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How workforce perceptions of safety culture in healthcare differ by race, ethnicity, and gender

A strong safety culture is an essential foundation as organizations work to reduce harm. However, safety culture in healthcare has declined during the COVID-19 pandemic, as national safety event rates—like CLABSI, falls, and pressure injuries—also worsened. Healthcare leaders must focus on driving safety culture—a leading indicator of improved safety outcomes.

To do this effectively, it's important to identify disparities in safety culture perceptions across different employee subgroups. New Press Ganey data, from the largest national safety culture dataset, shows that workforce perceptions of safety culture differ by race, ethnicity, and gender. Addressing these gaps can both increase employee buy-in for safety and drive down harm.

In addition, safety culture is strongly correlated to perceptions of diversity and equity—which, in turn, are strongly correlated to employees’ risk of voluntary churn. Therefore, this work on promoting safety culture and reducing disparities in safety culture perceptions has a potentially significant impact on creating a culture of inclusion and improving employees’ likelihood to stay—two critical metrics when the nation is experiencing a healthcare staffing shortage.

About this analysis: Press Ganey measures safety culture with a 19-question validated instrument that includes three domains: “Prevention & Reporting,” “Pride & Reputation,” and “Resources & Teamwork” (Figure 1). This analysis focuses on the “Prevention & Reporting” domain, with feedback collected between January and November 2021 from 143,896 respondents at 57 client organizations.

FIGURE 1: Data and Methodology

Figure 1

Key findings for safety culture in healthcare

There are significant differences in perceptions of safety culture by race and gender. Overall, respondents who identify as Asian have a stronger perception of safety culture compared to those who identify as White. Respondents who identify as Black/African American, Native Hawaiian, two or more races, or “other” have a worse perception across all questions in the domain. Women also have lower perceptions than men. (Figure 2)

FIGURE 2: Average Difference vs. Comparison Group

Figure 2

When segmenting by role, differences also exist in perceptions of safety culture by race and/or gender. Among physicians, race/ethnicity did not show substantial differences, but gender mattered considerably. It's also important to note the lack of representation (with low sample size) of physicians who are American Indian or Alaska Native. (Figure 3)

FIGURE 3: Average Difference vs. Comparison Group - Physician Only

Figure 3

Among nurses, Asian respondents report significantly more positive perceptions of nearly all measures compared to those who identify as White. Black/African American nurses have significantly higher scores for two of the measures (“organization is improving patient safety” and “employees/managers work toward a safe workplace”); nurses who identify as Native Hawaiian/other Pacific Islander, “two or more races,” or “other” have lower perceptions. Women also have lower perceptions than their male counterparts. (Figure 4)

FIGURE 4: Average Difference vs. Comparison Group - Nursing (RN) Only

Figure 4

For service roles, only Asian staff report more favorable experiences than White staff—all other racial groups report worse perceptions compared to White staff. Of note, Hispanic/Latino ethnicity does not seem to be a substantial factor in perceptions for any job category subgroup. (Figure 5) 

FIGURE 5: Average Difference vs. Comparison Group - Service Only

Figure 5

Black/African American managers have substantially lower perceptions of safety culture than their peers. (Figure 6)

FIGURE 6: Average Difference vs. Comparison Group - Management Only

Figure 6

Takeaways for patient safety culture

Safety culture is foundational to patient safety. And improving patient safety culture must be a leadership imperative.

Implementing the following four fundamentals of high reliability organizing is key to transforming your safety culture.

  1. Adopt the goal of zero harm goal and message on safety
  2. Measure harm and make harm visible
  3. Foster a fair and just culture
  4. Practice daily check-ins for safety

It's critical to bring the equity lens to all the important work we do to advance patient safety. As leaders work to implement these culture transformation strategies reliably and equitably, it's important to understand that there are key differences in how subgroups of employees perceive safety culture—both overall and within job types—particularly by race and gender. But identifying the differences is just the first step: Next is understanding why these differences exist at all.

Conducting focus groups and pulse surveying on safety culture items can help get to the root causes. Running targeted interventions on demographics who report lower perceptions of safety culture—notably, women physicians and Black managers—is also a critical strategy for retaining these key leaders at your organization.

Ultimately, the goal is to optimize safety culture in healthcare by identifying gaps and then implementing interventions to close them. Achieving this will require organizations to redouble their efforts toward a safety-first, zero harm culture for all patients and associates. At the same time, they will need to integrate DEI competence into safety culture, including cultural competence or bias training. Breaking down silos between the domains of safety culture and diversity and inclusion initiatives will prove essential to success.

Accelerate your organization’s journey to zero harm. Take the Safety 2025 pledge, learn more about Press Ganey’s Equity Partnership, or have a patient safety culture expert reach out directly.



About the data

  • Even a small difference in mean score could represent a meaningful difference in percentile ranks. Of note, a 0.05 decrease can be the equivalent of 8–10 percentile points.
  • A change in score of +/- 0.05 is associated with a percentile rank change for a facility at the 50th percentile. There's a range (9–13 rank increase, 8–10 rank decrease) because each of the items in the subtheme has a slightly different distribution.
  • We control for the system and the job category when summarizing the differences between groups.

About the author

As Chief Safety and Transformation Officer, Dr. Gandhi, MPH, CPPS is responsible for improving patient and workforce safety, and developing innovative healthcare transformation strategies. She leads the Zero Harm movement and helps healthcare organizations recognize inequity as a type of harm for both patients and the workforce. Dr. Gandhi also leads the Press Ganey Equity Partnership, a collaborative initiative dedicated to addressing healthcare disparities and the impact of racial inequities on patients and caregivers. Before joining Press Ganey, Dr. Gandhi served as Chief Clinical and Safety Officer at the Institute for Healthcare Improvement (IHI), where she led IHI programs focused on improving patient and workforce safety.

Profile Photo of Dr. Tejal Gandhi, MPH, CPPS