Measuring safety climate in health care

Psychometric properties and criterion related validity of the Norwegian version of hospital survey on patient safety culture 2.0

BACKGROUND

Several studies have been conducted with the 1.0 version of the Hospital Survey on Patient Safety Culture (HSOPSC) in Norway and globally. The 2.0 version has not been translated and tested in Norwegian hospital settings. This study aims to 1) assess the psychometrics of the Norwegian version (N-HSOPSC 2.0), and 2) assess the criterion validity of the N-HSOPSC 2.0, adding two more outcomes, namely 'pleasure of work' and 'turnover intention'.

METHODS

The HSOPSC 2.0 was translated using a sequential translation process. A convenience sample was used, inviting hospital staff from two hospitals (N = 1002) to participate in a cross-sectional questionnaire study. Data were analyzed using Mplus. The construct validity was tested with confirmatory factor analysis (CFA). Convergent validity was tested using Average Variance Explained (AVE), and internal consistency was tested with composite reliability (CR) and Cronbach's alpha. Criterion related validity was tested with multiple linear regression.

RESULTS

The overall statistical results using the N-HSOPSC 2.0 indicate that the model fit based on CFA was acceptable. Five of the N-HSOPSC 2.0 dimensions had AVE scores below the 0.5 criterium. The CR criterium was meet on all dimensions except Teamwork (0.61). However, Teamwork was one of the most important and significant predictors of the outcomes. Regression models explained most variance related to patient safety rating (adjusted R2 = 0.38), followed by 'turnover intention' (adjusted R2 = 0.22), 'pleasure at work' (adjusted R2 = 0.14), and lastly, 'number of reported events' (adjusted R2=0.06).

CONCLUSION

The N-HSOPSC 2.0 had acceptable construct validity and internal consistency when translated to Norwegian and tested among Norwegian staff in two hospitals. Hence, the instrument is appropriate for use in Norwegian hospital settings. The ten dimensions predicted most variance related to 'overall patient safety', and less related to 'number of reported events'. In addition, the safety culture dimensions predicted 'pleasure at work' and 'turnover intention', which is not part of the original instrument.

Interprofessional collaboration mediates the relationship between perceived organizational learning and safety climate in hospitals: A cross-sectional study

BACKGROUND

Organizational learning (OL) and interprofessional collaboration (IPC) are said to enhance medical safety in hospitals, but the relationship between these variables has not been quantitatively tested.

OBJECTIVE

This study examines the mediating effects of IPC on the relationship between OL and safety climate (improvement, compliance, and patient/family involvement).

METHODS

An anonymous self-reporting questionnaire was administered to 1,495 healthcare workers from November 2021 to January 2022. The questions regarded the hospital's safety climate, OL, and IPC. A mediation analysis using structural equation modeling was conducted to examine the mediating role of IPC on the relationship between OL and the three safety climates. The indirect effect was estimated using 2,000 bootstrap samples.

RESULTS

Responses from 643 healthcare workers were analyzed. The direct effects of OL were 𝛽 = .74, 75 (p < .001) on improvement and involvement and 𝛽 = 0.1 (p > .05) on compliance. The indirect effects of IPC on improvement and involvement were 𝛽 = .14 (95%CI: .00 ∼ .06) and 𝛽 = .37 (95%CI: .04 ∼ .09), respectively.

CONCLUSION

This study determined the mechanisms that enhance a hospital's safety climate, demonstrating that IPC mediates the relationship between OL and improvement and patient/family involvement. However, OL and IPC are not related to compliance.

Adaptation and validation of a Korean version of the speaking up about patient safety questionnaire (KSUPS-Q)

BACKGROUND

Speaking up by healthcare providers is an essential assertive communication strategy for ensuring patient safety and preventing incidents. However, more is needed to know about speaking up and instruments to assess it in the Korean context. Therefore, we assessed the psychometric properties of the Korean version of the Speaking Up about Patient Safety Questionnaire (KSUPS-Q) for measuring speaking up-related behavior and climate among nurses.

METHODS

The translation and adaptation process followed the guidelines of the International Society for Pharmacoeconomics and Outcomes Research and the World Health Organization. Content validity was assessed by a six-member expert panel using the content validity index. In total, 314 nurses participated in an online survey to examine the psychometric properties. Internal consistencies were tested using Cronbach's alpha and McDonald's omega. Confirmatory factor analyses were conducted to examine the subscales' construct. The convergent validity of the speaking up-related climate scale was assessed by testing correlations with teamwork and safety climate domains of the Safety Attitudes Questionnaire. In addition, we investigated the convergent validity of the speaking up-related behavior scale by examining its correlation with the climate scale.

RESULTS

The reliability of the 11-item behavior scale was satisfactory. Confirmatory factor analysis confirmed that a three-subscale model (perceived concerns, withholding voice, and speaking up) was appropriate (CFI = 0.98, TLI = 0.98, and SRMR = 0.05). Furthermore, the 11-item climate scale demonstrated satisfactory internal consistency. A three-subscale model (psychological safety, encouraging environment, and resignation) was confirmed (CFI = 0.98, TLI = 0.97, and SRMR = 0.05). The convergent validity of the climate scale was verified based on correlations with the teamwork (r = 0.68, p < 0.001) and safety climate (r = 0.68, p < 0.001) domains of the Safety Attitudes Questionnaire. In addition, speaking up-related behavior and climate showed a significant association, indicating that the behavior scale is conceptually valid.

CONCLUSIONS

This study demonstrates that the KSUPS-Q is a valid and reliable instrument in Korea. This instrument can help nurse managers simultaneously monitor the behavior and climate of their organizations and evaluate the outcomes of interventions to enhance speaking up. Future research is needed to explore diverse factors contributing to speaking up, including clinical roles, team relationships, and supportive culture, to identify areas requiring further improvement.

