Unsustainable Working Conditions, Unsafe Care: Psychosocial Risks and the Pathways Linking Burnout to Patient Safety Culture

Abstract

Healthcare systems face increasing pressure from demographic, technological, and organizational changes that intensify psychosocial risks and threaten both healthcare workers’ well-being and patient safety. This study investigates whether burnout mediates the relationship between psychosocial risk factors and patient safety culture in healthcare settings. A cross-sectional study was conducted with 220 Portuguese healthcare workers using three validated instruments: the Psychosocial Risks Scale (INSAT_ERPS), the Burnout Assessment Tool (BAT-23), and the Hospital Survey on Patient Safety Culture (HSOPSC). Descriptive statistics, Pearson correlations, and mediation analyses were performed using SPSS (version 31.0) and the PROCESS (version 5) macro. Results showed a moderately strong positive association between psychosocial risks and burnout, and a significant negative association between burnout and patient safety culture. Psychosocial risks were not directly associated with patient safety culture. However, burnout indirectly mediated this relationship, indicating that adverse working conditions impair safety perceptions through their impact on psychological strain. These findings highlight burnout as a significant key mediator linking unsustainable working conditions to unsafe care, showing the relevance of the psychosocial environment. Targeted interventions to reduce psychosocial risks are thus fundamental to improving patient safety culture and promoting the sustainable functioning of healthcare systems.

1. Introduction

The demand for care and the structure of health systems are changing globally due to external and internal factors. Demographic changes and climate change, as well as the intensification of digitalization of health services, are increasing pressure on available healthcare resources [1,2,3,4]. Additionally, the resilience and performance of health systems are further conditioned by internal organizational obstacles such as inadequate leadership, poor communication, deficient safety culture, and the increasing complexity of care procedures [5,6]. Healthcare has become increasingly demanding due to advancements in technology, heightened cognitive requirements, human resource shortages, and persistent challenges such as antimicrobial resistance and healthcare-associated infections. These factors impose significant pressure on the daily tasks of healthcare organizations [3,7,8]. These conditions not only affect the quality of care but also have a profound impact on the safety and well-being of both healthcare workers and patients.

The growing interest in patient safety culture emerged following the publication of two important reports, “To Err Is Human” from the Institute of Medicine of the USA [6] and “An organization With Memory” from the Department of Health of the UK [9], which highlighted the substantial burden of preventable healthcare errors and emphasized the need for systemic safety improvements. This also increased the attention concerning the development of a patient safety culture, defined as the shared values, beliefs, attitudes, and behaviors that support safe patient care and organizational learning from errors [10,11]. Considering this perspective, patient safety culture is recognized as a multidimensional organizational construct that contemplates communication openness, teamwork, leadership support, error reporting, and continuous improvement processes that contribute to safer healthcare services [10,12].

The International Labour Organization (ILO) emphasized that unsafe and unhealthy working conditions are critical threats to sustainable development, mainly in high-demand sectors such as healthcare [13]. Likewise, the World Health Organization (WHO) highlighted the central role of a sustainable workforce in healthcare to ensure the delivery of effective, efficient, equitable, and safe care [14]. In this context, the sustainability of health systems cannot be understood solely in terms of financial or structural factors; the incorporation of the human dimension is crucial. The psychological and cognitive demands of healthcare workers in high-pressure and complex conditions must be considered to understand the sustainability of health systems. Within this complex scenario, psychosocial risks (PSR) can impact on the well-being and performance of healthcare workers.

Psychosocial risks (PSR) encompass a variety of less obvious aspects of work that impact health and well-being, such as work intensity and pace, working hours, conflicts in social relationships at work, work relationships, emotional demands, and work-related values [15,16]. Therefore, workplace dynamics and quality of work life play a crucial role in predicting mental health problems. These factors appear as significant predictors of mental health problems among healthcare workers, highlighting the psychological strain between personal resources and organizational demands [17,18].

The psychosocial risk factors in healthcare settings are theoretically understood through well-established occupational health models that describe how work environments affect workers’ performance and well-being. Among these frameworks, the Job Demands–Resources Model (JD-R) is one of the most widely applied. It suggests that high job demands, such as workload, emotional demands, and time pressure, cause physical and psychological strain, when there is a lack of resources to cope with them [19,20]. From this perspective, high demands are important indicators of exhaustion, burnout, and poor cognitive and emotional functioning, with a negative and high impact on organizations. The Demand-Control Model [21] highlights the interaction between job demands and workers’ decision latitude. Stressful work environments arise when individuals face intense workloads while having limited autonomy to influence how tasks are organized and performed. The Conservation of Resources Theory (COR) [22,23] further reinforces this view by proposing that individuals strive to protect their limited psychological resources. Under chronic exposure to psychosocial risks, workers experience progressive resource depletion, resulting in reduced energy and motivation. To prevent further loss, they may withdraw from high-effort behaviors, such as proactive communication or collaborative teamwork [20]. From a Human Factors perspective, healthcare workers constitute the critical human-in-the-loop whose psychological functioning acts as a primary barrier against system failures [24]. Indeed, burnout—characterized by cognitive and emotional exhaustion—weakens these primary human defenses, subsequently eroding patient safety culture and increasing the probability of active errors [25,26]. Taken together, these models provide robust theoretical evidence for understanding how psychosocial working conditions in healthcare settings undermine both professional well-being and patient safety. In this sense, burnout is not merely an individual condition; it operates as a mechanism that translates psychological strain into system-level vulnerabilities. When healthcare workers are exhausted or mentally distanced, their awareness and collaborative behaviors, can compromise patient safety culture (PSC).

