In 2022, older adults accounted for 17.5% of the population in Korea, and this proportion is expected to surpass 20.6% by 2025, officially classifying Korea as a super-aged society.¹⁾ Advances in medical science and technology, combined with increased life expectancy, have significantly altered the population structure. Social changes, such as the rise of nuclear families, greater workforce participation by women, and declining birth rates, have led to lifestyle shifts. Consequently, family roles in caregiving have diminished, turning the question of “Who should care for aging parents?” into a pressing societal issue rather than an individual concern.²⁾

Chronic diseases, geriatric degenerative diseases, and population aging have significantly emphasized the critical role of primary caregivers, resulting in an increasing dependence on their services.³⁾ Caregivers play an essential role in alleviating patients' and guardians' anxiety by assisting with recovery and enabling patients and their families to maintain their daily lives.⁴⁾ Home-visit caregivers provide essential support under the Long-Term Care Insurance system, visiting the homes of older adults who face challenges with daily activities and physical tasks due to aging or diseases.⁵⁾ Their services include primary care activities such as eating, personal hygiene, mobility, and excretion, as well as housekeeping assistance for those unable to live independently. To qualify as a home-visit caregiver, individuals must complete a training program of up to 320 hour including content on patient safety, at an accredited educational institution and pass a certification examination administered by the mayor or provincial governor, as required under the Elderly Welfare Act.⁵⁾ Since the implementation of long-term care insurance for older adults in 2008, there has been a significant increase in the number of older adults applying for home-visit care services and the caregivers providing them. By the end of 2022, approximately 564,243 caregivers were employed, among whom about 486,523 were engaged in home welfare services.⁶⁾

Patient safety, a cornerstone of person-centered care, is particularly important in home care settings, where many older adults prefer to receive care instead of in facilities. It is defined as “the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health care to an acceptable minimum.”⁷⁾ Home-visit care should prioritize patient safety to ensure the physical and emotional stability of patients and their families. The home care setting, where home-visit caregivers provide care, presents various challenges to patient safety, similar to those encountered in hospital environments.⁸⁾ Falls and pressure ulcers are also identified as major issues in patient safety.⁷⁾ Caregivers are at a higher risk of encountering issues such as falls and pressure ulcers because they care for individuals who have geriatric conditions such as dementia and Parkinson disease or face difficulties with daily activities and physical mobility due to aging. Residential conditions, including damp environments in basement dwellings and poor indoor air quality, can negatively affect the health of care recipients.⁸⁾ Notably, the home care setting often involves situations that are beyond the control of home-visit caregivers, unlike the structured environment of hospitals.⁸⁾ Caregivers may have limited education or professional knowledge regarding patient safety compared to healthcare professionals, and home care services are frequently provided without direct supervision.⁸⁾ Additionally, individual households may lack adequate personal protective equipment (PPE) such as gloves and masks, and critical measures for infection prevention and control, such as disinfectants and waste disposal protocols, may be insufficient.⁸⁾ These factors collectively pose significant threats to patient safety within home care environments.

To ensure patient safety, caregivers’ knowledge and attitudes toward patient safety, awareness of patient safety, and patient safety activities are deemed important. Patient safety knowledge refers to the appropriate level of understanding regarding safety when treating or caring for patients.⁹⁾ Without adequate knowledge, caregivers may fail to recognize safety risks or implement preventive measures effectively. Patient safety attitude refers to the tendencies of individuals or organizational members regarding their beliefs, values, emotions, and behaviors related to patient safety.¹⁰⁾ Patient safety culture refers to the values, attitudes, and behaviors that influence an organization’s commitment to patient safety. It encompasses both organizational and individual approaches to safety.¹⁰⁾ Using a patient safety culture tool allows for the indirect assessment of individual awareness and actions regarding patient safety. Additionally, a culture of patient safety includes individual-level awareness aimed at preventing potential safety incidents during the delivery of healthcare services. Therefore, understanding the culture of patient safety is a critical method for managing and minimizing risks in healthcare institution.¹¹⁾

Positive attitude toward patient safety can create a culture of vigilance and responsibility to prioritize patient safety.¹²⁾ According to the transtheoretical model (TTM), cognitive factors such as knowledge, emotional factors such as attitudes, and positive awareness of behavior are emphasized as key drivers of behavioral change.¹³⁾ In this context, for home-visit caregivers to effectively perform patient safety activities in home-visit care, they require knowledge, attitudes, and a positive awareness of patient safety.

Understanding the relationship between home-visit caregivers’ knowledge, attitudes, awareness of patient safety, and their patient safety activities is essential. Such insights can shed light on practitioners’ awareness and attitudes toward safety, while also identifying challenges and areas for improvement in patient safety practices.