Speaking Up and Taking Action: Psychological Safety and Joint Problem-Solving Orientation in Safety Improvement

Healthcare organizations face stubborn challenges in ensuring patient safety and mitigating clinician turnover. This paper aims to advance theory and research on patient safety by elucidating how the role of psychological safety in patient safety can be enhanced with joint problem-solving orientation (JPS). We hypothesized and tested for an interaction between JPS and psychological safety in relation to safety improvement, leveraging longitudinal survey data from a sample of 14,943 patient-facing healthcare workers. We found a moderation effect, in which psychological safety was positively associated with safety improvement, and the relationship was stronger in the presence of JPS. Psychological safety and JPS also interacted positively in predicting clinicians' intent to stay with the organization. For theory and research, our findings point to JPS as a measurable factor that may enhance the value of psychological safety for patient safety improvement-perhaps because voiced concerns about patient safety often require joint problem-solving to produce meaningful change. For practice, our conceptual framework, viewing psychological safety and JPS as complementary factors, can help organizations adopt a more granular approach towards assessing the interpersonal aspect of their safety climate. This will enable organizations to obtain a more nuanced understanding of their safety climate and identify areas for improvement accordingly.

Human Healthcare and Its Pharmacy Component from a Safety Point of View

Healthcare plays a crucial role in public and national safety as a significant part of state activity and a component of national safety, whose mission is to organize and ensure affordable medical care for the population. The four stages of the genesis of healthcare safety development with the corresponding safety models of formation were defined: technical, human factor or security management, systemic security management, and cognitive complexity. It was established that at all stages, little attention is paid to the issues of the formation of the pharmaceutical sector's safety. Taking into account the development of safety models that arise during the four stages of the genesis of safety science, we have proposed a model of the evolution of pharmaceutical safety formation. At the same time, future research is proposed to focus on new holistic concepts of safety, such as "Safety II", evaluation and validation methods, especially in the pharmaceutical sector, where the development of this topic remained in the second stage of the evolution of science, the search for pharmaceutical errors related to drugs.

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.

Enhancing Patient Safety Culture in Hospitals

Patient safety has become a top priority for healthcare organizations. A better patient safety environment is associated with a lower probability of significant complications. Training programmers is critical to promoting patient safety and minimizing misunderstandings. The quality, performance, and productivity of the healthcare industry can be dramatically improved by changing the patient safety atmosphere operating within the hospital sector. Hospitals can significantly reduce medical errors and adverse events by implementing the program and training programmers to prioritize patient safety. This will improve patient outcomes and increase efficiency and effectiveness. Creating a patient safety culture within hospitals will contribute to a higher standard of care and improved overall performance in the healthcare industry. Hospitals can identify systemic problems and implement proactive measures to prevent future incidents by creating an environment in which healthcare professionals feel comfortable reporting errors. A patient safety culture encourages collaboration and open communication among healthcare teams leading to more effective and coordinated care.

An integrative review of research evaluating organisational culture in residential aged care facilities

BACKGROUND

Evidence suggests that the culture of healthcare organisations, including residential aged care facilities (RACFs), is linked to the quality of care offered. The number of people living in RACFs has increased globally, and in turn, attention has been placed on care quality. This review aimed to identify how organisational culture is studied, sought to elucidate the results of previous studies, and aimed to establish what interventions are being used to improve organisational culture in RACFs.

METHODS

We employed an integrative review design to provide a comprehensive understanding of organisational culture. Five academic data bases were searched (Ovid Medline, Scopus, PsycInfo, CINAHL, Embase). Articles were included if they were empirical studies, published in peer reviewed journals in English, conducted in a RACF setting, and were focused on organisational culture/climate.

RESULTS

Ninety-two articles were included. Fifty-nine studies (64.1%) utilised a quantitative approach, while 24 (26.0%) were qualitative, and nine used mixed methods (9.8%). Twenty-two (23.9%) aimed to describe the culture within RACFs, while 65 (70.7%) attempted to understand the relationship between culture and other variables, demonstrating mixed and indeterminate associations. Only five (5.4%) evaluated an intervention.

CONCLUSIONS

This review highlights the heterogenous nature of this research area, whereby differences in how culture is demarcated, conceptualised, and operationalised, has likely contributed to mixed findings. Future research which is underpinned by a sound theoretical basis is needed to increase the availability of empirical evidence on which culture change interventions can be based.

Issues and complexities in safety culture assessment in healthcare

The concept of safety culture in healthcare-a culture that enables staff and patients to be free from harm-is characterized by complexity, multifacetedness, and indefinability. Over the years, disparate and unclear definitions have resulted in a proliferation of measurement tools, with lack of consensus on how safety culture can be best measured and improved. A growing challenge is also achieving sufficient response rates, due to "survey fatigue," with the need for survey optimisation never being more acute. In this paper, we discuss key challenges and complexities in safety culture assessment relating to definition, tools, dimensionality and response rates. The aim is to prompt critical reflection on these issues and point to possible solutions and areas for future research.

Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame

PURPOSE OF REVIEW

Despite healthcare workers' best intentions, some patients will suffer harm and even death during their journey through the healthcare system. This represents a major challenge, and many solutions have been proposed during the last decades. How to reduce risk and use adverse events for improvement?

RECENT FINDINGS

The concept of safety culture must be acknowledged and understood for moving from blame to learning. Procedural protocols and reports are only parts of the solution, and this overview paints a broader picture, referring to recent research on the nature of adverse events. The potential harm from advice based on faulty evidence represents a serious risk.

SUMMARY

Focus must shift from an individual perspective to the system, promoting learning rather than punishment and disciplinary sanctions, and the recent opioid epidemic is an example of bad guidelines.

Measuring the patient safety culture at a tertiary care hospital in Pakistan using the Hospital Survey on Patient Safety Culture (HSOPSC)

BACKGROUND

Patient safety is a top priority for many healthcare organisations worldwide. However, most of the initiatives aimed at the measurement and improvement of patient safety culture have been undertaken in developed countries. The purpose of this study was to measure the patient safety culture at a tertiary care hospital in Pakistan using the Hospital Survey on Patient Safety Culture (HSOPSC).

