An educational intervention to enhance nurse leaders' perceptions of patient safety culture

Effect of interventions to improve safety culture on healthcare workers in hospital settings: a systematic review of the international literature

BACKGROUND

In an era of safety systems, hospital interventions to build a culture of safety deliver organisational learning methodologies for staff. Their benefits to hospital staff are unknown. We examined the literature for evidence of staff outcomes. Research questions were: (1) how is safety culture defined in studies with interventions that aim to enhance it?; (2) what effects do interventions to improve safety culture have on hospital staff?; (3) what intervention features explain these effects? and (4) what staff outcomes and experiences are identified?

METHODS AND ANALYSIS

We conducted a mixed-methods systematic review of published literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted in MEDLINE, EMBASE, CINAHL, Health Business Elite and Scopus. We adopted a convergent approach to synthesis and integration. Identified intervention and staff outcomes were categorised thematically and combined with available data on measures and effects.

RESULTS

We identified 42 articles for inclusion. Safety culture outcomes were most prominent under the themes of leadership and teamwork. Specific benefits for staff included increased stress recognition and job satisfaction, reduced emotional exhaustion, burnout and turnover, and improvements to working conditions. Effects were documented for interventions with longer time scales, strong institutional support and comprehensive theory-informed designs situated within specific units.

DISCUSSION

This review contributes to international evidence on how interventions to improve safety culture may benefit hospital staff and how they can be designed and implemented. A focus on staff outcomes includes staff perceptions and behaviours as part of a safety culture and staff experiences resulting from a safety culture. The results generated by a small number of articles varied in quality and effect, and the review focused only on hospital staff. There is merit in using the concept of safety culture as a lens to understand staff experience in a complex healthcare system.

An authentic leadership training programme to increase nurse empowerment and patient safety: A quasi-experimental study

BACKGROUND

Authentic leadership and empowered nurses are necessary if a healthy work environment is to be created and patient safety maintained; however, few studies have examined the impact of authentic leadership, on nurse empowerment and the patient safety climate.

PURPOSE

The aim of the study was to investigate the impact of an educational intervention delivered through a multi-faceted training programme on nurses' perceptions of authentic leadership, nurse empowerment (both structural and psychological) and the patient safety climate.

DESIGN

A quasi-experimental study using a one-group pretest-posttest design consistent with TREND guidelines.

METHODS

The study was conducted in a university hospital between December 2018 and January 2020. Participants were followed for 6 months. The programme involved 36 head nurses (leaders) and 153 nurses (followers). The effectiveness of the programme was evaluated using repeated measures of analysis of variance, dependent sample t-tests and hierarchical regression analysis.

RESULTS

Following the intervention, safety climate and authentic leadership scores increased among both leaders and followers. Structural and psychological empowerment scores also increased among followers. We found that authentic leadership and structural empowerment were predictors of safety climate.

CONCLUSION

The implementation of the education programme resulted in positive changes in participants' perceptions of authentic leadership and empowerment, which can enhance patient safety.

IMPLICATIONS

Healthcare organizations can implement similar multi-faceted training programmes focused on authentic leadership, and nurse empowerment to increase patient safety. Achieving effective results in such programmes can be facilitated by motivating participants with the support of the top management.

PATIENT OR PUBLIC CONTRIBUTION

The study included nurses in the intervention and the data collection processes.

IMPACT

Patient safety is a global concern, and improving patient safety culture/climate is a key strategy in preventing harm. Authentic leadership and nurse empowerment are essential in creating healthy work environments and delivering safe, high-quality care. Training programmes addressing these issues can help bring about improvements in healthcare organizations.

The impact of an educational program on knowledge and perception of patient safety culture among nurses in the two medical colleges of Manipur: A quasi-experimental study

Background

Nurses' leaders are protracted as high-leverage players who would be instrumental in initiating or bettering the culture of safety in the hospital, with no previous intervention done for the same in Manipur.

Objectives

The aim of this study was to assess the effectiveness of an educational intervention program on patient safety culture among nurses in Manipur.

Materials and Methods

A quasi-experimental study was conducted from July 2019 to December 2021 among the 32 nurses of two tertiary-level hospitals in Manipur. A structured questionnaire and Hospital Survey on Patient Safety Culture version 2 were used (Hospital Survey on Patient Safety Culture (HSOPSC) version 2.O (AHRQ, Rockyville, Maryland, USA)). A 2-day intervention based on the WHO's Multi-Professional Patient Safety Curriculum Guide was used. Data were collected before, immediately, and 3 months after the intervention. Data were summarized using descriptive using IBM SPSS 26. Paired t-test, Chi-square test, and t-test were employed to check for differences within and between the groups, and P < 0.05 was taken as statistically significant.

Results

The mean knowledge scores were comparable between the groups at baseline (7.13 ± 3.3, 8.44 ± 3.74; P = 0.142) but differed significantly at posttest and follow-up tests (P < 0.0001). The dimensions of "staffing and work pace" and "reporting patient safety events" had the lowest positive responses from both the groups at baseline. There is a significant increase in the total safety score from baseline to posttest and follow-up in the intervention group (P < 0.001).

Conclusions

The study asseverated the effectiveness of an educational intervention in increasing the knowledge and perception of patient safety culture, but the results highlighted the need for training at regular intervals.

Perceptions of Patient Safety Culture Dimensions among Hospital Nurses: A Systematic Review

Background

Patient safety culture, an important aspect in the field of patient safety, plays an important role in the promotion of healthcare quality. Improved patient safety culture decreases patient readmission rates, lengths of hospital stay, and patient safety issues. Patient safety culture includes a set of dimensions. This review focuses on the differing perceptions of these dimensions among healthcare providers in hospitals.

Aims

This study aimed to identify studies examining healthcare providers’ perceptions of patient safety culture in hospitals and to summarize the data from these studies.

