Cross-cultural adaptation and validation of Hospital Survey on Patient Safety Culture in Bengali version (B-HSOPSC 2.0) among nurses in Bangladesh: a cross-sectional study

Cross-cultural adaptation and validation of Hospital Survey on Patient Safety Culture in Bengali version (B-HSOPSC 2.0) among nurses in Bangladesh: a cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Cross-cultural adaptation and validation of Hospital Survey on Patient Safety Culture in Bengali version (B-HSOPSC 2.0) among nurses in Bangladesh: a cross-sectional study Md Abdul Khalek, K. A. T. M. Ehsanul Huq, Tomonori Hasegawa, Yosuke Hatakeyama, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8668706/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background The Hospital Survey on Patient Safety Culture (HSOPSC 2.0) was developed and updated by the Agency for Healthcare Research and Quality in 2019. It has now been widely adopted and translated into different languages worldwide. However, the validity and reliability of the Bengali version of HSOPSC 2.0 (B-HSOPSC 2.0) have not been tested among healthcare professionals. This study aimed to determine the validity and reliability of the B-HSOPSC 2.0 with cross-cultural adaptations, among hospital nurses in Bangladesh. Methods The study was conducted among nurses in eight tertiary-level government medical college hospitals in Bangladesh. A two-step study design was employed, encompassing the translation, cultural adaptation, and psychometric evaluation of B-HSOPSC 2.0. The translation process included forward and backward translation by panel, expert consensus, review, and pretesting. Content validity, reliability, and test-retest reliability were assessed using the content validity index, Cronbach’s alpha, and the interclass correlation coefficient, respectively. Construct validity was evaluated through confirmatory factor analysis (CFA), and convergent validity was examined using average variance extraction and Spearman's correlation coefficient. Results Out of 7,170 eligible nurses, 4,982 completed questionnaires (response rate: 69.5%), and a subset (n = 424) provided retest responses. The words “manager” and “clinical leader” were removed, and the word “units” was replaced with “wards,” as they were deemed inappropriate for the Bangladeshi healthcare system. The content validity index provides strong evidence of effective measures of the instruments (I-CVI = 0.83-1.00, S-CVI = 0.98). B-HSOPSC 2.0 demonstrated a good internal consistency (Cronbach’s α = 0.70–0.76), and test-retest reliability (ICC = 0.65–0.76) showed acceptable reliability. In the CFA model, the indices for the 10 and 9 dimensions were CFI = 0.79, 0.83; NFI = 0.78, 0.82; TLI = 0.74, 0.79; GFI = 0.91, 0.92; RMSEA = 0.06, 0.06; SRMR = 0.07, 0.06, respectively. Conclusions The psychometric properties of the Bengali version showed acceptable reliability and validity characteristics. Findings suggest that it can be used to measure nurses' perceived patient safety culture in hospital settings in Bangladesh. This validated tool will enhance safety culture and benefit nursing practice. Further studies are required, as the psychometric properties of B-HSOPSC 2.0 among other healthcare professionals in Bangladesh remain to be confirmed. Clinical trial number Not applicable. Cross-cultural Safety culture Hospital survey Patient safety Reliability Figures Figure 1 Figure 2 Figure 3 Background Patient safety is a fundamental pillar of high-quality healthcare, essential for preventing avoidable harm and ensuring safe healthcare worldwide [ 1 ]. Healthcare itself can cause harm that originates largely from unsafe systems and organizational factors, rather than individual errors [ 2 , 3 ]. The World Health Organization (WHO) convened international experts and policymakers for effective collaboration on patient safety action globally [ 4 ]. WHO defined patient safety as protecting patients from preventable harm and minimizing the risk of unnecessary injury during healthcare to the lowest possible level [ 5 ]. The National Institute for Occupational Safety and Health (NIOSH) explained that safety culture is an organizational commitment to health and safety, reflected in shared values, attitudes, perceptions, and behaviors of individuals or groups characterized by mutual trust, open communication, and confidence in preventive measures [ 6 ]. The culture of patient safety is the sum of beliefs and practices that shape the way healthcare is provided [ 7 ]. Lack of a patient safety culture can cause adverse events due to inadequate medical management rather than underlying illness, such as medication errors, falls, infections, pressure ulcers, and equipment failures [ 8 , 9 ]. It was estimated that 1 in every 10 patients in high-income countries (HICs) experiences adverse events, and 2.6 million people in low-and middle-income countries (LMICs) died due to unsafe care in hospitals in 2019 [ 10 ]. In LMICs, unsafe healthcare affects up to 40% of patients, resulting in more than 3 million deaths annually [ 5 ]. About half of these incidents are preventable, with many linked to medication errors [ 10 ]. Moreover, LMICs confront challenges such as workforce shortages, fragmented care, and inadequate infrastructure, which amplify risks and make patient safety a critical public health concern [ 11 ]. It is anticipated that if the patient safety culture is continuously evaluated and improved, patient outcomes and overall safety will be increased [ 12 , 13 ]. Nurses, the largest group of healthcare providers, play a key role in preventing errors [ 14 ], and their proficiency is essential for identifying risks, warning signs, and fostering a culture of patient safety [ 15 ]. Preventing safety errors and improving quality of care depend on nurses’ competency and principal of patient safety [ 16 ]. A study finding from Bangladesh revealed gaps in infection control knowledge and practices of nurses, emphasizing the need to strengthen patient safety initiatives [ 17 ]. Therefore, continuous improvement of nurses’ ability is essential to maintain a successful and comprehensive patient safety strategy [ 18 ]. Strengthening patient safety culture is a global priority, with experts recommending validated tools for precise assessment and targeted improvement [ 19 , 20 ]. Various patient safety survey instruments are used worldwide to assess organizational safety, environment, and culture. Notable instruments include the Surveys on Patient Safety Culture™ (SOPS®) by Agency for Healthcare Research and Quality (AHRQ) [ 7 ], the Safety Attitudes Questionnaire (SAQ) by University of Texas [ 21 ] the Manchester Patient Safety Framework (MaPSaF) by University of Manchester [ 22 ] and the Patient Safety Climate in Healthcare Organizations (PSCHO) by Stanford University [ 23 ]. The SAQ is shorter and effectively measures perceptions of teamwork and safety climate; however, it offers limited insight into broader organizational culture factors [ 21 ]. In contrast, MaPSaF offers a qualitative and multidimensional assessment of safety culture; however, it lacks standardization and is difficult to benchmark quantitatively [ 24 ]. The PSCHO used to assess organizational climate also has notable weaknesses, including poor internal consistency, lack of CFA, low response rates, and limited generalizability beyond U.S. settings [ 23 ]. HSOPSC 2.0 is a standardized widely used tool that provides benchmarking data and identifies improvement areas, while SAQ helps to address only concerns, foster a positive culture, and gain employee support [ 25 ]. The Hospital Survey on Patient Safety Culture was developed in 2004 and updated in 2019 (HSOPSC 2.0) and has been widely used in developed and developing countries. AHRQ recommends authentic translations to ensure cross-cultural consistency, making HSOPSC 2.0 reliable globally [ 26 ]. Since its release, it has been translated into 35 different languages and administered in 62 countries worldwide [ 26 ]. As a well-validated and widely recognized instrument, we used this tool to thoroughly assess nurses' patient safety culture in hospitals. It provides meaningful insights and benchmarking opportunities relevant to nursing practice [ 27 ]. Research on patient safety culture in Bangladesh remains limited despite global concern [ 28 ]. In Bangladesh, studies have reported poor infection control practices, with more than 30% of hospital-acquired infections in some facilities reflecting an inadequate patient safety culture [ 29 ]. A national health facility survey found that 21% of inpatients at Upazila Health Complexes, 21% at District Hospitals, and 20.8% at Maternal and Child Health facilities received all prescribed drugs, indicating significant medication safety gaps [ 30 ]. Poor safety performance in public hospitals emphasizes the urgent need to strengthen patient safety culture, reduce patient harm, and restore quality in healthcare services [ 28 ]. Moreover, nurses’ perceptions of patient safety culture in Bangladesh are unknown, highlighting the need for evidence to improve safety practices and guide healthcare policy [ 17 ]. Therefore, this study aimed to culturally adapt a valid and reliable Bengali version of HSOPSC 2.0 to assess patient safety culture among nurses working at government tertiary-level medical college hospitals in Bangladesh. Methods This was a two-step design study comprising translation and cultural adaptations, followed by psychometric evaluation of the Bengali version of Surveys on Patient Safety Culture™ (SOPS®) hospital survey 2.0 (B-HSOPSC 2.0). The translation process used a forward-backwards method, and pretesting was conducted in accordance with AHRQ translation guidelines [ 31 ]. Further, validity was checked by content and construct validity, and reliability was assessed by internal consistency and test-retest reliability (Fig. 1 ). Setting and Sampling As there are eight administrative divisions in Bangladesh, we conducted our study in eight tertiary-level government medical college hospitals, one per division, to cover the whole country. The study population included all nurses (N = 8907) working in different wards of those hospitals. Based on the reference table in the AHRQ guidelines, our minimum required sample size was 4,575 out of a total of 8,907 nurses from 8 hospitals [ 32 ]. We recruited all nurses who met the inclusion criteria: being nurses with at least 2 years of experience, working for at least 2 months in the current ward, and willing to participate in this study. We excluded nurses who were not involved in direct patient care, those in administrative roles, and those on leave during the data collection period. A total of 7,170 (80.5%) nurses met the inclusion criteria and received questionnaires. Among them, 5003 nurses completed the survey, and after data cleaning, 4,982 valid responses were retained (69.5% valid response rate). Study Period Data were collected between April and September 2025. HSOPSC 2.0 Instruments The AHRQ HSOPSC 2.0 [ 33 ] consists of 34 items. Among all items, 32 items comprised 10 composite dimensions with 5-point Likert scales of agreement (from 1 = strongly disagree to 5 = strongly agree) or frequency (from 1 = never to 5 = always). According to AHRQ guidelines, these scale scores are re-coded as 1–2 = 1, 3 = 2, and 4–5 = 3, used to compute the average percent positive response rate of each dimension. The survey includes 2 single-item outcome measures: frequency of events reported (none = 1; 1 to 2 = 2; 3 to 5 = 3; 6 to 10 = 4; 11 or more = 5) and patient safety rating (from poor = 1, fair = 2, good = 3, very good = 4, and excellent = 5). We re-coded items into 3 levels: poor = 1 (1–2), fair = 2 (3), good/excellent = 3 (4–5). Additionally, we included nine background questions including participants’ age, gender, nursing education, total professional experience, experience in current hospitals, working wards, experience in current wards, in-service training like nursing care, nursing administration, infection prevention and control-related training. HSOPSC 2.0 Bengali version (B-HSOPSC 2.0) development procedures The HSOPSC 2.0 English version was translated into Bengali following the Translation Guidelines established by the AHRQ for the Surveys on Patient Safety Culture™ (SOPS®) [ 31 ]. The translation procedure was conducted in 7 sequential steps (Fig. 1 ). First, we obtained written permission from AHRQ to use a translated Bengali version of the English instrument. Then we performed forward and backward translation between English