The exposure to stressful working conditions is a predictor of burnout and psychological distress, reducing the well-being of healthcare workers. From a sustainability perspective, these problems should not be seen as merely individual issues; rather, they reflect underlying psychosocial risks (PSR) in healthcare work systems [2]. Among the various mental health outcomes observed in occupational settings, burnout has emerged as a significant problem, prompting urgent calls to action in healthcare systems [27].

Burnout in the healthcare sector is increasingly acknowledged as a public and occupational health issue requiring immediate attention [28]. The consequences of burnout impact not only healthcare workers’ health and well-being but also have impacts at an organizational level, leading to lower productivity and raising the risk of errors, endangering patient safety and quality of care [29]. Research has connected higher levels of burnout among doctors and nurses to worse patient satisfaction and more medical errors [30,31,32].

Healthcare workers’ functional ability plays a major role in mediating the effects of psychological risk factors on patient safety. Adverse working conditions not only impact individual mental health but also shape how workers perceive and engage in organizational culture and processes that ensure safe clinical practice and patient safety [33]. These impairments also have an impact on how safety is seen and implemented inside organizations. Effective communication, teamwork, and situational awareness are essential components of patient safety culture, based on values, beliefs, and norms held by healthcare workers that shape their actions and behaviors [34]. These elements may be adversely affected by psychological strain. Patient Safety Culture (PSC) has been associated with error reporting, teamwork and clinical outcomes across diverse health systems [35,36,37]. Several studies show that PSC varies significantly across institutions and is influenced by contextual factors, affecting safety procedures in hospital settings, including staffing, teamwork, safety climate, and leadership participation. PSC is also sensitive to the psychosocial and emotional conditions of healthcare workers. In this way, PSC may be a partial reflection of employees’ psychological states, linking individual functioning to organizational climate [35,38,39].

This study emphasizes that enhancing working conditions is crucial for both safeguarding the health of employees and maintaining secure and long-lasting healthcare systems by showing that burnout mediates the association between psychosocial risks and patient safety culture.

Figure 1 shows the conceptual framework describing the causal pathway: Psychosocial risks—Burnout—Patient Safety Culture.

Based on the previous evidence, the objective of this study is to analyze whether burnout mediates the impact of psychosocial risks on patient safety culture. We hypothesized that psychosocial risk factors are positively associated with burnout among healthcare professionals, that burnout is negatively associated with patient safety culture, and that burnout statistically mediates the association between psychosocial risk factors and patient safety culture.

2. Materials and Methods

2.1. Study Design and Ethics

In this cross-sectional study, the sample was collected among Portuguese healthcare workers from various public and private hospitals. Participants were contacted through personal networks who consented to share the research with healthcare workers at hospitals on social media platforms, such as WhatsApp and LinkedIn. Data were gathered online by sharing a questionnaire through Google Forms from 6 February 2025 to 15 November 2025. The questionnaire has a cover page with the study’s objectives and a brief explanation. For the present study, the protocol included 3 distinct scales to assess specific dimensions: the Psychosocial Risks Scale (INSAT_ERPS), the Burnout Assessment Tool (BAT-23), and the Patient Safety Culture Version 1.0. (HSOPSC).

The criteria for participation were voluntary involvement and confidentiality, and informed consent was provided by the participants. The inclusion criteria were being over 18 years of age, working as a healthcare professional, and being actively employed at the time of completing the questionnaire. Only participants who provided complete responses to all questionnaire items were included in the analysis; incomplete responses were defined as questionnaires with any missing data and were excluded. Participation in the online survey was entirely voluntary. Based on the eligibility requirements and answer completeness, a screening procedure was used. Participants completed the questionnaire only after providing their informed consent. A total of 220 healthcare workers completed the full questionnaire for the subscales of interest. All items from the questionnaire are marked as mandatory, so the data collected includes complete responses for every item in the study protocol. The estimated time required to complete the full questionnaire was approximately 15 min.

