Demographic differences between health care workers who did or did not respond to a safety and organizational culture survey.

Abstract

ABSTRACT:
Areas for institutional improvement to enhance patient safety are commonly identified by surveying health care workers' (HCWs) attitudes, values, beliefs, perceptions and assumptions regarding institutional practices. An ideal response rate of 100% is rarely achieved in such surveys, and non-response bias can occur when non-respondents differ from respondents on a dimension likely to influence survey conclusions. The conditions for non-response bias to occur can be detected by comparing demographic characteristics of respondents and non-respondents and relating any differences to findings in the literature of differences in the construct of interest as a function of these demographic characteristics. The current study takes this approach.
All 5,609 HCWs at a university medical center were invited to participate in a survey measuring safety and organizational culture (response rate = 53.40%). Respondents indicated their professional group, gender, age group, years of working in the hospital and executive function. Because all HCWs were invited, the demographic composition of the group who did not respond was known. Differences in the demographic composition of respondents and non-respondents were compared using separate Pearson's chi-square tests for each demographic characteristic.Nurses and clinical workers were generally more likely to respond than were physicians, laboratory workers and non-medical workers. Male HCWs were less likely to respond than were females, HCWs aged younger than 45 years old had a lower response rate than did HCWs aged 45 to 54 years old, HCWs who had worked in the hospital for less than 5 years were less likely to respond than were those who had worked in the hospital for 5 years or more and HCWs without an executive function were less likely to respond than were executives.
Demographic characteristics can be linked to response rates and need to be considered in conducting surveys among HCWs. The possibility of non-response bias can be reduced by conducting analyses separately as a function of relevant demographic characteristics, sampling a higher percentage of groups that are known to be less likely to respond, or weighting responses with the reciprocal of the response rate for the respective demographic group.

Full text

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SHORT REPORTOpen Access
Demographic differences between health care
workers who did or did not respond to a safety
and organizational culture survey
Tita A Listyowardojo1*, Raoul E Nap2and Addie Johnson1
Abstract
Background: Areas for institutional improvement to enhance patient safety are commonly identified by surveying
health care workers’ (HCWs) attitudes, values, beliefs, perceptions and assumptions regarding institutional practices. An
ideal response rate of 100% is rarely achieved in such surveys, and non-response bias can occur when non-respondents
differ from respondents on a dimension likely to influence survey conclusions. The conditions for non-response bias to
occur can be detected by comparing demographic characteristics of respondents and non-respondents and relating
any differences to findings in the literature of differences in the construct of interest as a function of these demographic
characteristics. The current study takes this approach.
Findings: All 5,609 HCWs at a university medical center were invited to participate in a survey measuring safety and
organizational culture (response rate = 53.40%). Respondents indicated their professional group, gender, age group,
years of working in the hospital and executive function. Because all HCWs were invited, the demographic composition
of the group who did not respond was known. Differences in the demographic composition of respondents and non-
respondents were compared using separate Pearson’s chi-square tests for each demographic characteristic.
Nurses and clinical workers were generally more likely to respond than were physicians, laboratory workers and
non-medical workers. Male HCWs were less likely to respond than were females, HCWs aged younger than 45
years old had a lower response rate than did HCWs aged 45 to 54 years old, HCWs who had worked in the
hospital for less than 5 years were less likely to respond than were those who had worked in the hospital for
5 years or more and HCWs without an executive function were less likely to respond than were executives.
Conclusions: Demographic characteristics can be linked to response rates and need to be considered in
conducting surveys among HCWs. The possibility of non-response bias can be reduced by conducting analyses
separately as a function of relevant demographic characteristics, sampling a higher percentage of groups that are
known to be less likely to respond, or weighting responses with the reciprocal of the response rate for the
respective demographic group.
Background
Patient safety in the hospital depends on health care work-
ers’ (HCWs) commitment to safety (i.e., safety culture)
[1-9]. Periodic assessment of safety culture is necessary in
order to pinpoint attitudes, values, beliefs or perceptions
that may need to be changed in order to improve patient
safety [1,3-9]. Safety culture is typically assessed with sur-
veys whose results are then used to design patient safety
improvement programs, to evaluate the effectiveness of
intervention programs and to track transformations of
safety culture over time [1,3,4,8].
