Hospitals are places of health services that include local, national and even international community services [1]. Health services supported through quality health services have become a central topic in hospital management, so hospital management needs to pay important attention to the concept of patient safety [1]. Patient safety is a program created by hospitals to ensure that nursing care for patients is safer, which includes risk assessment, identification and management of critical patients, reporting and analysis of accidents, the ability to learn from accidents and follow-up and implementation of problem solving [2].

Nurses play a strategic role in dominating health workers and are the spearhead and most vital resource where almost 60-80% of hospital services are provided by nurses [3]. According to Aburuz [2] hospitals have potential dangers such as infectious diseases, situations and conditions that give rise to occupational safety and health (K3) so that the concept of patient safety plays a very important role. This potential danger includes individual factors of health workers (nurses), work environment and nursing organizations [4]. The work of a nurse is a job that has high stress, because it is in direct contact with various kinds of patients with different disease diagnoses and responses as well as the environment and organizations that manage them [5].

The patient safety program aims to create a culture of patient safety in hospitals so that it can increase accountability, reduce adverse events (KTD) and prevent adverse events and improve hospital K3 performance [6]. Patient safety culture is related to work stress, where work stress can be influenced by the implementation of patient safety culture. The better the implementation of patient safety culture, the more controllable or controlled nurses' work stress will be in a positive direction [7]. This patient safety culture is starting to become a global concern, where in the research of Sorra et al. shows that adverse events in several hospitals in the world are 2.9-3.7%, of which 6.6-13.6% die due to patient safety incidents that lack culturally based implementation. Starting from this report, various patient safety studies continue to be carried out in various countries around the world, including in hospitals in the Kuwait region.

Hospitals are developing rapidly in the world, including in Kuwait, making patient safety culture a program that must be implemented by every nurse. The target of every hospital in the Kuwait region is to demand that KTD be controlled to build hospital management to make several breakthroughs, including implementing a patient safety culture [4]. The work stress experienced by nurses in hospitals in the Kuwait region is quite high, including physiological, psychological problems and changes in behavior. Nurse work stress requires relaxation from hospital management to be able to control or even reduce nurse work stress with the aim of maintaining the quality of health services [4].

Nurse work stress is a negative attitude and the health sector (nursing) has the highest prevalence of work stress in the world [8]. The prevalence of stress shows that in 2013-2016, 82% of health workers experienced work stress [9]. The implementation of a patient safety culture was formed to prevent unforeseen accidents which will relax nurses from work stress due to incidents. Patient safety culture is one of the hospital management programs that includes a work culture of openness, fairness, reporting, learning and information in maintaining and controlling nurses' work stress.

Research by Budiyanto, Rattu and Umboh [10] also adds that nurses' work stress is caused by emotional fatigue and high depersonalization from problematic work such as patient safety incidents. The research results of Gatchel and Schultz [11] and Cooper [12] show that the prevalence of work stress among nurses is quite high, 45% of health workers including nurses experience work stress and this is the highest prevalence during the three survey periods. Patient safety incidents are a source of added stress for nurses because they create higher work pressure to prevent accidents from occurring, so by implementing a patient safety culture that includes every nurse cultivating work of openness, fairness, active reporting, improving learning and providing information to each other, it will be able to reduce work stress of nurses themselves.

Salem et al.'s research [13] shows that patient safety incidents in the Middle Eastern countries including Kuwait still reach 20-25%, such as unforeseen accidents that result in death. This, of course, affects the quality of health services in every hospital in Kuwait. According to the WHO report [14], it is estimated that one in ten patients in developing and developed countries, including Kuwait, experienced an injury while undergoing treatment in hospital which included an adverse event or patient safety incident [15]. WHO [14] recommends that every hospital not only implement a patient safety program but simultaneously implement a patient safety culture in order to protect every health worker (nurse) from work stress.