This study received approval from the Ethics Committee of the Faculty of Human and Social Sciences of the University of Fernando Pessoa (protocol code, Ref. FCHS/PI—475/23-4; date of approval, 20 March 2024, Porto, Portugal) and adhered to all procedures outlined in the Declaration of Helsinki.

2.2. Instruments

This study included the Psychosocial Risks Scale (INSAT_ERPS), the Burnout Assessment Tool (BAT-23), and AHRQ Hospital Survey on Patient Safety Culture V1.0 (HSOPSC).

The Psychosocial Risks Scale (INSAT_ERPS) is a self-reported questionnaire that measures working conditions and risk factors [40]. This instrument was created on the tenet that work analysis must be the foundation for risk assessment and prevention. This method comprises comprehending psychosocial risks within a contextualized framework, while recognizing that the choice of items was influenced by both empirical research and a review of the literature [15,41,42]. The INSAT_ERPS comprises forty-four items distributed across seven categories with varying numbers of items: high demands and work intensity (WI: eleven items, e.g., “Frequent interruptions”); working hours (WH: six items, e.g., “Exceeding normal working hours”); lack of autonomy and initiative (AI: four items, e.g., “Not being able to participate in decisions regarding my work”); social work relations (SWR: eight items; e.g., “Needing help from colleagues and not having it”); employment relations (ER: six items, e.g., “I feel exploited most of the time”); emotional demands (ED: five items, e.g., “Being exposed to the difficulties and/or suffering of other people”); and work value conflicts (WV: four items, e.g., “My professional conscience is undermined”). All items were measured on a 6-point Likert scale ranging from 0 (not being exposed) to 5 (being exposed with high discomfort). The Cronbach’s alpha and McDonald’s Omega values for this sample are 0.894 and 0.899, respectively.

The Burnout Assessment Tool (BAT-23) [43] is a self-report questionnaire that conceptualizes burnout as a syndrome assessed with 23 items, distributed within four core dimensions—exhaustion, mental distance, emotional impairment, and cognitive impairment. All items are rated on a five-point Likert scale ranging from 1 (“Never”) to 5 (“Always”) [43,44]. The four dimensions of the BAT evaluated: (a) Exhaustion (eight items, e.g., “At work, I feel mentally exhausted”), which indicates a significant energy depletion leading to both physical (e.g., tiredness, weakness) and mental (e.g., feeling drained and worn out) fatigue; (b) Emotional impairment (five items, e.g., “At work, I feel unable to control my emotions”), which indicates strong emotional responses and feelings of emotional overload; (c) Cognitive impairment (five items, e.g., “At work, I have trouble staying focused”), which includes decreased cognitive performance as well as issues with memory, focus, and attention; and (d) Mental distance (five items, e.g., “I struggle to find any enthusiasm for my work”), which is a sign of psychological disengagement from work and is frequently manifested as a strong dislike or reluctance to participate in work-related activities. The Cronbach’s alpha and McDonald’s Omega values for this sample are 0.915 and 0.922, respectively.

The AHRQ Hospital Survey on Patient Safety Culture V1.0 (HSOPSC) [10], translated and culturally adapted to the Portuguese population, was used to evaluate the patient safety culture in hospitals [24]. The instrument has fifty items, six for sociodemographic characterization and forty-four related to patient safety culture. These items are grouped in twelve categories as follows: (1) The safety culture within the unit (teamwork in the unit (TwU: four items), expectations and actions to promote patient safety of the supervisor/manager (ExpS; four items), organizational learning and continuous improvement (OrgI; three items), feedback and communication regarding errors (FcE; three items), openness to communications (OpC; three items), staff (Stf; four items), and non-punitive responses to errors (NpE; three items)). (2) The safety culture within the hospital organization (support from hospital management for patient safety (SpPS: three items), teamwork between hospital units (TwH; four items), internal transfers and on-call shifts (ITr; four items)). (3) Outcomes (general perception of patient safety (GpPS; four items), frequency of reported events (FrE; three items)). Finally, two questions are included to assess global patient safety and the number of events reported by workers in the last 12 months. The Cronbach’s alpha and McDonald’s Omega values for this sample are 0.891 and 0.901, respectively.

Internal consistency analysis indicated good to excellent reliability for all variables, with Cronbach’s alpha and McDonald’s Omega coefficients ranging between 0.891 and 0.915, and between 0.899 and 0.922, respectively. Reliability analyses at the dimensional level also showed acceptable to high internal consistency values (Supplementary Table S1).

2.3. Data Analysis

Data analysis was conducted using the IBM SPSS statistical program for Windows, version 31.0 (SPSS Inc., Chicago, IL, USA). A descriptive statistical analysis of all variables assessed was performed. Frequency and percentage analyses were performed on the sociodemographic characteristics of the participants. Descriptive analysis, including range, mean, standard deviation, skewness, and kurtosis, was performed on the scores of the psychosocial risk factors scale, burnout scale, and patient safety culture scale.