A challenge in surveying HCWs is to achieve a high
response rate. Physicians, in particular, often show rela-
tively low response rates [1,10-15]. For example, in a study
by Singer et al. [1], the response rate of physicians was
33%, considerably lower than the response rate of 60%
that is recommended for achieving sufficient reliability in
the measurement of safety culture [5]. In fact, response
rates of 60% or higher are rarely achieved [1,3]. A major
problem with low response rates is that they may result in
* Correspondence: t.a.listyowardojo@rug.nl
1Faculty of Behavioral and Social Sciences, University of Groningen,
Groningen, The Netherlands
Full list of author information is available at the end of the article
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© 2011 Listyowardojo et al; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.

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under- or over-representation of particular groups and,
thus, in non-response bias [4,16-18]. Non-response bias is
said to occur when a significant number of those who do
not respond differ in terms of relevant characteristics (i.e.,
characteristics that can influence survey outcomes and
conclusions) from those who do respond. Non-response
bias is a real concern in health care settings. It has been
found as a function of gender with regards to identifying
best practices [19], duration of employment with regards
to attitudes towards changes in national health programs
[20], and age with regards to evaluation of alcohol abuse
programs [21].
One way to detect non-response bias is to contact
non-respondents personally in order to investigate
whether non-respondents’ opinions differ substantially
from those of respondents [20,21]. This way of dealing
with non-response cannot be applied when surveys are
anonymous, as is likely to be the case when HCWs are
surveyed [7,10,15]. However, when the demographic
characteristics of the surveyed population are known,
even anonymous surveys can benefit from comparing
the demographic composition of respondents with that
of non-respondents [12,16,19-22].
Although some safety culture surveys conducted in the
past have considered the effects of demographic variables
on how safety culture is evaluated [2,3,6,7,23], most stu-
dies of safety culture fail to consider the role of demo-
graphic characteristics in the evaluation of safety culture
or make only vague reference to such differences [2]. An
explanation for this might be that the goal of many studies
of safety culture is to capture organizational (and not indi-
vidual) factors that influence patient safety and that the
importance of demographic differences in safety culture
research has not been recognized [24]. We argue that
demographic characteristics should be considered in
understanding whether HCWs will be likely to respond to
safety culture surveys and that they should be taken into
account in reducing the risk of non-response bias for
anonymously conducted surveys. The purpose of this
study was thus to compare the demographic composition
of the groups of HCWs who did or did not respond to a
survey measuring safety and organizational culture. Differ-
ences in demographic characteristics of respondents and
non-respondents that should be taken into account to
reduce the risk of non-response bias are documented and
suggestions are made for understanding the responding
behavior and increasing the response rate of HCWs.
Methods
Participants
In April 2009, invitations to participate in a safety and
organizational culture survey were sent electronically (via
intranet) to 5,609 HCWs (out of a total of approximately
8,000 HCWs) involved in patient care (including
managers) at the University Medical Center Groningen
(UMCG), The Netherlands. The UMCG is a large univer-
sity medical center that has approximately 1,300 beds,
including 53 surgical and medical adult intensive care
beds and 46 neonatal and pediatric intensive care beds.
Reminders were sent in May and again in June. Participa-
tion was on a voluntary basis and no incentives to respond
(financial or otherwise) were offered. Anonymity was
ensured and informed consent was given by those who
responded.
Instrument
Nine dimensions of safety and organizational culture were
assessed in a survey containing 99 items (see Additional
File 1). Because the survey addressed general organiza-
tional concerns such as work satisfaction, working condi-
tions and perceptions towards the hospital, in addition to
aspects of safety culture, it was relevant to all HCWs who
were invited to participate. Additional questions addressed
department, gender, age, years of working in the hospital
and whether one worked in an executive or non-executive
function. Because some HCWs could belong to more than
one department (e.g., a medical specialist who also teaches
at the university belongs to both medical specialist and
teaching departments), HCWs were asked to indicate the
department where they spent most of their time as stated
on their work contract. The ten departments were com-
bined into five professional groups because of similar job
descriptions (e.g., the medical specialist and physician
assistant departments were combined). The five profes-
sional groups thus obtained were “physicians” (e.g., medi-
cal specialists and physician assistants), “nurses” (e.g.,
nurse practitioners and intensive care nurses), “clinical
workers” (e.g., dieticians, psychologists and pharmacists),
laboratory workers (e.g., laboratory technologists and tech-
nicians) and non-medical workers (e.g., facility manage-
ment workers, secretarial and administrative workers and
managers). The age groups used were 15-24 years old,
25-34 years old, 35-44 years old, 45-54 years old and older
than 54 years old. The categories used for years of working
in the hospital were less than 5 years, 5-9 years, 10-20
years and longer than 20 years. Members of any profes-
sional group were considered to hold an executive func-
tion if they led a sector, department, unit, subunit or
clinic; data were coded according to the number of
respondents who worked in an executive or non-executive
function.