The patient safety incident report from the Kuwait Hospital Patient Safety Committee for 2015-2020 shows that there were reported cases of adverse events (12.3%) and near misses (KNC) of 14.5%. Another report from a Kuwait regional hospital stated that there were 97 patient safety incident reports submitted to the team but nurses were not used to reporting, correcting or providing information to each other [16]. Some of the results of this research show that in hospitals in the Kuwait region quite a lot of patient safety incidents occur but few are reported to the Hospital Patient Safety Committee and this is not a good patient safety culture [16]. Meanwhile, hospitals are in line with government regulations that patient safety incidents can result in or have the potential to result in injury to patients that should not occur [16].

Patient safety incidents will trigger work stress for nurses because of the impact of losses on patients which also have an impact on nurses and the hospital as well as failure of occupational health safety management (MK3L) and the environment in providing protection to patients and the hospital [16]. Losses to patients are caused by the costs that must be borne by patients becoming greater, patients being treated in hospital for longer, so there is a need to implement a patient safety culture [17]. One strategy for reducing patient safety incidents in a health service is to stimulate a culture of openness and a reflective attitude towards mistakes made and unexpected events through a patient safety culture [18]. 

Nurses are also the single most representative health professional in hospitals, because they spend the most time directly providing care to patients [19]. Nursing problems that add to stress include harsh societal characteristics, geopolitics and monarchical government patterns that greatly influence work authority [18]. The response experienced by these nurses needs to be taken into account so that the adaptation process carried out by each nurse does not cause work stress. Nurses are the biggest key element in building a culture of patient safety in hospitals as well as providing relaxation to overcome the stress of nurses' work. Accredited hospitals with very high mobility of health services, patients increase every day with patient characteristics in a varied environment which is of course more attentive and the service is more emotional than in hospitals in general.

The research results of Asefzadeh, Kalhor and Tirc [20] show that the implementation of patient safety culture has an impact on dealing with nurses' work stress. Nurses' work stress can be relaxed and controlled through the implementation of patient safety culture [20]. The research results of Kustriyani and Mariyati [21] also show that the implementation of patient safety culture has a correlation in reducing nurses' work stress. The correlation between work stress and the implementation of patient safety culture has a positive impact in overcoming it [22]. The research results of Tekingündüz, Yıldız and Inci [22] show that nurses' work stress is influenced by the implementation of patient safety culture. Aini [23] also added that the implementation of patient safety culture has an influence in overcoming nurses' work stress.

A preliminary study in November 2022 revealed that there were several programs in the implementation of patient safety programs that were not running optimally. Programs that have not been implemented optimally for patient safety targets include accurate identification, increasing effective communication, drug safety that needs to be monitored and reducing the risk of patient falls. The patient safety culture is still not embedded in the program alone and employee stress levels are quite high. The results of the preliminary study also explain that patient safety problems include the lack of a culture of openness by nurses, so that sometimes errors in patient identification, medication and transfusion errors are found, resulting in patient safety incidents including untimely accidents.

The perception of fear of severe punishment if reporting a patient safety incident and the perception of a culture of justice is that nurses never provide information and involve families fairly in every decision making due to the insufficient number of nurses and the high workload resulting in work stress. The preliminary study was also strengthened based on a search of hospital report documents, it was found that patient safety incidents in 2021 amounted to 3.5%, including the risk of patient falls, drug storage and accuracy of patient identification. This patient safety incident has decreased compared to the report for the 2020 period, there were 2% incidents since this hospital started the patient safety program.

A preliminary study was also conducted on ten Indonesian nurses at this hospital, explaining that nurses experienced symptoms of work stress, such as concerns about arguing when reprimanded by the head of the room or their co-workers. Apart from that, the workload from hospital organizational demands is too heavy, work time is urgent, the quality of supervision is low and the work climate is unhealthy. The environment and infrastructure are still not optimal, resulting in nurses needing to be selective in preventing work accident incidents. Symptoms of stress that arise include physiological disorders (headaches and sleep disorders), psychological (anxiety, tension, worry and frustration) and behavior (postponing work, overthinking and increased aggressiveness). Seeing the things above, patient safety incidents in hospitals and complaints of work stress and the lack of a culture of patient safety culture, the researcher felt interested in conducting research with the title implementation of patient safety culture with work stress of Indonesian nurses in the Kuwait region. 