As all variables were collected using self-report measures at a single time point, Harman’s single-factor test was performed to assess the potential influence of common method bias [45]. Subsequently, a correlation analysis with the Pearson coefficient was performed to analyze the existing correlations, based on Cohen’s criteria [46].

Finally, the statistical tool PROCESS macro was applied, bias-corrected bootstrap confidence intervals (95%) were estimated using 5000 resamples, and heteroscedasticity-consistent standard errors (HC3) were used (which provide robust estimates under potential violations of homoscedasticity and residual normality assumptions) to analyze whether burnout statistically mediates the relationship between psychosocial risks and patient safety outcomes, as explained by the underlying mechanisms (Model 4): (a) the effect of psychosocial risks on burnout; (b) the effect of burnout on patient safety culture; (c) the total effect of psychosocial risks on patient safety culture; (d) the direct effect between psychosocial risks and patient safety when controlling for burnout; and (e) the indirect effect corresponding to the multiplication of paths a and b. The research produced trustworthy confidence intervals using 5000 bias-corrected bootstrap samples, verifying the general structure of the suggested model and demonstrating the relevance of the serial indirect impact.

G*Power software (Version 3.1.9.6—Mac OS X version, Heinrich Heine University Düsseldorf, Germany) was used to perform a post hoc power analysis to determine whether the sample size was sufficient for analysis [47]. For Model 4 (two predictors), a power of 0.99 was obtained. These results demonstrate that the sample size of 220 individuals was adequate to identify medium effects with high confidence, assuming the F-test family (linear multiple regression—R² deviation from zero), with α = 0.05, desired power of 0.80 and a medium effect size (Cohen’s f² = 0.10).

3. Results

3.1. Descriptive Analysis

The sample of this study consisted of 220 healthcare workers from various public (57.3%) and private (42.7%) hospitals, 86.4% of whom were female, with participant age varying from 20 to 72 years old (mean = 42.51, median = 43, SD = 11.088). The majority reported being married or in a de facto union (65.5%), the rest single (26.4%), or divorced (8.2%). Considering education level, 4.5% held an ungraduated degree, 59.5% held a graduate university degree, 30.9% a master’s degree and 5.0% a PhD. The participants were employed under permanent work contracts (79.5%) and temporary contracts (20.5%).

The descriptive analysis for each scale from this study is presented in

Table 1. Descriptive analyses for Psychosocial Risks, Patient Safety Culture, and Burnout scales.

Dimensions	Min	Max	Mean	SD	Skewness		Kurtosis
					γ1	SE	γ2	SE
Psychosocial Risks (ERPS)
Psychosocial Risks total mean score	1.87	3.83	2.73	0.402	0.133	0.164	−0.226	0.327
Patient Safety Culture (HSOPSC)
Patient Safety Culture mean score	0	89.58	43.16	21.246	0.184	0.164	−0.758	0.327
Burnout (BAT-23)
Burnout total mean score	1.00	4.70	2.25	0.692	0.90	0.16	1.09	0.327

Legend: SD—standard deviation; SE—standard error; γ—gamma squared.

. Means and standard deviations, skewness, and kurtosis of the distributions are presented.

Table 1 shows that all variables were approximately normally distributed, with skewness indices (|γ1|) and kurtosis indices (|γ2|) within ±2, meeting the recommended thresholds for normality [48].

A deeper analysis shows that burnout displayed moderate levels with greater dispersion, while psychosocial risk variables showed moderate levels with very little variability. Significant variability was observed in patient safety culture (M = 43.16, SD = 21.25), which may be attributable to both individual differences and contextual variation within healthcare organizations. Descriptive analysis for each subscale is presented in the Supplementary Materials (Supplementary Table S2).

Due to the collection method performed (self-report questionnaires administered to the same participants at a single time point), Harman’s single-factor test was conducted to evaluate the potential influence of common method variance. The results of the unrotated factor analysis showed that the first factor explained 16.26% of the total variance, which is below the 50% threshold suggested [45]. These findings suggest that common method variance is unlikely to have substantially affected the observed relationships among the study variables.

3.2. Correlation Analysis

A correlation analysis, using the Pearson coefficient, was applied between (1) the INSAT_ERPS and BAT-23 scales to investigate if psychosocial risks are associated with burnout; (2) the INSAT_ERPS and HSOPSC scales to test if psychosocial risk factors are associated with patient safety culture; and (3) the BAT-23 and HSOPSC scales to assess if burnout is associated with patient safety culture (

Table 2. Pearson’s correlations between psychosocial risks and mental health dimensions, and patient safety culture and mental health dimensions.

