Investigating the Mediating Effect of Patient Self-Efficacy on the Relationship between Patient Safety Engagement and Patient Safety in Healthcare Professionals

Patient safety and involvement of the patients in their safety engagement activities are considered the most important elements in the healthcare professions due to their impact on various individual and organizational outcomes. The study used responses of 456 patients. The simple random sampling (SRS) technique was used to collect data from the respondents. The researcher used individuals as the unit of analysis in this study. The results revealed that patient safety engagement had a positive significant effect on patient safety. When the mediating variable of self-efficacy was analyzed, it showed a significant mediated effect on patient safety. Therefore, it was concluded that self-efficacy mediated the relationship between patient safety engagement and patient safety. The findings of the current study convey that engagement of the patient in the practices for patient safety is predicted through the level of self-efficacy of the patient. The study discussed various implications for theory and practice. The study also discussed potential avenues for future research.


Introduction
In order to reduce medical mistakes, patient safety and patient participation in safety engagement activities are seen to be the most important aspects [1]. Te role of patients to participate and contribute in the error-prevention programs also helps management to efectively manage patient care during hospitalization of the patients. Error-prevention techniques were developed with the purpose of altering how people approach their profession. Tese methods are meant to be easy to use and, taken together, to emphasize the importance of three fundamental ideas: a personal commitment to safety, close attention to detail, and clear communication. Error reduction includes specifc strategies for dealing with complacency, complexity, and the source of mistakes. Recognizing their responsibility, leaders must look for and implement into practice strategies to minimize the chance and consequences of human error. For this, healthcare organizations try to induce patient involvement to improve patient safety [2] as evidenced by the World Health Organization's [3] patient safety campaigns. Tere are a few studies that have investigated patient involvement to increase patient safety [4]. However, such studies are required to be conducted by scholars to improve patient safety [5]. According to Pursio et al. [5], along with other institutional stakeholders, the patients themselves are required to contribute to their own safety. Terefore, the current study would investigate patients' self-efcacy as a potential mediating factor that mediates the relationship between patient safety engagement activities and patient safety in healthcare organizations. Patient safety depicts the absence of damage, injuries, or harm to the patient which can be carried out through the efective engagement and the involvement of the patient [6]. Since self-efcacy is delineated in a way that it is the process that involves cognition where an individual acquires novel behavioral conducts for the improvement of their capabilities to meet future happening through external environmental and societal infuence [7]. So, the desired level of self-efcacy could help to improve the outcomes of the healthcare practice and ultimately the safety of the patient [8]. Davis et al. [9] stated that the elements that assisted to sustain the willingness of the patients to engage in an active manner towards the improvement of the patient safety potentially afected the engagement of patients. According to Davis et al. [9], some important factors of patient safety include the following: (1) patients (personal attributes, knowledge, self-confdence, and self-efcacy), (2) health conditions (nature of the health crisis and severeness of the disease), (3) healthcare workers (the level of their skills, knowledge, and abilities), (4) tasks (patients' safety and patient safety engagement), and (5) workplace setting of healthcare professionals. Tis study attempted to fnd out how patient safety engagement and patient safety are interlinked and how patient self-efcacy afects this relationship. Some previous research studies tried to explicate the relationship between patient involvement and patient safety and how to enhance the patient engagement to determine the safety of the patients [4].
Te main objective of the study is to analyze the patient's safety engagement and patient safety by means of the patient's self-efcacy. Te main aim of the research was to investigate the mediating efect of patients' self-efcacy on the relationship between patient safety engagement and patient safety in healthcare professionals. Terefore, the researcher used quantitative research as the research approach because valid measurement scales are available for the variables of interest in this study.
Te paper is organized as follows: Section 2 describes the literature review of the study; the conceptual framework of the study is discussed in Section 3; Section 4 indicates the methodology; Section 5 discusses the data analysis; Section 6 indicates the discussion of the study; and fnally, Section 6 describes the conclusion of the study.