Literature Review

Implementation of patient safety culture includes a culture of openness, a culture of justice, a culture of reporting, a culture of learning and an informed culture. Openness culture is how to communicate effectively with procedures for providing information between professions in order to provide services to hospital patients by nurses. Justice culture, namely taking responsibility for errors that occur, focuses on finding the cause of the problem, not looking for who is at fault, the cause of the problem is sought by studying the system, then analyzing the provision of patient safety information. Reporting culture is how often nurses report adverse events (KTD) and near misses (KNC). Learning culture is the process of learning from errors, how they occur and preventive measures that must be taken so that errors do not occur again, which then creates a continuous learning process that brings positive change. Informed culture is a process of conveying information messages from staff without fear or freely, both regarding the actions they have decided and if they see something negatively that could affect patients to nurses in the hospital.

Job stress includes physiological, psychological and behavioral symptoms. Physiological manifestations include increased heart rate, blood pressure, gastrointestinal disorders, increased frequency of physical injuries and accidents, physical fatigue, respiratory problems, skin disorders, headaches, lower back pain, muscle tension and sleep disorders. Psychologically manifested as anxiety, tension, confusion and irritability, feelings of frustration, anger and resentment (hatred), sensitivity and hyperreactivity, harboring feelings, withdrawal and depression, ineffective communication, feelings of isolation and alienation as well as boredom and dissatisfaction work, mental fatigue, decreased intellectual function and loss of concentration. Behavior manifested as procrastination, avoidance of work and absence from work, increased use of alcohol and drugs, abnormal eating behavior, increased aggressiveness, vandalism and crime, decreased quality of interpersonal relationships with family and friends.

Research Purposes

The purpose of this study was to analyze the relationship between of the implementation of patient safety culture and the work stress of Indonesian nurses in hospitals in the Kuwait region.

The research method is a quantitative research method with a descriptive correlation type using a cross sectional approach. The population of this study were 60 Indonesian nurses in hospitals in the Kuwait region. The sampling technique used total sampling technique so that the number of research samples was 60 respondents. The data collection technique is distributing questionnaires by filling in the answer choices in the form of a Likert scale. The questionnaire consists of implementation of patient safety culture variables (reliability value 0.91) and work stress variables (reliability value 0.98). The data were analyzed using the Chi-Square test. The researcher gave an explanation before data collection with the respondent signing an informed consent. The research was conducted for 1 month in October 2023.

Based on the research results in Table 1, it shows that the majority (68%) of patient safety culture implementation is in the good category.

Table 1: Distribution Implementation of Patient Safety Culture Frequency

Table 2: Distribution of Work Stress Frequency

Table 3: Analysis of Implementation of Patient Safety Culture with Work Stress Indonesian Nurses in hospitals in the Kuwait Region

Based on the research results in Table 2, it shows that the majority (75%) of Indonesian nurses' work stress is in the high category.

Based on Table 3 shows that the significance value is 0.015 <Sig.0.05. So the conclusion of the analysis is that there is a relationship between of implementation of patient safety culture with work stress indonesian nurses in hospitals in the Kuwait region.

Implementation of Patient Safety Culture

The results of research on the implementation of patient safety culture in hospitals show that implementation is predominantly in the good and very good categories. Research by Chen [19] and Yilmaz [24] suggests that the implementation of patient safety culture is still poor because nurses rarely implement a culture of openness, such as carrying out confirmation of openness or not providing good comprehensive examination results. Apart from that, lack of teamwork in dividing patient safety tasks also causes three times more patient safety incidents to occur and many nurses are still afraid to ask questions when they find out something is wrong in patient care. The results of this research are supported by research by Thampson which defines that the lack of implementation of patient safety culture is caused by a lack of culture of openness by nurses in confirming with the implementation team, due to the lack of achieving the same goal so that everyone wants to look better. Chen [19] stated that openness cannot be formed if nurses feel embarrassed to talk about something and ask something that doesn't seem right.