Method

Electronic database searching was based on the research question. Two electronic databases were used: CINHAL and Scopus. The search was limited to the period 2005–2012, and studies examining healthcare providers’ perceptions of patient safety culture were identified. Key terms were used to search the articles that were selected on the basis of inclusion and exclusion criteria. Articles examining healthcare providers’ perceptions of patient safety culture in hospitals without comparison between nurses and other healthcare professionals were selected.

Results

Eight articles were reviewed. Several questionnaires were used to assess healthcare providers’ perceptions of patient safety culture in these articles. Our review indicated differences in healthcare providers’ perceptions. In two articles, participants reported a high positive response to teamwork. In addition, participants in the other two articles reported a high positive response to job satisfaction.

Conclusion

The results of the current review reveal healthcare providers’ perceptions of patient safety culture. The results highlight that careful recognition and committed work on various scales/dimensions of patient safety culture can improve healthcare quality and consequently decrease patient safety issues associated with nursing care. Our findings also encourage hospital management and decision-makers to focus on and establish improvements in areas that will positively affect the quality of healthcare.

Patient Safety Activity Under the Social Insurance Medical Fee Schedule in Japan: An Overview of the 2010 Nationwide Survey

OBJECTIVES

Little is known about patient safety performance under the social insurance medical fee schedule in Japan. The Health Ministry in Japan introduced the preferential patient safety countermeasure fee (PPSCF) to promote patient safety in 2006 and revised the PPSCF system in 2010. This study aims to address the patient safety performance status at hospitals implementing the PPSCF.

METHODS

A nationwide questionnaire survey targeting 2674 hospitals with the PPSCF was performed in 2010 to 2011. The 627 participant hospitals were divided into the following three groups: 178 hospitals implementing PPSCF 1 with 400 beds or more (group A), 286 hospitals implementing PPSCF 1 with 399 beds or fewer (group B), and 163 hospitals implementing PPSCF 2 (group C).

RESULTS

The mean numbers (standard errors) of patient safety managers were 1.45 (0.07) in group A, 1.12 (0.04) in group B, and 0.37 (0.12) in group C (P < 0.001). The participation number and rates of all staff for the patient safety seminar were 1721 (167) and 1.64 (0.10) in group A, 580 (26) and 1.94 (0.09) in group B, and 349 (31) and 1.98 (0.17) in group C (P < 0.001, P = 0.105).These results can be explained because hospitals with PPSCF 1 (groups A and B) must assign at least one full-time patient safety manager, whereas hospitals with PPSCF 2 (group C) are not required to do so. Patient safety performance at hospitals with PPSCF 1 was more active than that at hospitals with PPSCF 2. However, when the values were converted to per capita or per 100 beds, there were no differences across the three groups.

CONCLUSIONS

The PPSCF encourages hospitals to perform actions for patient safety by providing incentives under the social insurance medical fee schedule in Japan.

Quality control circle: a tool for enhancing perceptions of patient safety culture among hospital staff in Chinese hospitals

OBJECTIVE

To explore whether quality control circle (QCC) is associated with hospital staff's perceptions of patient safety culture (PSC).

DESIGN

A cross-sectional survey in 12 public hospitals from October to December 2018 and a longitudinal survey in one public hospital from November 2017 to November 2018.

SETTING

In 12 public hospitals from six provinces located in eastern, central and western of China, and one public hospital in eastern China.

PARTICIPANTS

In total, 811 and 102 hospital staff participated in the cross-sectional survey and the longitudinal survey, respectively. These participants included doctors, nurses, medical technicians and administrative staff.

MAIN OUTCOME MEASURES

Hospital staff's perceptions of PSC were measured by the Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire. The association between QCC implementation and PSC was identified by univariate analysis and multiple linear regression analysis.

RESULTS

Univariate analysis showed that the staff from hospitals that had implemented QCC received significantly higher HSOPSC scores than those from hospitals where QCC had not been implemented (3.73 ± 0.61 vs. 3.57 ± 0.41, P < 0.05). The QCC implementation was a significant predictor in the established multiple linear regression model. One year after QCC implementation, the hospital involved in the longitudinal survey scored higher in HSOPSC than before (3.75 ± 0.42 vs. 3.60 ± 0.36, P < 0.001).

CONCLUSIONS

QCC implementation was positively associated with PSC and the former could promote the establishment of the latter. It is suggested that QCC can play an active role in enhancing PSC so as to further improve patient safety management.

The effect of education around ethical principles on nurses' perception to patient safety culture in an Iranian mental health inpatient unit: a pilot study

Background & objectives

Patient safety is a crucial factor in the provision of quality healthcare and is therefore a global health concern. It is an area in which ethical concerns and high-quality clinical practice are inextricably linked. This study investigates the effect of education around ethical principles on nurses’ perception of patient safety in a psychiatric unit.

Materials & methods

This pre- and post-test descriptive study was conducted in a mental health inpatient unit in a hospital in Tehran, capital of Iran, in 2018. A total of 33 nurses, selected by census sampling, participated in the study. Data was collected using a demographics questionnaire and Hospital Survey on Patient Safety Culture (HSOPSC), and was analyzed with SPSS21.

Results

The mean score of patient safety was 116.85 ± 9.98 before the educational intervention, 143.58 ± 7.21 immediately after intervention, and 153.12 ± 9.47 1 month after intervention. The rate of error report by most participants over the past 12 months was 3–5 and 6–10 events before intervention, and 6–10 events immediately after and 1 month after intervention. Also, 42.4% of the participants assessed patient safety after intervention as very good and 36.4% assessed it as acceptable and very good 1 month after intervention whereas most of the participants (45.5%) assessed patient safety as acceptable before intervention.

Conclusion

Education on ethical principles exerts a positive effect on nurses’ perception of patient safety culture. Thus, it is recommended as an effective method of promoting nurses’ perception of this variable. In this way, healthcare quality and enhanced patient safety can be achieved.

WHO surgical safety checklist training: An alternative approach to training in local safety standards for invasive procedures

BACKGROUND

Despite efforts to promote the effective use of the WHO surgical safety checklist, wrong tooth extractions have continued to occur within dentistry.