Patients' Safety.
Aspden et al. [10] defned patients' safety as the act of preventing the inauspicious and unfavorable happening during the provision of healthcare services for the patients. Previous studies described patients' safety as the cognitive procedure or the practice by application of which helps to mitigate the possibilities of unfavorable happening of events that are consequences to the health-or medical-care system [11]. Patient safety is an important aspect of nursing care that aims to reduce preventable mistakes and patient damage. Patient safety is a characteristic of a healthcare system and a group of triedand-true methods for enhancing treatment. To increase the dependability of care delivery systems, staf can use these safety improvement techniques. However, at present, patients still sufer from accidental injuries or medical damage due to healthcare despite of all medical and technological advancements. At frst, it was measured by Brennan et al. [12], and they found that 3.7% of patients were being negatively afected in terms of patient safety. According to Kohn et al. [13], medical and healthcare errors and faults fall between one of the major and greatest reasons for causing serious medical injuries and the death of patients. So, more improvement and advancement in the healthcare sector are deemed necessarily important for the safety of patients as a prime concern. According to Aspden et al. [10], for ensuring the safety of the patients and for the improvement of the healthcare system, the process of reporting of any unusual happening should be stimulated so that lessons could be learned from past errors or faults in order to prevent those same errors in future. Patients' safety can be assured by utilizing and practicing reactive and proactive safety indicators proposed by Reason [14] and improved by Reiman and Pietikäinen [15]. An ongoing need to encourage patient involvement and patient knowledge of patient safety. Te study's fndings can be used to develop targeted content for educational programs. Prioritizing vulnerable groups within the population will help to increase patient safety and participation [16]. Reactive safety indicators refer to the results, opinions, and judgments drawn and taken out from historic happening of events, for instance, the percentage or the rate at which any certain infection occurs in the patients. On the other hand, proactive safety indicators refer to the close examination and recognition of the factors which could have negative efects on the healthcare organizations in terms of the patients' safety.

Patient Safety Engagement.
Patient engagement refers to the act of participation of patients themselves and their families along with the healthcare provider for the amelioration of medical facilities and the healthcare safety [17]. Patient engagement involves encouraging consumers to access educated decisions regarding their own health. Patients who are "activated" or "engaged" exhibit good behavior, such as taking charge of their own health and treatment, and are sometimes referred to as "active patients." Tis improves health outcomes while also lowering expenditures. It relieves and facilitates the patient's engagement when the patient is informed about how to maintain their own safety. It is vital to ensure the patient's safety and that they are able to take part in and accept the efort. Willingness and responsiveness relevant to the instructed tasks are needed from the side of patients too [18]. Te researchers found that most of the patients are prepared and confdent for the engagement in the diferent sets of activities which are being proposed by the diferent organizations working for the safety of the patients [19]. Te persons who required medical care are uninterrupted observed and monitored by the staf in the hospital but in other circumstances like ambulatory settings, the healthcare provider, family of the patient, and patient himself have the predominant and the opportunities to the greater extent for the promotion of safety in collaboration with the diverse medical care units [20].
According to Hall et al. [21], patients' engagement leads to the betterment and improvement with the help of selfsupervision of the medication, creating a design of the patients' reading materials and stuf, and by taking part in the personalized self-management counseling [21]. Due to the patient engagement, novel ideas are being brought by the patients to work in a progressive way [22]. So, this concept of patient engagement be named as a successful widespread drug [23]. As patients present specifc and unusual point of view regarding their own health care as being profcient and expert about their own health which assists in the forging of healthcare policies [22]. Patients acknowledged their own health and recognize it in a better way which ultimately leads to better choices related to the healthcare services and the better utilization of the resources [24].