According to Cahyono, disrupted teamwork performance is also one of the causes of a lack of open communication regarding patient safety incidents, which is a combination of failures in the openness system. This is different from Ariyani's research which informs about a culture of openness that nurses carry out their work well and always work together between teams in carrying out patient safety. The weak culture of openness in hospitals results in nurses not being good at confirming and admitting that the main problem that occurs is the exchange of information which is caused by a lack of culture of openness so that it has an effect on health services and they should be more open and in the division of tasks they must work together in teams. Teamwork and nurses must be more able to express or convey what they feel is not good. A concrete example of a culture of openness is that nurses dare to reveal mistakes that occur in the room rather than covering them up, nurses feel free to speak up if they see an incident that has a negative impact on the patient and feel free to question decisions or actions related to authority as well as confirmed orders or patient examination results. very well even though there are mistakes.

Research by Moussapi [25] and Yilmaz [24] suggests that a culture of justice is also an obstacle in implementing a poor patient safety culture. Nurses have not implemented a culture of justice, such as not taking responsibility for patient safety errors that occur, only focusing on finding the cause of the problem. The cause of the problems that occur is by studying the patient safety system, then analyzing the provision of patient safety information. The results of research on the implementation of patient safety culture are not good in accordance with research by Wagner [18] which states that the implementation of patient safety culture is not good because nurses do work too quickly in an ineffective time frame for doing the work. According to Jardali [26], health service organizations that have fewer nurses than are needed to provide services to patients, these nurses will feel tired when working. In contrast to Chen's [19] research, a culture of justice becomes an obstacle because nurses feel that the number working in the hospital is sufficient to implement patient safety while working.

Previous research by Moussapi [25] and Yilmaz [24] and Chen [19] stated that the number of nurses must be in accordance with what is needed, so that there is no dissatisfaction with work and recommended that additional nurses be added and that the skills of nurses be in accordance with the needs that exist in each area. units needed to support a fair ratio of nurses and patients so as to minimize safety incidents. A concrete example of a culture of justice is that nurses do not feel that the mistakes they make are something scary for them, the mistakes made by nurses do not focus on finding individual mistakes but focus on studying the system that causes errors, not the perpetrators and the availability of a working climate through policies for nurses. that supports patient safety. Poor implementation of patient safety culture is also due to a lack of reporting culture. Research by Fujita and Chen [19] suggests that the reporting culture is not optimal, this could be because nurses still rarely implement the reporting culture, such as nurses being lazy about reporting, nurses lacking understanding about reporting and nurses feeling afraid of being blamed if they report. 

The culture of reporting has not grown evenly due to the lack of activeness on the part of the Hospital Patient Safety Committee in documenting incidents. Incidents that occur due to the absence of reports from nurses endanger patients. The results of this research are in accordance with research by Gunawan which states that the level of incident reporting is still low due to a lack of understanding by officers to report, less than optimal implementation of the reporting system, fear of reporting and the high workload of human resources. Bump's [27] research conducted at 10 hospitals in the city of Pitts Burgh, United States stated that they had not reported patient safety incidents for 12 months, because they were afraid to report and most nurses made medical errors every day for every week never reporting their own mistakes. . If an error occurs, it is hoped that it can increase motivation to report the incident by eliminating the feeling of fear of being blamed. According to Najihah, reporting patient safety incidents can increase the implementation of patient safety culture so that patient safety incidents can be avoided. However, there are still many health workers who ignore reporting these incidents because they feel they can handle the incident themselves and only report it if an injury has occurred. Concrete examples of a reporting culture are nurses reporting errors even though they are made unintentionally, incidents of errors are often reported regarding patient safety even though they are immediately corrected before they affect the patient, even though the error does not endanger the patient it is still reported and every nurse pays attention to patient safety issues to report it.

Poor implementation of patient safety culture is also due to a lack of learning culture. Research by Al Mamari and Wagner [18] suggests that learning is not good because nurses have not implemented a learning culture such as a lack of understanding by nurses regarding patient safety training, there is no feedback from the organization and teammates so that the patient safety learning program does not run well. , because nurses do not care about incidents that occur due to nurses not understanding the learning culture. The results of previous research by Budiharjo were categorized as poor due to the lack of implicit or explicit knowledge of nurses to learn about handling patient safety incidents. According to Setiowati nurses did not study the events that occurred, did not take action regarding the events that occurred. There are still many nurses who are not willing to explore knowledge in this hospital and not all nurses are willing to implement changes or improvements. 

