Neonatal intensive care unit safety culture varies widely

Longer work experience and age associated with safety attitudes in operating room nurses: an online cross-sectional study

BACKGROUND

Patient safety is fundamental when providing care in the operating room. Still, adverse events and errors are a challenge for patient safety worldwide. To avoid preventable patient harm, organisations need a positive safety culture, the measurable component of which is known as the safety climate. To best improve the safety climate the current attitudes to safety must first be understood.

AIM

To explore operating room nurses' safety attitudes and their views on how to improve patient safety in operating rooms.

METHOD

A cross-sectional study using the Swedish-translated version of the Safety Attitudes Questionnaire, Operating Room version. Data were collected using an online survey platform.

RESULTS

358 operating room nurses completed the questionnaire. The results show that the older age group rated their working conditions and management support as better than the younger age groups. The older age group also rated their stress recognition as lower compared with the younger age groups. The same pattern was seen in terms of work experience, with more-experienced respondents showing a higher mean score for the factor working conditions and a lower mean score for the factor stress recognition as compared with their less-experienced colleagues. When comparing hospital types, county hospital employees had higher factor scores for safety climate, job satisfaction and working conditions than university hospital employees. The respondents' most recurring recommendations for improving patient safety were 'Having better and clearer communication' followed by 'Having enough time to do things the way they should be done'.

CONCLUSION

More focus on safety with increasing age and experience was observed in this cohort. Need for improvements is reported for patient safety in operating rooms, mainly when it comes to communication and workload. To improve and develop patient safety in the operating room, the organisational safety climate needs to be actively managed and developed. One step in actively managing the safety climate may be efforts to retain experienced operating room nurses.

A systematic review critically appraising quantitative survey measures assessing power dynamics among multidisciplinary teams in acute care settings

By valuing the knowledge of each discipline holistic patient-centered care can be achieved as decisions arise from expertise rather than established hierarchies. While healthcare has historically operated as a hierarchical power structure (i.e., some voices have more influence), these dynamics are rarely discussed. This review addresses this issue by appraising extant quantitative measures that assess multidisciplinary team (MDT) power dynamics. By identifying psychometrically sound measures, change agents can uncover the collective thought processes informing power structures in practice and develop strategies to mitigate power disparities. Several databases were searched. English language articles were included if they reported on quantitative measures assessing power dynamics among MDTs in acute/hospital settings. Results were synthesized using a narrative approach. In total, 6,202 search records were obtained of which 62 met the eligibility criteria. The review reveals some promising measures to assess power dynamics (e.g., Interprofessional Collaboration Scale). However, the findings also confirm several gaps in the current evidence base: 1) need for further psychometric and pragmatic testing of measures; 2) inclusion of more representative MDT samples; 3) further evaluation of unmatured power dimensions. Addressing these gaps will support the development of future interventions aimed at mitigating power imbalances and ultimately improve collaborative working within MDTs.

[Patient safety culture in neonatal intensive care units as seen by nurses]

Neonatal intensive care units (NICUs) are critical environments in terms of safety of care, with a high risk of adverse events. Measuring the patient safety culture of the professionals working there should help to improve the care offered. A descriptive cross-sectional study, conducted among 141 nurses and childcare workers in 2020 in 5 Tunisian hospitals, examined this question.

End-of-Life Decision-Making in Pediatric and Neonatal Intensive Care Units in Croatia—A Focus Group Study among Nurses and Physicians

Background and Objectives: Working in pediatric and neonatal intensive care units (ICUs) can be challenging and differs from work in adult ICUs. This study investigated for the first time the perceptions, experiences and challenges that healthcare professionals face when dealing with end-of-life decisions in neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs) in Croatia. Materials and Methods: This qualitative study with focus groups was conducted among physicians and nurses working in NICUs and PICUs in five healthcare institutions (three pediatric intensive care units (PICUs) and five neonatal intensive care units (NICUs)) at the tertiary level of healthcare in the Republic of Croatia, in Zagreb, Rijeka and Split. A total of 20 physicians and 21 nurses participated in eight focus groups. The questions concerned everyday practices in end-of-life decision-making and their connection with interpersonal relationships between physicians, nurses, patients and their families. The constant comparative analysis method was used in the analysis of the data. Results: The analysis revealed two main themes that were the same among the professional groups as well as in both NICU and PICU units. The theme “critical illness” consisted of the following subthemes: the child, the family, myself and other professionals. The theme “end-of-life procedures” consisted of the following subthemes: breaking point, decision-making, end-of-life procedures, “spill-over” and the four walls of the ICU. The perceptions and experiences of end-of-life issues among nurses and physicians working in NICUs and PICUs share multiple common characteristics. The high variability in end-of-life procedures applied and various difficulties experienced during shared decision-making processes were observed. Conclusions: There is a need for further research in order to develop clinical and professional guidelines that will inform end-of-life decision-making, including the specific perspectives of everyone involved, and the need to influence policymakers.

Changing safety culture

Safety culture, an aspect of organizational culture, that reflects work place norms toward safety, is foundational to high-quality care. Improvements in safety culture are associated with improved operational and clinical outcomes. In the neonatal intensive care unit (NICU), where fragile infants receive complex, coordinated care over prolonged time periods, it is critically important that unit norms reflect the high priority placed on safety. Changing the safety culture of the NICU involves a systematic process of measurement, identifying strengths and weaknesses, deploying targeted interventions, and learning from the results, to set the stage for an iterative process of improvement. Successful change efforts require: effective partnerships with key stakeholders including management, clinicians, staff, and families; using data to make the case for improvement; and leadership actions that motivate change, channel resources, and support active problem- solving. Sustainable change requires buy-in from NICU staff and management, resources, and long-term institutional commitment.

Do trained nurses feel more psychologically safe?-Results from a multi-level modelling approach

Aim

To analyse the associations between a nurse's psychological safety and her/his additional training.