According to previous research, a correct attitude toward patient safety and the abilities required to effectively perform patient safety activities are crucial for ensuring patient safety. Research has implied the need for correct patient safety attitude and performance ability for practicing patient safety activities; a positive attitude toward patient safety precedes patient safety activities.¹⁴⁾ Several studies have shown a significant correlation between patient safety attitudes and patient safety activities.^14-16) Furthermore, patient safety attitude was the most influential factor in performing patient safety activities.¹⁵⁾ Moreover, previous research has emphasized the importance of maintaining caregivers' knowledge of patient safety as a critical factor in ensuring patient safety.¹⁷⁾

Current research on patient safety in Korea has been limited to examining the perception of patient safety among nurses, doctors, and other hospital workers.^18,19) Hospitals provide highly specialized medical services to patients of various ages within limited hospitalization periods, presenting a different concept of patient safety compared to the home care environment where home-visit caregivers work. Nursing homes provide long-term care and treatment for vulnerable older adults, so the concept of patient safety in nursing homes may align to some extent with that of the home care setting. However, significant differences exist, such as the distinction between home and hospital environments and between hospital workers and home-visit caregivers, making the two concepts clearly distinct. However, there is a lack of research on patient safety focusing on caregivers who are responsible for daily life care directly linked to patient safety.

Therefore, this study is a preliminary investigation of patient safety activities according to the increasing trend of home-visit caregivers. It aims to identify the relationship between caregivers’ knowledge, attitude, awareness of patient safety, and patient safety activities and the main factors influencing patient safety. The results are intended to be used as data to seek ways to improve the patient safety management competency of home-visit caregivers and ensure that patient safety activities are performed systematically and efficiently.

In total, 210 home-visit caregivers returned the questionnaires. Data from 35 respondents who provided insufficient answers were excluded. Finally, data from 175 home-visit caregivers were included in the analysis (valid response rate of 83.3%).

Table 1 presents the demographic data of the participants and descriptive statistics for each variable. The average age of the respondents was 59.58±8.06 years, with 50 (28.6%) aged between 60 and 65 years, followed by 46 (26.3%) aged 65 or older, 45 (25.7%) younger than 55 years, and 34 (19.4%) aged between 55 and 60 years. In terms of education, 97 (55.4%) were high school graduates, followed by 44 (25.2%) college graduates and 34 (19.4%) middle school graduates or lower.

As for the average daily working hours, 135 (77.1%) worked for less than 8 hours, and 40 (22.9%) for more than 8 hours and less than 12 hours. Clinical career was 5.99±5.06 years on average, with 66 participants (37.7%) having three to less than 7 years, followed by 60 (34.3%) with 7 years or more, and 49 (28.0%) with less than 3 years.

Career in current department was 2.58±2.34 years; the majority of participants had worked at the current place for 1 year to less than 3 years (n=69; 39.4%), followed by 3 years or more (n=68; 38.9%) and less than 1 year (n=38; 21.7%).

In the past year, 110 (62.9%) had experience in patient safety education, and 65 (37.1%) had no experience in education. The average number of patient safety education in the last year was 4.65±4.50. In the past year, 58 (33.1%) have experienced patient safety campaigns, and 117 (66.9%) have never experienced them.

The participants’ patient safety knowledge, attitudes, awareness and activities are presented in Table 2. The overall average scores were 3.79±0.63 for knowledge, 3.76±0.43 for attitudes, 3.89±0.41 for awareness, and 4.06±0.47 for activities.

Table 3 shows the difference in patient safety activities according to the general characteristics of the participants. Patient safety activities according to the general characteristics showed significant differences according to the participant's age (F=4.55, p=0.004), average daily working hours (t=-2.92, p=0.004), patient safety education experience over the past year (t=3.65, p<0.001), and patient safety campaign experience over the past year (t=3.83, p<0.001). As a result of the post-test, the patient safety activities score was significantly higher in the case where the participants were under 55 years of age than in the case of 65 years of age or older.

Table 4 shows the results of descriptive statistics and Cronbach's alpha for each variable and Pearson correlation analysis. In the relationships between the knowledge, attitude, and awareness of patient safety and patient safety activities of home-visit caregivers, patient safety activities were significantly positively correlated with patient safety knowledge (r=0.63, p<0.001), patient safety attitude (r=0.49, p<0.001), and patient safety awareness (r=0.69, p<0.001).