Argote [28] learning as changes in organizational knowledge itself in various ways, including changes in routines and behavior. Although individual members are the mechanism through which organizational learning generally occurs, the knowledge possessed by individuals must be embedded in individual suprainternal repositions for organizational learning to occur. This means that individual knowledge must be embedded in the organization so that members can access it, even if the individual leaves the organization. Concrete examples of a learning culture are nurses understanding that patient safety culture is better self-learning, nurses getting socialization about patient safety learning, nurses getting training on patient safety learning culture and nurses always discussing ways to prevent errors from happening again. Poor implementation of patient safety culture is also due to a lack of informed culture. Research by Zhao [29] and Yudanur suggests that learning culture is still categorized as poor because nurses have not implemented an information culture well, such as nurses not reviewing incident reports directly, nurses identifying incidents that may occur only through direction and discussion from the head. room and a written report about the patient's condition during shift change. The results of this research are in accordance with research by Reason which states that activities in forming an information system that collects, analyzes and informs incidents are not proactive. Each individual must always have detailed information regarding patient safety which can be known through reports or data. Nasution explains that information perceives the actions that occur to the patient if there is no confirmation that occurs if surgery is carried out, the response is not good because the information is not good. 

Different results were shown by Siregar explaining that information is very useful for the team and patients when patient safety incidents occur. The problem that occurs is the lack of information (informed culture), organizations are able to learn from past experiences so that they have the ability to identify and avoid incidents that will occur because they have learned and are clearly informed from incidents that have already occurred, for example from incident reporting and investigations. The existing information culture is still weak. Various studies abroad have proven that hospitals that have good information systems tend to be successful in fostering a good patient safety culture. Concrete examples of information culture are nurses informing other room nurses of errors that occur, nurses being informed about errors that occur, nurses receiving feedback regarding changes made based on error reporting information and nurses regarding information on the unit when completing tasks can be completely accessed, including about error.

Implementation of patient safety culture to achieve excellent implementation of patient safety culture requires several strengthening. Several strengthening the implementation of patient safety culture because there is still a lack of a culture of openness in the poor category, a culture of justice in the less good category, a learning culture in the less good category and an information culture that is still not running optimally so that the implementation of patient safety culture is categorized as not good.

Work Stress 

Nurse work stress is a dynamic condition where nurses are faced with opportunities, limitations or demands in accordance with the expectations that nurses want to achieve in important and uncertain conditions [30]. Nurse work stress is an adaptive response, through the characteristics of nurses and/or direct psychological processes to the actions, situations and external events in question [31]. The results of this study indicate that the average level of work stress for hospital nurses is high, so attention is needed so as not to cause a prolonged negative response to nurses' performance. In line with Febriandini et al. [30]. Murhayati and Kusmato stated that stress is a reality of daily life that cannot be avoided by nurses, where the demand for nurses to be skilled, make quick and accurate decisions causes nurses to sometimes lose motivation, get bored and have an impact on nurse performance. decreased performance.

The work stress that is still experienced by nurses at this hospital ranges from low levels to some who experience high levels of stress. This cannot be separated from the condition of this hospital as an international standard hospital which requires Indonesian nurses to be extra skilled, to work quickly without having to go the extra mile. all mistakes and in line with Murhayati and Kusmato. Can sometimes cause nurses to lose willpower, fatigue, boredom and it is possible that this will result in decreased performance. Robbins [32] also added that work stress is in the interests of organizations as employers and nurses as job recipients, meaning that it is handled together, not unilaterally. Research by Febriandini [30] and Aiska [31] shows that work stress in nurses which still occurs at low to high levels is a form of abnormal response by nurses. In line with Febriandini [30] and Aiska [31], work stress at RSKK requires countermeasures to reduce work stress. According to Febriandini [30] and Aiska [31] and Murhayati and Kusmato [33] work stress can occur due to factors within the scope of work. The scope of work includes the individuals within it, the work environment and of course the hospital as an organization in managing every employee, including nurses [31]. Murhayati and Kusmato [33] added that work stress is common if it is still in the low category to support nurses in their work, if it is more it will have a negative impact on nurse performance.