METHOD

A training initiative combined methods of teaching comprising of a presentation, video and simulation to deliver LocSSIP training at an Oral Surgery Department of a UK dental hospital. Participant feedback was analysed to determine their perception of using combined methods to deliver the training.

RESULT

Overall feedback was very positive with regard to relevance of the training, and its ability to meet the learning needs of all participants. Participants advocated that there should be regular re-training and incorporation of this training into the local induction programme. Almost About 94% of staff members Strongly Agreed or Agreed that they would recommend this format of training to other departments.

CONCLUSION

Effective training is essential to maintain safe clinical practice within health care, and training methods that are inclusive of various learning styles are well received.

Patient safety culture among nurses working in Palestinian governmental hospital: a pathway to a new policy

Background

Providing safe care helps to reduce mortality, morbidity, length of hospital stay and cost. Patient safety is highly linked to attitudes of health care providers, where those with more positive attitudes achieve higher degrees of patient safety. This study aimed to assess attitudes of nurses working in governmental hospitals in the Gaza-Strip toward patient safety and to examine factors impacting their attitudes.

Methods

This is a cross-sectional, descriptive study with a convenient sample of 424 nurses, working in four governmental hospitals. The Attitudes to Patient Safety Questionnaire III, a validated tool consisting of 29 items that assesses patient safety attitudes across nine main domains, was used.

Results

Nurses working in governmental hospitals showed overall only slightly positive attitudes toward patient safety with a total score of 3.68 on a 5-point Likert scale, although only 41.9% reported receiving patient safety training previously. The most positive attitudes to patient safety were found in the domains of ‘working hours as a cause of error’ and ‘team functioning’ with scores of 3.94 and 3.93 respectively, whereas the most negative attitudes were found in ‘importance of patient safety in the curriculum’ with a score of 2.92. Most of the study variables, such as age and years of experience, did not impact on nurses’ attitudes. On the other hand, some variables, such as the specialty and the hospital, were found to significantly influence reported patient safety attitudes with nurses working in surgical specialties, showing more positive attitudes.

Conclusion

Despite the insufficient patient safety training received by the participants in this study, they showed slightly positive attitudes toward patient safety with some variations among different hospitals and departments. A special challenge will be for nursing educators to integrate patient safety in the curriculum, as a large proportion of the participants did not find inclusion of patient safety in the curriculum useful. Therefore, this part of the curriculum in nurses’ training should be targeted and developed to be related to clinical practice. Moreover, hospital management has to develop non-punitive reporting systems for adverse events and use them as an opportunity to learn from them.

Local opinion leaders: effects on professional practice and healthcare outcomes

BACKGROUND

Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Local opinion leaders (OLs) are individuals perceived as credible and trustworthy, who disseminate and implement best evidence, for instance through informal one-to-one teaching or community outreach education visits. The use of OLs is a promising strategy to bridge evidence-practice gaps. This is an update of a Cochrane review published in 2011.

OBJECTIVES

To assess the effectiveness of local opinion leaders to improve healthcare professionals' compliance with evidence-based practice and patient outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers on 3 July 2018, together with searching reference lists of included studies and contacting experts in the field.

SELECTION CRITERIA

We considered randomised studies comparing the effects of local opinion leaders, either alone or with a single or more intervention(s) to disseminate evidence-based practice, with no intervention, a single intervention, or the same single or more intervention(s). Eligible studies were those reporting objective measures of professional performance, for example, the percentage of patients being prescribed a specific drug or health outcomes, or both. We included all studies independently of the method used to identify OLs.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane procedures in this review. The main comparison was (i) between any intervention involving OLs (OLs alone, OLs with a single or more intervention(s)) versus any comparison intervention (no intervention, a single intervention, or the same single or more intervention(s)). We also made four secondary comparisons: ii) OLs alone versus no intervention, iii) OLs alone versus a single intervention, iv) OLs, with a single or more intervention(s) versus the same single or more intervention(s), and v) OLs with a single or more intervention(s) versus no intervention.

MAIN RESULTS

We included 24 studies, involving more than 337 hospitals, 350 primary care practices, 3005 healthcare professionals, and 29,167 patients (not all studies reported this information). A majority of studies were from North America, and all were conducted in high-income countries. Eighteen of these studies (21 comparisons, 71 compliance outcomes) contributed to the median adjusted risk difference (RD) for the main comparison. The median duration of follow-up was 12 months (range 2 to 30 months). The results suggested that the OL interventions probably improve healthcare professionals' compliance with evidence-based practice (10.8% absolute improvement in compliance, interquartile range (IQR): 3.5% to 14.6%; moderate-certainty evidence).Results for the secondary comparisons also suggested that OLs probably improve compliance with evidence-based practice (moderate-certainty evidence): i) OLs alone versus no intervention: RD (IQR): 9.15% (-0.3% to 15%); ii) OLs alone versus a single intervention: RD (range): 13.8% (12% to 15.5%); iii) OLs, with a single or more intervention(s) versus the same single or more intervention(s): RD (IQR): 7.1% (-1.4% to 19%); iv) OLs with a single or more intervention(s) versus no intervention: RD (IQR):10.25% (0.6% to 15.75%).It is uncertain if OLs alone, or in combination with other intervention(s), may lead to improved patient outcomes (3 studies; 5 dichotomous outcomes) since the certainty of evidence was very low. For two of the secondary comparisons, the IQR included the possibility of a small negative effect of the OL intervention. Possible explanations for the occasional negative effects are, for example, the possibility that the OLs may have prioritised some outcomes, at the expense of others, or that an unaccounted outcome difference at baseline, may have given a faulty impression of a negative effect of the intervention at follow-up. No study reported on costs or cost-effectiveness.We were unable to determine the comparative effectiveness of different approaches to identifying OLs, as most studies used the sociometric method. Nor could we determine which methods used by OLs to educate their peers were most effective, as the methods were poorly described in most studies. In addition, we could not determine whether OL teams were more effective than single OLs.

