for staff on the patient safety climate was .20, demonstrating that competitor orientation and interfunctional coordination positively influenced the patient safety climate through the mediating effect of hospital support for staff. The total effects of interfunctional coordination and competitor orientation on the patient safety climate were .038 (0.19 × 0.20) and .052 (0.26 × 0.20).

Discussion

Customer orientation exerted the greatest influence on patient safety procedures. Berntsen (2006) indicated that health care managers can enhance patient safety by implementing patient-centered nursing. In addition, nonprofit organizations can encourage staff members to focus on customer orientation culture through staff training (Gainer & Padanyi, 2005). Nurses who exhibit a high level of customer orientation work diligently to understand patient needs and perform patient-centered actions (Darby & Daniel, 1999). Adopting patient-centered approaches benefits the quality of care and patient safety by generating or enhancing of patient care principles, rules, and procedures that hospital staff members can realistically implement (Hunt, 2010; Wolf et al., 2008). Furthermore, establishing a formal channel through which staff members can directly respond to patient safety problems accelerates enhancing the patient safety climate (Hughes et al., 2009; Matsubara et al., 2008).

If hospitals are highly patient oriented and focus on health care quality, the nurses reach a consensus, emphasizing patient safety and providing patient safety services (Berntsen, 2006). This prompts managers to place increased value on safety-related rules and be willing to accept additional patient safety training to improve their knowledge. When managers understand that the team values and prioritizes safety, they become actively involved in tasks related to the safety climate (Naveh, Katz-Navon, & Stern, 2005), strictly adhering to related rules and procedures, and encouraging staff members to emphasize safety, and follow and improve safety rules and procedures. In addition, managers aid staff members in solving safety problems to avoid taking risks that might jeopardize the safety climate (Blegen, Pepper, & Rosse, 2005; Katz-Navon et al., 2005). Health care managers must be committed to safety to generate a strong patient safety climate (Hughes et al., 2009).

When nurses exhibited high levels of customer orientation, they focused on obeying new patient safety guidelines, striving to understand the safety-related information, rules, and procedures promulgated through various channels and actively participating in related training courses. Patient-oriented staff members actively develop safety-related principles and procedures, establishing systems that facilitate collecting and managing information regarding health care quality (Berry et al., 2003; Stone et al., 2007; Wolf et al., 2008). Such staff members also collect and distribute patient safety information through formal and informal channels (Berntsen, 2006; Dixon-Woods, 2010; Hunt, 2010). Using various methods to distribute safety information provides all staff members with increased access to relevant knowledge, increasing the flow of safety-related information (Katz-Navon et al., 2005; Naveh et al., 2005).

An organization that exhibits a high level of customer orientation prioritizes customer needs; thus, in hospitals, patient safety is prioritized (Teng et al., 2012; Tzeng & Yin, 2007). Nurses occasionally ignore patient safety procedures and rules to complete their work when their stress or workload is increased (Nabirye, Brown, Maples, & Pryor, 2011). When patient safety is not prioritized, it becomes gradually disregarded, negatively affecting the quality of care (Aiken, Clarke, Sloane, Sochalski, & Busse, 2001). Clarke, Rockett, Sloane, and Aiken (2006) emphasized that excessive nursing workloads can substantially increase the occurrence rates of adverse events that endanger patient safety. They also observed that frontline nurses who were highly customer oriented continued to prioritize patients when confronted with job stress, ensuring patient safety.