METHODS

The HSOPSC was used to measure the patient safety culture across 12 dimensions at Aga Khan University Hospital, Karachi. 2,959 individuals, who had been working at the hospital, were administered the HSOPSC in paper form between June and September 2019.

RESULTS

The response rate of the survey was 50%. In the past 12 months, 979 respondents (33.1%) had submitted at least one event report. Results showed that the personnel viewed the patient safety culture at their hospital favourably. Overall, respondents scored highest in the following dimensions: 'feedback and communication on error' (91%), 'organisational learning and continuous improvement' (85%), 'teamwork within units' (83%), 'teamwork across units' (76%). The dimensions with the lowest positive per cent scores included 'staffing' (40%) and 'non-punitive response to error' (41%). Only the reliability of the 'handoffs and transitions', 'frequency of events reported', 'organisational learning' and 'teamwork within units' was higher than Cronbach's alpha of 0.7. Upon regression analysis of positive responses, physicians and nurses were found to have responded less favourably than the remaining professional groups for most dimensions.

CONCLUSION

The measurement of safety culture is both feasible and informative in developing countries and could be broadly implemented to inform patient safety efforts. Current data suggest that it compares favourably with benchmarks from hospitals in the USA. Like the USA, high staff workload is a significant safety concern among staff. This study lays the foundation for further context-specific research on patient safety culture in developing countries.

Preventing Surgical Site Infections: Are Safety Climate Level and Its Strength Associated With Self-reported Commitment To, Subjective Norms Toward, and Knowledge About Preventive Measures?

OBJECTIVES

Surgical site infections (SSIs) represent a major source of preventable patient harm. Safety climate in the operating room personnel is assumed to be an important factor, with scattered supporting evidence for the association between safety climate and infection outcome so far. This study investigated perceptions and knowledge specific to infection prevention measures and their associations with general assessments of safety climate level and strength.

METHODS

We invited operating room personnel of hospitals participating in the Swiss SSI surveillance program to take a survey (response rate, 38%). A total of 2769 responses from 54 hospitals were analyzed. Two regression analyses were performed to identify associations between subjective norms toward, commitment to, as well as knowledge about prevention measures and safety climate level and strength, taking into account professional background and number of responses per hospital.

RESULTS

Commitment to perform prevention measures even when situational pressures exist, as well as subjective norm of perceiving the expectation of others to perform prevention measures were significantly (P < 0.05) related to safety climate level, while for knowledge about preventative measures this was not the case. None of the assessed factors was significantly associated with safety climate strength.

CONCLUSIONS

While pertinent knowledge did not have a significant impact, the commitment and the social norms to maintain SSI prevention activities even in the face of other situational demands showed a strong influence on safety climate. Assessing the knowledge about measures to prevent SSIs in operating room personnel opens up opportunities for designing intervention efforts in reducing SSIs.

Patient safety and its relationship with specific self-efficacy, competence, and resilience among nursing students: A quantitative study

BACKGROUND

Patient safety is a relevant subject in the nursing curriculum. Each university programs patient safety teaching and practical training differently. However, few studies have sought to explore the relationship between patient safety as perceived by nursing students and other important psychosocial competencies in the nursing curriculum, such as self-efficacy, competence, and resilience.

OBJECTIVES

To analyze differential patient safety integration into three nursing education programs, and to assess agreement levels regarding patient safety climate, students' knowledge of patient safety and correlations with specific self-efficacy, competence and resilience.

METHODS

Participants were 647 undergraduate students from three universities. Patient safety climate and knowledge of patient safety (good praxis) were measured using the Hospital Survey on Patient Safety Culture for nursing students, and other psychosocial variables were also analyzed using other instruments: specific self-efficacy, perceived competence and resilience. Nursing education programs and patient safety climate were analyzed using the Rwg(j) and ICC measures of inter-rater agreement across different academic levels.

RESULTS

The ICC and Rwg indexes revealed high inter-rate agreement in all three universities. Differences were observed between Univ-2 and Univ-3 in patient safety climate scores and agreement values between academic levels. Differences in good praxis were found when academic levels were compared in Univ1-and Univ-2. Patient safety climate was found to correlate significantly with the psychosocial variables studied, but only in Univ-1.

CONCLUSIONS

Perceived patient safety climate differs between universities and academic levels. This competency is related to self-efficacy, competence and resilience, which endorses the assessment of patient safety integration from a broader perspective.

An Approach to Leadership Development and Patient Safety and Quality Improvement Education in the Context of Professional Identity Formation in Pre-Clinical Medical Students

Objectives

Leadership and patient safety and quality improvement (PSQI) are recognized as essential parts of a physician's role and identity, which are important for residency training. Providing adequate opportunities for undergraduate medical students to learn skills related to these areas, and their importance, is challenging.

Methods

The Western University Professional Identity Course (WUPIC) was introduced to develop leadership and PSQI skills in second-year medical students while also aiming to instill these topics into their identities. The experiential learning portion was a series of student-led and physician-mentored PSQI projects in clinical settings that synthesized leadership and PSQI principles. Course evaluation was done through pre/post-student surveys and physician mentor semi-structured interviews.

Results

A total of 108 of 188 medical students (57.4%), and 11 mentors (20.7%), participated in the course evaluation. Student surveys and mentor interviews illustrated improved student ability to work in teams, self-lead, and engage in systems-level thinking through the course. Students improved their PSQI knowledge and comfort levels while also appreciating its importance.

Conclusion

The findings from our study suggest that undergraduate medical students can be provided with an enriching leadership and PSQI experience through the implementation of faculty-mentored but student-led groups at the core of the curricular intervention. As students enter their clinical years, their first-hand PSQI experience will serve them well in increasing their capacity and confidence to take on leadership roles.