AUTHORS' CONCLUSIONS

Local opinion leaders alone, or in combination with other interventions, can be effective in promoting evidence-based practice, but the effectiveness varies both within and between studies.The effect on patient outcomes is uncertain. The costs and the cost-effectiveness of the intervention(s) is unknown. These results are based on heterogeneous studies differing in types of intervention, setting, and outcomes. In most studies, the role and actions of the OL were not clearly described, and we cannot, therefore, comment on strategies to enhance their effectiveness. It is also not clear whether the methods used to identify OLs are important for their effectiveness, or whether the effect differs if education is delivered by single OLs or by multidisciplinary OL teams. Further research may help us to understand how these factors affect the effectiveness of OLs.

Improving the safety climate in hospitals by a vignette-based analysis of adverse events: a cluster randomised study

OBJECTIVE

To assess the impact of a vignette-based analysis of adverse events (AEs) on the safety climate (SC) of care units.

DESIGN

Prospective, open, cluster (a unit) randomised controlled trial.

SETTING

Eighteen acute care units of seven hospitals in France.

PARTICIPANTS

Healthcare providers who worked in the units.

INTERVENTION

Vignette-based analyses of AEs were conducted with unit's providers once per month for six consecutive months. The AEs were real cases that occurred in other hospitals. The hospital risk manager conducted each analysis as follows: analysis of the immediate and root causes of the AE; assessment of the care unit's vulnerabilities and existing barriers in the occurrence of an identical AE and search for solutions.

MAIN OUTCOME MEASURE

SC was measured using the French version of the Hospital Survey on Patient Safety Culture questionnaire. The primary outcome was the difference in the 'Organisational learning and continuous improvement' dimension score, from before to after the analyses.

RESULTS

Median participation rate in the analyses was 20% (range: 7-45%). Before intervention, the response rate to the SC survey was 80% (n = 210) in the intervention group and 73% (n = 191) in the control group. After intervention, it was 59% (n = 141) and 63% (n = 148), respectively. The dimension score evolved differently for the groups from before to after intervention (intervention: +10.2 points ±8.8; control: -3.0 points ±8.5, P = 0.04). Side effects were not measured.

CONCLUSIONS

Vignette-based analysis was associated with the improvement of the perception of participants regarding their institution's capacity for organisational learning and continuous improvement.

The quality perception gap between employees and patients in hospitals

BACKGROUND

To assess hospital performance, quality perceptions of various stakeholders are increasingly taken into account. However, because of substantial background differences, various stakeholder groups might have different and even contrasting quality perceptions.

PURPOSE

We test the hypothesis that an overall perception gap exists between employees and patients with respect to perceived hospital quality. We additionally elaborate on how various employee groups differ from each other and from patients.

METHODOLOGY

We use primary survey data on perceived hospital quality from 9,979 patients and 4,306 employees from 11 German hospitals. With a multilevel regression and variance analysis, we test the impact of respondent type (employee or patient) on quality perception scores and test the interaction with hospital size. We additionally contrast different employee groups and test differences for various quality dimensions.

RESULTS AND CONCLUSION

Hospital employees score hospital quality consistently lower than patients and are also more heterogeneous in their assessments. This makes it from a managerial point of view relevant to subdivide employees in more homogeneous subgroups. Hospital size has no clear effect on the perception gap. Doctors compared to patients and other employee groups have substantially different perceptions on hospital quality.

PRACTICE IMPLICATIONS

Our findings fuel the practical and ethical debate on the extent that perception gaps could and should be allowed in the context of high-quality and transparent hospital performance. Furthermore, we recommend that the quality perception gap is a substantial part of the overall hospital evaluation for ethical reasons but also to enable managers to better understand the (mis)match between employees' priorities and patients' preferences. However, we do warn practitioners that perceptions are only to a limited extent related to the organizational level (in contrast to the individual level), and only minimal improvements can thus be reached by differentiating from other hospitals.

Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review

BACKGROUND

Leadership is critical in building quality work environments, implementing new models of care, and bringing health and wellbeing to a strained nursing workforce. However, the nature of leadership style, how leadership should be enacted, and its associated outcomes requires further research and understanding. We aimed to examine the relationships between various styles of leadership and outcomes for the nursing workforce and their work environments.

METHODS

The search strategy of this systematic review included 10 electronic databases. Published, quantitative studies that examined the correlations between leadership behaviours and nursing outcomes were included. Quality assessments, data extractions and analysis were completed on all included studies by independent reviewers.

RESULTS

A total of 50,941 titles and abstracts were screened resulting in 129 included studies. Using content analysis, 121 outcomes were grouped into six categories: 1) staff satisfaction with job factors, 2) staff relationships with work, 3) staff health & wellbeing, 4) relations among staff, 5) organizational environment factors and 6) productivity & effectiveness. Our analysis illuminated patterns between relational and task focused leadership styles and their outcomes for nurses and nursing work environments. For example, 52 studies reported that relational leadership styles were associated with higher nurse job satisfaction, whereas 16 studies found that task-focused leadership styles were associated with lower nurse job satisfaction. Similar trends were found for each category of outcomes.

CONCLUSIONS

The findings of this systematic review provide strong support for the employment of relational leadership styles to promote positive nursing workforce outcomes and related organizational outcomes. Leadership focused solely on task completion is insufficient to achieve optimum outcomes for the nursing workforce. Relational leadership practices need to be encouraged and supported by individuals and organizations to enhance nursing job satisfaction, retention, work environment factors and individual productivity within healthcare settings.

Collaborating with nurse leaders to develop patient safety practices

Purpose

The organisational level and leadership development are crucial elements in advancing patient safety, because patient safety weaknesses are often caused by system failures. However, little is known about how frontline leader and director teams can be supported to develop patient safety practices. The purpose of this study is to describe the patient safety development process carried out by nursing leaders and directors. The research questions were: how the chosen development areas progressed in six months’ time and how nursing leaders view the participatory development process.