Design

A cross‐sectional survey conducted between September 2015 and August 2016.

Methods

A multi‐level modelling approach was used considering unit membership. We used data from 1,239 questionnaires completed by nurses on 75 different German neonatal intensive care units, and 75 questionnaires completed by the corresponding leading nurse.

Results

We found the additional managerial training as a charge nurse to be a positive predictor for psychological safety (β = .346, p ≤ .05). Surprisingly, the additional clinical training in paediatric intensive care is negatively associated with psychological safety (β = −.192, p ≤ .01). Our model estimates that this negative association can be inhibited if the team's share of nurses with an additional clinical training increases (β = .313, p ≤ .05).

The effect of repeated high-fidelity in situ simulation-based training on self-efficacy, self-perceived leadership qualities and team performance: A quasi-experimental study in a NICU-setting

BACKGROUND

Simulation-based training has been widely used in various disciplines and has increasingly been recognized as useful in healthcare education during the past decade. In nursing schools, simulation-based training was initially used to train nursing students. However, there is a growing trend to use simulation-based training for continuing education and lifelong learning among professional healthcare workers.

OBJECTIVES

To investigate if simulation-based training has an effect on self-efficacy, self-perceived leadership qualities and team performance in a neonatal intensive care unit.

DESIGN

Time series design.

SETTING

One referral neonatal intensive care unit in a general hospital in Flanders, Belgium.

PARTICIPANTS

Convenience sample of 71 nurses and midwives.

METHODS

Participants were involved in a series of three simulation-based training sessions. Before and after these series, a set of validated questionnaires was completed to measure the self-efficacy and self-perceived leadership qualities of the participants. Each session was videotaped and assessed for team performance (n = 8).

RESULTS

Participating in repeated high-fidelity in situ simulation-based training resulted in a significant increase in self-efficacy (p < 0.001) and self-perceived leadership qualities (p < 0.001). The intervention did not lead to a significant improved team performance (p = 0.209).

CONCLUSION

Repeated high-fidelity in situ simulation-based training in the NICU had a positive effect on self-efficacy and self-perceived leadership abilities in registered nurses and midwives in acute care situations. Repeated participation in simulation-based training had a positive effect on these outcomes, regardless of the number of years of NICU experience. The effect on team performance could not be confirmed in this study.

The Correlation Between Neonatal Intensive Care Unit Safety Culture and Quality of Care

Supplemental digital content is available in the text.

Key validated clinical metrics are being used individually and in aggregate (Baby-MONITOR) to monitor the performance of neonatal intensive care units (NICUs). The degree to which perceptions of key components of safety culture, safety climate, and teamwork are related to aspects of NICU quality of care is poorly understood. The objective of this study was to test whether NICU performance on key clinical metrics correlates with caregiver perceptions of safety culture.

Maternal and neonatal health care worker well-being and patient safety climate amid the COVID-19 pandemic

OBJECTIVE

To assess maternal and neonatal healthcare workers (HCWs) perspectives on well-being and patient safety amid the COVID-19 pandemic.

STUDY DESIGN

Anonymous survey of HCW well-being, burnout, and patient safety over the prior conducted in June 2020. Results were analyzed by job position and burnout status.

RESULT

We analyzed 288 fully completed surveys. In total, 66% of respondents reported symptoms of burnout and 73% felt burnout among their co-workers had significantly increased. Workplace strategies to address HCW well-being were judged by 34% as sufficient. HCWs who were "burned out" reported significantly worse well-being and patient safety attributes. Compared to physicians, nurses reported higher rates of unprofessional behavior (37% vs. 14%, p = 0.027) and difficulty focusing on work (59% vs. 36%, p = 0.013).

CONCLUSION

Three months into the COVID-19 pandemic, HCW well-being was substantially compromised, with negative ramifications for patient safety.

Patient safety attitudes among critical care nurses: A case study in North Cyprus

INTRODUCTION

Patient safety has become a crucial priority in quality healthcare. Adverse events and serious errors involving critically ill patients are common and can be potentially life-threatening. Thus, this study aimed to examine patient safety attitudes among critical care nurses.

METHODS

This cross-sectional study was conducted in two hospitals in North Cyprus. Eighty nurses working in critical care units participated in the study. Following ethical approval, data were collected between September and October 2018, using the Demographic Characteristics Questionnaire and Safety Attitudes Questionnaire.

FINDINGS

Nurses' overall scores regarding patient safety attitudes were found to be negative. The highest positive rate was for safety climate, followed by perception of management, teamwork, working conditions, job satisfaction, and stress recognition, respectively. There were significant differences among working conditions, perception of management, and stress recognition based on participants' positions and event reporting.

CONCLUSION

Our findings indicate safety culture needs to be improved in the hospitals included in the study. Healthcare managers and decision-makers should foster patient safety culture through in-service education, management support, institutional regulations, and updated guidelines.

Safety attitudes in hospital emergency departments: a systematic review

PURPOSE

The purpose of this paper is to perform and report a systematic review of published research on patient safety attitudes of health staff employed in hospital emergency departments (EDs).

DESIGN/METHODOLOGY/APPROACH

An electronic search was conducted of PsychINFO, ProQuest, MEDLINE, EMBASE, PubMed and CINAHL databases. The review included all studies that focussed on the safety attitudes of professional hospital staff employed in EDs.

FINDINGS

Overall, the review revealed that the safety attitudes of ED health staff are generally low, especially on teamwork and management support and among nurses when compared to doctors. Conversely, two intervention studies showed the effectiveness of team building interventions on improving the safety attitudes of health staff employed in EDs.

RESEARCH LIMITATIONS/IMPLICATIONS

Six studies met the inclusion criteria, however, most of the studies demonstrated low to moderate methodological quality.