Patient safety culture in the operating room: a cross-sectional study using the Hospital Survey on Patient Safety Culture (HSOPSC) Instrument

BACKGROUND

Credible evidence has established a link between the level of patient safety culture in healthcare environments and patient outcomes. Patient safety culture in the operating room has received scant attention despite the burden of adverse events among surgical patients. We aimed to evaluate the safety culture in our operating rooms and compare with existing data from other operating room settings.

METHODS

We investigated the patient safety culture in the operating rooms of our hospital as perceived by the surgeons, nurse anaesthetists and perioperative nurses using the Hospital Survey on Patient Safety Culture (HSOPSC) instrument. IBM Statistical Package for Social Science software, version 25, was used for data entry and analysis. Differences were considered significant when p < 0.05.

RESULTS

Only 122 completed surveys were returned out of a survey population of 132 frontline staff, yielding a response rate of 92.4%. The overall average composite score was 47%. The average composite scores ranged from 17-79.6% across the 12 dimensions of the HSOPSC, with teamwork within units being the only dimension with demonstrable strength. Non-punitive response to error, communication openness, feedback and communication about error", frequency of events reported", handoffs and transition and staffing need improvement. The perceived safety culture varied according to work areas and professional roles with nurse anaesthetists having the highest perception and the surgeons the least.

CONCLUSION

Patient safety culture in our operating rooms is adjudged to be weak, with only one of the twelve dimensions of HSOPSC demonstrating strength. This is notwithstanding its comparative strengths relative to other operating room settings.

Patient Safety Culture in Latin American Hospitals: A Systematic Review with Meta-Analysis

INTRODUCTION

Adverse events in hospitals are prevented through risk reduction and reliable processes. Highly reliable hospitals are grounded by a robust patient safety culture with effective communication, leadership, teamwork, error reporting, continuous improvement, and organizational learning. Although hospitals regularly measure their patient safety culture for strengths and weaknesses, there have been no systematic reviews with meta-analyses reported from Latin America.

PURPOSE

Our systematic review aims to produce evidence about the status of patient safety culture in Latin American hospitals from studies using the Hospital Survey on Patient Safety Culture (HSOPSC).

METHODS

This systematic review was guided by the JBI guidelines for evidence synthesis. Four databases were systematically searched for studies from 2011 to 2021 originating in Latin America. Studies identified for inclusion were assessed for methodological quality and risk of bias. Descriptive and inferential statistics, including meta-analysis for professional subgroups and meta-regression for subgroup effect, were calculated.

RESULTS

In total, 30 studies from five countries-Argentina (1), Brazil (22), Colombia (3), Mexico (3), and Peru (1)-were included in the review, with 10,915 participants, consisting primarily of nursing staff (93%). The HSOPSC dimensions most positive for patient safety culture were "organizational learning: continuous improvement" and "teamwork within units", while the least positive were "nonpunitive response to error" and "staffing". Overall, there was a low positive perception (48%) of patient safety culture as a global measure (95% CI, 44.53-51.60), and a significant difference was observed for physicians who had a higher positive perception than nurses (59.84; 95% CI, 56.02-63.66).

CONCLUSIONS

Patient safety culture is a relatively unknown or unmeasured concept in most Latin American countries. Health professional programs need to build patient safety content into curriculums with an emphasis on developing skills in communication, leadership, and teamwork. Despite international accreditation penetration in the region, there were surprisingly few studies from countries with accredited hospitals. Patient safety culture needs to be a priority for hospitals in Latin America through health policies requiring annual assessments to identify weaknesses for quality improvement initiatives.

The Impact of a 22-Month Multistep Implementation Program on Speaking-Up Behavior in an Academic Anesthesia Department

BACKGROUND

Speaking-up is a method of assertive communication that increases patient safety but often encounters barriers. Numerous studies describe programs introducing speaking-up with varying success; the common denominator seems to be the need for a multimodal and sustained approach to achieve the required change in behavior and culture for safer health care.

METHODS

Before implementing a 22-month multistep program for establishing and strengthening speaking-up at our institution, we assessed perceived safety culture using the "Safety Attitudes Questionnaire." After program completion, participants completed parts of the same Safety Attitudes Questionnaire relevant to speaking-up, and preresult and postresult were compared. In addition, levels of speaking-up and assertive communication were compared with a Swiss benchmark using results from the "Speaking-up About Patient Safety Questionnaire."

RESULTS

Safety Attitudes Questionnaire scores were significantly higher after program completion in 2 of 3 answered questions (median [first quartile, third quartile), 5.0 [4.0, 5.0] versus 4.0 [4.0, 5.0], P = 0.0002, and 5.0 [4.0, 5.0] versus 4.0 [4.0, 4.0] P = 0.002; n = 34). Our composite score on the Speaking-up About Patient Safety Questionnaire was significantly higher (mean ± SD, 5.9 ± 0.7 versus 5.2 ± 1.0; P < 0.001) than the benchmark (n = 65).

CONCLUSIONS

A long-term multimodal program for speaking-up was successfully implemented. Attitude and climate toward safety generally improved, and postprogram perceived levels of assertive communication and speaking-up were higher than the benchmark. These results support current opinion that multimodal programs and continued effort are required, but that speaking-up can indeed be strengthened.