Design/methodology/approach

Participatory action research was used to engage frontline nursing leaders and directors into developing patient safety practices. Semi-structured group interviews (N = 10) were used in data collection at the end of a six-month action cycle, and data were analysed using content analysis.

Findings

The participatory development process enhanced collaboration and gave leaders insights into patient safety as a part of the hospital system and their role in advancing it. The chosen development areas advanced to different extents, with the greatest improvements in those areas with simple guidelines to follow and in which the leaders were most participative. The features of high-reliability organisation were moderately identified in the nursing leaders’ actions and views. For example, acting as a change agent to implement patient safety practices was challenging. Participatory methods can be used to support leaders into advancing patient safety. However, it is important that the participants are familiar with the method, and there are enough facilitators to steer development processes.

Originality/value

Research brings more knowledge of how leaders can increase their effectiveness in advancing patient safety and promoting high-reliability organisation features in the healthcare organisation.

Factors Associated With the Use of the Reactive Approach to Preventing Patient Safety Events

The aim was to investigate the prevalence of using the reactive approach to patient safety event prevention in home-visit nursing agencies and explore factors associated with this approach. Multiple logistic regression analysis was conducted to investigate possible reactive approach-related factors. Two hundred forty-five agencies (71.0%) reported using the reactive approach to prevent event recurrence. Use of the reactive approach in agencies was significantly associated with having administrators who had attended an education course before employment in an administrative position (odds ratio = 1.95). To increase patient safety knowledge and awareness, administrator candidates must attend a course on home-visit agency management. Nursing researchers and policy makers should reexamine and adjust prerequisites for administrator registration at home-visit nursing agencies in Japan.

Knowledge, Attitudes and Challenges of Healthcare Professionals Managing People With Eating Disorders: A Literature Review

This review consolidates findings regarding knowledge and attitudes of healthcare professionals, together with challenges faced while caring for patients with eating disorders. A rigorous and systematic approach was taken to identify 21 articles, which include 12 quantitative, 7 qualitative, and 2 mixed-method papers. Healthcare professionals' knowledge and attitudes toward patients with eating disorders will be discussed, while identifying if factors like age, gender, work experience or profession have an impact on these two variables. Challenges faced during care provision will also be examined. Methodological limitations and knowledge gaps from these articles will be discussed, together with implications of this review.

Time to change: a review of organisational culture change in health care organisations

Purpose

The culture of an organization shapes the attitudes and behaviors of employees and plays a key role in driving organizational outcomes. Yet, it is enormously challenging to manage or change. The purpose of this paper is to review the recent literature on culture change interventions in health care organizations to identify the common themes underpinning these interventions.

Design/methodology/approach

The paper is developed from an extensive review of the literature on culture change interventions in health care from 2005 to 2015, building on previous reviews and highlighting examples of good practice.

Findings

All culture change interventions included in the review used processes and techniques that can be classified into Lewin’s (1951) three stage model of change. These include providing evidence for the need for change through data, a range of successful change strategies, and strategies for embedding the culture change into business as usual.

Practical implications

There is no “one size fits all” recipe for culture change. Rather, attention to context with key features including diagnosis and evaluation of culture, a combination of support from leaders and others in the organization, and strategies to embed the culture change are important for the change process to happen.

Originality/value

The authors provide an important insight into the key principles and features of culture change interventions to provide practitioners with guidance on the process within health care and other organizations.

Testing a theoretical model of clinical nurses' intent to stay

BACKGROUND

Published theoretical models of nurses' intent to stay (ITS) report inconsistent outcomes, and not all hypothesized models have been adequately tested. Research has focused on cognitive rather than emotional determinants of nurses' ITS.

PURPOSE

The aim of this study was to empirically verify a complex theoretical model of nurses' ITS that includes both affective and cognitive determinants and to explore the influence of relational leadership on staff nurses' ITS.

METHODOLOGY

The study was a correlational, mixed-method, nonexperimental design. A subsample of the Quality Work Environment Study survey data 2009 (n = 415 nurses) was used to test our theoretical model of clinical nurses' ITS as a structural equation model.

RESULTS

The model explained 63% of variance in ITS. Organizational commitment, empowerment, and desire to stay were the model concepts with the strongest effects on nurses' ITS. Leadership practices indirectly influenced ITS.

PRACTICE IMPLICATIONS

How nurses evaluate and respond to their work environment is both an emotional and rational process. Health care organizations need to be cognizant of the influence that nurses' feelings and views of their work setting have on their intention decisions and integrate that knowledge into the development of retention strategies. Leadership practices play an important role in staff nurses' perceptions of the workplace. Identifying the mechanisms by which leadership influences staff nurses' intentions to stay presents additional focus areas for developing retention strategies.

Effects of patient safety culture interventions on incident reporting in general practice: a cluster randomised trial

BACKGROUND

A constructive safety culture is essential for the successful implementation of patient safety improvements.

AIM

To assess the effect of two patient safety culture interventions on incident reporting as a proxy of safety culture.

DESIGN AND SETTING

A three-arm cluster randomised trial was conducted in a mixed method study, studying the effect of administering a patient safety culture questionnaire (intervention I), the questionnaire complemented with a practice-based workshop (intervention II) and no intervention (control) in 30 general practices in the Netherlands.

METHOD

The primary outcome, the number of reported incidents, was measured with a questionnaire at baseline and a year after. Analysis was performed using a negative binomial model. Secondary outcomes were quality and safety indicators and safety culture. Mixed effects linear regression was used to analyse the culture questionnaires.

RESULTS

The number of incidents increased in both intervention groups, to 82 and 224 in intervention I and II respectively. Adjusted for baseline number of incidents, practice size and accreditation status, the study showed that practices that additionally participated in the workshop reported 42 (95% confidence interval [CI] = 9.81 to 177.50) times more incidents compared to the control group. Practices that only completed the questionnaire reported 5 (95% CI = 1.17 to 25.49) times more incidents. There were no statistically significant differences in staff perception of patient safety culture at follow-up between the three study groups.