ORIGINALITY/VALUE

Teamwork, communication and management support are central to positive safety attitudes. Teamwork training can improve safety attitudes. Given that EDs are the "front-line" of hospital care and patients within EDs are especially vulnerable to medical errors, future research should focus on the safety attitudes of medical staff employed in EDs and its relationship to medical errors.

An Ethnography of Parents' Perceptions of Patient Safety in the Neonatal Intensive Care Unit

BACKGROUND

Parents of neonates are integral components of patient safety in the neonatal intensive care unit (NICU), yet their views are often not considered. By understanding how parents perceive patient safety in the NICU, clinicians can identify appropriate parent-centered strategies to involve them in promoting safe care for their infants.

PURPOSE

To determine how parents of neonates conceptualize patient safety in the NICU.

METHODS

We conducted qualitative interviews with 22 English-speaking parents of neonates from the NICU and observations of various parent interactions within the NICU over several months. Data were analyzed using thematic content analysis. Findings were critically reviewed through peer debriefing.

FINDINGS

Parents perceived safe care through their observations of clinicians being present, intentional, and respectful when adhering to safety practices, interacting with their infant, and communicating with parents in the NICU. They described partnering with clinicians to promote safe care for their infants and factors impacting that partnership. We cultivated a conceptual model highlighting how parent-clinician partnerships can be a core element to promoting NICU patient safety.

IMPLICATIONS FOR PRACTICE

Parents' observations of clinician behavior affect their perceptions of safe care for their infants. Assessing what parents observe can be essential to building a partnership of trust between clinicians and parents and promoting safer care in the NICU.

IMPLICATIONS FOR RESEARCH

Uncertainty remains about how to measure parent perceptions of safe care, the level at which the clinician-parent partnership affects patient safety, and whether parents' presence and involvement with their infants in the NICU improve patient safety.

Diagnostic errors in the neonatal intensive care unit: State of the science and new directions

Diagnostic errors remain understudied in neonatology. The limited available evidence, however, suggests that diagnostic errors in the neonatal intensive care unit (NICU) result in significant and long-term consequences. In this narrative review, we discuss how the concept of diagnostic errors framed as missed opportunities can be applied to the non-linear nature of diagnosis in a critical care environment such as the NICU. We then explore how the etiology of an error in diagnosis can be related to both individual cognitive factors as well as organizational and systemic factors - all of which often contribute to the error. This multifactorial causation has limited the development of methodology to measure diagnostic errors as well as strategies to mitigate and prevent their adverse effects. We recommend research focused on the frequency and etiology of diagnostic error in the NICU as well as potential mitigation strategies to advance this important field in neonatal intensive care.

Exploring leading nurses' work values and their association with team safety climate: Results from a questionnaire survey in neonatal intensive care units

AIM

To explore leading nurses' work values and their effect on the safety climate in neonatal intensive care units (NICUs).

BACKGROUND

Despite their significance for behaviour, the work values of leading nurses are still insufficiently studied. We explore the impact of work value dimensions (self-transcendence, self-enhancement, conservation, and openness to change) on the safety climate.

METHODS

A cross-sectional study was conducted in 86 German NICUs between September 2015 and August 2016. Our analyses relate questionnaire data from 75 leading nurses to the shared perceptions regarding safety among their team members (n = 1,277). We used fractional response modelling to identify important work values.

RESULTS

The analysis showed differences between the dimensions of work values and their association with the safety climate. A significant positive association was found between the work value dimension self-transcendence (including the work values relationships with others and altruism) and safety climate (β = 0.255, p = .001). A large team size has a negative impact on the safety climate.

CONCLUSION

The findings indicate that the leading nurse's score on self-transcendence is positively related to the safety climate.

IMPLICATIONS FOR NURSING MANAGEMENT

The results demonstrate that it might be useful to consider work values in the selection of nurse leaders.

Nurses' Perceptions of Patient Safety Culture in Intensive Care Units: A Cross-Sectional Study

BACKGROUND

Patient safety culture is a relatively new focus where little is known about its current status in Egypt's teaching hospitals, mainly intensive care units (ICUs). Therefore, the authors of this study attempted to assess the patient safety culture dimensions from the nurses' perspective.

METHODS

An exploratory cross-sectional study was conducted in two ICUs (pediatric ICU and adult ICU) at the University Hospital over 3 months from October till December 2018. Sixty nurses were interviewed using the Hospital Survey on Patient Safety Culture.

RESULTS

The current study findings revealed an average positive response to individual items ranging from 6% to 51%. The "Organizational learning" dimension had the highest average percent positive patient safety dimension score (51%) among all respondents, while the "Frequency of events reported" dimension had the lowest one (6%). No statistically significant difference was reported between the pediatric and adult ICUs for all mean scores except for the "Non-punitive response to error" dimension which was reported to be greater in the pediatric intensive care unit (PICU) compared to adult ICU (P < 0.005). The overall patient safety grade was rated acceptable by 47.5% of the interviewed nurses.

CONCLUSION

The current study shows that patient safety is fragile in ICUs, and more effort is recommended to increase the awareness of health care providers. Also, hospital managers need to enhance the performance and practices of patient safety within a non-punitive reporting environment.

Safety climate, safety climate strength, and length of stay in the NICU

Background

Safety climate is an important marker of patient safety attitudes within health care units, but the significance of intra-unit variation of safety climate perceptions (safety climate strength) is poorly understood. This study sought to examine the standard safety climate measure (percent positive response (PPR)) and safety climate strength in relation to length of stay (LOS) of very low birth weight (VLBW) infants within California neonatal intensive care units (NICUs).

Methods

Observational study of safety climate from 2073 health care providers in 44 NICUs. Consistent perceptions among a NICU’s respondents, i.e., safety climate strength, was determined via intra-unit standard deviation of safety climate scores. The relation between safety climate PPR, safety climate strength, and LOS among VLBW (< 1500 g) infants was evaluated using log-linear regression. Secondary outcomes were infections, chronic lung disease, and mortality.