and Bengali, conducted by two bilingual translators who were professors with PhD degrees and experts in translation. Another two bilingual reviewers (experts in patient safety and survey methodology) assessed the translations to ensure clarity, conceptual accuracy, and contextual appropriateness, confirming that the Bengali version faithfully reflected the meaning of the original instrument. The instrument was further reconciled by an expert committee consisting of eight bilingual professionals, including academic faculty with higher education, who possess both clinical and teaching experience; a clinical nurse specialist with expertise in patient safety; and two bilingual translators. All members reviewed the original translation using the master comparison table, which contained forward-backwards-translated comments and reconciled columns. Through detailed discussion and consensus, the committee resolved semantic and cultural discrepancies, ensuring conceptual equivalence with the original instrument. The pre-testing of the instrument was conducted by administrating 17 nurses working at two tertiary medical college hospitals from eight study hospitals. Eleven nurses participated in face-to-face cognitive interviews (retrospective probing) using semi-structured interview guidelines. Another 6 nurses participated in a focus group discussion (FGD). Participants were asked to identify any translated items, response options, or survey instructions that they found confusing or difficult to understand. Notes were taken during interviews and FGDs. Then, the previous translation team (8 experts) again reviewed and incorporated all pretest findings and finalized the Bengali version (B-HSOPSC 2.0). Data Collection Procedures After obtaining written permission from the respective hospital directors to conduct the research, the Principal Investigator (PI, the first author) convened meetings with the nursing heads, ward in-charges and nurses in the respective hospital conference rooms. The PI explained the study objectives, ethical considerations, and inclusion/ exclusion criteria as well as the role of the participants. Consent was obtained from those who met the eligibility criteria, and questionnaires were distributed. The research assistant (RAs) team assisted and monitored data collection procedures in the wards. Completed questionnaires were collected into secure drop boxes placed in the nurses’ duty rooms and in the nursing supervisor's room. For retest, data were also collected from 424 participants out of 3727 (11.38%) from three study hospitals, two weeks apart from the main survey. Ethical consideration The study was conducted in accordance with the principles of ethical research in the Declaration of Helsinki 2025 [ 34 ]. Ethical approval was obtained from the National Research Ethics Committee of the Bangladesh Medical Research Council (Registration No. 64002032025). Written informed consent was obtained from all the participants. Data Analysis The data were analyzed using SPSS for Windows version .31.0 (IBM Crop Armonk, NY, USA) and JMP Student Edition version 19.1 (SAS Institute Inc., Cary, NC, USA). All negative items were reverse-coded for analysis. Significance was set at p < 0.05. Descriptive statistics were used to evaluate participants’ characteristics and each B-HSOPSC 2.0 subscale [ 35 ]. Content validity of the instrument was evaluated using the content validity index; reliability was assessed with Cronbach’s alpha coefficient, and test-retest reliability was determined using the interclass correlation coefficient (ICCs). Construct validity was evaluated using confirmatory factor analysis (CFA), and convergent validity was examined using Spearman's correlation coefficients. Reliability was measured with Cronbach’s Alpha, ranging from 0.80-1.00, and was considered very good and 0.60–0.79 acceptable [ 36 , 37 ]. Test-retest reliability was evaluated using ICCs (two-way mixed model, absolute agreement), with ICC > 0.75 considered acceptable [ 38 ]. CFA was used to test whether observed variables fit a hypothesized factor structure derived from theory or prior research. In CFA, the cut-off value 0.30 for factor loadings is considered significant when the sample size is ≥ 350 [ 39 ]. Items loading below 0.30 may need removal to avoid weak constructs [ 40 ]. We used SEM and adopted fit criteria from Byrne (1999), specifying that Goodness of Fit Index (GFI) and Comparative Fit Index (CFI) values ≥ 0.80 indicate acceptable model fit [ 41 , 42 ]. A Root Mean Square Error of Approximation (RMSEA) value < 0.06 and a Standardized Root Mean Square Residual (SRMR) value < 0.08 were considered a good fit [ 41 ]. To provide further evidence of construct validity, Spearman's correlation coefficient was used to examine the relationships among the dimensions [ 43 , 44 ]. Results Characteristics of the participants A total of 4,982 registered nurses participated from the 8 hospitals. The mean age and standard deviation (SD) of the nurses were 37 (7.8) years, 26.3% aged ≤ 31 years, 48.8% were 31-41 years, and 24.9% were > 41 years old. Most were female (91.1%). More than half held a nursing diploma (59.8%), followed by a bachelor (26.1%) and a master’s degree or higher (14.2%) (Table 1). Table 1 Socio-demographic and professional characteristics of the participants (n=4982) Variables Categories N (%) Age in years (mean, SD) (37.09, 7.8) ≤ 31 1309 26.3 32- 41 2433 48.8 > 41 1240 24.9 Gender Male 441 8.9 Female 4541 91.1 Nursing education Diploma in nursing (3 years of education) 2977 59.8 BSc in nursing (4 years of education) 1299 26.1 Master and above 706 14.2 Professional experience in years (mean, SD) (12.16, 7.14) ≤ 7 1317 26.4 8-15 2470 49.6 > 15 1195 24.0 Job experience in hospital (years) (mean, SD) 8.62, 6.14) ≤ 5 1884 37.8 6-10 1984 39.8 > 10 1114 22.4 Working ward Medicine 1149 23.1 Surgery 690 13.8 Emergency 215 4.3 Intensive care unit 449 9.0 Cardiology/CCU 263 5.3 Operation theater 392 7.9 Orthopedics/orthopedic surgery 218 4.4 Gynecology and obstetrics 428 8.6 Pediatric/ neonatology 576 11.6 Urology/nephrology 206 4.1 Oncology/hematology 189 3.8 Neurology/neurosurgery 207 4.2 Job experience in ward (years) (mean, SD) (3.92, 3.29) ≤ 2 2074 41.6 3-5 1871 37.6 > 5 1037 20.8 Note: SD=Standard deviation; CCU=Critical care unit Content Validity The content validity of the B-HSOPSC 2.0 was checked by a group of experts (n=6), including academic faculty, clinical nurse specialists, and a patient safety researcher. They individually rated the cultural relevance, clarity, and appropriateness of each translated item using a 4-point scale ranging from 1 (not relevant) to 4 (highly relevant). They recorded the values 1 and 2=0 and 3 and 4=1. The Bengali version obtained excellent content validity, with all items having a content validity index (I-CVI) range of 0.83-1, all dimensions 0.92-1, and the total scale (34 items) S-CVI=0.98 (range 0.92-1), indicating good to excellent content validity [45, 46] (Supplementary Table 1). Construct validity The Kaiser-Meyer-Olkin (KMO) test was performed to evaluate sampling adequacy for factor analysis, yielding a value of 0.858, which indicates a strong shared variance, as a value of ≥ 0.60 is generally considered acceptable. Bartlett’s Test of Sphericity shows sufficient inter-variable correlations (p < 0.001), supporting the data suitability of B-HSOPSC 2.0 with 32 items for factor analysis [47]. CFA was performed to assess construct validity and overall model goodness-of-fit. Two models were developed: one for the original 10-dimensional structure with 32 items (Model 1: Fig. 2) and another for the 9-dimensional structure with 28 items (excluding dimension 2 which consists of 4 items) (Model 2: Fig. 3). The CFA of the Model 1 for B-HSOPSC 2.0 showed mixed fit: CFI (0.79) and Tucker-Lewis Index (TLI) (0.74) indicated suboptimal comparative fit (< 0.90), while GFI (0.90) met acceptable absolute thresholds (≥ 0.90). RMSEA (0.06) and SRMR (0.06) demonstrated excellent fit ≤ 0.06 and ≤0.08, respectively. model 1: Fig. 2). In model 1, the factor loading for dimension 2, four items A2, A3r, A5r and A11r factor loading was 0.05, -0.11, 0.003 and 0.04, respectively (< 0.3 is not ideal) low factor loadings (<0.30) within the “Staffing and Work Pace”, so we removed it and CFA was re-estimate in model 2: Fig. 3. The CFA of Model 2 (9 dimensions) for B-HSOPSC 2.0 demonstrated incremental improvement over Model 1. Comparative fit indices showed CFI = 0.83 (marginally acceptable, ≥0.80) and TLI = 0.79 (below threshold, ≥ 0.90), with NFI = 0.82 indicating marginal fit. Absolute fit was acceptable with GFI = 0.92 (≥ 0.90, improved from Model 1), while RMSEA (0.06, ≤ 0.06) and SRMR (0.06, ≤ 0.08) confirmed excellent fit. These results support the suitability of Model 2 for evaluating patient safety culture among Bangladeshi nurses (Table 2). Table 2 Fit indices for the B-HSOPSC 2.0 (10- and 9-dimension model) Fit indices Mode l Model 2 Threshold Interpretation CFI 0.79 0.83 (0.80-0.90) Model 1 unacceptable Model 2 marginal/acceptable NFI 0.78 0.82 (≥ 0.80) Model 1 unacceptable Model 2 marginal TLI 0.74 0.79 (≥ 0.90) Poor fit for both models GFI 0.91 0.92 (≥ 0.90) Acceptable; Model 2 is slightly better RMSEA 0.06 0.06 (< 0.06) Excellent for both SRMR 0.07 0.06 (< 0.08) Excellent; Model 2 superior χ²/df 20.48 20.56 (< 5) Unacceptable for both CFI: 0.80-0.90 marginal/acceptable; ≥ 0.90 acceptable, ≥ 0.95 good [47]; NFI: 0.80 marginal, ≥ 0.90 acceptable, ≥ 0.95 good [48]; TLI: Poor fit 0.95 [47]; GFI: < 0.90 poor, 0.95 good/excellent [48]; RMSEA: 0.06 acceptable, > 0.08 terrible [49]; SRMR: 0.08 acceptable, > 0.10 terrible [49]. Reliability and positive response rate of patient safety culture Reliability of the Bengali version with 10-dimension scale was checked and an acceptable threshold of Cronbach’s Alpha (α) ≥ 0.70 was obtained for each dimension. The participants’ dimension-specific positive response rates ranged from 22% to 78% compared to U.S. data, ranging from 51% to 82% in 2021. In this study, teamwork achieved the highest rate at 78% (U.S. 82%), whereas reporting patient safety events recorded the lowest rates at 22% (U.S. 74%) and responses were found to be lower compared to the U.S. population (Table 3). Table 3 Reliability statistics and positive response rate of patient safety culture Subscale (Number of items) Cronbach’s Alpha Positive responses (%) This Study HOSPS 2.0 This Study Reference (U.S.) 1. Teamwork (3) 0.73 0.76 78 82 2. Staffing and work pace (4) 0.76 0.67 37 58 3. Organizational learning-continuous improvement (3) 0.71 0.76 75 72 4. Response to error (4) 0.72 0.83 54 64 5. Supervisor support for patient safety (3) 0.72 0.77 71 80 6. Communication about the error (3) 0.70 0.89 72 71 7. Communication openness (4) 0.70 0.83 55 51 8. Reporting patient safety events (2) 0.76 0.75 22 74 9. Hospital management support for patient safety (3) 0.71 0.77 62 67 10. Handoffs and exchange information (3) 0.73 0.72 38 64 HOSPSC-Hospital Survey on Patient Safety Culture, U.S.