CONCLUSION

Educating staff and facilitating discussion about patient safety culture in their own practice leads to increased reporting of incidents. It is beneficial to invest in a team-wise effort to improve patient safety.

Patient Safety Competence of Nursing Students in Saudi Arabia: A Self-Reported Survey

OBJECTIVE

With the growing recognition of the significance of patient safety (PS) in educational institutions and health organizations, it is essential to understand the perspective of nursing students on their own PS competence. This study analyzed the self-reported PS competence of nursing students at a government university in Saudi Arabia.

METHODOLOGY

A cross-sectional self-reported survey of 191 respondents, using the Health Professional Education in Patient Safety Survey (H-PEPSS) was conducted. The survey tool reflected 6 key socio-cultural dimensions assessing competence in classroom and clinical setting.

RESULTS

Female nursing students reported higher PS competence in both the classroom and clinical settings along the dimensions 'working in teams' and 'communicating effectively' while males reported higher competence in both settings as to the 'managing safety risks' and 'understanding human and environmental factors' dimensions. The respondents' academic level and self-reported PS competence have weak negative correlation in the classroom while a strong negative correlation between the 2 variables existed in the clinical setting. Self-reported PS competence for the dimensions 'working in teams', 'recognize and respond to remove immediate risks of harm', and 'culture of safety' is significantly higher in classroom than in the clinical setting.

CONCLUSION

Generally, the Saudi nursing students reported varying levels of competence in the six dimensions of patient safety. Significant gap between the perceived PS competence was observed between learning settings. Educational and training interventions are suggested for implementation to bridge this gap.

Understanding nurses' and physicians' fear of repercussions for reporting errors: clinician characteristics, organization demographics, or leadership factors?

Background

Identifying and understanding factors influencing fear of repercussions for reporting and discussing medical errors in nurses and physicians remains an important area of inquiry. Work is needed to disentangle the role of clinician characteristics from those of the organization-level and unit-level safety environments in which these clinicians work and learn, as well as probing the differing reporting behaviours of nurses and physicians. This study examines the influence of clinician demographics (age, gender, and tenure), organization demographics (teaching status, location of care, and province) and leadership factors (organization and unit leadership support for safety) on fear of repercussions, and does so for nurses and physicians separately.

Methods

A cross-sectional analysis of 2319 nurse and 386 physician responders from three Canadian provinces to the Modified Stanford patient safety climate survey (MSI-06). Data were analyzed using exploratory factor analysis, multiple linear regression, and hierarchical linear regression.

Results

Age, gender, tenure, teaching status, and province were not significantly associated with fear of repercussions for nurses or physicians. Mental health nurses had poorer fear responses than their peers outside of these areas, as did community physicians. Strong organization and unit leadership support for safety explained the most variance in fear for both nurses and physicians.

Conclusions

The absence of associations between several plausible factors including age, tenure and teaching status suggests that fear is a complex construct requiring more study. Substantially differing fear responses across locations of care indicate areas where interventions may be needed. In addition, since factors affecting fear of repercussions appear to be different for nurses and physicians, tailoring patient safety initiatives to each group may, in some instances, be fruitful. Although further investigation is needed to examine these and other factors in detail, supportive safety leadership appears to be central to reducing fear of reporting errors for both nurses and physicians.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0987-9) contains supplementary material, which is available to authorized users.

The impact of educational interventions on enhancing perceptions of patient safety culture among Jordanian senior nurses

BACKGROUND

The worldwide rate of medical errors and the subsequent patient harm triggered the healthcare organizations to find solutions to transform their punitive culture to safety culture.

AIM

The purpose of this study was to examine the impact of patient safety educational interventions among senior nurses on their perceptions of safety culture, and the rate of reported adverse events, pressure ulcers, and patients' falls.

METHODS

The design of the study was a quasi-experimental without control group. Fifty-seven senior nurses received the educational program. The Hospital Survey on Patient Safety Culture (HSPSC) was administered pre and 4 months post the educational program, and the rate of reported adverse events, pressure ulcers, and patients' falls were collected 4 months pre and 4 months post the educational program.

RESULTS

There were significant improvements of senior nurses' positive scores of two composites, "Frequency of event reporting" and "Non-punitive response to errors," and significant decline of the rate of adverse events.

CLINICAL RELEVANCE

The findings of the study suggested that patient safety educational interventions could be used by nursing administrators to enhance subcultures of patient safety such as "reporting" and "blame free," and to decrease the rate of adverse events.

Quality improvement training: experiences of frontline staff

PURPOSE

Healthcare organizations have employed numerous strategies to promote quality improvement (QI) initiatives, yet little is known about their effectiveness. In 2008, staff in one organization developed an in-house QI training program designed for frontline managers and staff and this article aims to report employee perspectives.

DESIGN/METHODOLOGY/APPROACH

Qualitative interviews were conducted with 22 course participants to examine satisfaction, self-assessed change in proficiency and ability to successfully engage with QI initiatives. Sampling bias may have occurred as the participants volunteered for the study and they may not represent all course participants. Recall bias is also possible since most interviews took place one year after the course was completed to assess long-term impact. Respondents were asked to self-rate their pre- and post-course knowledge and skill, which may not represent what was actually learned.

FINDINGS

Informants reported that the course expanded their QI knowledge and skills, and that supervisor support for the course was essential for success. Additionally, the course QI project provided participants with an opportunity to translate theory into practice, which has the potential to influence patient outcomes.

PRACTICAL IMPLICATIONS

Several lessons for future QI training can be gleaned from this evaluation, including respondent opinions that it is challenging to offer one program when participants have different QI knowledge levels before the course begins, that "booster sessions" or refresher classes after the course ends would be helpful and that supervisor support was critical to successful QI-initiative implementation.