Patient Safety Engagement and Patient Safety.
According to the studies of Duhn and Medves [25] and Abid et al. [26], patient safety engagement positively afects patient safety. Terefore, patient safety engagements are encouraged by the scholars and practitioners [25,26]. In under developing countries, every year around 134 million unfavorable events happening occur due to which 2.6 million people died as a result of unsecured and unsafe medical care [27]. Te Development of complications in the procedures and accelerating injuries and damage related to health care give birth to this patient safety discipline. Te purpose and intention of patient safety are to mitigate medical risks and to make a reduction in the number of errors and damage to the patients throughout healthcare services while the fundamental principle of this concept is established upon learning from past experiences and inauspicious events [28]. According to the World Health Organization [28], patients' involvement or patients' engagement is one of the prime factors that ascertain the desired outcomes and the successful implementation along with other factors such as the level of skill of healthcare workers, leadership capabilities, and distinct policies and procedures. Lack or absence of confrmation or verifcation from the side of medical healthcare workers along with the defciency of patients' involvement and lack of knowledge in patients and lack of patient engagement regarding their own health are the most inherent elements that contribute towards the happening of errors [28]. Te following fve outcomes are frequently used to evaluate patient safety: errors, adverse events, infections, injuries, and mortality. Te fnal measurements for patient safety that are utilized to describe the harms that patients experience are these results.
Steps taken towards safety engagement in order to ensure the patients' safety depends upon three keen domains: engaging the patients for the detection of the adverse happenings, increasing the confdence of the patients by empowerment for the assurance of the medical care, and accenting the patient engagement as the signifcant way for the amelioration of the patients' safety [29]. Studies found that the rate of the unfavorable and inauspicious happening can be cut down and patients' safety can be improved with the help of the involvement of the patients and families [26,29]. In spite of the fact that patients' engagement is the anticipating systematic plan of action for the diminution of errors, it is the merely just transferring and shifting of the irresponsibleness of the safety of the patients from the healthcare provider towards the patients and their family [29]. [7] defned self-efcacy as the confdence, sureness, or the feeling of trust of an individual in his or her own abilities and qualities by using which he or she can attain the specifc predecided and desired goals and objectives, and this level of confdence regulates the selection, persistency, consistency, and drive of that particular individual towards the accomplishment of the task. Self-efcacy is one of the crucial concepts that help to mediate the practical application of the preacquired knowledge, skills, and abilities for the attainment of desired behavior [30].

Patients' Self-Efcacy. Bandura
Previous studies refected the self-efcacy of the patients as one of the causal and prime factors for the following medication programs without any interruption [31]. An eminent or higher degree of self-efcacy in the patients leads to higher confdence in them regarding the medication programs and the positive outcomes [32]. Alhalaiqa et al. [33] concluded that the patients possessing a prominent degree of self-efcacy had higher self-confdence and higher chances of rapid recovery. Self-efcacy has been found to be an efective and vital factor that can predict the intent to alter the behavior of the patients [34]. Most individuals are not self-efcacious but their capacity and capabilities to produce the desired efect and results are tied to the specifc functioning areas, they have diverse levels of efcacy regarding diferent functioning areas; an individual who is assured and self-confdent in the adoption of the balanced and healthy diet may or may not be assured and confdent to that level regarding his capacity for daily exercise, generally, selfefcacy is determined by the circumstances and the requirement of individual [30]. Self-efcacy is the degree to which a person believes in their own skills. Self-efcacy is an excellent indicator of motivation and behavior since it is founded on feelings of control and self-confdence.

