Patient engagement and safety mediated by self-efficacy: a cross-sectional study from Malaysian hospitals

Unsafe care remains a significant contributor to preventable harm. While patient engagement is promoted as a route to safer care, its benefits may be shaped by social determinants and hospital hierarchies. This study examines whether patients’ self-efficacy links engagement to patient-reported safety in Malaysian tertiary hospitals. Bandura’s self-efficacy theory is integrated with a critical public-health lens on voice, hierarchy, and equity. Cross-sectional survey of adult inpatients across four tertiary hospitals (N = 986) using validated Malay instruments (IMSIS, GSES, PMOS-10). Measurement adequacy was tested by CFA; structural relations were estimated via SEM with bias-corrected bootstrap CIs. Ethics approvals and informed consent were obtained. Model fit was good (e.g., CFI = 0.983; RMSEA = 0.043). Engagement predicted higher self-efficacy, and self-efficacy predicted better patient-reported safety. The direct engagement → safety path was small and non-significant after including self-efficacy; the indirect effect was significant, indicating indirect-only mediation. Findings suggest engagement improves safety primarily by strengthening patients’ confidence to act and be heard. Practice should combine engagement initiatives with self-efficacy-building supports and responsive speaking-up systems that counteract hierarchical silencing; equity-sensitive implementation is needed for patients with lower literacy and socioeconomic precarity.