The Double-Edged Sword of Safety Training for Safety Behavior: The Critical Role of Psychological Factors during COVID-19

Safety training (ST) is the primary means of avoiding unsafe behaviors, but it has not achieved the expected impact on improving workplace safety because of the high psychological stress it brings to workers. The coronavirus disease 2019 (COVID-19) further threatens workers' psychological conditions, thereby diminishing the effectiveness of ST. However, the existing literature has mainly laid emphasis on the bright side of ST and neglected examining its impact on safety behavior (SB) from detrimental psychological factors. Drawing from the conservation of resources theory, a novel two-staged model was established to understand how these psychological factors mediate and moderate the association between ST and SB. We incorporated resource consumption (e.g., role overload (RO) and COVID-19-related task setbacks) and resource generation (e.g., psychological resilience) into the model to consider both detrimental and protective psychological factors against ST. We then implemented a time-separated, three-wave data collection on a sample of frontline workers to validate this hypothetical model. Consistent with our hypothesis, RO played a significant mediating role between ST and SB, that is, ST leads to RO, and in turn, holds up SB. Surprisingly, contrary to our hypothesis, COVID-19-related task setbacks weakened the negative and indirect impact of ST on SB via RO. This is one of the first empirical studies to highlight how detrimental psychological factors caused by ST constrict or amplify SB. In practice, the efficacy of ST can be enhanced by cultivating psychological resilience and clarifying employees' job responsibilities to reduce the ambiguity of roles.

Differences in employment, job characteristics, and work-related perceptions by sociodemographic factors among registered nurses of diverse race/ethnicity

BACKGROUND

Available research on registered nurses (RNs) indicates that RNs with diverse race/ethnicity are more likely to work in disadvantaged workplaces.

PURPOSE

To examine differences in employment, job characteristics and perceptions about work among RNs by sociodemographic characteristics.

METHODS

We analyzed data from statewide random samples of California RNs (N=895).

FINDINGS

Increased age was associated with increased likelihoods of working part-time, day-shift, and in non-hospital settings and having managerial positions. Asian and Black nurses were more likely to work in urban areas than White nurses. The levels of job demand, job control, job satisfaction, perceived organizational culture, and safety climate were significantly different by sociodemographic characteristics. Greater intention to leave the job was associated with younger age and working in non-hospital settings.

DISCUSSION

The findings suggest that differences exist in nurses' employment, job characteristics, and perceptions about their work and work environment by sociodemographic characteristics among RNs of diverse race/ethnicity.

Checklists in Healthcare: Operational Improvement of Standards using Safety Engineering - Project CHOISSE - A framework for evaluating the effects of checklists on surgical team culture

The CHOISSE multi-stage framework for evaluating the effects of electronic checklist applications (e-checklists) on surgical team members' perception of their roles, performance, communication, and understanding of checklists is introduced via a pilot study. A prospective interventional cohort study design was piloted to assess the effectiveness of the framework and the sociotechnical effects of the e-checklist. A Delphi process was used to design the stages of the framework based on literature and expert consensus. The CHOISSE framework was applied to guide the implementation and evaluation of e-checklists on team culture for ten pilot teams across the US over a 24-week period. The pilot results revealed more engagement by surgeons than non-surgeons, and significant increases in surgeons' perception of communication and engagement during surgery with a small sample. Mixed methods analysis of the data and lessons learned were used to identify iterative improvements to the CHOISSE framework and to inform future studies.

Comparative Assessment of the Level of Patient Safety Culture between Surgical and Nonsurgical Units in Bulgarian Hospitals

Patient safety culture is a key component of the organizational culture and a critical measure of the quality of healthcare. The aim of this study was to gain an insight into the problems concerning patient safety culture, based on the analysis of data, collected after interviewing healthcare specialists working in surgical and nonsurgical units in selected Bulgarian hospitals. This was a cross-sectional online study using a web-platform and the Bulgarian Version of Hospital Survey on Patient Safety Culture. It was conducted among healthcare workers (n = 620) in 2021. The B-HSOPSC incudes 42 scales grouped in 12 different domains. We compared the percentage of positive ratings and outcome dimensions between surgical and other hospital departments with the nonparametric Mann–Whitney U test, χ² tests, Fisher’s Exact Test, and OR. The results showed that there are no statistically significant differences between the ratings on Patient Safety Culture given by the surgical and the nonsurgical staff except for the dimension “Hospital management support for patient safety”. Results from the study highlighted that the most important aspect of hospital patient safety is the shortage of medical staff in both surgical and nonsurgical hospital units. Communication, work shift organization, handoffs and transitions between shifts and among different hospital units, as well as communication with line managers were rated as satisfactory in Bulgarian hospitals.

Cross-culture adaptation and validation of the Indonesian version of the Hospital Survey on Patient Safety Culture (HSOPSC 2.0)

Background

Hospital Survey on Patient Safety Culture (HSOPSC) is considered one of the most scientifically rigorous tools available with excellent psychometric properties. However, it is not yet available in an Indonesian version.

Objective

This study aimed to determine the validity of the content and psychometric properties of HSOPSC 2.0 for use in Indonesian hospitals.

Methods

The study was divided into three stages: translation, adaptation, and validation. Culture-adaptation was assessed using cognitive interviews with ten direct care nurses who worked in the hospital to evaluate their perceptions and the coherence of the translated items, response categories, and questionnaire directions. Content validity was also done by ten experts from academic and clinical settings. Finally, Confirmatory Factor Analysis (CFA) and reliability testing were conducted among 220 nurses from two Indonesian hospitals.

Results

The cognitive test results indicated that the language clarity was 87.8 % and 84.5% for cultural relevance. The Content Validity Index (CVI) ranged between 0.73 to 1.00, while the construct validity results indicated that each factor had factor loadings above 0.4, from 0.47 to 0.65. The fit indices showed an acceptable fit for the data provided by the 10-factor model, with RMSEA = 0.052, SRMR = 0.089, and CFI = 0.87. The Pearson correlation coefficients between the ten subscales ranged from 0.276 to 0.579 (p < 0.05). The Cronbach's alpha for all sub-scales was more than 0.70, except for organizational learning - continuous improvement, response to error, and communication openness.

Conclusion

This study offers initial evidence of the psychometric properties of the Indonesian-HSOPSC 2.0. Future studies are needed to examine its psychometric features to improve generalizability. However, nurses and other healthcare professionals could use the tool to measure hospital patient safety culture in Indonesia.