Patients' Self-Efcacy as the Mediator of Association between Patients' Safety Engagement and Patients' Safety.
Involvement or the engagement of the patient in the practices for patient safety can be predicted through the level of self-efcacy of the patient and capabilities to prevent the faws and errors related to medical or health care [35]. Most of the scholars stated that the patient engagement is signifcant for the improvement of the patient safety which ultimately leads to the minimization of the adverse impact of the events on the health of patients, this depends upon the knowledge, information, and medical facts that are known by the patient [36]. Te patient engagement framework is the result of nearly 150 professionals in healthcare, human psychology, and technology working together. Te framework ofers support to healthcare organizations of all sizes and implementation phases. Te framework's objective is to assist healthcare organizations in developing care delivery models that are more efective and efcient while placing the needs of the patient frst. Te patient engagement framework contains fve stages, each with its own tools and resources. In regard to engaging patients efectively, the education of healthcare professionals should be assured that they must be clearheaded and free from any type of confusion related to the importance of the role of the patient in patient safety [37]. Previous studies conducted regarding the investigation of the relationship between the patient safety engagement and the patient safety demonstrated that the patient himself/ herself and his/her family had distinctive information related to the patient safety of the patient which could yield positive outcomes [38]. Indicators demonstrated that the engagement of the patients facilitated them in the improvement of the patient safety and also assisted in the restraining of the disease [39].
Based upon a critical review of the relevant literature, the researcher framed the following conceptual framework through which hypotheses were also developed.

Conceptual Framework
To achieve the research objectives, the current study would use the following model ( Figure 1):

Hypotheses.
On the basis of the conceptual framework, the following hypotheses were developed by the researcher to test them in this study: Hypothesis 1. Patient safety engagement directly afects patient self-efcacy.

Hypothesis 2. Patient self-efcacy directly afects patient safety.
Hypothesis 3. Patient self-efcacy mediates the relationship between patient safety engagement and patient safety.

Methodology
Te researcher used pragmatism as a research philosophy in the current study due to its applied nature in the current research. Pragmatism is a philosophical movement that comprises individuals who believe that an ideology or concept is true if it functions smoothly, that the signifcance of a notion may be discovered in the practical implications of recognizing it, and that unrealistic ideas should be avoided. It is characterized as a way of thinking about things that emphasizes a logical or practical solution. Pragmatism, as an example, involves solving issues logically and realistically. Te aim of this research was to investigate the mediating efect of patients' self-efcacy on the relationship between patient safety engagement and patient safety in healthcare professionals. Terefore, the researcher used quantitative research as the research approach because valid measurement scales are available for the variables of interest to this study. Tose measurement scales would help in getting a quantitative data set which would help the researcher to produce empirical results. Research on health and social care commonly uses quantitative research techniques. Tey employ objective measures in conjunction with statistical methodologies, mathematics, economic studies, or computational modeling to allow for a systematic, rigorous, empirical examination. Contrarily, qualitative health research involves the gathering and methodical analysis of nonquantitative data regarding people's experiences with health or sickness, and the healthcare system provides a number of strategies that can assist to reduce these risks. Te researcher used survey design as an appropriate research strategy because it is directly related to the people who would be involved as the respondent of this study. Moreover, according to Fink [40]; it is better to use survey research as the research strategy when the data is related to the attitudes and behaviors of the people as in the current study the people are involved [41].
Te researcher targeted 550 patients admitted to hospitals in China. Among them, only 456 structured self-administered questionnaires were returned that were completely flled-in in all respects. According to Krejcie and Morgan [42], a total of 384 (minimum) sample size was required in this study. Hence, it was considered an appropriate sample size with a confdence interval (alpha) of 5% and a confdence level of 95%. Tis sample was chosen by using a simple random sampling (SRS) technique to collect data from the respondents. In order to ensure that each sampling unit has an equal probability of being selected, simple random sampling (SRS) selects a sample of n sampling units from a population of N sampling units. In systematic sampling, all people are chosen at random, as opposed to simple random sampling, which requires that each component of the population be recognized and chosen separately. Te researcher used individuals as the unit of analysis. As the researcher used the survey as the research strategy, there was no issue of ethical aspects related to human participants (ethical approval form/ consent form) that is necessarily required to be followed in experimental research. Te collected data was managed in Statistical Package for Social Sciences (SPSS). For the purposes of group identifcation, forecasting numerical results, and descriptive statistics, SPSS analyzes data. For efective data management, this tool also features data processing, graphing, and direct marketing features. Te main features of SPSS include the ability to create tables and charts with frequency counts or summary statistics over (groups of) cases and variables while using inferential statistics such as ANOVA, regression, and factor analysis. Also, it uses several diferent fle formats for saving data and output. Te SPSS fles we will utilize in this study fall into three categories: output fles (spv), syntax fles (sps), and data fles (sav). Various tests of descriptive statistics and inferential statistics would be used to fnd the answers to research questions and to testify the hypotheses. Te researcher used measurement scales of self-efcacy (SE) of Elder et al. [43], patient safety engagement of Grafgna et al. [44], and patient safety of Ricci-Cabello et al. [45].