-United States Test-retest reliability We found overall Cronbach’s alpha of the Bengali version with all 34 items was 0.813, indicating acceptable reliability (>0.70 as acceptable). The test-retest analysis revealed consistent reliability by Cronbach’s alpha (test: α= 0.78; retest: α= 0.78) (data were not shown). The test-retest indicated low single-measure ICCs (0.071-0.069) (acceptable values 0.6-0.74). However, the average-measure ICCs were 0.717-0.723 (p<0.001), demonstrating acceptable reliability at the group level of the B-HSOPSC 2.0 (Supplementary Table 2) [49].. Convergent validity and composite reliability We assessed the convergent validity and composite reliability (CR) of the 10-dimension B-HSOPSC 2.0 and observed that 4 dimensions (5, 6, 8 and 10) met the acceptance threshold. Reporting patient safety events (AVE = 0.91, CR = 0.95) (dimension 8) showed the highest accepted threshold of convergent validity and internal consistency followed by communication about errors (AVE = 0.66, CR = 0.85) (dimension 6), supervisor support (AVE = 0.58, CR = 0.70) (dimension 5) and handoffs and information exchange (AVE = 0.51, CR = 0.71) (dimension 10). The remaining 6 dimensions (1, 2, 3, 4, 7 and 9) did not meet the acceptance thresholds and dimension 3 had the lowest thresholds (Table 4). Table 4 Convergent validity and composite reliability of the ten dimensions of B-HSOPSC 2.0 Dimension with items no Factor Loading AVE CR 1. Teamwork (3) 0.38, 0.34, 0.43 0.15 0.34 2. Staffing and work pace (4) 0.05, -0.11, 0.03, 0.04 0.00 0.00 3. Organizational learning-continuous improvement (3) 0.59, 0.47, 0.31 0.22 0.44 4. Response to error (4) 0.67, 0.64, 0.27, 0.50 0.30 0.61 5. Supervisor support for patient safety (3) 0.96, -0.15, 0.90 0.58 0.70 6. Communication about the error (3) 0.80, 0.83, 0.80 0.66 0.85 7. Communication openness (4) 0.71, 0.63, 0.60, 0.23 0.33 0.64 8. Reporting patient safety events (2) 0.98, 0.93 0.91 0.95 9. Hospital management support for patient safety (3) 0.85, 0.81, 0.13 0.46 0.67 10. Handoffs and exchange information (3) 0.87, 0.86, 0.18 0.51 0.71 Note: AVE: Average Variance Extracted, CR: composite reliability (accepted threshold is AVE ≥ 0.50 and CR ≥ 0.70) Correlation among 10-dimension of B-HSOPSC 2.0 Table 5 presents Spearman correlations among 10-dimension of the B-HSOPSC 2.0, ranging from -0.029 to 0.430. The strongest associations linked communication-related constructs: Communication Openness with Communication About Error (ρ=0.430, p<0.001) and Supervisor Support (ρ= 0.322, p <0.001). Staffing and Work Pace showed weak or negative correlations (e.g., Teamwork: ρ=-0.029, p<0.05), which confirmed the interconnected structure supporting fit. Discussion To the best of our knowledge, this is the first study to conduct a cross-cultural adaptation and psychometric evaluation of the Bengali version of the HSOPSC 2.0 among nurses working at tertiary-level hospitals in Bangladesh, following AHRQ guidelines. The findings of this study revealed that the Bengali version is a valid and reliable instrument for assessing patient safety culture among nurses in Bangladesh. The study included nurses working in hospitals, who represent the largest professional group in the health sector and serve as the first point of contact in patient care. Other studies also evaluated this scale involving nurses with a large sample size in hospital settings [50, 51]. Translation and cultural adaptation A rigorous methodological process was undertaken for the translation and validation of B-HSOPSC 2.0. During cultural adaptation, the terms “manager” and “clinical leader” were removed as those terms did not align with the local nursing hierarchy, where senior staff nurses directly report to the nursing superintendent via the nursing supervisor. Similarly, “units” was replaced by “wards,” the standard terminology for functional divisions familiar to the Bangladesh health system [52]. For the item A5r (“on temporary, float, or PRN staff”), a semantic adjustment was made to reflect local practice, where nurses are often reassigned between wards due to a shortage of staff and huge workloads. Therefore, in the final version, it was changed to “on-demand nurses from other wards” and considered contextually more appropriate for the Bangladeshi healthcare context [53]. Similar pattern was seen across both HICs and LMICs, where HSOPSC items were adjusted to reflect better staffing realities and organizational structures, rather than U.S based systems [54, 55]. Validity The 10-dimension of B-HSOPSC 2.0 demonstrated an excellent level of content validity for items (I-CVI 0.83 to 1.0) and scale (S-CVI 0.98). These findings reflect adaptation relevance, where experts strongly agree with the significance of all dimensions for addressing workforce shortage, suboptimal working conditions and emerging safety culture initiatives, yielding stronger consensus than other high-and middle-income countries (I-CVI-0.73 to 1.0) [56–60]. The CFA result showed the 10-dimension (Model 1) structure of the B-HSOPSC 2.0 with acceptable model fit; however, we observed that dimension 2 had low factor loadings (<0.30), which is considered unacceptable. Additionally, items in dimensions 4 (A10; when staff make errors, this unit focuses on learning rather than blaming individuals), 5 (B2r; my supervisor wants us to work faster during busy times, even if it means taking shortcut), 7 (C7r; in this unit, staff are afraid to ask questions when something does not seem right), 9 (F3r; hospital management seems interested in patient safety only after an adverse event happens), and 10 (F6; during shift changes, there is adequate time to exchange all key patient care information) had low factor loading. These findings reflect the critical nurses’ shortage, where Bangladesh has 0.6 nurses and midwives per 1,000 population compared to the WHO-recommended 4.45 per 1,000 [61]. Moreover, nurses manage 50-70% more patients compared to the hospital bed capacity [62]. Low factor loadings might be influenced by the hierarchical blame culture and heavy workloads in public hospitals. A blame-oriented approach prioritizes individual accountability over learning (A10) [63], while understaffing normalizes supervisory pressure for work speed (B2r). Hierarchical structures discourage questioning, reduce the openness of communication (C7r), centralized decision-making yields reactive management (F3r) [64], and overcrowding and heavy workloads limit handoffs and transitions (F6) [65]. Therefore, we conducted Model 2 with 9 dimensions by removing dimension 2 and found a better model fit, improving most of fit indices. The studies conducted in resource shortages in LMICs versus stable structures in higher-income countries (HICs) showed mixed CFA fits and model modifications across countries reflect context-specific healthcare realities [57, 58, 66, 67]. Both HICs and LMICs adaptations removed several items and composites, reflecting context-specific differences of psychometric properties in the scale structure. For convergent validity, we found four dimensions met acceptable thresholds, consistent with findings reported in other studies [66, 68]. The observed correlation pattern provides evidence of construct validity for the Bengali version. Communication- and leadership-related dimensions demonstrated positive inter-relationships consistent with shared day-to-day safety practices, whereas Staffing and Work Pace showed weak correlations, likely reflecting the contextual normalization of workload pressures in Bangladesh’s resource-constrained and overcrowded health system rather than measurement failure. Incongruent findings are reported in HICs, where flexible resources, temporary staffing, and process optimization yield balanced correlations among 10-dimension without major outliers [58]. Despite low factor loadings and AVE values below the accepted threshold in dimensions, all items were retained for theoretical relevance within Bangladeshi healthcare settings and internal consistency (alpha ≥ 0.70). The 10-dimension, 32-item structure was retained in the Bengali version to preserve the integrity of the composite measure and ensure cross-study comparability. Reliability We found the 10-dimension had acceptable reliability ranging from (Cronbach’s α = 0.70-0.76) and good test–retest reliability (average-measure ICC = 0.717-0.723). These findings reflect that the dimension and the items of B-HSOPSC 2.0 had good internal consistency and were suitable for evaluating the patient safety culture for nurses in Bangladesh. In contrast, other studies conducted in HICs and LMICs observed diverse reliability (Cronbach’s α = 0.67-0.89), which might be for flexible staffing and stable safety initiatives, with stronger communication and teamwork with differences in resources related dimensions D2, D3, D4 and D10 [49, 57, 69, 70]. Additionally, four dimensions met the CR threshold (≥0.70), driven by strong loadings on modifiable, behaviour-based safety practices, while resource-dependent dimensions showed lower CRs, consistent with LMIC constraints. Therefore, based on our study findings, Cronbach’s alpha, ICCs and CR indicate the overall reliability of B-HSOPSC 2.0 among hospital nurses in Bangladesh. Positive response rate of patient safety culture We compared the 10-dimension-wise positive responses with the U.S. HSOPSC 2.0 data as a reference and found Bangladeshi nurses scored higher on dimensions 1, 3, 6 and 7 compared to the U.S. population. We found the highest responses for dimension 1 (teamwork) and the lowest for dimension 8 (reporting patient safety events). Therefore, special attention needs to be given to improve the reporting system of patient safety events through teamwork among nurses and other healthcare professionals. Similar findings from LMIC studies reported low scores for Staffing and Work Pace (Dimension 2), consistent with our results and notably lower than those reported in U.S. (HIC) studies [49, 67, 71]. Strengths This is the first validated and reliable Bengali version of the HSOPSC 2.0, addressing a critical gap in assessing patient safety culture among hospital nurses in Bangladesh. The culturally adapted tool enhances accuracy in measuring safety perceptions, supports cross-national comparability, and offers evidence for developing locally relevant instruments while guiding quality improvement efforts. Limitations This study employed purposive sampling limited to nurses from eight Bangladeshi government medical college hospitals, excluding other professional medical staff members (e.g., physicians, laboratory and supporting staff), which may introduce social desirability bias due to reliance on self-reports. As we collected data from hospital nurses throughout the country, the results could be generalized for nurses; however, not for broader professionals. Future research needs diverse, representative samples and concurrent validity testing against gold-standard scales. Future research Future studies should aim to achieve higher adherence rates and include multi-professional samples to strengthen the robustness of CFA results amid mixed fit. Additionally, this study highlights priority areas that include enhancing work environments and reporting systems to advance patient safety culture. Conclusion This study translated the original English HSOPSC 2.0 scale into Bengali and validated its suitability for use among nurses in Bangladeshi hospitals. The Bengali version showed acceptable content and construct validity. The 10-dimension, 32-item Bengali version of HSOPSC 2.0 found a good fit; however, the 9-dimension (without dimension 2) model with 28 items was found to be a better fit than 10-dimension for nurses working at the hospitals in Bangladesh. All 32 items and their respective subscales demonstrated acceptable reliability, with group-level test–retest reliability. As dimension 2 (Staffing and work pace) is an essential component for the development of patient safety culture, especially in resource-poor settings, policymakers should take proper initiatives to improve hospital staffing and work pace systems. In the absence of a culturally adapted, reliable Bengali HSOPSC 2.0, this tool fills an important gap by providing a standardized measure to lead hospital safety assessment and policy decisions. However, its psychometric properties among physicians and other allied health professionals remain untested. Further research including all healthcare professionals, will increase the likelihood of effectively testing and measuring a suitable Bengali version of HSOPSC 2.0 in this group. Abbreviations HSOPSC Hospital Survey on Patient Safety Culture PSC Patient safety culture PS Patient safety CFA Confirmatory factor analysis CFI Comparative fit index GFI Goodness of fit index RMSEA Root mean square error of approximation SRMR Standardized root mean square residual Declarations Acknowledgments The authors sincerely thank the directors and nursing heads of the participating hospitals for granting permission to conduct this study. We also express our heartfelt gratitude to all expert panels for their tremendous support in questionnaire adaptation processes. We are deeply grateful to the registered nurses who willingly participated and generously contributed their valuable time despite busy work schedules. We also acknowledge the research team for their dedicated efforts in data collection and preparation for analysis. Authors’ contributions MAK conceptualization, project administration, data collection, data analysis, interpretation and writing - original draft. KATMEH methodology, writing - review and editing. TH conceptualization, writing - review and editing. YH writing - review and editing. AOB analysis and interpretation of the data. MM conceptualization, supervision, project administration, writing - review and editing. All authors provided input to improve the manuscript, read and approved the final version for submission. Funding Japan International Cooperation Agency (JICA) and Hiroshima University. The funder had no control over the interpretation, writing, or publication of this work. Availability of data The datasets generated and/or analyzed during the current study are not publicly available due to the confidentiality of the participants. Data are available from the corresponding author upon reasonable request. Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki 2025. Ethical approval was obtained from the National Research Ethics Committee of the Bangladesh Medical Research Council (Ref: BMR/NREC/2025-2027/207; Registration No. 64002032025). Each participant was voluntary and written informed consent was obtained from all participants in this study. All methods were conducted in accordance with relevant guidelines and regulations. Consent for publication Not applicable. All authors consent to the publication of the work Competing interests The authors declare that there is no conflict of interest. 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A. T. M. Ehsanul Huq","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"K.","middleName":"A. T. M. Ehsanul","lastName":"Huq","suffix":""},{"id":579620352,"identity":"a6d3f55f-764e-4fc9-8a9f-9de31bfb63d8","order_by":2,"name":"Tomonori Hasegawa","email":"","orcid":"","institution":"Toho University","correspondingAuthor":false,"prefix":"","firstName":"Tomonori","middleName":"","lastName":"Hasegawa","suffix":""},{"id":579620355,"identity":"82f66a46-d248-4fb9-a879-60c61f2a0406","order_by":3,"name":"Yosuke Hatakeyama","email":"","orcid":"","institution":"Toho University","correspondingAuthor":false,"prefix":"","firstName":"Yosuke","middleName":"","lastName":"Hatakeyama","suffix":""},{"id":579620356,"identity":"7e5b4b26-aec4-4c3e-bfec-63258f459a32","order_by":4,"name":"Abdulfatai Olamilekan Babaita","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Abdulfatai","middleName":"Olamilekan","lastName":"Babaita","suffix":""},{"id":579620357,"identity":"7f51c184-0b1c-4a79-8c34-49b7cd61cf8f","order_by":5,"name":"Michiko Moriyama","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Michiko","middleName":"","lastName":"Moriyama","suffix":""}],"badges":[],"createdAt":"2026-01-22 10:53:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8668706/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8668706/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101366018,"identity":"c848c13a-69ba-4c64-baca-ad384eab5caa","added_by":"auto","created_at":"2026-01-29 00:59:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":97286,"visible":true,"origin":"","legend":"\u003cp\u003eHSOPSC 2.0 Bengali version development procedures\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8668706/v1/f32dd20dcf80c64e96e47772.png"},{"id":101366017,"identity":"78ae249c-6c97-429e-b406-b49cc457f187","added_by":"auto","created_at":"2026-01-29 00:59:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":85290,"visible":true,"origin":"","legend":"\u003cp\u003eConfirmatory factor analysis of the B-HSOPSC 2.0 scale among nurses (Model 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e CFI = 0.79; NFI=0.78; TLI=0.74; GFI=0.91; RMSEA=0.06; SRMR= 0.07\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviation: \u003c/strong\u003eDimension:D1: teamwork, D2: Staffing and work pace, D3: organizational learning continuous improvement, D4: response to error, D5: supervisor support for patient safety, D6: communication about error, D7: communication openness, D8: reporting patient safety events, D9: hospital management support for patient safety, D10: handoffs and information exchange\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8668706/v1/902e94bbb67a411cc8848697.png"},{"id":101366015,"identity":"e7be2c5e-ba39-4ecd-8407-8411c4ea3cbd","added_by":"auto","created_at":"2026-01-29 00:59:32","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":65699,"visible":true,"origin":"","legend":"\u003cp\u003eConfirmatory factor analysis of B-HSOPSC 2.0 scale among nurses (Model 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e CFI = 0.83; NFI=0.82; TLI=0.79; GFI=0.92; RMSEA=0.06; SRMR= 0.06\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviation: \u003c/strong\u003eDimension:D1: teamwork, D3: organizational learning continuous improvement, D4: response to error, D5: supervisor support for patient safety, D6: communication about error, D7: communication openness, D8: reporting patient safety events, D9: hospital management support for patient safety, D10: handoffs and information exchange\u003c/p\u003e","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8668706/v1/3fe9f63a97b59e6514b23d2c.png"},{"id":101398380,"identity":"363390fa-82da-4710-88cf-0f0eb45e64e0","added_by":"auto","created_at":"2026-01-29 09:41:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1409554,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8668706/v1/cd5e6727-8119-4778-8978-d1b85b2063b7.pdf"},{"id":101366016,"identity":"ed142379-f5c5-4933-9d50-dcb603dbd85a","added_by":"auto","created_at":"2026-01-29 00:59:32","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":20981,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable12.docx","url":"https://assets-eu.researchsquare.com/files/rs-8668706/v1/99596c9b038e5265c33b5df7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cross-cultural adaptation and validation of Hospital Survey on Patient Safety Culture in Bengali version (B-HSOPSC 2.0) among nurses in Bangladesh: a cross-sectional study","fulltext":[{"header":"Background","content":"\u003cp\u003ePatient safety is a fundamental pillar of high-quality healthcare, essential for preventing avoidable harm and ensuring safe healthcare worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Healthcare itself can cause harm that originates largely from unsafe systems and organizational factors, rather than individual errors [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The World Health Organization (WHO) convened international experts and policymakers for effective collaboration on patient safety action globally [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. WHO defined patient safety as protecting patients from preventable harm and minimizing the risk of unnecessary injury during healthcare to the lowest possible level [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The National Institute for Occupational Safety and Health (NIOSH) explained that safety culture is an organizational commitment to health and safety, reflected in shared values, attitudes, perceptions, and behaviors of individuals or groups characterized by mutual trust, open communication, and confidence in preventive measures [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The culture of patient safety is the sum of beliefs and practices that shape the way healthcare is provided [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLack of a patient safety culture can cause adverse events due to inadequate medical management rather than underlying illness, such as medication errors, falls, infections, pressure ulcers, and equipment failures [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. It was estimated that 1 in every 10 patients in high-income countries (HICs) experiences adverse events, and 2.6\u0026nbsp;million people in low-and middle-income countries (LMICs) died due to unsafe care in hospitals in 2019 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In LMICs, unsafe healthcare affects up to 40% of patients, resulting in more than 3\u0026nbsp;million deaths annually [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. About half of these incidents are preventable, with many linked to medication errors [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Moreover, LMICs confront challenges such as workforce shortages, fragmented care, and inadequate infrastructure, which amplify risks and make patient safety a critical public health concern [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. It is anticipated that if the patient safety culture is continuously evaluated and improved, patient outcomes and overall safety will be increased [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNurses, the largest group of healthcare providers, play a key role in preventing errors [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], and their proficiency is essential for identifying risks, warning signs, and fostering a culture of patient safety [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Preventing safety errors and improving quality of care depend on nurses\u0026rsquo; competency and principal of patient safety [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A study finding from Bangladesh revealed gaps in infection control knowledge and practices of nurses, emphasizing the need to strengthen patient safety initiatives [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Therefore, continuous improvement of nurses\u0026rsquo; ability is essential to maintain a successful and comprehensive patient safety strategy [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStrengthening patient safety culture is a global priority, with experts recommending validated tools for precise assessment and targeted improvement [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Various patient safety survey instruments are used worldwide to assess organizational safety, environment, and culture. Notable instruments include the Surveys on Patient Safety Culture\u0026trade; (SOPS\u0026reg;) by Agency for Healthcare Research and Quality (AHRQ) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], the Safety Attitudes Questionnaire (SAQ) by University of Texas [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] the Manchester Patient Safety Framework (MaPSaF) by University of Manchester [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and the Patient Safety Climate in Healthcare Organizations (PSCHO) by Stanford University [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The SAQ is shorter and effectively measures perceptions of teamwork and safety climate; however, it offers limited insight into broader organizational culture factors [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In contrast, MaPSaF offers a qualitative and multidimensional assessment of safety culture; however, it lacks standardization and is difficult to benchmark quantitatively [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The PSCHO used to assess organizational climate also has notable weaknesses, including poor internal consistency, lack of CFA, low response rates, and limited generalizability beyond U.S. settings [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. HSOPSC 2.0 is a standardized widely used tool that provides benchmarking data and identifies improvement areas, while SAQ helps to address only concerns, foster a positive culture, and gain employee support [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The Hospital Survey on Patient Safety Culture was developed in 2004 and updated in 2019 (HSOPSC 2.0) and has been widely used in developed and developing countries. AHRQ recommends authentic translations to ensure cross-cultural consistency, making HSOPSC 2.0 reliable globally [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Since its release, it has been translated into 35 different languages and administered in 62 countries worldwide [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. As a well-validated and widely recognized instrument, we used this tool to thoroughly assess nurses' patient safety culture in hospitals. It provides meaningful insights and benchmarking opportunities relevant to nursing practice [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearch on patient safety culture in Bangladesh remains limited despite global concern [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In Bangladesh, studies have reported poor infection control practices, with more than 30% of hospital-acquired infections in some facilities reflecting an inadequate patient safety culture [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. A national health facility survey found that 21% of inpatients at Upazila Health Complexes, 21% at District Hospitals, and 20.8% at Maternal and Child Health facilities received all prescribed drugs, indicating significant medication safety gaps [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Poor safety performance in public hospitals emphasizes the urgent need to strengthen patient safety culture, reduce patient harm, and restore quality in healthcare services [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Moreover, nurses\u0026rsquo; perceptions of patient safety culture in Bangladesh are unknown, highlighting the need for evidence to improve safety practices and guide healthcare policy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Therefore, this study aimed to culturally adapt a valid and reliable Bengali version of HSOPSC 2.0 to assess patient safety culture among nurses working at government tertiary-level medical college hospitals in Bangladesh.