Organizational Factors Are Key Predictors of Physicians’ Confidence in Handling Workplace Violence

Many studies have investigated health-care workers’ confidence in handling workplace violence with the aim of preventing negative outcomes and fear of such events. The aim of this cross-sectional study was to identify the predictors of physicians’ confidence in handling workplace violence. A self-administered questionnaire was used to collect data on various factors related to workplace violence against physicians in four regional teaching hospitals in northern Taiwan. Of the 180 respondents, 78 (43.3%) had experienced workplace violence in the 3 months preceding the study; they were assigned to the “victim group”. The others (102 respondents) were assigned to the “nonvictim group”. According to multiple linear regression analysis, the factors significantly associated with physicians’ confidence in handling workplace violence in the victim group were perceived organizational support and workplace violence-related training courses. In the nonvictim group, affiliated department and perceived safety climate were key factors. Organizational factors are key predictors of physicians’ confidence in handling workplace violence. Therefore, hospital managers should strive to bolster physicians’ confidence in handling workplace violence. For victims of workplace violence, team-based trainings may improve their interpersonal skills and perceived support from colleagues, both of which can prevent workplace violence events and the repetition of such events.

Patient Safety Culture in European Hospitals: A Comparative Mixed Methods Study

BACKGROUND

Poorly organized health systems with inadequate leadership limit the development of the robust safety cultures capable of preventing consequential adverse events. Although safety culture has been studied in hospitals worldwide, the relationship between clinician perceptions about patient safety and their actual clinical practices has received little attention. Despite the need for mixed methods studies to achieve a deeper understanding of safety culture, there are few studies providing comparisons of hospitals in different countries.

PURPOSE

This study compared the safety culture of hospitals from the perspective of nurses in four European countries, including Croatia, Hungary, Spain, and Sweden.

DESIGN

A comparative mixed methods study with a convergent parallel design.

METHODS

Data collection included a survey, participant interviews, and workplace observations. The sample was nurses working in the internal medicine, surgical, and emergency departments of two public hospitals from each country. Survey data (n = 538) was collected with the Hospital Survey on Patient Safety Culture (HSOPSC) and qualitative date was collected through 24 in-depth interviews and 147 h of non-participant observation. Survey data was analyzed descriptively and inferentially, and content analysis was used to analyze the qualitative data.

RESULTS

The overall perception of safety culture for most dimensions was 'adequate' in Sweden and 'adequate' to 'poor' in the other countries with inconsistencies identified between survey and qualitative data. Although teamwork within units was the most positive dimension across countries, the qualitative data did not consistently demonstrate support, respect, and teamwork as normative attributes in Croatia and Hungary. Staffing and workload were identified as major areas for improvement across countries, although the nurse-to-patient ratios were the highest in Sweden, followed by Spain, Hungary, and Croatia.

CONCLUSIONS

Despite all countries being part of the European Union, most safety culture dimensions require improvement, with few measured as good, and most deemed to be adequate to poor. Dimension level perceptions were at times incongruent across countries, as observed patient safety practices or interview perspectives were inconsistent with a positive safety culture. Differences between countries may be related to national culture or variability in health system structures permitted by the prevailing European Union health policy.

A Systematic Review of Patient-Report Safety Climate Measures in Health Care

OBJECTIVES

Patients are a valuable, yet underutilized source of information for safety measurement and improvement in health care. The aim of this review was to identify patient-report safety climate (SC) measures described in the literature, analyze the included items to consider their alignment with previously established SC domains, evaluate their validity and reliability, and make recommendations for best practice in using patient-report measures of SC in health care.

METHODS

Searches were conducted, with no limit on publication year, using MEDLINE, EMBASE, CINAHL, PsycINFO, and Academic Search Complete in November 2019. Reference lists of included studies and existing reviews were also screened. English-language, peer-reviewed studies that described the development or use of a patient-report measure to assess SC in health care were included. Two researchers independently extracted data from studies and applied a quality appraisal tool.

RESULTS

A total of 5060 studies were screened, with 44 included. Included studies described 31 different SC measures. There was much variability in the coverage of SC domains across included measures. Poor measure quality was marked by inadequacies in the testing and reporting of validity and reliability. There was also a lack of usability testing among measures.

CONCLUSIONS

This review identified the extant patient-reported SC measures in health care and demonstrated significant variance in their coverage of SC domains, validity and reliability, and usability. Findings suggest a pressing need for a stand-alone measure that has a high validity and reliability, and assess core SC domains from the patient perspective, particularly in primary care.

Patients' perception of safety climate in Irish general practice: a cross-sectional study

BACKGROUND

Although patients have the potential to provide important information on patient safety, considerably fewer patient-report measures of safety climate (SC) have been applied in the primary care setting as compared to secondary care. Our aim was to examine the application of a patient-report measure of safety climate in an Irish population to understand patient perceptions of safety in general practice and identify potential areas for improvement. Specifically, our research questions were: 1. What are patients' perceptions of SC in Irish general practice? 2. Do patient risk factors impact perceptions of SC? 3. Do patient responses to an open-ended question about safety enhance our understanding of patient safety beyond that obtained from a quantitative measure of SC?

METHODS

The Patient Perspective of Safety in General Practice (PPS-GP) survey was distributed to primary care patients in Ireland. The survey consisted of both Likert-response items, and free-text entry questions in relation to the safety of care. A series of five separate hierarchical regressions were used to examine the relationship between a range of patient-related variables and each of the survey subscales. A deductive content analysis approach was used to code the free-text responses.

RESULTS

A total of 584 completed online and paper surveys were received. Respondents generally had positive perceptions of safety across all five SC subscales of the PPS-GP. Regarding patient risk factors, younger age and being of non-Irish nationality were consistently associated with more negative SC perceptions. Analysis of the free-text responses revealed considerably poorer patient perceptions (n = 85, 65.4%) of the safety experience in primary care.

CONCLUSION

Our findings indicate that despite being under-utilised, patients' perceptions are a valuable source of information for measuring SC, with promising implications for safety improvement in general practice. Further consideration should be given to how best to utilise this data in order to improve safety in primary care.