ORIGINALITY/VALUE

This study conducts in-depth interviews with QI course participants to elicit staff feedback on program structure and effectiveness. These findings can be used by QI educators to disseminate more effective training programs.

'Not another safety culture survey': using the Canadian patient safety climate survey (Can-PSCS) to measure provider perceptions of PSC across health settings

Background

The importance of a strong safety culture for enhancing patient safety has been stated for over a decade in healthcare. However, this complex construct continues to face definitional and measurement challenges. Continuing improvements in the measurement of this construct are necessary for enhancing the utility of patient safety climate surveys (PSCS) in research and in practice. This study examines the revised Canadian PSCS (Can-PSCS) for use across a range of care settings.

Methods

Confirmatory factor analytical approaches are used to extensively test the Can-PSCS. Initial and cross-validation samples include 13 126 and 6324 direct care providers from 119 and 35 health settings across Canada, respectively.

Results

Results support a parsimonious model of direct care provider perceptions of patient safety climate (PSC) with 19 items in six dimensions: (1) organisational leadership support for safety; (2) incident follow-up; (3) supervisory leadership for safety; (4) unit learning culture; (5) enabling open communication I: judgement-free environment; (6) enabling open communication II: job repercussions of error. Results also support the validity of the Can-PSCS across a range of care settings.

Conclusions

The Can-PSCS has several advantages: (1) it is a theory-based instrument with a small number of actionable dimensions central to the construct of PSC; (2) it has robust psychometric properties; (3) it is validated for use across a range of care settings, therefore suitable for use in regionalised health delivery systems and can help to raise expectations about acceptable levels of PSC across the system; (4) it has been tested in a publicly funded universal health insurance system and may be suitable for similar international systems.

Validation of the French version of the Hospital Survey on Patient Safety Culture questionnaire

OBJECTIVE

To assess the psychometric properties of the French version of the Hospital Survey on Patient Safety Culture questionnaire (HSOPSC) and study the hierarchical structure of the measured dimensions.

DESIGN

Cross-sectional survey of the safety culture.

SETTING

18 acute care units of seven hospitals in South-western France.

PARTICIPANTS

Full- and part-time healthcare providers who worked in the units.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Item responses measured with 5-point agreement or frequency scales. Data analyses A principal component analysis was used to identify the emerging components. Two structural equation modeling methods [LInear Structural RELations (LISREL) and Partial Least Square (PLS)] were used to verify the model and to study the relative importance of the dimensions. Internal consistency of the retained dimensions was studied. A test-retest was performed to assess reproducibility of the items.

RESULTS

Overall response rate was 77% (n = 401). A structure in 40 items grouped in 10 dimensions was proposed. The LISREL approach showed acceptable data fit of the proposed structure. The PLS approach indicated that three dimensions had the most impact on the safety culture: 'Supervisor/manager expectations & actions promoting safety' 'Organizational learning-continuous improvement' and 'Overall perceptions of safety'. Internal consistency was above 0.70 for six dimensions. Reproducibility was considered good for four items.

CONCLUSIONS

The French HSOPSC questionnaire showed acceptable psychometric properties. Classification of the dimensions should guide future development of safety culture improving action plans.

The Effect of an Organizational Network for Patient Safety on Safety Event Reporting

Health care organizations continue to implement organization-wide educational approaches to enhance patient safety with less attention on evaluating the impact of these approaches. In this context, a study was conducted to measure the impact of an organization-wide patient safety network approach on patient safety event reporting. A time-series analysis with reported rates of adverse events (major and moderate), near misses, sentinel events, and incidents from 2 years prior through 13 months following implementation was conducted. Study findings include a significant increase in reporting of patient safety events (an approximately 50% increase in overall reporting of safety events was observed; p < .001), especially near misses (an approximately 100% increase following implementation; p = .002). Study findings suggest that a multifaceted networked approach does contribute to improving patient safety event reporting.

Organizational safety culture and medical error reporting by Israeli nurses

PURPOSE

To investigate the association between patient safety culture (PSC) and the incidence and reporting rate of medical errors by Israeli nurses.

DESIGN

Self-administered structured questionnaires were distributed to a convenience sample of 247 registered nurses enrolled in training programs at Tel Aviv University (response rate = 91%).

METHODS

The questionnaire's three sections examined the incidence of medication mistakes in clinical practice, the reporting rate for these errors, and the participants' views and perceptions of the safety culture in their workplace at three levels (organizational, departmental, and individual performance). Pearson correlation coefficients, t tests, and multiple regression analysis were used to analyze the data.

FINDINGS

Most nurses encountered medical errors from a daily to a weekly basis. Six percent of the sample never reported their own errors, while half reported their own errors "rarely or sometimes." The level of PSC was positively and significantly correlated with the error reporting rate. PSC, place of birth, error incidence, and not having an academic nursing degree were significant predictors of error reporting, together explaining 28% of variance.

CONCLUSIONS

This study confirms the influence of an organizational safety climate on readiness to report errors. Senior healthcare executives and managers can make a major impact on safety culture development by creating and promoting a vision and strategy for quality and safety and fostering their employees' motivation to implement improvement programs at the departmental and individual level.

CLINICAL RELEVANCE

A positive, carefully designed organizational safety culture can encourage error reporting by staff and so improve patient safety.

Nurses' perceptions of patient safety climate in intensive care units: a cross-sectional study

OBJECTIVES

To investigate registered nurses' perceptions of the patient safety climate in intensive care units and to explore potential predictors for overall perception of safety and frequency of incident reporting.

RESEARCH METHODOLOGY/DESIGN

A cross-sectional design was conducted, using the questionnaire Hospital Survey on Patient Safety Culture, measuring 12 patient safety climate dimensions: seven at unit and three at hospital level, two outcomes and in addition two outcome items.

SETTING

Ten intensive care units (ICUs) in six hospitals in one hospital trust in Norway.