Data analyses
Because of the need to preserve anonymity, data were
available only for the demographic characteristics of the
group and not for the conjunctions of the variables for
each individual (i.e., we had available to us the data
regarding how many, e.g., nurses responded, but not
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their age distribution, gender, etc., as this would uniquely
identify individuals). It was therefore not possible to
carry out multivariate analysis to identify which charac-
teristics differed between groups of respondents and
non-respondents while taking other characteristics into
account. Instead, differences in the demographic charac-
teristics of respondents and non-respondents were tested
using Pearson’s chi-square tests separately for each
demographic characteristic (i.e., professional group, gen-
der, age group, years of working in the hospital, and
executive function), with group (respondents vs. non-
respondents) and category (e.g., for the characteristic
“gender” the categories were male and female) as factors.
If interactions of group and category were found (i.e., if
the demographic composition of respondents and non-
respondents differed), follow-up pairwise Pearson’s chi-
square tests were conducted between sub-groups. Odds
ratios (where an odds ratio of 1 indicates that the demo-
graphic composition of respondents and non-respon-
dents did not differ) were used to calculate effect size. A
significance level of p < .05, Bonferroni correction for
each family of comparisons, was used where necessary.
Results
Out of 5,609 invitations sent, 2,995 were responded to
(response rate = 53.40%). Response rates as a function of
demographic characteristic are summarized in Table 1.
Chi-square analyses (n = 5609) revealed interactions
between group (respondents vs. non-respondents) and
each of the demographic characteristics. The Group ×
Professional Group interaction (X2(4) = 53.54, p < .001)
reflects that nurses and clinical workers had significantly
higher response rates than did physicians and non-medical
workers, and that nurses also had a significantly higher
response rate than did laboratory workers (see Table 2 for
all follow-up comparisons and odds ratios). The Group ×
Gender interaction (X2(1) = 6.33, p < .05) reflects that
female HCWs had a higher response rate than did males.
The Group × Age Group interaction (X2(4) = 30.07, p <
.001) reflects that HCWs who were younger than 45 years
old had significantly lower response rates than did those
aged 45 to 54 years old. The Group × Years of Working in
the Hospital interaction (X2(3) = 41.31, p < .001) reflects
that HCWs who had worked in the hospital for less than
five years had a significantly lower response rate than did
those who had worked in the hospital for five years or
more. The Group × Executive Function interaction (X2
(1) = 24.77, p < .001) reflects that HCWs with an executive
function had a significantly higher response rate than did
those without an executive function.
Discussion
The demographic composition of groups who did or did
not respond to a survey of safety and organizational
culture was analyzed and significant differences between
groups of respondents and non-respondents were found.
Response rate was found to depend on professional group,
gender, age, years of working in the hospital and executive
function.
The survey study on which the current study of demo-
graphic differences in response rates is based revealed not
only differences in response rates, but differences in how
aspects of safety and organizational culture are perceived
[Unpublished data of T. A. Listyowardojo, R. E. Nap and
A. Johnson]. The existence of differences in response rates
as a function of demographic characteristics makes it
important to consider whether non-response bias is likely
to have influenced the interpretation of the survey results.
In our study of safety and organizational culture, the data
were analyzed and reported per group, and the major find-
ing of the study was that perceptions of safety and organi-
zational culture differed significantly across professional
group, with physicians and non-medical workers tending
to give more positive ratings of safety and organizational
culture than did nurses, clinical workers and laboratory
workers.
The key question addressed in this paper is whether
non-response bias due to unequal representation of pro-
fessional groups influences study results. If group compo-
sition is not taken into account when analyzing survey
results, under- or over-representation of some groups can
influence the conclusions that are drawn. For example, it
might be that physicians and non-medical workers, who
were relatively positive in their ratings of safety and orga-
nizational culture, are less likely to respond to safety cul-
ture surveys than are nurses and clinical workers because
they feel that changes in institutional practices are not
urgently needed. Basing conclusions on the response
group as a whole could then lead to an overly negative
evaluation of safety culture. More specific aspects of safety
culture, such as fear of shame and blame [3], have been
shown to be evaluated differently by nursing professionals
than by physicians, and their evaluation may thus also be
subject to non-response bias.
The relatively low response rate of physicians may also,
in part, be due to the perception that they are too often
asked to respond to surveys and that their time is too
valuable to be spent completing them [12,20,25,26].
Whereas physicians have been found to complain about
being asked to participate in surveys too often, nurses
and clinical workers have reported that they are not
asked for their professional views often enough [12].