	Psychosocial Risk Factors (ERPS)	Patient Safety Culture (HSOPSC)	Burnout (BAT-23)
Psychosocial risks (INSAT_ERPS)	-
Patient safety culture (HSOPSC)	−0.117 (p = 0.054, 95% CI (−0.245, 0.016))	-
Burnout (BAT-23)	0.482 (p < 0.001, 95% CI (0.374, 0.578))	−0.271 (p < 0.001, 95% CI (−0.389, −0.14))	-

). The correlation between psychosocial risk factors (total mean score) and patient safety culture (total mean score) was −0.117 (p = 0.084), which is considered weak but acceptable for mediation.

The data show a statistically significant, moderate-to-strong positive correlation (r = 0.482, p < 0.001) between psychosocial risks and burnout, based on Cohen’s criteria. This means that higher psychosocial risks are strongly associated with a high level of burnout (exhaustion, mental distance, cognitive impairment and emotional impairment). When analyzing the correlations between patient safety culture and burnout, the data show a weak negative correlation (r = −0.271, p < 0.001), based on Cohen’s criteria, but acceptable for mediation. This means that a better patient safety culture is associated with a low level of burnout. The correlation between psychosocial risk factors and patient safety culture was negative but not statistically significant (r = −0.117, p = 0.054).

3.3. Mediation Analysis

The mediation analysis, using PROCESS macro (model 4), was conducted to examine whether burnout mediates the relationship between psychosocial risk factors and the patient safety culture (

Table 3. Mediation analysis considering Psychosocial Risks (PSR) and Patient Safety Culture (PSC), mediated by Burnout.

Path	B	SE	β	t	p	95% CI
(a) (PSR → Burnout)	0.830	0.117	0.482	7.098	<0.001	(0.599; 1.060)
(b) (Burnout → PSC)	−8.571	2.201	−0.279	−3.894	<0.001	(−12.909; −4.233)
(c) Total effect	−6.180	3.473	−0.117	−1.779	0.077	(−13.030; 0.670)
(d) (direct effect) (PSR → PSC)	0.932	3.627	0.018	0.257	0.797	(−6.217; 8.081)
(e) Indirect effect (a × b) (PSR → Burnout→ PSC)	−7.112	2.057	−0.135	—	—	(−11.527; −3.320)

Model 1 (Burnout): R² = 0.232, F(HC3) = 50.387, p < 0.001, f² = 0.303. Model 2 (Patient Safety Culture): R² = 0.073, F(HC3) = 8.697, p < 0.001. Burnout: f² = 0.065; Psychosocial Risk Factors: f² < 0.001. Legend: CI—confidence interval; SE—standard error; β—standardized coefficients (StandYX) estimated by PROCESS Model 4.

).

The results showed that burnout was positively correlated with psychosocial risk factors (B = 0.83, SE = 0.12, p < 0.001) and negatively correlated with patient safety culture (B = −8.57, SE = 2.20, p < 0.001). Both the overall impact of psychosocial risk factors on patient safety culture (B = − 6.18, p = 0.077) and the direct effect after adjusting for burnout (B = 0.93, p = 0.797) were not statistically significant. The association between psychosocial risk factors and patient safety culture is statistically mediated by burnout, as evidenced by the considerable indirect effect (B = − 7.11, 95% CI (−11.53, −3.32)).

The regression model predicting burnout from psychosocial risk factors showed that 23.2% of the variance in burnout was explained by the statistically significant regression model that predicted burnout from psychosocial risk factors (F(HC3) = 50.387, p < 0.001; R² = 0.232). The standardized effect of psychosocial risk factors on burnout was considered moderate (β = 0.482), with a medium-to-large effect size (f² = 0.303).

Additionally, the regression model predicting patient safety culture from psychosocial risk factors and burnout was also statistically significant (F(HC3) = 8.697, p <0.001), which explained 7.3% of the variance in patient safety culture (R² = 0.073). While psychosocial risk variables did not reveal a significant direct effect (β = 0.018, f² < 0.001), burnout had a significant negative standardized correlation with patient safety culture (β = −0.279, f² = 0.065). The completely standardized indirect effect was −0.135 (95% CI (−0.216, −0.064)), indicating a small-to-moderate indirect effect of psychosocial risk factors on patient safety culture through burnout.

Figure 2 helps to better visualize the mediation role of burnout on the relation between psychosocial risks and patient safety culture.

4. Discussion

This study’s aim was to analyze the role of burnout in the association between psychosocial risk factors and patient safety culture in healthcare settings. The results empirically support the model and our hypotheses, in which the impact of psychosocial risks on patient safety outcomes is not direct but operates through the psychological strain experienced by healthcare workers.