Results

NICUs had safety climate PPRs of 66 ± 12%, intra-unit standard deviations 11 (strongest) to 23 (weakest), and median LOS 60 days. NICUs with stronger climates had LOS 4 days shorter than those with weaker climates. In interaction modeling, NICUs with weak climates and low PPR had the longest LOS, NICUs with strong climates and low PPR had the shortest LOS, and NICUs with high PPR (both strong and weak) had intermediate LOS. Stronger climates were associated with lower odds of infections, but not with other secondary outcomes.

Conclusions

Safety climate strength is independently associated with LOS and moderates the association between PPR and LOS among VLBW infants. Strength and PPR together provided better prediction than PPR alone, capturing variance in outcomes missed by PPR. Evaluations of NICU safety climate consider both positivity (PPR) and consistency of responses (strength) across individuals.

Attitudes of Doctors and Nurses toward Patient Safety within Emergency Departments of a Saudi Arabian Hospital: A Qualitative Study

Background: The attitudes of doctors and nurses toward patient safety representa significant contributing factor to hospital safety climates and medical error rates. Yet, there are very few studies of patient safety attitudes in Saudi hospitals and none conducted in hospital emergency departments. Aims: The current study aims to investigate and compare the patient safety attitudes of doctors and nurses in a Saudi hospital emergency department. Materials and Method: The study employed a qualitative research design via semi-structured interviews with Saudi and non-Saudi doctors and nurses working in a Saudi hospital emergency department to determine their attitudes and experiences about the patient safety climate. Results: Findings revealed doctors and nurses held some similar safety attitudes; however, nurses reported issues with doctors with respect to their teamwork, communication, and patient safety attitudes. Moreover, several barriers to the patient safety climate were identified, including limits to resources, teamwork, communication, and incident reporting. Conclusion: The findings provide one of the few research contributions to knowledge regarding the patient safety attitudes of Saudi and non-Saudi doctors and nurses and suggest the application of such knowledge would enhance positive patient outcomes in emergency departments.

Attitudes of doctors and nurses toward patient safety within emergency departments of two Saudi Arabian hospitals

Background

A hospital culture that promotes and insures patient safety is a critical aspect for the effective delivery of hospital services and patient care. Yet there are significant patient health and safety issues in hospitals worldwide. This study aims to investigate doctors’ and nurses’ attitudes toward patient safety in the emergency departments (ED) of two Saudi hospitals.

Method

A cross-sectional survey using a validated Safety Attitudes Questionnaire (SAQ) was used. Total of 503 ED doctors and nurses completed SAQ. Correlation analysis, using Spearman’s Rho, was performed between the number of incidents reported and each dimension of the SAQ.

Results

The mean score of each SAQ dimension was < 75%, indicating that nurses and doctors generally had less than a positive safety attitudes. This was especially prominent with dimensions of stress recognition (58.1%) and perceptions of hospital management (56.9%). Furthermore, nurses reported significantly lower on the teamwork climate dimension than doctors (p < .01), whereas doctors reported significantly lower on the hospital work conditions dimension than nurses (p < .01). There was a significant negative correlation between the number of errors reported and teamwork climate, job satisfaction, and work conditions.

Conclusion

Safety attitudes of doctors and nurses employed in EDs of Saudi hospitals are less than positive and correlate with the number of reported errors. Safety training interventions and management support would appear to be the most likely avenues to improve the safety attitudes and performance within Saudi ED’s.

Never judge a book by its cover: how NICU evaluators reach conclusions about quality of care

OBJECTIVE

To identify key features in the NICU care delivery context that influence quality of care delivery.

STUDY DESIGN

Qualitative study using in-depth, semi-structured interviews with 10 NICU quality experts with extensive experience conducting NICU site visits and evaluating quality of care. Analyses were performed using the method of constant comparison based on grounded theory.

RESULTS

Qualitative analysis yielded three major themes: (1) the foundation for high quality care is a cohesive unit culture, characterized by open communication, teamwork, and engagement of families; (2) effective linkages between measurement and improvement action is necessary for continuous improvement; and (3) NICU capacity for improvement is sustained by active support, exchange of skills, and resources from the hospital.

CONCLUSIONS

Team cohesion, engagement of families, culture of improvement supported by measurement and institutional support from the hospital are some of the key contextual and managerial features critical to high-quality NICU care.

Context in Quality of Care: Improving Teamwork and Resilience

Quality improvement in health care is an ongoing challenge. Consideration of the context of the health care system is of paramount importance. Staff resilience and teamwork climate are key aspects of context that drive quality. Teamwork climate is dynamic, with well-established tools available to improve teamwork for specific tasks or global applications. Similarly, burnout and resilience can be modified with interventions such as cultivating gratitude, positivity, and awe. A growing body of literature has shown that teamwork and burnout relate to quality of care, with improved teamwork and decreased burnout expected to produce improved patient quality and safety.

Interprofessional team assessments of the patient safety climate in Swedish operating rooms: a cross-sectional survey

BACKGROUND

A positive patient safety climate within teams has been associated with higher safety performance. The aim of this study was to describe and compare attitudes to patient safety among the various professionals in surgical teams in Swedish operating room (OR) departments. A further aim was to study nurse managers in the OR and medical directors' estimations of their staffs' attitudes to patient safety.

METHODS

A cross-sectional survey with the Safety Attitudes Questionnaire (SAQ) was used to elicit estimations from surgical teams. To evoke estimations from nurse managers and medical directors about staff attitudes to patient safety, a short questionnaire, based on SAQ, was used. Three OR departments at three different hospitals in Sweden participated. All licensed practical nurses (n=124), perioperative nurses (n=233), physicians (n=184) and their respective manager (n=22) were invited to participate.