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis was a two-step design study comprising translation and cultural adaptations, followed by psychometric evaluation of the Bengali version of Surveys on Patient Safety Culture\u0026trade; (SOPS\u0026reg;) hospital survey 2.0 (B-HSOPSC 2.0). The translation process used a forward-backwards method, and pretesting was conducted in accordance with AHRQ translation guidelines [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Further, validity was checked by content and construct validity, and reliability was assessed by internal consistency and test-retest reliability (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting and Sampling\u003c/h2\u003e \u003cp\u003eAs there are eight administrative divisions in Bangladesh, we conducted our study in eight tertiary-level government medical college hospitals, one per division, to cover the whole country. The study population included all nurses (N\u0026thinsp;=\u0026thinsp;8907) working in different wards of those hospitals. Based on the reference table in the AHRQ guidelines, our minimum required sample size was 4,575 out of a total of 8,907 nurses from 8 hospitals [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. We recruited all nurses who met the inclusion criteria: being nurses with at least 2 years of experience, working for at least 2 months in the current ward, and willing to participate in this study. We excluded nurses who were not involved in direct patient care, those in administrative roles, and those on leave during the data collection period. A total of 7,170 (80.5%) nurses met the inclusion criteria and received questionnaires. Among them, 5003 nurses completed the survey, and after data cleaning, 4,982 valid responses were retained (69.5% valid response rate).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Period\u003c/h3\u003e\n\u003cp\u003eData were collected between April and September 2025.\u003c/p\u003e\n\u003ch3\u003eHSOPSC 2.0 Instruments\u003c/h3\u003e\n\u003cp\u003eThe AHRQ HSOPSC 2.0 [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] consists of 34 items. Among all items, 32 items comprised 10 composite dimensions with 5-point Likert scales of agreement (from 1\u0026thinsp;=\u0026thinsp;strongly disagree to 5\u0026thinsp;=\u0026thinsp;strongly agree) or frequency (from 1\u0026thinsp;=\u0026thinsp;never to 5\u0026thinsp;=\u0026thinsp;always). According to AHRQ guidelines, these scale scores are re-coded as 1\u0026ndash;2\u0026thinsp;=\u0026thinsp;1, 3\u0026thinsp;=\u0026thinsp;2, and 4\u0026ndash;5\u0026thinsp;=\u0026thinsp;3, used to compute the average percent positive response rate of each dimension. The survey includes 2 single-item outcome measures: frequency of events reported (none\u0026thinsp;=\u0026thinsp;1; 1 to 2\u0026thinsp;=\u0026thinsp;2; 3 to 5\u0026thinsp;=\u0026thinsp;3; 6 to 10\u0026thinsp;=\u0026thinsp;4; 11 or more\u0026thinsp;=\u0026thinsp;5) and patient safety rating (from poor\u0026thinsp;=\u0026thinsp;1, fair\u0026thinsp;=\u0026thinsp;2, good\u0026thinsp;=\u0026thinsp;3, very good\u0026thinsp;=\u0026thinsp;4, and excellent\u0026thinsp;=\u0026thinsp;5). We re-coded items into 3 levels: poor\u0026thinsp;=\u0026thinsp;1 (1\u0026ndash;2), fair\u0026thinsp;=\u0026thinsp;2 (3), good/excellent\u0026thinsp;=\u0026thinsp;3 (4\u0026ndash;5). Additionally, we included nine background questions including participants\u0026rsquo; age, gender, nursing education, total professional experience, experience in current hospitals, working wards, experience in current wards, in-service training like nursing care, nursing administration, infection prevention and control-related training.\u003c/p\u003e\n\u003ch3\u003eHSOPSC 2.0 Bengali version (B-HSOPSC 2.0) development procedures\u003c/h3\u003e\n\u003cp\u003eThe HSOPSC 2.0 English version was translated into Bengali following the Translation Guidelines established by the AHRQ for the Surveys on Patient Safety Culture\u0026trade; (SOPS\u0026reg;) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The translation procedure was conducted in 7 sequential steps (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). First, we obtained written permission from AHRQ to use a translated Bengali version of the English instrument. Then we performed forward and backward translation between English and Bengali, conducted by two bilingual translators who were professors with PhD degrees and experts in translation. Another two bilingual reviewers (experts in patient safety and survey methodology) assessed the translations to ensure clarity, conceptual accuracy, and contextual appropriateness, confirming that the Bengali version faithfully reflected the meaning of the original instrument. The instrument was further reconciled by an expert committee consisting of eight bilingual professionals, including academic faculty with higher education, who possess both clinical and teaching experience; a clinical nurse specialist with expertise in patient safety; and two bilingual translators. All members reviewed the original translation using the master comparison table, which contained forward-backwards-translated comments and reconciled columns. Through detailed discussion and consensus, the committee resolved semantic and cultural discrepancies, ensuring conceptual equivalence with the original instrument. The pre-testing of the instrument was conducted by administrating 17 nurses working at two tertiary medical college hospitals from eight study hospitals. Eleven nurses participated in face-to-face cognitive interviews (retrospective probing) using semi-structured interview guidelines. Another 6 nurses participated in a focus group discussion (FGD). Participants were asked to identify any translated items, response options, or survey instructions that they found confusing or difficult to understand. Notes were taken during interviews and FGDs. Then, the previous translation team (8 experts) again reviewed and incorporated all pretest findings and finalized the Bengali version (B-HSOPSC 2.0).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eData Collection Procedures\u003c/h3\u003e\n\u003cp\u003eAfter obtaining written permission from the respective hospital directors to conduct the research, the Principal Investigator (PI, the first author) convened meetings with the nursing heads, ward in-charges and nurses in the respective hospital conference rooms. The PI explained the study objectives, ethical considerations, and inclusion/ exclusion criteria as well as the role of the participants. Consent was obtained from those who met the eligibility criteria, and questionnaires were distributed. The research assistant (RAs) team assisted and monitored data collection procedures in the wards. Completed questionnaires were collected into secure drop boxes placed in the nurses\u0026rsquo; duty rooms and in the nursing supervisor's room. For retest, data were also collected from 424 participants out of 3727 (11.38%) from three study hospitals, two weeks apart from the main survey.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical consideration\u003c/h2\u003e \u003cp\u003eThe study was conducted in accordance with the principles of ethical research in the Declaration of Helsinki 2025 [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Ethical approval was obtained from the National Research Ethics Committee of the Bangladesh Medical Research Council (Registration No. 64002032025). Written informed consent was obtained from all the participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe data were analyzed using SPSS for Windows version .31.0 (IBM Crop Armonk, NY, USA) and JMP Student Edition version 19.1 (SAS Institute Inc., Cary, NC, USA). All negative items were reverse-coded for analysis. Significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Descriptive statistics were used to evaluate participants\u0026rsquo; characteristics and each B-HSOPSC 2.0 subscale [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Content validity of the instrument was evaluated using the content validity index; reliability was assessed with Cronbach\u0026rsquo;s alpha coefficient, and test-retest reliability was determined using the interclass correlation coefficient (ICCs). Construct validity was evaluated using confirmatory factor analysis (CFA), and convergent validity was examined using Spearman's correlation coefficients.\u003c/p\u003e \u003cp\u003eReliability was measured with Cronbach\u0026rsquo;s Alpha, ranging from 0.80-1.00, and was considered very good and 0.60\u0026ndash;0.79 acceptable [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Test-retest reliability was evaluated using ICCs (two-way mixed model, absolute agreement), with ICC\u0026thinsp;\u0026gt;\u0026thinsp;0.75 considered acceptable [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCFA was used to test whether observed variables fit a hypothesized factor structure derived from theory or prior research. In CFA, the cut-off value 0.30 for factor loadings is considered significant when the sample size is \u0026ge;\u0026thinsp;350 [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eItems loading below 0.30 may need removal to avoid weak constructs [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. We used SEM and adopted fit criteria from Byrne (1999), specifying that Goodness of Fit Index (GFI) and Comparative Fit Index (CFI) values\u0026thinsp;\u0026ge;\u0026thinsp;0.80 indicate acceptable model fit [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. A Root Mean Square Error of Approximation (RMSEA) value\u0026thinsp;\u0026lt;\u0026thinsp;0.06 and a Standardized Root Mean Square Residual (SRMR) value\u0026thinsp;\u0026lt;\u0026thinsp;0.08 were considered a good fit [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. To provide further evidence of construct validity, Spearman's correlation coefficient was used to examine the relationships among the dimensions [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eCharacteristics of the participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 4,982 registered nurses participated from the 8 hospitals. The mean age and standard deviation (SD) of the nurses were 37 (7.8) years, 26.3% aged \u0026le; 31 years, 48.8% were 31-41 years, and 24.9% were \u0026gt; 41 years old. Most were female (91.1%). More than half held a nursing diploma (59.8%), followed by a bachelor (26.1%) and a master\u0026rsquo;s degree or higher (14.2%) (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Socio-demographic and professional characteristics of the participants (n=4982)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"576\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategories\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eAge in years\u0026nbsp;(mean, SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 150px;\"\u003e\n \u003cp\u003e(37.09, 7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026le; 31\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e1309\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e26.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e32- 41\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e2433\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e48.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026gt; 41\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e1240\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e24.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e441\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e4541\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e91.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eNursing education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eDiploma\u0026nbsp;in nursing (3\u0026nbsp;years of education)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e2977\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e59.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eBSc in nursing (4 years of education)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e1299\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e26.