Patient Safety Culture and Nurses' Compliance with Healthcare-Associated Infection Control Standards in Iraqi Teaching Hospitals: A Multicenter Cross-Sectional Correlational Study

Abstract

Background: Healthcare-associated infections (HAIs) remain a leading cause of preventable harm in low- and middle-income hospitals. Patient safety culture is a recognized organizational determinant of nurses' adherence to infection-control standards, but multicenter Iraqi data linking the two are limited. Aim: To characterize patient safety culture among nurses in four Iraqi teaching hospitals using the AHRQ Hospital Survey on Patient Safety Culture (HSOPSC), measure observed compliance with HAI-control standards, and quantify the association between safety culture and compliance. Methods: A multicenter cross-sectional correlational study was conducted between September 2025 and February 2026 across the medical–surgical, intensive care, emergency, and neonatal wards of four teaching hospitals in central and northern Iraq, in line with the STROBE statement. The protocol was prospectively registered (ATU-RIR-2025-14, registered 5 September 2025). The HSOPSC (42 items, 12 dimensions) was administered to 380 eligible nurses; 358 returned complete responses (response rate 94.2%). Direct unobtrusive observation captured 1,200 hand-hygiene opportunities using the WHO Five Moments framework, alongside structured audits of personal protective equipment (PPE), sharps and waste management, isolation precautions, and environmental hygiene. Pearson correlations and multivariable linear regression with cluster-robust standard errors at the hospital level were used to identify predictors of total HAI compliance. Results: Overall HSOPSC positive response rate was 56.4% across 12 dimensions, with the highest rates for teamwork within units (78.4%) and organizational learning (71.2%), and the lowest for non-punitive response to error (38.1%) and staffing adequacy (42.7%). Mean overall HAI compliance was 68.5% (95% CI 66.4–70.6); hand hygiene compliance was 64.2%, PPE 71.4%, sharps and waste 78.6%, isolation precautions 65.1%, and environmental hygiene 63.2%. Total HSOPSC score correlated moderately with overall HAI compliance (r = 0.42, p < 0.001); the strongest dimension-level correlations were management support for safety (r = 0.46) and feedback and communication (r = 0.41). In the adjusted model, total HSOPSC score (β = 0.34, p < 0.001), prior infection-control training (β = 0.21, p < 0.001), and ICU posting (β = 0.17, p = 0.004) independently predicted higher HAI compliance. Conclusion: Patient safety culture is a meaningful, modifiable predictor of HAI compliance among Iraqi teaching-hospital nurses. Hospital management should prioritize improvements in non-punitive error reporting, staffing adequacy, and management visibility around safety, alongside repeated infection-control training. The two-instrument framework used here is feasible for routine quality monitoring.