RESULTS

Mean percentage positive scores for the six SAQ factors and the three professional groups varied, and most factors (safety climate, teamwork climate, stress recognition, working conditions and perceptions of management), except job satisfaction, were below 60%. Significantly lower mean values were found for perioperative nurses compared with physicians for perceptions of management (56.4 vs 61.4, p=0.013) and working conditions (63.7 vs 69.8, p=0.007). Nurse managers and medical directors' estimations of their staffs' ratings of the safety climate cohered fairly well.

CONCLUSIONS

This study shows variations and some weak areas for patient safety climate in the studied ORs as reported by front-line staff and acknowledged by nurse managers and medical directors. This finding is a concern because a weak patient safety climate has been associated with poor patient outcomes. To raise awareness, managers need to support patient safety work in the OR.

Teamwork in the NICU Setting and Its Association with Health Care-Associated Infections in Very Low-Birth-Weight Infants

Background and Objective Teamwork may affect clinical care in the neonatal intensive care unit (NICU) setting. The objective of this study was to assess teamwork climate across NICUs and to test scale-level and item-level associations with health care-associated infection (HAI) rates in very low-birth-weight (VLBW) infants. Methods Cross-sectional study of the association between HAI rates, defined as any bacterial or fungal infection during the birth hospitalization, among 6,663 VLBW infants cared for in 44 NICUs between 2010 and 2012. NICU HAI rates were correlated with teamwork climate ratings obtained in 2011 from 2,073 of 3,294 eligible NICU health professionals (response rate 63%). The relation between HAI rates and NICU teamwork climate was assessed using logistic regression models including NICU as a random effect. Results Across NICUs, 36 to 100% (mean 66%) of respondents reported good teamwork. HAI rates were significantly and independently associated with teamwork climate (odds ratio, 0.82; 95% confidence interval, 0.73-0.92, p = 0.005), such that the odds of an infant contracting a HAI decreased by 18% with each 10% rise in NICU respondents reporting good teamwork. Conclusion Improving teamwork may be an important element in infection control efforts.

Factors Associated With Provider Burnout in the NICU

BACKGROUND

NICUs vary greatly in patient acuity and volume and represent a wide array of organizational structures, but the effect of these differences on NICU providers is unknown. This study sought to test the relation between provider burnout prevalence and organizational factors in California NICUs.

METHODS

Provider perceptions of burnout were obtained from 1934 nurse practitioners, physicians, registered nurses, and respiratory therapists in 41 California NICUs via a validated 4-item questionnaire based on the Maslach Burnout Inventory. The relations between burnout and organizational factors of each NICU were evaluated via t-test comparison of quartiles, univariable regression, and multivariable regression.

RESULTS

Overall burnout prevalence was 26.7% ± 9.8%. Highest burnout prevalence was found among NICUs with higher average daily admissions (32.1% ± 6.4% vs 17.2% ± 6.7%, P < .001), higher average occupancy (28.1% ± 8.1% vs 19.9% ± 8.4%, P = .02), and those with electronic health records (28% ± 11% vs 18% ± 7%, P = .03). In sensitivity analysis, nursing burnout was more sensitive to organizational differences than physician burnout in multivariable modeling, significantly associated with average daily admissions, late transfer proportion, nursing hours per patient day, and mortality per 1000 infants. Burnout prevalence showed no association with proportion of high-risk patients, teaching hospital distinction, or in-house attending presence.

CONCLUSIONS

Burnout is most prevalent in NICUs with high patient volume and electronic health records and may affect nurses disproportionately. Interventions to reduce burnout prevalence may be of greater importance in NICUs with ≥10 weekly admissions.

Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections

OBJECTIVE

To examine burnout prevalence among California neonatal intensive care units (NICUs) and to test the relation between burnout and healthcare-associated infection (HAI) rates in very low birth weight (VLBW) neonates.

STUDY DESIGN

Retrospective observational study of provider perceptions of burnout from 2073 nurse practitioners, physicians, registered nurses and respiratory therapists, using a validated four-item questionnaire based on the Maslach Burnout Inventory. The relation between burnout and HAI rates among VLBW (<1500 g) neonates from each NICU was evaluated using multi-level logistic regression analysis with patient-level factors as fixed effects.

RESULTS

We found variable prevalence of burnout across the NICUs surveyed (mean 25.2±10.1%). Healthcare-associated infection rates were 8.3±5.1% during the study period. Highest burnout prevalence was found among nurses, nurse practitioners and respiratory therapists (non-physicians, 28±11% vs 17±19% physicians), day shift workers (30±3% vs 25±4% night shift) and workers with 5 or more years of service (29±2% vs 16±6% in fewer than 3 years group). Overall burnout rates showed no correlation with risk-adjusted rates of HAIs (r=-0.133). Item-level analysis showed positive association between HAIs and perceptions of working too hard (odds ratio 1.15, 95% confidence interval 1.04-1.28). Sensitivity analysis of high-volume NICUs suggested a moderate correlation between burnout prevalence and HAIs (r=0.34).

CONCLUSION

Burnout is most prevalent among non-physicians, daytime workers and experienced workers. Perceptions of working too hard associate with increased HAIs in this cohort of VLBW infants, but overall burnout prevalence is not predictive.

Safety Culture in Neonatal Intensive Care Units in the Gaza Strip, Palestine: A Need for Policy Change

INTRODUCTION

Assessment of the prevailing safety culture within the Gazan health care system can be used to identify problem areas. Specifically, the need for improvements, raising awareness about patient safety, the identification and evaluation of existing safety programs and interventions for improving the safety culture. This study aims to assess the safety culture in the neonatal intensive care units (NICUs) in Gaza Strip hospitals and to assess the safety culture in regards to caregivers' characteristics.

METHODS

In a cross-sectional study using a census sample, we surveyed all nurses and physicians working in at all the NICUs in the Gaza Strip, Palestine. The Safety Attitudes Questionnaire (SAQ) which includes six scales was used to assess participants' attitudes towards safety culture.