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eMaster and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e706\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e14.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eProfessional experience in years (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 150px;\"\u003e\n \u003cp\u003e(12.16, 7.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026le; 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e1317\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e26.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e8-15\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e2470\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e49.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026gt; 15\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e1195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e24.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eJob experience in hospital (years) (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 150px;\"\u003e\n \u003cp\u003e8.62, 6.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026le; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e1884\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e37.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e6-10\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e1984\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e39.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026gt; 10\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e1114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e22.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eWorking ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eMedicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e1149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e23.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eSurgery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e690\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e13.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eEmergency\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e215\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eIntensive\u0026nbsp;care\u0026nbsp;unit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e449\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eCardiology/CCU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eOperation theater\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e392\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eOrthopedics/orthopedic\u0026nbsp;surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eGynecology and\u0026nbsp;obstetrics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e428\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003ePediatric/\u0026nbsp;neonatology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e576\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e11.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eUrology/nephrology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e206\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eOncology/hematology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e189\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eNeurology/neurosurgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003eJob experience in ward (years) (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 150px;\"\u003e\n \u003cp\u003e(3.92, 3.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026le; 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e2074\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e41.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e3-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e1871\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e37.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026gt; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e1037\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e20.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: SD=Standard deviation; CCU=Critical care unit\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContent Validity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe content validity of the B-HSOPSC 2.0 was checked by a group of experts (n=6), including academic faculty, clinical nurse specialists, and a patient safety researcher. They individually rated the cultural relevance, clarity, and appropriateness of each translated item using a 4-point scale ranging from 1 (not relevant) to 4 (highly relevant). They recorded the values 1 and 2=0 and 3 and 4=1. The Bengali version obtained excellent content validity, with all items having a content validity index (I-CVI) range of 0.83-1, all dimensions 0.92-1, and the total scale (34 items) S-CVI=0.98 (range 0.92-1), indicating good to excellent content validity [45, 46] (Supplementary Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConstruct validity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Kaiser-Meyer-Olkin (KMO) test was performed to evaluate sampling adequacy for factor analysis, yielding a value of 0.858, which indicates a strong shared variance, as a value of \u0026ge; 0.60 is generally considered acceptable. Bartlett\u0026rsquo;s Test of Sphericity shows sufficient inter-variable correlations (p \u0026lt; 0.001), supporting the data suitability of B-HSOPSC 2.0 with 32 items for factor analysis [47].\u003c/p\u003e\n\u003cp\u003eCFA was performed to assess construct validity and overall model goodness-of-fit. Two models were developed: one for the original 10-dimensional structure with 32 items (Model 1: Fig. 2) and another for the 9-dimensional structure with 28 items (excluding dimension 2 which consists of 4 items) (Model 2: Fig. 3). The CFA of the Model 1 for B-HSOPSC 2.0 showed mixed fit: CFI (0.79) and Tucker-Lewis Index (TLI) (0.74) indicated suboptimal comparative fit (\u0026lt; 0.90), while GFI (0.90) met acceptable absolute thresholds (\u0026ge; 0.90). RMSEA (0.06) and SRMR (0.06) demonstrated excellent fit \u0026le; 0.06 and \u0026le;0.08, respectively. model 1: Fig. 2). In model 1, the factor loading for dimension 2, four items A2, A3r, A5r and A11r factor loading was 0.05, -0.11, 0.003 and 0.04, respectively (\u0026lt; 0.3 is not ideal) low factor loadings (\u0026lt;0.30) within the \u0026ldquo;Staffing and Work Pace\u0026rdquo;, so we removed it and CFA was re-estimate in model 2: Fig. 3. The CFA of Model 2 (9 dimensions) for B-HSOPSC 2.0 demonstrated incremental improvement over Model 1. Comparative fit indices showed CFI = 0.83 (marginally acceptable, \u0026ge;0.80) and TLI = 0.79 (below threshold, \u0026ge; 0.90), with NFI = 0.82 indicating marginal fit. Absolute fit was acceptable with GFI = 0.92 (\u0026ge; 0.90, improved from Model 1), while RMSEA (0.06, \u0026le; 0.06) and SRMR (0.06, \u0026le; 0.08) confirmed excellent fit. These results support the suitability of Model 2 for evaluating patient safety culture among Bangladeshi nurses (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e Fit indices for the B-HSOPSC 2.0 (10- and 9-dimension model)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFit indices\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMode l\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 2\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThreshold\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterpretation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eCFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e(0.80-0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eModel 1 unacceptable\u003c/p\u003e\n \u003cp\u003eModel 2 marginal/acceptable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e(\u0026ge; 0.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eModel 1 unacceptable\u003c/p\u003e\n \u003cp\u003eModel 2 marginal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eTLI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e(\u0026ge; 0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003ePoor fit for both models\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eGFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e(\u0026ge; 0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eAcceptable; Model 2 is slightly better\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eRMSEA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e(\u0026lt; 0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eExcellent for both\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eSRMR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e(\u0026lt; 0.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eExcellent; Model 2 superior\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;/df\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e20.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e20.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e(\u0026lt; 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eUnacceptable for both\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCFI: 0.80-0.90 marginal/acceptable; \u0026ge; 0.90 acceptable, \u0026ge; 0.95 good [47]; NFI: 0.80 marginal, \u0026ge; 0.90 acceptable, \u0026ge; 0.95 good [48]; TLI: Poor fit \u0026lt;0.90, Marginal/acceptable 0.90-0.95; Good fit \u0026gt; 0.95 [47]; GFI: \u0026nbsp;\u0026lt;\u0026thinsp;0.90 poor, \u0026lt;\u0026thinsp;0.95 acceptable, \u0026gt;\u0026thinsp;0.95 good/excellent [48]; RMSEA: \u0026lt;\u0026thinsp;0.06 excellent, \u0026gt; 0.06 acceptable, \u0026gt;\u0026thinsp;0.08 terrible [49]; SRMR: \u0026lt;\u0026thinsp;0.08 excellent, \u0026gt;\u0026thinsp;0.08 acceptable, \u0026gt;\u0026thinsp;0.10 terrible [49].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReliability and positive response rate of patient safety culture\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReliability of the Bengali version with 10-dimension scale was checked and an acceptable threshold of Cronbach\u0026rsquo;s Alpha (\u0026alpha;) \u0026ge; 0.70 was obtained for each dimension. The participants\u0026rsquo; dimension-specific positive response rates ranged from 22% to 78% compared to U.S. data, ranging from 51% to 82% in 2021. In this study, teamwork achieved the highest rate at 78% (U.S. 82%), whereas reporting patient safety events recorded the lowest rates at 22% (U.S. 74%) and responses were found to be lower compared to the U.S. population (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Reliability statistics and positive response rate of patient safety culture\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"592\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 305px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubscale (Number of items)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCronbach\u0026rsquo;s Alpha\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePositive responses (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003eThis Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eHOSPS 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eThis Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eReference (U.S.)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 305px;\"\u003e\n \u003cp\u003e1. Teamwork (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 305px;\"\u003e\n \u003cp\u003e2. Staffing and work pace (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 305px;\"\u003e\n \u003cp\u003e3. Organizational learning-continuous improvement (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 305px;\"\u003e\n \u003cp\u003e4. Response to error (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 305px;\"\u003e\n \u003cp\u003e5. Supervisor support for patient safety (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 305px;\"\u003e\n \u003cp\u003e6. Communication about the error (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 305px;\"\u003e\n \u003cp\u003e7. Communication openness (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 305px;\"\u003e\n \u003cp\u003e8. Reporting patient safety events (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 305px;\"\u003e\n \u003cp\u003e9. Hospital management support for patient safety (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 305px;\"\u003e\n \u003cp\u003e10. Handoffs and exchange information (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHOSPSC-Hospital Survey on Patient Safety Culture, U.S.