Lowe, Schellenberg, and Shannon (2003) observed that sufficient communication and supportive leadership accounted for nearly 30% of the variation in the perceptions of a healthy work environment among hospital staff members. Therefore, a healthy work environment is important to shaping a safety-oriented culture (Lowe, 2008). Dixon-Woods (2010) observed that interprofessional communication is essential to improving patient safety in hospitals. In the current study, competitor orientation and interfunctional coordination affected the patient safety climate through the hospital support provided to staff members. Competitor-oriented organizations continually monitor progress compared with competitors, gaining opportunities to improve the product and service quality by providing services that are superior to those of competitors, or using a second-but-better approach (Grinstein, 2008). Patient safety is an important factor in improving health care quality in hospitals. When frontline nurses perceive high levels of competitor orientation and interfunctional coordination, they are likely to understand the patient safety strategies and methods used at competing hospitals. Subsequently, these nurses pass their competitive knowledge to other organizational staff members. When they perceive that the frontline nurses and competitors consider patient safety essential, hospital managers emphasize patient safety to ensure that the hospital remains competitive. In addition, interdepartmental communication and coordination facilitates distributing market information (e.g., competitor information) among staff members (Hampton & Hamptonb, 2004). This increases the manager support of patient safety, enhancing the willingness of frontline nurses to provide services based on a patient safety perspective (Squires et al., 2010). Squires, Tourangeau, Laschinger, and Doran (2010) and Lowe (2008) indicated that supportive and visible leadership substantially contributes to a safety-oriented culture and climate. Therefore, hospital support is important for generating a strong climate of patient safety.

Research Limitations and Suggestions for Future Research

Certain differences exist between the Taiwanese and international nursing environments; therefore, we suggest that researchers investigate large-scale data sets belonging to other national hospitals. Because of time limitations, we employed a cross-sectional research design. However, future researchers should collect information by using longitudinal data to clarify how market orientation affects patient safety climate over a long period of time. In addition, this study explored only how market orientation influenced the patient safety climate, but numerous organizational factors might affect the behaviors, perceptions, and beliefs of employees. Subsequent studies can investigate other potential contextual factors (e.g., team effectiveness and organizational culture) that contribute to the patient safety climate among nurses.

Conclusion and Implications

In this study, customer orientation was the highest scoring dimension of market orientation. Customer orientation directly and positively affected the climate of patient safety, whereas competitor orientation and interfunctional coordination indirectly affected the climate of patient safety through the mediation of hospital support for staff. Therefore, health professionals must focus on market orientation to improve the hospital climate of patient safety.

Implications

In an increasingly competitive health care environment, hospitals must efficiently and effectively respond to changes in customer needs and expectations to become market-oriented organizations (Weng, Huang, & Lin, 2013). Frontline health care professionals are primary care providers who frequently interact with patients, substantially influencing the success of market orientation; thus, they are vital to promoting patient safety in hospitals. In this study, we determined that market orientation is crucial for improving the patient safety climate among hospital managers and health care professionals. In addition, effective internal marketing enhances employee beliefs in, understanding of, and commitment to market orientation, enhancing the market orientation in the hospital (Huang et al., 2013).

In this study, the internal hospital marketing activities comprised employee understanding of the hospital’s vision, human resource development, and a reward system. Hospital managers should establish appealing goals and appropriate reward systems, promoting a hospital culture in which employees are encouraged and rewarded for behavior that promotes market orientation (Huang et al., 2013). Furthermore, hospital managers should develop human resources and training systems to collect, disseminate, and respond to market intelligence. Such training systems can be used to improve the sensitivity of hospital employees to customer needs and competitor strategies, enhancing market orientation (Iliopoulos & Priporas, 2011; Tsai & Wu, 2011). Therefore, improving internal marketing can enhance the market orientation of health care professionals, promoting a climate of patient safety.

In addition, managers should establish a formal mechanism for collecting, disseminating, and responding to market intelligence in hospitals to provide health care professionals with clear implementation procedures and sufficient administrative support. This should enhance the efficiency and effectiveness of customer and competitor information distribution and responsiveness. Hospital managers should also attempt to understand customer needs and competitor strategies and actions, actively promulgating market information to frontline health care professionals by using various methods (e.g., holding conferences and contests). Finally, health care professionals should share competitor intelligence throughout the organization, both strengthening competitor orientation and ensuring that information regarding patient demands and competitor intelligence is voluntarily collected.

Footnotes

Acknowledgment

The authors would like to thank the editor and the anonymous reviewers for their constructive comments and recommendations.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a grant from the National Science Council in Taiwan (NSC 97-2410-H-041-005-MY2).

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