The findings highlight burnout as a key explanatory pathway linking adverse working conditions to lower patient safety perceptions. This pattern is aligned with occupational health frameworks, which emphasize the importance of understanding how work-related stressors affect employee well-being and thus organizational outcomes [20,49]. These findings contribute to the evidence that the sustainability and safety of healthcare systems are intrinsically dependent on the psychological functioning of the workforce.

4.1. Association Between Psychosocial Risks and Burnout (Path a)

In line with the correlation results between Psychosocial risks and Burnout, the analysis showed a robust and statistically significant positive association between psychosocial risk and burnout (path a), which confirms our first hypothesis. These results confirm that exposure to adverse psychosocial working conditions by healthcare workers is closely associated with increased levels of burnout and are theoretically consistent with the Job Demands–Resources Model (JD-R) [19,20]. High workloads, emotional demands, and organizational pressures have been repeatedly associated with burnout in healthcare settings, highlighting the critical role that psychosocial risks play in causing occupational strain [50,51,52].

This finding emphasizes the need to encourage healthy work environments as a prerequisite for sustaining a resilient healthcare workforce from a sustainability perspective. According to other authors [50], burnout is related to absenteeism, turnover intentions, decreased productivity, and staff shortages, which compromise the performance of the healthcare system and the sustainability of the organization. Therefore, reducing psychosocial risks supports SDG 3 by safeguarding the mental health and wellbeing of healthcare professionals while also directly contributing to SDG 8, which emphasizes safe and healthy working conditions.

4.2. Association Between Burnout and Patient Safety Culture (Path b)

In accordance with the observed correlation, burnout was found to significantly and negatively predict patient safety culture (route b), and the second hypothesis was confirmed. This indicates that lower perceptions of safety in healthcare organizations are linked to higher levels of burnout. This result is in accordance with earlier studies that highlight how burnout adversely affects attention, cognitive functioning, teamwork, communication, and decision-making, thereby increasing the likelihood of patient safety incidents and reduced quality of care [53].

From the perspective of Human Factors, decreased psychological and cognitive functioning associated with burnout compromises organizational procedures and safety-related behaviors, increasing medical errors, diminishing quality of care, and weaking safety-related performance [25,31,51]. When healthcare workers experience emotional exhaustion and reduced functioning, their ability to engage in safety-related behaviors may be compromised. Therefore, burnout can be considered as a factor that links strain at the human level to safety results at the system level.

This finding has important consequences for organizations’ sustainability. Healthcare systems that fail to protect employee well-being may experience declines in patient safety, with adverse consequences for service quality, organizational performance, and public trust. As a result, workforce well-being should be considered as a strategic organizational resource that supports SDG 8 through healthier and more sustainable workplaces as well as SDG 3 through safer healthcare delivery.

4.3. Total Effect of Psychosocial Risks on Patient Safety Culture (Path c)

In accordance with the weak and non-significant correlation between these variables, the overall impact of psychosocial risk factors on patient safety culture (path c) was negative but not statistically significant. This suggests that there is no consistent or significant association between psychosocial risks and patient safety culture. Psychosocial risks tend to contribute to safety outcomes only through intermediate psychological processes, not directly through them. This pattern is in accordance with previous studies, which demonstrate that employee well-being acts as a mediator in the indirect association between work-related stressors and patient safety outcomes [49].

An important consideration is that patient safety culture is a complex organizational construct that is influenced by various factors, such as organizational learning, teamwork, leadership, communication, staffing adequacy, and safety management practices [33,37,39]. As a result, differences in patient safety culture may not be directly explained by psychosocial risks alone. It is not appropriate to interpret the lack of a significant total effect as evidence that psychosocial risks are irrelevant to patient safety. Rather, it highlights the importance of considering human factors when assessing organizational sustainability by inferring that their influence may function indirectly through employee well-being.

4.4. Direct Effect Between Psychosocial Risks and Patient Safety Culture (Path d)

The results showed that when burnout was included in the model (path d), the direct effect of psychosocial risk factors on patient safety culture became apparently non-significant, demonstrating the absence of an independent relationship between these variables. This result suggests that burnout statistically mediates the association, since there is no significant correlation between psychosocial risks and patient safety culture. According to the JD-R theory, rather than directly influencing organizational outcomes, job demands primarily affect psychological strain [20]. Therefore, psychosocial risks do not appear to influence safety culture independently of burnout.

This finding contrasts with other research that shows a direct correlation between working conditions and safety outcomes. A possible explanation for this divergence is that earlier studies frequently concentrated on outcomes like safety incidents, adverse events, or medical errors rather than more comprehensive assessments of patient safety culture [29,31,32]. Disparities between studies may also result from variations in professional groups, study settings, and measurement approaches.