The Ambulatory Version of the Safety Attitude Questionnaire: Psychometric Validation and Measurement Properties in Nigerian Clinical Setting

BACKGROUND

Understanding the safety culture of health care providers can help administrators improve patient safety. However, it is difficult to measure complex constructs such as safety culture without valid and reliable tools. This study determined the measurement properties of the ambulatory version of the safety attitude questionnaire (SAQ-AV) in the Nigerian clinical setting.

METHODS

A multiphase, iterative research involving clinical staff in primary and tertiary level of care in South-south Nigeria. The phases included face and content validity by subject experts, pretesting with clinical staff and a field validation involving 812 clinical staff. The acceptability, reliability (internal consistency), and validity (face, content, and construct) of the SAQ-AV were determined. All quantitative analysis was conducted using the SPSS Version 22 statistical package with statistical significance set at a P value of less than 0.05.

RESULTS

A response rate of 53.7% was obtained during the field validation study. The item nonresponse rates were less than 10%, whereas extremes of the response scale were frequently endorsed. The internal consistency of the scale was good (Cronbach's α of 0.91 for entire scale and ranged from 0.62 to 0.76 among the different domains of the tool). Patient safety culture scores from primary and tertiary health care facilities assessed were significantly different.

CONCLUSIONS

The SAQ-AV is an acceptable, reliable, and valid tool for use in assessing patient safety culture in ambulatory settings in Nigeria. There is a need to determine its dimensionality and factor structure in future research.

Development and validation of a patient-report measure of safety climate for general practice

BACKGROUND

Patients remain an under-utilized source of information on patient safety, as reflected by the dearth of patient-report measures of safety climate, particularly for use in general practice settings. Extant measures are marked by poor coverage of safety climate domains, inadequate psychometric properties and/or lack of consideration of usability.

OBJECTIVE

To develop a novel patient-report measure of safety climate specifically for completion by general practice patients, and to establish the validity, reliability and usability of this measure.

METHODS

An iterative process was used to develop the safety climate measure, with patient and general practitioner input. A cross-sectional design was employed to examine the validity (content, construct and convergent), reliability (internal consistency), and usability (readability and burden) of the measure.

RESULTS

A total of 584 general practice patients completed the measure. The exploratory factor analysis identified five factors pertaining to safety climate in general practice: Feeling of Safety with GP; Practice Staff Efficiency and Teamwork; Staff Stress and Workload; Patient Knowledge and Accountability, and; Safety Systems and Behaviours. These factors strongly correlated with two global safety measures, demonstrating convergent validity. The measure showed strong internal consistency, and was considered usable for patients as indicated by readability and duration of completion.

CONCLUSION

Our novel measure of safety climate for use in general practice demonstrates favourable markers of validity, reliability and usability. This measure will provide a mechanism for the patient voice to be heard in patient safety measurement, and to be used to improve patient safety in general practice.

Effectiveness of customised safety intervention programmes to increase the safety culture of hospital staff

The aim of this study was to investigate the effectiveness of customised safety interventions in improving the safety cultures of both clinical and non-clinical hospital staff. This was assessed using the Safety Attitude Questionnaire-Chinese at baseline, 2 years and 4 years after the implementation of safety interventions with a high response rate ranging from 80.5% to 87.2% and excellent internal consistency (Cronbach’s alpha=0.93). The baseline survey revealed a relatively low positive attitude response in the Safety Climate (SC) domain. Both SC and Working Conditions (WC) domains were shown to have increased positive attitude responses in the second survey, while only the Management Perception domain had gained 3.8% in the last survey. In addition, safety dimensions related to collaboration with doctors and service delays due to communication breakdown were significantly improved after customised intervention was applied. Safety dimensions related to safety training, reporting and safety awareness had a high positive response in the initial survey; however, the effect was difficult to sustain subsequently. Multilevel analysis further illustrated that non-clinical staff were shown to have a more positive attitude than clinical staff, while female staff had a higher positive attitude percentage in job satisfaction than male staff. The results showed some improvements in various safety domains and dimensions, but also revealed inconsistent changes in subsequent surveys. The change in positive safety culture over the years and its sustainability need to be further explored. It is suggested that hospital management should continuously monitor and evaluate their strategies while delivering multifaceted interventions to be more specifically focused and to motivate staff to be enthusiastic in sustaining patient safety culture.

Patient Safety Climate in General Public Hospitals in China: A Multiregion Study

OBJECTIVE

This study aimed to analyze the potential difference in patient safety climate by region (Shanghai vs Hubei Province vs Gansu Province) and general public hospital level (tertiary vs secondary) in China.

METHODS

Using a stratified sampling method, employees from 54 public general hospitals in Shanghai, Hubei Province, and Gansu Province in China were surveyed in 2015. The Patient Safety Climate in Health Care Organizations tool and the percentage of "problematic responses" (PPRs) were used to measure and analyze the patient safety climate. A χ2 test and hierarchical linear modeling were applied for the analysis.

RESULTS

In the study, 4121 valid questionnaires were collected. The psychometric analysis supported the validity and reliability of our Chinese version of the Patient Safety Climate in Health Care Organizations. The overall patient safety climate was relatively good and exhibited no significant differences among the surveyed hospitals by various regions (Shanghai vs Hubei Province vs Gansu Province) and diverse hospital levels (tertiary vs secondary) using hierarchical linear models. "Fear of blame and punishment" and "fear of shame" had the highest PPRs and were prevalent in various types of hospitals. "Provision of safe care" and "organizational resources for safety" also had notably high PPRs. There were 4 dimensions varied by region and hospital level in this survey.

CONCLUSIONS

Fear of shame and fear of blame are the most important barriers to the improvement of patient safety in the hospitals of China. Facility characteristics contributed somewhat to hospital patient safety climate in some dimensions. The initiatives to improve hospital patient safety climate are necessary and its implementation strategies needs to be shared.