Analysis of Implementation of Patient Safety Culture with Work Stress

Research by Chen et al. [19] and Yilmaz et al. [24] stated that the implementation of a patient safety culture in hospitals will have an impact on the management and control of all human resources (nurses) to be more effective and efficient. Control and control of the performance of nurses who have high workload routines are required to be able to face work pressure, which will give rise to the potential for work stress for nurses [19]. Nurses need strong coping mechanisms so that their work can be relaxed from the stress of nursing work and patient safety culture is one of the forms of coping mechanisms for nurses in dealing with work stress. Patient safety culture stimulates nurses to work with openness, fairness, information, learning facilities and forming comprehensive work reports, so that nurses who have routine high workloads and are required to face work pressure can be overcome through the patient safety culture system. Chen et al. [19] and Yilmaz et al. [24] in line with research results concluded that the impact of implementing patient safety culture is that it can positively control nurses' work stress in the hospital environment.

Almamari's research [16] suggests that implementing a patient safety culture will trigger safety and comfort for employers (hospitals), job recipients (nurses) and patient consumers). Work safety and comfort are important indicators for nurses to be able to work without work stress which can affect nurse performance [16]. Implementing a patient safety culture also creates shared positive goals for all hospital employees so that it will have a positive impact on nurses' work. The implementation of patient safety culture has a positive impact on the work environment with work safety and comfort which can positively control nurses' work stress, so that it is in line with research results that the implementation of patient safety culture has an effect on nurses' work stress. 

Research by Moussapi [25] and Yilmaz [24] suggests that the implementation of a patient safety culture creates accountability for patient safety errors from the work of all hospital employees (nurses). Responsibility for patient safety errors by implementing a patient safety culture creates protection for nurses because every safety incident which is one of the stressors of nurses' work can be accommodated because every safety incident that occurs does not only focus on the error but also focuses on finding the cause of the problem and a solution. together [24]. This creates peace for nurses at work so that each nurse can improve their coping mechanisms in dealing with work stress, so that it is in line with research results that the implementation of patient safety culture can influence nurses' work stress.

The research results have shown that the implementation of patient safety culture is related to nurses' work stress (p-value of 0.015) in this study. According to research by Febriandini [30], nurses' work stress can be influenced by other factors such as the dynamic conditions of nurses who are limited in having work authority, such as a fairly strong hierarchy between doctors and nurses. Apart from that, according to research [31], it is stated that nurses' work stress can be influenced by other factors, namely relationships between co-workers in the same profession and across professions that are less than harmonious. Nurses' work stress can be influenced by other factors such as boredom with work routines and high workloads [33]. Meanwhile, according to Robbins [32], other factors that influence nurses' work stress are individual characteristics such as work background, education, culture and demographics of the nurses themselves. So it can be concluded that apart from the implementation of a patient safety culture which has an influence on work stress, there are also other factors related to nurse work stress such as dynamic conditions, limited hierarchy between doctors and nurses, harmonization of relationships between co-workers in the same profession and across professions, boredom in work routines and workload, high level of work and individual characteristics of nurses.

The implementation of patient safety culture in this hospital is mostly implemented well. Job stress: Most of these hospital nurses have high levels of job stress. There is a significant relationship between the implementation of patient safety culture and the work stress of Indonesian nurses at Kuwait Regional Hospital. For hospital management, provide maximum support for the needs of strengthening patient safety culture such as patient safety culture motivation workshops, in-house patient safety culture training at least once every 6-12 months, forming a patient safety culture reporting team and reports are updated every month and annually and it is recommended to implement family gatherings of nursing as a form of outreach to strengthen the organization and minimize and relax work stress at least once every 1-2 years. For nurses, increase awareness to report incidents which are updated every month and annually and report things that can trigger work stress and solutions that can be offered as well as apply coping mechanisms and stress management from mental nursing science. Future researchers need to consider using qualitative data in order to measure the obstacles that occur in implementing patient safety culture and other factors that influence work stress besides implementing patient safety culture so that they can further explore.

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