Reliability Analysis.
Te data collected from 456 patients were analyzed with the help of SPSS. Cronbach's alpha measures internal consistency or how closely connected a group of things is. It is regarded as a gauge for the dependability of scales. It is not necessary for the measure to have a "high" value for alpha for it to be one-dimensional. Te following reliability statistics (Table 1) are presented to reveal the reliability of the dataset: SPSS will initially delete all observations with one or more missing values across all variables provided for the current process when a statistical operation is performed. Tis is referred to as LISTWISE deletion because it is the default procedure. On the basis of the results provided in the tables given above, it was concluded that all the scales had the required level of reliability in the scales used for measuring the variables of interest in this study. Terefore, the researcher went for other analyses.

. Descriptive Statistics
Descriptive statistics are provided in a summary that details the data sample and its measurements and defnes, illustrates, and summarizes the key characteristics of a dataset found in the particular research. Reliability analysis may be used to investigate the characteristics of measuring scales and their constituent parts. Te reliability analysis approach also generates a number of commonly used scale reliability measures in addition to data on correlations between the scale's individual components. Te results of the descriptive statistics of the data ( Table 2) collected from the sample of the study are provided in Table 2: In Table 2, the description of all concerned variables (patient self-efcacy, patient safety engagement, and patient safety) is provided. When the distribution of data values is symmetrical and there are no obvious outliers, it is optimal to utilize the mean. Te median should be used when there are obvious outliers or when the distribution of the data values is skewed. Te results showed that the means (the average levels) of the variables including patient self-efcacy, patient safety engagement, and patient safety were more than the average level as 4.2789, 4.1075, and 3.7873, respectively. All the mean values were more than the average response. Te Valid N (listwise) indicates the number of nonmissing values. Te variable has N valid observations, which is the number of observations. Te sum of N and the number of missing values equals the total number of observations. Tese showed that the responses were facing safety issues. However, they had an adequate level of selfefcacy and safety engagement. Moreover, the values of standard deviations and variance were good enough to show minor deviations.