RESULTS

The overall score for SAQ was 63.9. Domains' scores ranged between 55.5 (perception of management) and 71.8 (stress recognition). The scores reported by our participants fell below the 75 out of a possible score of 100, which was considered as a cut-off point for a positive score. Moreover, our results revealed substantial variation in safety culture domain scores among participating NICUs.

CONCLUSION

These results should be an indicator to our health care policy makers to modify current or adopt new health care policies to improve safety culture. It should also be a call to design customized programs for improving the safety culture in NICUs in the Gaza Strip.

A cross-sectional study to assess the patient safety culture in the Palestinian hospitals: a baseline assessment for quality improvement

Objectives

To measure and establish a baseline assessment of the patient safety culture in the Palestinian hospitals.

Design

A cross-sectional descriptive study using the Arabic version of the Safety Attitude Questionnaire (Short Form 2006).

Participants

A total of 339 nurses and physicians returned the questionnaire out of 370 achieving a response rate of 91.6%.

Setting

Four public general hospitals in the Gaza Strip, Palestine.

Methods

Nurses and physicians were randomly selected using a proportionate random sampling. Data analysis performed using Statistical Package for the Social Sciences software version 20, and p value less than 0.05 was statistically significant.

Main outcomes measures

Current status of patient safety culture among healthcare providers and percentage of positive attitudes.

Results

Male to female ratio was 2.16:1, and mean age was 36.5 ± 9.4 years. The mean score of Arabic Safety Attitude Questionnaire across the six dimensions on 100-point scale ranged between 68.5 for Job Satisfaction and 48.5 for Working Condition. The percentage of respondents holding a positive attitude was 34.5% for Teamwork Climate, 28.4% for Safety Climate, 40.7% for Stress Recognition, 48.8% for Job Satisfaction, 11.3% for Working Conditions and 42.8% for Perception of Management. Healthcare workers holding positive attitudes had better collaboration with co-workers than those without positive attitudes.

Conclusion

Findings are useful to formulate a policy on patient safety culture and targeted a specific safety culture dimension to improve the safety of patients and improve the clinical outcomes within healthcare organisations.

Nursing work environment, patient safety and quality of care in pediatric hospital

Objectives To describe the characteristics of the nursing work environment, safety attitudes, quality of care, measured by the nursing staff of the pediatric units, as well as to analyze the evolution of quality of care and hospital indicators. Methods Descriptive study with 136 nursing professionals at a paediatric hospital, conducted through personal and professional characterization form, Nursing Work Index - Revised, Safety Attitudes Questionnaire - Short Form 2006 and quality indicators. Results The professionals perceive the environment as favourable to professional practice, and consider good quality care that is also observed by reducing the incidence of adverse events and decreased length of stay. The domain job satisfaction was considered favourable to patient safety. Conclusions The work environment is favourable to nursing practice, the professionals nursing approve the quality of care and the indicators tended reducing adverse events and length of stay.

Assessing safety culture in NICU: psychometric properties of the Italian version of Safety Attitude Questionnaire and result implications

RATIONALE, AIMS AND OBJECTIVE

Neonatal intensive care units (NICUs) are a high-risk setting. The Safety Attitude Questionnaire (SAQ) is a widely used tool to measure safety culture. The aims of the study are to verify the psychometric properties of the Italian version of SAQ, to evaluate safety culture in the NICUs and to identify improvement interventions.

METHOD

A cross-sectional study was conducted in 6 level III NICUs. The SAQ was translated into Italian and adapted to the context, a confirmatory factor analysis (CFA) was performed to validate the questionnaire.

RESULTS

193 questionnaires were collected. The mean response rate was 59.7% (range 44.5%-95.7%). The answers were analysed according to six factors: f1 - teamwork climate, f2 - safety climate, f3 - job satisfaction, f4 - stress recognition, f5 - perception of management, f6 - working conditions. The CFA indexes were adequate (McDonald's omega indexes varied from 0.74 to 0.94, the SRMR index was equal to 0.79 and the RMSEA index was 0.070, 95% CI = 0.063-0.078). The mean composite score was 57.6 (SD 17.9), ranging between 42.3 and 69.7 on a standardized 100-point scale. We highlighted significant differences among units and professions (P < 0.05).

CONCLUSIONS

The Italian version of the SAQ proved to be an effective tool to evaluate and compare the safety culture in the NICUs. The obtained scores significantly varied both within and among the NICUs. The organizational and structural characteristics of the involved hospitals probably affect the safety culture perception by the staff.

Comparing NICU teamwork and safety climate across two commonly used survey instruments

Background and objectives

Measurement and our understanding of safety culture are still evolving. The objectives of this study were to assess variation in safety and teamwork climate and in the neonatal intensive care unit (NICU) setting, and compare measurement of safety culture scales using two different instruments (Safety Attitudes Questionnaire (SAQ) and Hospital Survey on Patient Safety Culture (HSOPSC)).

Methods

Cross-sectional survey study of a voluntary sample of 2073 (response rate 62.9%) health professionals in 44 NICUs. To compare survey instruments, we used Spearman's rank correlation coefficients. We also compared similar scales and items across the instruments using t tests and changes in quartile-level performance.

Results

We found significant variation across NICUs in safety and teamwork climate scales of SAQ and HSOPSC (p<0.001). Safety scales (safety climate and overall perception of safety) and teamwork scales (teamwork climate and teamwork within units) of the two instruments correlated strongly (safety r=0.72, p<0.001; teamwork r=0.67, p<0.001). However, the means and per cent agreements for all scale scores and even seemingly similar item scores were significantly different. In addition, comparisons of scale score quartiles between the two instruments revealed that half of the NICUs fell into different quartiles when translating between the instruments.

Conclusions

Large variation and opportunities for improvement in patient safety culture exist across NICUs. Important systematic differences exist between SAQ and HSOPSC such that these instruments should not be used interchangeably.

Staff and parents are discriminators for outcomes in neonatal intensive care units

AIM

We investigated the associations between staff work characteristics, parents' experiences and a number of medical outcome measures.