The results of multiple regression analysis to identify the predictive factors of patient safety activities of home-visit caregivers are shown in Table 5. To investigate the predictive factors of patient safety activities, age, average working hours per day, patient safety education experience in the past year, and patient safety campaign experience in the past year, which were significant in the difference analysis, were selected as independent variables, and multiple regression analysis was conducted by treating these variables as dummy variables.

To check whether it is suitable for analysis, the regression model was tested and the residual chart was checked for the equal variance test; the Durbin-Watson statistic was 1.583, which was close to 2, and thus, independence of the variables was confirmed as there was no autocorrelation. The tolerance limit of the independent variable was confirmed as 0.980, which was more than 0.1, and the variance expansion factor was below the standard value of 10, indicating that there was no problem of multicollinearity. Additionally, the goodness-of-fit F value of the regression model was 24.92, which was statistically significant (p=0.003), and the explanatory power of patient safety activities was 55%. Patient safety awareness (β=0.48, p<0.001) and patient safety knowledge (β=0.22, p=0.003) were found to affect patient safety activities.

This was a descriptive research study that aimed to identify the relationship between patient safety knowledge, attitude, and awareness and patient safety activities of home-visit caregivers. This study revealed significant positive correlations between patient safety activities and home-visit caregivers' knowledge, attitudes, and awareness. This provides valuable insights into the key factors influencing the effective execution of patient safety activities.

The home-visit caregivers' average score for patient safety knowledge was 3.79 of 5 points per item. The total mean score for all items is 26.58 out of 35 points, derived from the sum of responses to all questionnaire items related to patient safety knowledge, which is equivalent to 75.94 when converted to a 100-point scale. Kang and Lee’s study²⁴⁾ on nursing assistants in nursing hospitals, the average safety knowledge score was 13.52 out of 21 points, and when converted into 100 points, it was 64.38, which is lower than in this study. Using the same measurement tool as this study, Kim^18,19) conducted a study on the impact of patient safety knowledge among nurses in nursing hospitals, reporting an average score of 3.67 out of 5 points per item, which was slightly lower than the 3.79 out of 5 points found in this study. Kim’s study²⁹⁾ of nursing hospital nurses reported a score of 3.82 of 5 points, which was similar to this study on safety knowledge. There are some limitations to carrying out a direct comparison of scores between studies using different tools to measure patient safety knowledge; however, it can be seen that the overall level of knowledge about patient safety is sufficiently high, targeting caregivers who receive basic education related to patient safety.

The average score for the home-visit caregivers’ attitude toward patient safety was 3.76 of 5 points per item. Using the same tool, a previous study²³⁾ targeting nursing assistants in nursing hospitals obtained a score of 3.25 of 5 points, which is lower than the result of this study. The results of the previous study³⁰⁾ on caregivers at tertiary general hospital showed 4.07 points, higher than the results of this study. Participants’ moderate level of patient safety attitude in this study was likely attributed to their recognition of the importance of safety activities, but a lack of perceived need for stricter safety regulations.³⁰⁾ It is believed that the psychological discomfort of having to do their job while following the rules resulted in moderate level regarding attitude toward safety.

Home-visit caregivers’ patient safety culture awareness was above average, with an overall average score of 3.89 on a 5-point scale per item. A previous study on patient safety culture awareness among nursing hospital nurses yielded a score of 3.84 points,²⁹⁾ while a study involving doctors, pharmacists, and medical technicians engaged in patient care at tertiary general hospitals reported a score of 3.82 points³¹⁾; these results are similar to the current findings.

In terms of patient safety culture awareness by area, caregivers’ work attitude (4.02 points) was the highest, followed by leadership (3.93 points), work environment (3.88 points), employee education and training (3.77 points), and job satisfaction (3.69 points). The reason work attitude had the highest score is that the issue of patient safety has become common in society, and familiar and habitual work performance in caring for older adults can lead to major accidents. Presumably, participants’ work attitude was high because they were sensitive to their duties. On the other hand, job satisfaction (3.69 points) was lower than in other areas because of the relatively high stress caused by emotional labor owing to the nature of home-visit care. Moreover, 50 (28.6%) of the study participants were aged between 60 and 65 years. Considering that the participants’ average age was 59.58 years, their attention and concentration may be reduced owing to age, and they may be easily fatigued.³²⁾

Home-visit caregivers’ average score for patient safety activities was 4.06 out of 5 points per item. In a previous study by Oh³³⁾ on nursing assistants in nursing hospitals, the patient safety activities score was 3.64 points; the present study yielded a higher score. Kang and Lee's study²⁴⁾ on safety activity involving the same participants reported a score of 4.10 points. Another previous study by Jung²⁶⁾ investigated patient safety activities among caregivers in nursing hospitals and reported a score of 4.18 points, which is higher than that found in this study. Although it is difficult to clearly compare the safety activities performed by nursing assistants working in nursing hospitals and those of home-visit caregivers, this study’s participants showed high performance. This is possibly because of the rapid increase in interest in health and safety, owing to the development of advanced medical technology and various mass media, rapid increase in medical disputes related to patient safety, and legal binding force.