-United States\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTest-retest reliability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe found overall Cronbach\u0026rsquo;s alpha of the Bengali version with all 34 items was 0.813, indicating acceptable reliability (\u0026gt;0.70 as acceptable). The test-retest analysis revealed consistent reliability by Cronbach\u0026rsquo;s alpha (test: \u0026alpha;= 0.78; retest: \u0026alpha;= 0.78) (data were not shown). The test-retest indicated low single-measure ICCs (0.071-0.069) (acceptable values 0.6-0.74). However, the average-measure ICCs were 0.717-0.723 (p\u0026lt;0.001), demonstrating acceptable reliability at the group level of the B-HSOPSC 2.0 (Supplementary Table 2) [49]..\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConvergent validity and composite reliability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe assessed the convergent validity and composite reliability (CR) of the 10-dimension B-HSOPSC 2.0 and observed that 4 dimensions (5, 6, 8 and 10) met the acceptance threshold. Reporting patient safety events (AVE = 0.91, CR = 0.95) (dimension 8) showed the highest accepted threshold of convergent validity and internal consistency followed by communication about errors (AVE = 0.66, CR = 0.85) (dimension 6), supervisor support (AVE = 0.58, CR = 0.70) (dimension 5) and handoffs and information exchange (AVE = 0.51, CR = 0.71) (dimension 10). The remaining 6 dimensions (1, 2, 3, 4, 7 and 9) did not meet the acceptance thresholds and dimension 3 had the lowest thresholds (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e Convergent validity and composite reliability of the ten dimensions of B-HSOPSC 2.0\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"593\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDimension with items no\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor Loading\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAVE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e1. Teamwork (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e0.38, 0.34, 0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e2. Staffing and work pace (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e0.05, -0.11, 0.03, 0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e3. Organizational learning-continuous improvement (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e0.59, 0.47, 0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e4. Response to error (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e0.67, 0.64, 0.27, 0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e5. Supervisor support for patient safety (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e0.96, -0.15, 0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e6. Communication about the error (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e0.80, 0.83, 0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e7. Communication openness (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e0.71, 0.63, 0.60, 0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e8. Reporting patient safety events (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e0.98, 0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e9. Hospital management support for patient safety (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e0.85, 0.81, 0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003e10. Handoffs and exchange information (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e0.87, 0.86, 0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e AVE: Average Variance Extracted, CR: composite reliability (accepted threshold is AVE \u0026ge; 0.50 and CR \u0026ge; 0.70)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelation\u0026nbsp;among 10-dimension of B-HSOPSC 2.0\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 5 presents Spearman correlations among 10-dimension of the B-HSOPSC 2.0, ranging from -0.029 to 0.430. The strongest associations linked communication-related constructs: Communication Openness with Communication About Error (\u0026rho;=0.430, p\u0026lt;0.001) and Supervisor Support (\u0026rho;= 0.322, p \u0026lt;0.001). Staffing and Work Pace showed weak or negative correlations (e.g., Teamwork: \u0026rho;=-0.029, p\u0026lt;0.05), which confirmed the interconnected structure supporting fit.\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/127393_c7e80a1c9bb65875/127393_custom_files/img1769606029.png\" style=\"width: 647px;\"\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge, this is the first study to conduct a cross-cultural adaptation and psychometric evaluation of the Bengali version of the HSOPSC 2.0 among nurses working at tertiary-level hospitals in Bangladesh, following AHRQ guidelines. The findings of this study revealed that the Bengali version is a valid and reliable instrument for assessing patient safety culture among nurses in Bangladesh. The study included nurses working in hospitals, who represent the largest professional group in the health sector and serve as the first point of contact in patient care. Other studies also evaluated this scale involving nurses with a large sample size in hospital settings [50, 51].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTranslation and cultural adaptation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA rigorous methodological process was undertaken for the translation and validation of B-HSOPSC 2.0. During cultural adaptation, the terms \u0026ldquo;manager\u0026rdquo; and \u0026ldquo;clinical leader\u0026rdquo; were removed as those terms did not align with the local nursing hierarchy, where senior staff nurses directly report to the nursing superintendent via the nursing supervisor. Similarly, \u0026ldquo;units\u0026rdquo; was replaced by \u0026ldquo;wards,\u0026rdquo; the standard terminology for functional divisions familiar to the Bangladesh health system [52]. For the item A5r (\u0026ldquo;on temporary, float, or PRN staff\u0026rdquo;), a semantic adjustment was made to reflect local practice, where nurses are often reassigned between wards due to a shortage of staff and huge workloads. Therefore, in the final version, it was changed to \u0026ldquo;on-demand nurses from other wards\u0026rdquo; and considered contextually more appropriate for the Bangladeshi healthcare context [53]. Similar pattern was seen across both HICs and LMICs, where HSOPSC items were adjusted to reflect better staffing realities and organizational structures, rather than U.S based systems [54, 55].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eValidity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 10-dimension of B-HSOPSC 2.0\u0026nbsp;demonstrated\u0026nbsp;an excellent level of content validity for\u0026nbsp;items (I-CVI 0.83 to 1.0) and scale (S-CVI 0.98). These findings reflect adaptation relevance, where experts strongly agree with the significance of all dimensions for addressing workforce shortage, suboptimal working conditions and emerging safety culture initiatives, yielding stronger consensus than other high-and middle-income countries (I-CVI-0.73 to 1.0) [56\u0026ndash;60].\u003c/p\u003e\n\u003cp\u003eThe CFA result showed the 10-dimension (Model 1) structure of the B-HSOPSC 2.0 with acceptable model fit; however, we observed that dimension 2 had low factor loadings (\u0026lt;0.30), which is considered unacceptable. Additionally, items in dimensions 4 (A10; when staff make errors, this unit focuses on learning rather than blaming individuals), 5 (B2r; my supervisor wants us to work faster during busy times, even if it means taking shortcut), 7 (C7r; in this unit, staff are afraid to ask questions when something does not seem right), 9 (F3r; hospital management seems interested in patient safety only after an adverse event happens), and 10 (F6; during shift changes, there is adequate time to exchange all key patient care information) had low factor loading. These findings reflect the critical nurses\u0026rsquo; shortage, where Bangladesh has 0.6 nurses and midwives per 1,000 population compared to the WHO-recommended 4.45 per 1,000 [61]. Moreover, nurses manage 50-70% more patients compared to the hospital bed capacity [62]. Low factor loadings might be influenced by the hierarchical blame culture and heavy workloads in public hospitals. \u0026nbsp;A blame-oriented approach prioritizes individual accountability over learning (A10) [63], while understaffing normalizes supervisory pressure for work speed (B2r). Hierarchical structures discourage questioning, reduce the openness of communication (C7r), centralized decision-making yields reactive management (F3r) [64], and overcrowding and heavy workloads limit handoffs and transitions (F6) [65].\u003c/p\u003e\n\u003cp\u003eTherefore, we conducted Model 2 with 9 dimensions by removing dimension 2 and found a better model fit, improving most of fit indices. The studies conducted in resource shortages in LMICs versus stable structures in higher-income countries (HICs) showed mixed CFA fits and model modifications across countries reflect context-specific healthcare realities [57, 58, 66, 67]. Both HICs and LMICs adaptations removed several items and composites, reflecting context-specific differences of psychometric properties in the scale structure. For convergent validity, we found four dimensions met acceptable thresholds, consistent with findings reported in other studies [66, 68].\u003c/p\u003e\n\u003cp\u003eThe observed correlation pattern provides evidence of construct validity for the Bengali version. Communication- and leadership-related dimensions demonstrated positive inter-relationships consistent with shared day-to-day safety practices, whereas Staffing and Work Pace showed weak correlations, likely reflecting the contextual normalization of workload pressures in Bangladesh\u0026rsquo;s resource-constrained and overcrowded health system rather than measurement failure.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eIncongruent findings are reported in HICs, where flexible resources, temporary staffing, and process optimization yield balanced correlations among 10-dimension without major outliers\u0026nbsp;[58].\u003c/p\u003e\n\u003cp\u003eDespite low factor loadings and AVE values below the accepted threshold in dimensions, all items were retained for theoretical relevance within Bangladeshi healthcare settings and internal consistency (alpha \u0026ge; 0.70). The 10-dimension, 32-item structure was retained in the Bengali version to preserve the integrity of the composite measure and ensure cross-study comparability.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReliability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe found the 10-dimension had acceptable reliability ranging from (Cronbach\u0026rsquo;s \u0026alpha; = 0.70-0.76) and good test\u0026ndash;retest reliability (average-measure ICC = 0.717-0.723). These findings reflect that the dimension and the items of B-HSOPSC 2.0 had good internal consistency and were suitable for evaluating the patient safety culture for nurses in Bangladesh. In contrast, other studies conducted in HICs and LMICs observed diverse reliability (Cronbach\u0026rsquo;s \u0026alpha; = 0.67-0.89), which might be for flexible staffing and stable safety initiatives, with stronger communication and teamwork with differences in resources related dimensions D2, D3, D4 and D10 [49, 57, 69, 70]. Additionally, four dimensions met the CR threshold (\u0026ge;0.70), driven by strong loadings on modifiable, behaviour-based safety practices, while resource-dependent dimensions showed lower CRs, consistent with LMIC constraints.\u003c/p\u003e\n\u003cp\u003eTherefore, based on our study findings, Cronbach\u0026rsquo;s alpha, ICCs and CR indicate the overall reliability of B-HSOPSC 2.0 among hospital nurses in Bangladesh.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePositive response rate of patient safety culture\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe compared the 10-dimension-wise positive responses with the U.S. HSOPSC 2.0 data as a reference and found Bangladeshi nurses scored higher on dimensions 1, 3, 6 and 7 compared to the U.S. population. We found the highest responses for dimension 1 (teamwork) and the lowest for dimension 8 (reporting patient safety events). Therefore, special attention needs to be given to improve the reporting system of patient safety events through teamwork among nurses and other healthcare professionals. Similar findings from LMIC studies reported low scores for Staffing and Work Pace (Dimension 2), consistent with our results and notably lower than those reported in U.S. (HIC) studies [49, 67, 71].