The present findings support that psychosocial working conditions only become significant for an organization when they have an impact on employee well-being. This emphasizes how crucial it is to incorporate occupational health initiatives within organizational sustainability strategies rather than treating worker well-being and patient safety as distinct concerns.

4.5. Indirect Effect Between Psychosocial Risks and Patient Safety Culture Mediated by Burnout (Path e)

The mediation analysis showed a statistically significant indirect effect of psychosocial risk factors on patient safety culture through burnout (route e). This result consolidates the observed correlation pattern, which demonstrates that there is no direct relationship between psychosocial risks and safety culture, although burnout is significantly connected with patient safety culture, and psychosocial risks are strongly associated with burnout. This confirms the third hypothesis. Consequently, it is not appropriate to interpret these results as conflicting. Instead, the findings are consistent with an indirect-only mediation model, since the mediator entirely transmits the effect of the independent variable on the outcome [54].

Employee well-being has been shown to mediate the relationship between working conditions and safety outcomes, which is consistent with previous studies [49,53]. The significant statistical mediator by which psychosocial risk variables influence perceptions of organizational safety in this context is burnout. This research shows that unfavorable working conditions undermine safety culture indirectly by weakening healthcare workers’ psychological well-being and highlights that employee well-being plays a role in healthcare businesses from a sustainability perspective. In addition to infrastructure and technology, sustainable healthcare systems require a healthy workforce capable of providing safe, high-quality care. As a result, efforts to lower psychological strain may simultaneously improve patient safety (SDG 3) and worker well-being (SDG 8).

4.6. General Discussion and Limitations

The total effect of psychosocial risk factors on patient safety culture was not statistically significant, whereas the indirect effect through burnout was statistically significant, which is a crucial finding. The contemporary methodological literature has demonstrated that a statistically significant effect is not required to establish mediation, although traditional approaches to mediation analysis have suggested it as a prerequisite [54]. According to this author, even in cases when the total effect is not significant, there may still be a considerable indirect effect, especially if the independent variable’s impact on the result is mostly mediated by an intervening variable. Consequently, it is not appropriate to interpret the current results as conflicting. Instead, they align with an indirect-only mediation model that links patient safety to psychological risk factors. Although this is a fact, a lack of a substantial overall effect might indicate the influence of other mediating mechanisms. Patient safety culture has been linked to variables like work engagement, communication quality, leadership support, and organizational learning. These variables may also serve as alternative pathways connecting psychosocial risk factors to safety-related outcomes [37,39]. Furthermore, several organizational and human factors influence patient safety culture [5,25], which would have potentially reduced the magnitude of any direct correlation. Nevertheless, the combined pattern of correlations and mediation results indicates that psychosocial risk is not directly associated with patient safety culture. Instead, its impact is mediated through burnout, linking adverse working conditions to safety-related outcomes.

In fact, these findings reveal that burnout acts as a lever through which psychosocial risks translate into unsafe care. In other words, psychosocial risks do not directly undermine patient safety culture; instead, they indirectly erode the psychological well-being of healthcare workers. Following this, patient safety culture, as an organizational result, is influenced by how healthcare workers behave psychologically. Psychosocial risk factors are closely linked to mental health outcomes, such as psychological distress and burnout, which in turn affect safety-related behaviors, communication, and perceptions of safety. Psychosocial risk factors such as emotional demands, workload, and organizational constraints have been identified as important predictors of psychological strain and burnout in healthcare settings [52]. Considering the practical magnitude of the observed indirect effects, it seems that adverse working conditions do not merely coexist with safety concerns but actively erode patient safety culture by depleting the psychological and cognitive resources of the healthcare workers. Consequently, reducing psychosocial risk through structural interventions such as adequate staffing and workload regulation translates into meaningful organizational improvements. Moreover, proactive teamwork, open communication, and continuous learning from errors transform workforce well-being into a strategic resource for the sustainability and safety of the healthcare system. Maintaining safe practices and a strong safety culture depends on cognitive functioning, attention, and collaboration, all of which are compromised by this psychological burden [26]. As burnout has been shown to affect patient safety culture, emotional strain may decrease involvement, communication openness, and participation in safety activities.

Finally, the present findings contribute to a broader international agenda: SDG 3, which prioritizes health and patient safety, and SDG 8, which highlights the importance of safe, healthy, and sustainable working environments [2,13]. Patient safety, as a core component of SDG 3, depends fundamentally on the functional capacity of healthcare workers, which can be compromised by psychosocial risks and burnout. In fact, healthcare workers’ mental health has become a global concern, with numerous studies showing that they are more vulnerable to psychological distress than the general population. These conditions not only affect workers’ well-being but also have measurable consequences for the quality and safety of care [51,55].