Among subdomain about patient safety activities, the falls category had the highest score with 4.19 points. Presumably, the patients receiving care were older adults who had a high risk of falling; therefore, caregivers were more sensitive regarding their attitude about falls and performed safety activities. Fire category had the lowest score with 3.68 points in patient safety activities. Occurrence and management of fire hazards in daily life are very important for patient safety; however, unlike hospitals and nursing facilities, the scores may have been low owing to the difficulty in creating an environment related to the direct performance of this activity, considering the nature of work in-home visits. Therefore, proper training, such as simulation of specific situations, is necessary so that home-visit caregivers can familiarize themselves with regular fire drills and learn how to respond in case of a fire. Introducing simulation training based on specific scenarios into the mandatory training hours for home-visit caregivers could effectively enhance their ability to respond to emergency situations.

Furthermore, the results showed that the variables significantly affecting patient safety activities were patient safety culture awareness and patient safety knowledge. Furthermore, the factor with the highest explanatory power for patient safety activities was patient safety awareness, with an explanatory power of 55%. Kim and Lee’s recent study³⁴⁾ found that general hospital nurses’ perception of patient safety culture was the factor that had the largest influence on patient safety activities. Oh³³⁾ also found that patient safety culture awareness had the greatest impact on patient safety activities, consistent with the results of the present study. To increase patient safety activities, the establishment of positive safety awareness should precede safety performance.

Social awareness of the importance of patient safety is increasing, and safety activities are being emphasized as medical disputes related to patient safety are rapidly increasing.³⁵⁾ Caregivers working in facilities receive refresher training on a relatively regular basis; however, regular training opportunities for home-based caregivers are insufficient.¹⁶⁾ To increase these caregivers’ patient safety culture awareness, related research is needed, along with developing and providing regular safety-related education programs.

Participants’ patient safety knowledge was found to be a significant factor influencing patient safety activities. In previous studies,²⁴⁾ while safety knowledge showed a significant correlation with patient safety activities, it was not reported as a significant influencing factor; studies investigating patient safety knowledge targeting caregivers provided insufficient comparative data. However, in a previous study,³⁶⁾ nursing students’ patient safety knowledge had a significant relationship with patient safety attitudes. These findings are consistent with the present results.

According to the enforcement regulations of the Elderly Welfare Act in Korea, up to 320 hours of education are required to obtain a caregiver’s license, but the contents of the education on disaster or safety are very insufficient.⁵⁾ In-depth research on the effect of patient safety knowledge on safety activities is needed to ensure patient safety in home-visit care and to ensure caregivers’ practice of patient safety activities. There is a need for educational methods that can be used in practice, such as repetitive practical education and campaign experience suitable for the field, not just knowledge transfer.

Caregivers’ attitudes were not found to be a significant predictor of patient safety activities; however, attitudes showed a significant positive correlation with safety activities. Although there are limited studies on patient safety performance of caregivers, Seo and Jung¹⁶⁾ showed that attitudes were an important factor influencing caregivers’ safety performance. Kang and Lee²⁴⁾ also found that patient safety performance was highly related to attitudes. In this study, caregivers' attitudes did not emerge as a significant variable influencing patient safety activities, likely due to the participants’ moderate patient safety attitudes. More than half of the participants had limited recent experience with patient safety campaigns, and 37.1% reported not receiving any patient safety education. This indicates a need for more systematic education to foster a more positive attitude toward patient safety activities.

Caregivers’ attitudes can be changed through experience or learning. A positive attitude toward patient safety leads to an emphasis on personal safety. This is because an attitudinal change that can lead to behavioral change does not occur in a short time—systematic and continuous education is required. A change in attitude to comply with and practice safety regulations is necessary.

Finally, the fact that patient safety activities were found to increase significantly when participants had experience with safety campaigns, compared with cases where there was no recent campaign experience, can also be viewed as supporting the importance of education, emphasizing the cognitive aspect of caregivers. Therefore, it is necessary to develop an educational strategy that promotes cognitive change by reinforcing the content of patient safety knowledge in caregivers’ educational curriculum and organizing campaigns or practical activities that can bring about a change in attitude.

This study investigated the patient safety activities of caregivers, which are not well-revealed in current research, but are expected to play a major role in strengthening their capabilities through the research results.