Nurses and the clinical workers may thus embrace the
opportunity to voice their points of view by responding
to surveys.
The fact that gender affected response rate, with female
HCWs being more likely to respond than their male col-
leagues may be tied to the fact that nurses are
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predominantly female, and nurses have a higher response
rate. Because the effect of one demographic variable
could not be statistically isolated from the others, we can-
not say that females, in general, were more likely to
respond.
The finding that HCWs in the 45 to 54 year old age
group were more likely than were younger HCWs to
participate contrasts with previous findings of higher
response rates for younger HCWs [12,16,20,21]. The
fact that these previous studies sampled only physicians
(in contrast to the current study, in which all profes-
sional groups were surveyed) may be responsible for this
difference in findings. Alternatively, it may be that
HCWs in this age group were more likely to be senior
staff with administrative duties.
The lower response rate of HCWs who had worked in
the hospital for less than 5 years as compared to those who
had worked for 5 years or more may be related to profes-
sional commitment to the hospital, which can be expected
to increase as one works longer [25]. A final difference in
response rates was that those who had an executive func-
tion were twice as likely to participate as were HCWs with-
out an executive function. Those with executive functions
may be more willing to participate because they are among
those who will use the survey results to develop or defend
patient safety intervention programs [6].
Limitation
The main limitation of the current study is clearly the sur-
vey anonymity. The hospital would release only the demo-
graphic characteristics of the group as a whole and those
of the group of respondents, and not those of the indivi-
duals. Furthermore, because we could not contact non-
respondents, we were unable to investigate whether there
was a difference in the evaluation of safety and organiza-
tional culture between respondents and non-respondents.
However, previous studies have reported a strong link
between relevant demographic characteristics (i.e., profes-
sional groups, age, years of work experience and executive
function) and safety attitudes [1-3,6,24,27,28], making it
possible to draw tentative conclusions about the possibility
of non-response bias.
Conclusion
Demographic characteristics can be linked to response
rates and thus need to be taken into account in con-
ducting surveys among HCWs. The possibility of non-
response bias can be reduced by conducting analyses
separately as a function of relevant demographic charac-
teristics or by sampling a higher percentage of members
of groups that are known to be less likely to respond
[1-3]. Another approach to reducing the possibility of
non-response bias is to weight responses with the
Table 1 Response rates as a function of demographic characteristic
CategoryRespondents (n = 2995)
Non-respondents (n = 2614)
Response rate (%)
Professional groups
Physicians
Nurses
Clinical workers
Laboratory worker
Non-medical workers
496
1208
649
331
311
570
871
508
318
347
46.53
58.10
56.09
51.00
47.26
Gender
Male
Female
834
2161
808
1806
50.79
54.47
Age group
15-24 years old
25-34 years old
35-44 years old
45-54 years old
>54 years old
122
857
735
857
424
156
814
664
603
377
43.88
51.29
52.54
58.70
52.93
Years of working in the hospital
<5 years
5-9 years
10-20 years
>20 years
1059
825
593
518
1137
602
444
431
48.22
57.81
57.18
54.58
Executive function
Executive
Non-executive
167
2828
75
2539
69.01
52.69
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reciprocal of the response rate for the respective demo-
graphic group [1,29].
Additional material
Additional file 1: Overview of safety and organizational culture
dimensions and sample items. Overview of the dimensions included in
the safety and organizational survey and sample items.
Author details
1Faculty of Behavioral and Social Sciences, University of Groningen,
Groningen, The Netherlands.2University Medical Center Groningen,
Groningen, The Netherlands.
Authors’ contributions
TAL contributed to study conception and design, data analysis and
interpretation, drafting and critically revising the manuscript. REN
contributed to study conception and design and acquisition of data. AJ
contributed to data analysis and interpretation, and drafting and critically
revising the manuscript. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 12 March 2011 Accepted: 7 September 2011
Published: 7 September 2011
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• 5-9 years vs. 10-20 years
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• 10-20 years vs. >20 years
Executive function: Executive1vs. Non-executive
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0.75 - 1.07
24.771** 2.001.51 - 2.64
Bonferroni correction was used as appropriate for all analyses. ** p < .001. *p < .01.
1Had significantly higher response rate than the other sub-group.
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doi:10.1186/1756-0500-4-328
Cite this article as: Listyowardojo et al.: Demographic differences
between health care workers who did or did not respond to a safety
and organizational culture survey. BMC Research Notes 2011 4:328.
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Listyowardojo et al. BMC Research Notes 2011, 4:328
http://www.biomedcentral.com/1756-0500/4/328
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