METHODS

This explorative multicentre study took place in the neonatal intensive care units (NICUs) of five German university hospitals between 2009 and 2011. We assessed staff work characteristics by surveying 126 NICU nurses and 57 physicians and asked 214 parents about their relationships with staff. The outcome variables of 230 premature infants with birth weights of less than 1500 g were collected over a period of 18 months. We used analysis of variance (ANOVA) and regression analyses for statistical purposes.

RESULTS

We found differences in outcome measures between the NICUs, particularly parameters of respiratory support, weight gain and length of stay. When we controlled for the NICUs' baseline factors, perceptions of the relationship between staff and parents (empathy, p < 0.001; conversation duration and frequency, p < 0.05; familiarity, p < 0.05) and staff work characteristics (workload, p < 0.05) were associated with at least one of these outcome measures.

CONCLUSION

Staff and parents were discriminators for neonatal outcomes through perceptions of work characteristics and the relationship between staff and parents, respectively. Respiratory support and nutrition measures were particularly sensitive. This research has prompted a nationwide, multicentre study of 66 NICUs.

Characteristics of unit-level patient safety culture in hospitals in Japan: a cross-sectional study

BACKGROUND

Patient safety culture (PSC) has an important role in determining safety and quality in healthcare. Currently, little is known about the status of unit-level PSC in hospitals in Japan. To develop appropriate strategies, characteristics of unit-level PSC should be investigated. Work units may be classified according to the characteristics of PSC, and common problems and appropriate strategies may be identified for each work unit category. This study aimed to clarify the characteristics of unit-level PSC in hospitals in Japan.

METHODS

In 2012, a cross-sectional study was conducted at 18 hospitals in Japan. The Hospital Survey on Patient Safety Culture questionnaire, developed by the United States Agency for Healthcare Research and Quality, was distributed to all healthcare workers (n =12,076). Percent positive scores for 12 PSC sub-dimensions were calculated for each unit, and cluster analysis was used to categorise the units according to the percent positive scores. A generalised linear mixed model (GLMM) was used to analyse the results of the cluster analysis, and odds ratios (ORs) for categorisation as high-PSC units were calculated for each unit type.

RESULTS

A total of 9,124 respondents (75.6%) completed the questionnaire, and valid data from 8,700 respondents (72.0%) were analysed. There were 440 units in the 18 hospitals. According to the percent positive scores for the 12 sub-dimensions, the 440 units were classified into 2 clusters: high-PSC units (n =184) and low-PSC units (n =256). Percent positive scores for all PSC sub-dimensions for high-PSC units were significantly higher than those for low-PSC units. The GLMM revealed that the combined unit type of 'Obstetrics and gynaecology ward, perinatal ward or neonatal intensive care unit' was significantly more likely to be categorised as high-PSC units (OR =9.7), and 'Long-term care ward' (OR =0.2), 'Rehabilitation unit' (OR =0.2) and 'Administration unit' (OR =0.3) were significantly less likely to be categorised as high-PSC units.

CONCLUSIONS

Our study findings demonstrate that PSC varies considerably among different unit types in hospitals in Japan. Factors contributing to low PSC should be identified and possible measures for improving PSC should be developed and initiated.

Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout

BACKGROUND

Leadership WalkRounds (WR) are widely used in healthcare organisations to improve patient safety. The relationship between WR and caregiver assessments of patient safety culture, and healthcare worker burnout is unknown.

METHODS

This cross-sectional survey study evaluated the association between receiving feedback about actions taken as a result of WR and healthcare worker assessments of patient safety culture and burnout across 44 neonatal intensive care units (NICUs) actively participating in a structured delivery room management quality improvement initiative.

RESULTS

Of 3294 administered surveys, 2073 were returned for an overall response rate of 62.9%. More WR feedback was associated with better safety culture results and lower burnout rates in the NICUs. Participation in WR and receiving feedback about WR were less common in NICUs than in a benchmarking comparison of adult clinical areas.

CONCLUSIONS

WR are linked to patient safety and burnout. In NICUs, where they occurred more often, the workplace appears to be a better place to deliver and to receive care.

Burnout in the NICU setting and its relation to safety culture

BACKGROUND

Burnout is widespread among healthcare providers and is associated with adverse safety behaviours, operational and clinical outcomes. Little is known with regard to the explanatory links between burnout and these adverse outcomes.

OBJECTIVES

(1) Test the psychometric properties of a brief four-item burnout scale, (2) Provide neonatal intensive care unit (NICU) burnout and resilience benchmarking data across different units and caregiver types, (3) Examine the relationships between caregiver burnout and patient safety culture.

RESEARCH DESIGN

Cross-sectional survey study.

SUBJECTS

Nurses, nurse practitioners, respiratory care providers and physicians in 44 NICUs.

MEASURES

Caregiver assessments of burnout and safety culture.

RESULTS

Of 3294 administered surveys, 2073 were returned for an overall response rate of 62.9%. The percentage of respondents in each NICU reporting burnout ranged from 7.5% to 54.4% (mean=25.9%, SD=10.8). The four-item burnout scale was reliable (α=0.85) and appropriate for aggregation (intra-class correlation coefficient-2=0.95). Burnout varied significantly between NICUs, p<0.0001, but was less prevalent in physicians (mean=15.1%, SD=19.6) compared with non-physicians (mean=26.9%, SD=11.4, p=0.0004). NICUs with more burnout had lower teamwork climate (r=-0.48, p=0.001), safety climate (r=-0.40, p=0.01), job satisfaction (r=-0.64, p<0.0001), perceptions of management (r=-0.50, p=0.0006) and working conditions (r=-0.45, p=0.002).

CONCLUSIONS

NICU caregiver burnout appears to have 'climate-like' features, is prevalent, and associated with lower perceptions of patient safety culture.