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is the first validated and reliable Bengali version of the HSOPSC 2.0, addressing a critical gap in assessing patient safety culture among hospital nurses in Bangladesh. The culturally adapted tool enhances accuracy in measuring safety perceptions, supports cross-national comparability, and offers evidence for developing locally relevant instruments while guiding quality improvement efforts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed purposive sampling limited to nurses from eight Bangladeshi government medical college hospitals, excluding other professional medical staff members (e.g., physicians, laboratory and supporting staff), which may introduce social desirability bias due to reliance on self-reports. As we collected data from hospital nurses throughout the country, the results could be generalized for nurses; however, not for broader professionals. Future research needs diverse, representative samples and concurrent validity testing against gold-standard scales.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFuture research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFuture studies should aim to achieve higher adherence rates and include multi-professional samples to strengthen the robustness of CFA results amid mixed fit. Additionally, this study highlights priority areas that include enhancing work environments and reporting systems to advance patient safety culture.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study translated the original English HSOPSC 2.0 scale into Bengali and validated its suitability for use among nurses in Bangladeshi hospitals. The Bengali version showed acceptable content and construct validity. The 10-dimension, 32-item Bengali version of HSOPSC 2.0 found a good fit; however, the 9-dimension (without dimension 2) model with 28 items was found to be a better fit than 10-dimension for nurses working at the hospitals in Bangladesh. All 32 items and their respective subscales demonstrated acceptable reliability, with group-level test–retest reliability. As dimension 2 (Staffing and work pace) is an essential component for the development of patient safety culture, especially in resource-poor settings, policymakers should take proper initiatives to improve hospital staffing and work pace systems. In the absence of a culturally adapted, reliable Bengali HSOPSC 2.0, this tool fills an important gap by providing a standardized measure to lead hospital safety assessment and policy decisions. However, its psychometric properties among physicians and other allied health professionals remain untested. Further research including all healthcare professionals, will increase the likelihood of effectively testing and measuring a suitable Bengali version of HSOPSC 2.0 in this group.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHSOPSC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Hospital Survey on Patient Safety Culture\u003c/p\u003e\n\u003cp\u003ePSC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Patient safety culture\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Patient safety\u003c/p\u003e\n\u003cp\u003eCFA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Confirmatory factor analysis\u003c/p\u003e\n\u003cp\u003eCFI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Comparative fit index\u003c/p\u003e\n\u003cp\u003eGFI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Goodness of fit index\u003c/p\u003e\n\u003cp\u003eRMSEA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Root mean square error of approximation\u003c/p\u003e\n\u003cp\u003eSRMR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Standardized root mean square residual\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors sincerely thank the directors and nursing heads of the participating hospitals for granting permission to conduct this study. We also express our heartfelt gratitude to all expert panels for their tremendous support in questionnaire adaptation processes. We are deeply grateful to the registered nurses who willingly participated and generously contributed their valuable time despite busy work schedules. We also acknowledge the research team for their dedicated efforts in data collection and preparation for analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMAK conceptualization, project administration, data collection, data analysis, interpretation and writing - original draft. KATMEH methodology, writing - review and editing. TH conceptualization, writing - review and editing. YH writing - review and editing. AOB analysis and interpretation of the data. MM conceptualization, supervision, project administration, writing - review and editing. All authors provided input to improve the manuscript, read and approved the final version for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJapan International Cooperation Agency (JICA) and Hiroshima University. The funder had no control over the interpretation, writing, or publication of this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to the confidentiality of the participants. Data are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki 2025. Ethical approval was obtained from the National Research Ethics Committee of the Bangladesh Medical Research Council (Ref: BMR/NREC/2025-2027/207; Registration No. 64002032025). Each participant was voluntary and written informed consent was obtained from all participants in this study. All methods were conducted in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. All authors consent to the publication of the work\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHalligan M, Zecevic A. Safety culture in healthcare: a review of concepts, dimensions, measures and progress. 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BMC Health Serv Res. 2024;24(1):1287. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-024-11802-6\u003c/span\u003e\u003cspan address=\"10.1186/s12913-024-11802-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFekadu G, Marshall AP, Muir R, Tobiano G, Ireland MJ. Psychometric Evaluations of the Hospital Survey on Patient Safety Culture Version 2.0 in Ethiopia (E-HSoPSC 2.0): A Cross-Sectional Study. BMJ Open. 2025;15(11):e106109. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2025-106109\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2025-106109\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlsen E, Addo SAJ, Hernes SS, Christiansen MH, Haugen AS, Leonardsen AL. Psychometric properties and criterion related validity of the Norwegian version of hospital survey on patient safety culture 2.0.BMC Health. Serv Res. 2024;24(1):642. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-024-11097-7\u003c/span\u003e\u003cspan address=\"10.1186/s12913-024-11097-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKakemam E, Gharaee H, Rajabi MR, Nadernejad M, Khakdel Z, Raeissi P, et al. Nurses' perception of patient safety culture and its relationship with adverse events: a national questionnaire survey in Iran. 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Measuring the patient safety culture at a tertiary care hospital in Pakistan using the Hospital Survey on Patient Safety Culture (HSOPSC). BMJ Open Qual. 2023;12(1):e002029. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjoq-2022-002029\u003c/span\u003e\u003cspan address=\"10.1136/bmjoq-2022-002029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cross-cultural, Safety culture, Hospital survey, Patient safety, Reliability","lastPublishedDoi":"10.21203/rs.3.rs-8668706/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8668706/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe Hospital Survey on Patient Safety Culture (HSOPSC 2.0) was developed and updated by the Agency for Healthcare Research and Quality in 2019. It has now been widely adopted and translated into different languages worldwide. However, the validity and reliability of the Bengali version of HSOPSC 2.0 (B-HSOPSC 2.0) have not been tested among healthcare professionals. This study aimed to determine the validity and reliability of the B-HSOPSC 2.0 with cross-cultural adaptations, among hospital nurses in Bangladesh.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study was conducted among nurses in eight tertiary-level government medical college hospitals in Bangladesh. A two-step study design was employed, encompassing the translation, cultural adaptation, and psychometric evaluation of B-HSOPSC 2.0. The translation process included forward and backward translation by panel, expert consensus, review, and pretesting. Content validity, reliability, and test-retest reliability were assessed using the content validity index, Cronbach\u0026rsquo;s alpha, and the interclass correlation coefficient, respectively. Construct validity was evaluated through confirmatory factor analysis (CFA), and convergent validity was examined using average variance extraction and Spearman's correlation coefficient.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOut of 7,170 eligible nurses, 4,982 completed questionnaires (response rate: 69.5%), and a subset (n\u0026thinsp;=\u0026thinsp;424) provided retest responses. The words \u0026ldquo;manager\u0026rdquo; and \u0026ldquo;clinical leader\u0026rdquo; were removed, and the word \u0026ldquo;units\u0026rdquo; was replaced with \u0026ldquo;wards,\u0026rdquo; as they were deemed inappropriate for the Bangladeshi healthcare system. The content validity index provides strong evidence of effective measures of the instruments (I-CVI\u0026thinsp;=\u0026thinsp;0.83-1.00, S-CVI\u0026thinsp;=\u0026thinsp;0.98). B-HSOPSC 2.0 demonstrated a good internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.70\u0026ndash;0.76), and test-retest reliability (ICC\u0026thinsp;=\u0026thinsp;0.65\u0026ndash;0.76) showed acceptable reliability. In the CFA model, the indices for the 10 and 9 dimensions were CFI\u0026thinsp;=\u0026thinsp;0.79, 0.83; NFI\u0026thinsp;=\u0026thinsp;0.78, 0.82; TLI\u0026thinsp;=\u0026thinsp;0.74, 0.79; GFI\u0026thinsp;=\u0026thinsp;0.91, 0.92; RMSEA\u0026thinsp;=\u0026thinsp;0.06, 0.06; SRMR\u0026thinsp;=\u0026thinsp;0.07, 0.06, respectively.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe psychometric properties of the Bengali version showed acceptable reliability and validity characteristics. Findings suggest that it can be used to measure nurses' perceived patient safety culture in hospital settings in Bangladesh. This validated tool will enhance safety culture and benefit nursing practice. Further studies are required, as the psychometric properties of B-HSOPSC 2.0 among other healthcare professionals in Bangladesh remain to be confirmed.\u003c/p\u003e\u003ch2\u003eClinical trial number\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Cross-cultural adaptation and validation of Hospital Survey on Patient Safety Culture in Bengali version (B-HSOPSC 2.0) among nurses in Bangladesh: a cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-29 00:59:27","doi":"10.21203/rs.3.rs-8668706/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-03T04:59:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-31T11:43:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T14:33:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127392085562811585237504505075404006380","date":"2026-03-26T13:33:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68302022019567334475790868303982672861","date":"2026-03-26T11:40:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310057963365742237977475384400652480193","date":"2026-03-26T01:04:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T06:54:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57606901942251779119697534113478051046","date":"2026-03-13T04:00:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"219643604669930997742756609153294089766","date":"2026-03-06T16:14:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T14:24:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-28T11:22:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-28T04:44:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-28T04:43:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2026-01-22T10:20:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eeb3b5f3-241a-4935-89d9-5bd54df5e87e","owner":[],"postedDate":"January 29th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T18:38:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-29 00:59:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8668706","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8668706","identity":"rs-8668706","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}