This reinforces the idea that interventions targeting burnout prevention are not only beneficial for workers but also essential for strengthening safety culture. Reducing psychosocial risks and preventing burnout are not merely organizational priorities—they are public health imperatives that contribute to safer, more resilient, and more sustainable healthcare systems. Strategies such as improving staffing adequacy, enhancing leadership support, promoting open communication, and implementing evidence-based well-being programs can help protect both workers and patients [37,38,39,53].

Several limitations of this study should be considered. First, any causal conclusions about the relationships between psychosocial risks, burnout, and patient safety culture are precluded by the cross-sectional methodology. The temporal direction of these correlations cannot be conclusively determined, although a mediation study was done.

Second, the use of self-reported measures could inflate the observed associations by introducing social desirability effects and common method bias. Although Harman’s single-factor test suggested that common method variance was unlikely to have substantially affected the findings, the absence of a dominant single factor does not completely exclude the possibility of method-related bias. Moreover, the convenience sampling strategy may limit sample representativeness and the external validity of the findings due to selection and volunteer bias. While the demographic profile of the participants generally reflects characteristics commonly observed in the Portuguese healthcare workforce, the non-probabilistic nature of the sampling procedure prevents conclusions regarding population representativeness.

Third, while the sample’s inclusion of healthcare workers from various organizations improves generalizability, it also introduces contextual variability that was not specifically modelled (for example, through multilevel analysis), which might have affected how patient safety culture was perceived.

Fourth, the mediation model does not consider organizational and demographic factors. Variables including age, gender, occupation, years of experience, and organizational environment may potentially affect these constructs, even though the study was intended to evaluate a parsimonious theory-driven model that focused on psychosocial risk factors, burnout, and patient safety culture. As a result, it is impossible to rule out the possible influence of these contextual and individual traits.

Fifth, the research focused on global composite scores, which may mask more subtle associations at the dimensional level, even though other aspects of psychosocial risk and safety culture were evaluated.

Sixth, even though the study showed strong mediation effects and sufficient statistical power, other potentially important factors—such as organizational leadership, emotional intelligence, or aspects of the workplace—were left out and could help explain the associations found.

Finally, temporal precedence represents an additional limitation of this study. Although the proposed mediation model was theoretically grounded and supported by the previous literature, all variables were measured at a single time point. Consequently, it is not possible to determine whether psychosocial risk factors preceded burnout or whether burnout preceded perceptions of patient safety culture. Alternative temporal sequences and reciprocal relationships cannot be excluded. Therefore, the findings should be interpreted as evidence of statistical mediation that is consistent with the proposed theoretical model, rather than as evidence of causal mediation.

Future studies should consider multilevel strategies, longitudinal designs supported by more robust statistical approaches, and more comprehensive models that include more organizational and individual elements. More specific recommendations—such as prospective longitudinal studies, multicenter research, multilevel modelling, and intervention studies—are intended to reduce psychosocial risks and provide greater value for researchers. In this sense, researchers can better understand how adverse working conditions translate into system-level vulnerabilities and impact healthcare workers’ activity. This strategic resource can promote workforce well-being and endorse Patient Safety Culture for the entire healthcare system.

5. Conclusions

This study provides empirical evidence that the relationship between psychosocial risks and patient safety culture operates through burnout, underscoring the central role of healthcare workers’ psychological well-being in shaping safety-related outcomes. The results corroborate the hypothesized model. Higher psychosocial risks were associated with increased burnout and were negatively related to patient safety culture. Burnout mediated the impact of psychosocial risks on safety culture, highlighting that adverse psychosocial risk factors undermine safety-related behaviors. Although psychosocial risks and patient safety culture both reflect work environments, they represent conceptually distinct levels of analysis. Psychosocial risks concern individual experiences of job demands, whereas patient safety culture is a collective organizational construct shaped by leadership, staffing policies, and communication systems. This distinction clarifies why no direct association was observed between the two constructs and reinforces the relevance of burnout as the pathway through which adverse working conditions translate into safety-related perceptions and behaviors. From a policy and organizational governance perspective, these findings underscore the need for integrated strategies that simultaneously address individual-level psychosocial risk exposure and system-level determinants of safety culture. Reducing psychosocial risks requires structural interventions—such as adequate staffing, workload regulation, supportive supervision, and participatory management—that mitigate chronic job demands and strengthen workers’ psychological well-being. At the same time, improving patient safety culture demands organizational policies that promote transparent communication, effective leadership, and team-based safety practices. These findings advance theoretical understanding by reinforcing the relevance of occupational health frameworks that position burnout as a pivotal pathway linking adverse working conditions to organizational performance. Moreover, the results align with the broader sustainability agenda, demonstrating that safeguarding workers’ mental health is essential for ensuring safe, resilient, and sustainable healthcare environments, with direct implications for patient safety, workforce sustainability, and long-term system performance.