RESULTS

In total, 220 registered nurses (RNs) responded (72%). Seven of 12 dimensions achieved a RN proportion of positive scores over 55%. Five achieved a lower proportion. Significant differences in RNs' perceptions of patient safety were found between types of units and between the four hospitals. The total variance in the outcome measure explained by the model as a whole was for the outcome dimensions "overall perception of safety" 32%, and "frequency of incident reporting" 32%. The variables at the unit level made a significant contribution to the outcome.

CONCLUSION

RNs in ICU are most positive to patient safety climate at unit level, hence improvements are needed concerning incident reporting, feedback and communication about errors and organisational learning and continuous improvement.

Suboptimal reporting of adverse medical events to the FDA Adverse Events Reporting System by nurse practitioners and physician assistants

OBJECTIVES

The Adverse Events Reporting System (AERS) of the FDA is used to identify toxicities of drugs that are on the market. Nurse practitioners (NP) and physician assistants (PA), having an increasing role in the delivery of medical care, are also needed to participate in post-marketing pharmacovigilance. This study was performed to assess awareness and use of the AERS in voluntary reporting of drug toxicities by NPs and PAs.

METHODS

A cluster sample survey was issued at the Principles of Gastroenterology for the Nurse Practitioner and Physician Assistant course in August 2010. The survey assessed familiarity with the AERS, the number of adverse events seen and the frequency of reports sent to the AERS. NP and PA responses were compared using the two-tailed Fisher's exact.

RESULTS

Of the 92 respondents, 67 (72%) were NPs and 24 (26%) PAs. Of the 50 (54%) respondents that reported being familiar with the AERS system, 20 (40%) incorrectly identified the methods to report using the AERS. Overall reporting of adverse events was low, particularly in respondents seeing 5-12 adverse events per year.

CONCLUSION

The study suggests that improved education regarding the importance of using AERS for pharmacovigilance is suggested for NPs and PAs. Due to the small size of the study, these data should be viewed as preliminary, pending a larger confirmatory study.

[Concept analysis of patient safety]

PURPOSE

This study was conducted to investigate the clear concept of patient safety and obtain theoretical evidences.

METHODS

Research was conducted using Walker & Avant's conceptual analysis process.

RESULTS

Patient safety was defined as an activity that minimizes and removes possible errors and injuries to patients. It includes a basic desire to secure the patient's right to safety, and the legal regulations and duties of medical teams. The results of the establishment of a safety culture are patient-centered medical treatment and caring. Antecedents were found to be open and clear communications, continuous education and training for health care personnel, sufficient allocation of qualified personnel, cooperation among departments, improvements in the recognition of patient safety. Consequences were found to be the provision of high quality medical care and treatment, and increase in patient satisfaction.

CONCLUSION

Patient safety as defined by the results of this study will contribute to the foundation of institutionalization of the pursuit of patient safety and creation of a hospital culture focusing on patient safety as a first priority.

Local opinion leaders: effects on professional practice and health care outcomes

BACKGROUND

Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Opinion leaders disseminating and implementing 'best evidence' is one method that holds promise as a strategy to bridge evidence-practice gaps.

OBJECTIVES

To assess the effectiveness of the use of local opinion leaders in improving professional practice and patient outcomes.

SEARCH STRATEGY

We searched Cochrane EPOC Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, HMIC, Science Citation Index, Social Science Citation Index, ISI Conference Proceedings and World Cat Dissertations up to 5 May 2009. In addition, we searched reference lists of included articles.

SELECTION CRITERIA

Studies eligible for inclusion were randomised controlled trials investigating the effectiveness of using opinion leaders to disseminate evidence-based practice and reporting objective measures of professional performance and/or health outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from each study and assessed its risk of bias. For each trial, we calculated the median risk difference (RD) for compliance with desired practice, adjusting for baseline where data were available. We reported the median adjusted RD for each of the main comparisons.

MAIN RESULTS

We included 18 studies involving more than 296 hospitals and 318 PCPs. Fifteen studies (18 comparisons) contributed to the calculations of the median adjusted RD for the main comparisons. The effects of interventions varied across the 63 outcomes from 15% decrease in compliance to 72% increase in compliance with desired practice. The median adjusted RD for the main comparisons were: i) Opinion leaders compared to no intervention, +0.09; ii) Opinion leaders alone compared to a single intervention, +0.14; iii) Opinion leaders with one or more additional intervention(s) compared to the one or more additional intervention(s), +0.10; iv) Opinion leaders as part of multiple interventions compared to no intervention, +0.10. Overall, across all 18 studies the median adjusted RD was +0.12 representing a 12% absolute increase in compliance in the intervention group.

AUTHORS' CONCLUSIONS

Opinion leaders alone or in combination with other interventions may successfully promote evidence-based practice, but effectiveness varies both within and between studies. These results are based on heterogeneous studies differing in terms of type of intervention, setting, and outcomes measured. In most of the studies the role of the opinion leader was not clearly described, and it is therefore not possible to say what the best way is to optimise the effectiveness of opinion leaders.

A cognitive learning model of clinical nursing leadership

Cognitive modeling of competencies is important to facilitate learning and evaluation. Clinical nursing leadership is considered a competency, as it is a "complex know-act" that students and nurses develop for the quality of care of patients and their families. Previous research on clinical leadership describes the attributes and characteristics of leaders and leadership, but, to our knowledge, a cognitive learning model (CLM) has yet to be developed. The purpose of our research was to develop a CLM of the clinical nursing leadership competency, from the beginning of a nursing program to expertise. An interpretative phenomenological study design was used 1) to document the experience of learning and practicing clinical leadership, and 2) to identify critical-learning turning points. Data was gathered from interviews with 32 baccalaureate students and 21 nurses from two clinical settings. An inductive analysis of data was conducted to determine the learning stages experienced: awareness of clinical leadership in nursing; integration of clinical leadership in actions; active leadership with patient/family; active leadership with the team; and, embedded clinical leadership extended to organizational level and beyond. The resulting CLM could have significant impact on both basic and continuing nursing education.