Hypothesis Testing through Mediation Analysis.
In order to estimate the efect of independent variables on the dependent variable and to test the hypotheses, the researcher applied mediated regression analysis by running Hay's Macro. Mediation analysis also assumes all of the basic assumptions of the general linear model, such as linearity, normality, error variance homogeneity, and error independence. It is extremely important to double-check these assumptions before doing a mediational study. For significance testing, it either employs the Sobel test or bootstrapping. As this study was aimed at the fnding efect, regression analysis was run to test whether or not patient safety engagement signifcantly afected patient safety and whether patient self-efcacy mediated the relationship between patient safety engagement and patient safety. A proposed causal chain called mediation shows how one variable can impact another, which can then infuence a third. Te intervening variable, M, serves as the mediator. Using regression analysis, a powerful statistical method, you may examine the correlation between two or more important variables. Tere are many diferent types of regression analysis, but at its heart, each one examines the impact of one or more independent variables on a dependent variable. Te results of the analysis are provided in Table 3: Results provided in Table 3 show the efect of patient safety engagement (PSE) from the mediating variable selfefcacy (SE). Model ftness is established as the signifcance value (p value) was lower than the threshold value i.e., 0.05. Patient safety engagement (PSE) has a positive efect which is also signifcant as the signifcance value (p value) was lower than the threshold value i.e., 0.05. Moreover, the t-value is also greater than 1.96 i.e., 18.9286. As the values of LLCI and ULCI are not zero and both are positive, it can be inferred that the efect of IV from the mediator is signifcant.
Results provided in Table 4(the total efect model) show the efect of both the independent variable i.e., patient safety engagement (PSE) and the mediating variable i.e., selfefcacy (SE) on the dependent variable i.e., patient safety (PS). Model ftness is established as the signifcance value (p value) was lower than the threshold value i.e., 0.05. Patient safety engagement (PSE) and self-efcacy (SE) have positive efects which are also signifcant as the signifcance value (p value) was lower than the threshold value i.e., 0.05 for both the variables. Moreover, the t-values of both the variables are also greater than 1.96 with values of LLCI and ULCI being nonzero and positive. Terefore, it can be inferred that patient safety engagement (PSE) and self-efcacy (SE) have positive efects on patient safety (PS).
Results provided in Table 5 (direct and indirect efects) show the sole efect of patient safety engagement (PSE) on patient safety (PS). Patient safety is a healthcare discipline that developed in response to the increasing complexity of healthcare systems and the associated increase in patient harm in healthcare institutions. In order to provide patients with the best possible treatment, it aims to prevent and minimize risks, mistakes, and injuries. "Patient engagement" is a more comprehensive idea combining patient activation with treatments intended to boost activation and encourage benefcial patient behavior, including the combination of patient activation with treatments intended to boost activation and encourage benefcial patient behavior, including getting regular preventative care or exercise. Tis efect was Journal of Healthcare Engineering 5 signifcant as the signifcance value (p value) was lesser than the threshold value i.e., 0.05. On the contrary, the indirect or mediated efect of patient safety engagement (PSE) on patient safety (PS) through self-efcacy (SE) as the mediator was signifcant as shown by the lower limits (BootLLCI) and upper limits (BootULCI) both of them being positive. Terefore, it was concluded that self-efcacy mediated the relationship between patient safety engagement and patient safety. Terefore, all the hypotheses developed by the researcher were accepted by rejecting the null hypotheses of this study.

Discussions
Te current study found signifcant positive efects of patient safety engagement on the patient safety of the responding patients. Tis fnding is similar to the previous fndings of the studies where it was found that patient safety engagement signifcantly and positively afected patient safety. Te studies with similar fndings included the WHO [28], Duhn and Medves [25], and Abid et al. [26]. Almost the majority of the studies conducted on this topic found a signifcant and positive impact on patient safety engagement on patient safety. Te current study found that self-efcacy signifcantly mediated the relationship between patient safety engagement on patient safety. Tis means that patient safety engagement afected patients' self-efcacy which consequently afected patient safety. Terefore, it was concluded that selfefcacy mediated the relationship between patient safety engagement and patient safety. Tis fnding conveys that the engagement of the patient in the practices for patient safety is predicted through the level of self-efcacy of the patients. Tis fnding is similar to the fndings of Lee and Garvin [37], Schwappach [36], Davis et al. [35], Landers et al. [39], and Khan et al. [38].

Conclusion
Te current study recommends healthcare professionals to utilize patient engagement activities in enhancing their safety. Te managers, supervisors, and/or organizational leaders can use the fndings to guide their contemporary work environments too. Te current study also recommends the researcher to lead the research. Tis study observed various limitations due to limited time and limited fnancial resources. Tose limitations may serve as the opportunities for future research studies. Te current study used selfefcacy as the mediating variable that could possibly serve as a booster to enhance patient safety. However, some other variables might also be tested as potential mediators in this relationship such as self-regulation or psychological capital. Additionally, moderating variables may also be tested to clarify the fndings of the current study. Future studies may also be conducted by using moderated-mediation or mediated-moderation models while testing and verifying the fndings of the current study.

Data Availability
Te data used to support the fndings of this study are available from the corresponding author upon request.

Conflicts of Interest
Te authors declare that they have no conficts of interest.

Acknowledgments
Tis work was supported by the 2020 Health Commission of Henan Province.