The culture of patient safety in an Iranian intensive care unit

AIM

To explore nurses' and physicians' attitudes and perceptions relevant to safety culture and to elicit strategies to promote safety culture in an intensive care unit.

BACKGROUND

A strong safety culture is essential to ensure patient safety in the intensive care unit.

METHOD

This case study adopted a mixed method design. The Safety Attitude Questionnaire (SAQ-ICU version), assessing the safety climate through six domains, was completed by nurses and physicians (n = 42) in an academic intensive care unit. Twenty semi-structured interviews and document analyses were conducted as well. Interviews were analysed using a framework analysis method.

RESULT

Mean scores across the six domains ranged from 52.3 to 72.4 on a 100-point scale. Further analysis indicated that there were statistically significant differences between physicians' and nurses' attitudes toward teamwork (mean scores: 64.5/100 vs. 52.6/100, d = 1.15, t = 3.69, P < 0.001) and job satisfaction (mean scores: 78.2/100 vs. 57.7/100, d = 1.5, t = 4.8, P < 0.001). Interviews revealed several safety challenges including underreporting, failure to learn from errors, lack of speaking up, low job satisfaction among nurses and ineffective nurse-physician communication.

CONCLUSION

The results indicate that all the domains need improvements. However, further attention should be devoted to error reporting and analysis, communication and teamwork among professional groups, and nurses' job satisfaction.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers can contribute to promoting a safety culture by encouraging staff to report errors, fostering learning from errors and addressing inter-professional communication problems.

Measuring safety culture in Palestinian neonatal intensive care units using the Safety Attitudes Questionnaire

PURPOSE

This study aimed to measure safety culture, examine variations among neonatal intensive care units (NICUs), and assess the associations with caregiver characteristics.

MATERIALS AND METHODS

A cross-sectional design was used, utilizing the Arabic version of the Safety Attitudes Questionnaire, administered to all 305 nurses and physicians working in the 16 NICUs in the West Bank.

RESULTS

There were 204 participants, comprising of mainly nurses (80.4%), women (63%), 30 years or younger (62.6%), holding a bachelor's degree or more (66.7%), and with at least 5 years of experience in the profession (60.3%). Safety Attitudes Questionnaire mean domain scores ranged from 71.22 for job satisfaction to 63 for stress recognition on a 100-point scale; the scores varied significantly among NICUs (P<.05). About 85% of the participants rated the safety grade either excellent or very good; 71.0% did not report any event in the past year.

CONCLUSIONS

We found large variations in safety culture within and between a comprehensive sample of Palestinian NICUs. The findings suggest the need for a customized approach that builds on existing strengths and targets areas of opportunities for improvement to optimize health care delivery to the most vulnerable of patients, sick newborns in the NICU setting.

Correlation of neonatal intensive care unit performance across multiple measures of quality of care

OBJECTIVES

To examine whether high performance on one measure of quality is associated with high performance on others and to develop a data-driven explanatory model of neonatal intensive care unit (NICU) performance.

DESIGN

We conducted a cross-sectional data analysis of a statewide perinatal care database. Risk-adjusted NICU ranks were computed for each of 8 measures of quality selected based on expert input. Correlations across measures were tested using the Pearson correlation coefficient. Exploratory factor analysis was used to determine whether underlying factors were driving the correlations.

SETTING

Twenty-two regional NICUs in California.

PATIENTS

In total, 5445 very low-birth-weight infants cared for between January 1, 2004, and December 31, 2007.

MAIN OUTCOMES MEASURES

Pneumothorax, growth velocity, health care-associated infection, antenatal corticosteroid use, hypothermia during the first hour of life, chronic lung disease, mortality in the NICU, and discharge on any human breast milk.

RESULTS

The NICUs varied substantially in their clinical performance across measures of quality. Of 28 unit-level correlations, 6 were significant (ρ < .05). Correlations between pairs of measures of quality of care were strong (ρ ≥ .5) for 1 pair, moderate (range, ρ ≥ .3 to ρ < .5) for 8 pairs, weak (range, ρ ≥ .1 to ρ < .3) for 5 pairs, and negligible (ρ < .1) for 14 pairs. Exploratory factor analysis revealed 4 underlying factors of quality in this sample. Pneumothorax, mortality in the NICU, and antenatal corticosteroid use loaded on factor 1; growth velocity and health care-associated infection loaded on factor 2; chronic lung disease loaded on factor 3; and discharge on any human breast milk loaded on factor 4.

CONCLUSION

In this sample, the ability of individual measures of quality to explain overall quality of neonatal intensive care was modest.

The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU

BACKGROUND

Neonatal intensive care unit (NICU) safety culture, as measured by the Safety Attitudes Questionnaire (SAQ), varies widely. Associations with clinical outcomes in the adult intensive care unit setting make the SAQ an attractive tool for comparing clinical performance between hospitals. Little information is available on the use of the SAQ for this purpose in the NICU setting.

OBJECTIVES

To determine whether the dimensions of safety culture measured by the SAQ give consistent results when used as a NICU performance measure.

METHODS

Cross-sectional survey of caregivers in 12 NICUs, using the six scales of the SAQ: teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management and working conditions. NICUs were ranked by quantifying their contribution to overall risk-adjusted variation across the scales. Spearman rank correlation coefficients were used to test for consistency in scale performance. The authors then examined whether performance in the top four NICUs in one scale predicted top four performance in others.

RESULTS

There were 547 respondents in 12 NICUs. Of 15 NICU-level correlations in performance ranking, two were >0.7, seven were between 0.4 and 0.69, and the six remaining were <0.4. The authors found a trend towards significance in comparing the distribution of performance in the top four NICUs across domains with a binomial distribution p=0.051, indicating generally consistent performance across dimensions of safety culture.

CONCLUSION

A culture of safety permeates many aspects of patient care and organisational functioning. The SAQ may be a useful tool for comparative performance assessments among NICUs.