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.

Open organisational culture: what does it entail? Healthcare stakeholders reaching consensus by means of a Delphi technique

OBJECTIVES

Open organisational culture in hospitals is important, yet it remains unclear what it entails other than its referral to 'open communication' in the context of patient safety. This study aims to identify the elements of an open hospital culture.

METHODS

In this group consensus study with a Delphi technique, statements were constructed based on the existing patient safety literature and input of 11 healthcare professionals from different backgrounds. A final framework consisting of 36 statements was reviewed on inclusion and exclusion, in multiple rounds by 32 experts and professionals working in healthcare. The feedback was analysed and shared with the panel after the group reached consensus on statements (>70% agreement).

RESULTS

The procedure resulted in 37 statements representing tangible (ie, leadership, organisational structures and processes, communication systems, employee attitudes, training and development, and patient orientation) and intangible themes (ie, psychological safety, open communication, cohesion, power, blame and shame, morals and ethics, and support and trust). The culture themes' teamwork and commitment were not specific for an open culture, contradicting the patient safety literature. Thereby, an open mind was shown to be a novel characteristic.

CONCLUSIONS

Open culture entails an open mind-set and attitude of professionals beyond the scope of patient safety in which there is mutual awareness of each other's (un)conscious biases, focus on team relationships and professional well-being and a transparent system with supervisors/leaders being role models and patients being involved. Although it is generally acknowledged that microlevel social processes necessary to enact patient safety deserve more attention, research has largely emphasised system-level structures and processes. This study provides practical enablers for addressing system and microlevel social processes to work towards an open culture in and across teams.

Safety culture in the perception of public-hospital health professionals

OBJECTIVE

Evaluating safety culture in the perception of professionals working in public hospitals of the Unified Health System (SUS) of Distrito Federal, Brazil, three years after the implementation of the National Patient Safety Program (PNSP).

METHODS

Analytical cross-sectional study conducted in eleven public hospitals using the Safety Attitudes Questionnaire (SAQ) in electronic format. Stratified sampling was estimated according to the proportion of the total number of professionals in each hospital, as well as the representativeness of each professional group. The results of the total score and domains equal to or greater than 75 were considered positive. Descriptive and inferential analyses of professional groups and hospitals were carried out.

RESULTS

909 professionals participated. The total score by professional group was negative (62.5 to 69.5) and the domains differed statistically in all cases. The eleven hospitals had a negative total score (61.5 to 68.6). The domains to attain positive performance were job satisfaction, stress recognition and teamwork climate. The lowest results were in working conditions and management perception domains, for which none of the hospitals had an average above 75. Differences were also found for domain means across hospitals, except in management perception.

DISCUSSION

Three years after the implementation of PNSP, the safety culture in eleven hospitals evaluated was weak, although the domains of job satisfaction, stress recognition and teamwork climate had positive results. The results can contribute to decision-making by managers, as safety culture is an essential element in the implementation of patient safety policy.

Measuring the safety climate in an Australian emergency department

BACKGROUND

There are numerous intricate human, system and cultural factors that can impact upon the safe and effective implementation of patient safety systems (e.g. rapid response systems). Safety climate is one of these factors and is a measure of frontline healthcare workers' shared perceptions, behaviours, beliefs and attitudes towards the organisation's culture of safety. Safety climate scores are also associated with the frequency of errors and adverse events in the healthcare setting. However, there is little evidence regarding the relationships between attitudes to patient safety and staff characteristics such as emergency care expertise and experience. The aims of this study were to measure perceptions of the safety climate in an Australian metropolitan Emergency Department and examine relationships between safety climate perceptions and staff characteristics.

METHODS

The Victorian Managed Insurance Authority Safety Climate Survey was administered to all doctors (n = 44) and nurses (n = 119) at an Australian emergency department.

RESULTS

Completed surveys were received from 127 (78%) respondents, 25 (52%) doctors and 100 (84%) nurses. Reliability analysis showed very good internal consistency of all 43-items of the survey (α = 0.94). With the exception of stress recognition, nurses rated the organisation's commitment to patient safety higher than doctors in all remaining attitudinal domains (p < 0.05). Both groups acknowledge that fatigue, increased workload and stress recognition negatively impacts upon patient safety. There was a significant trend for declining safety climate ratings related to participants' clinical competence level and experience across all domains except stress recognition (p < 0.05).

CONCLUSIONS

The Safety Climate Survey appears to be a reliable measure of patient safety climate for use in Emergency Departments. Emergency doctors and nurses did not perceive there to be a strong organisational commitment to patient safety in an Australian Emergency Department. Emergency Departments can provide a safer environment through genuine commitment to safety culture improvement which capitalises on the insights, intrinsic strengths and behaviours characteristic of the ED team's expertise and experience. This kind of commitment can positively influence the effectiveness of actions taken to minimise risk to patient safety and improve ED staff job satisfaction and effectiveness.

A Systematic Review of Measurement Tools for the Proactive Assessment of Patient Safety in General Practice

BACKGROUND

Primary care physicians have reported a difficulty in understanding how best to measure and improve patient safety in their practices.

OBJECTIVES

The aims of the study were to identify measures of patient safety suitable for use in primary care and to provide guidance on proactively monitoring and measuring safety.

METHODS

Searches were conducted using Medline, Embase, CINAHL and PsycInfo in February 2016. Studies that used a measure assessing levels of or attitudes toward patient safety in primary care were considered for inclusion. Only studies describing tools focused on the proactive assessment of safety were reviewed. Two independent reviewers extracted data from articles and applied the Quality Assessment Tool for Studies with Diverse Designs.

RESULTS

More than 2800 studies were screened, of which 56 were included. Most studies had used healthcare staff survey or interviews to assess patient safety (n = 34), followed by patient chart audit (n = 14) or use of a practice assessment checklist (n = 7). Survey or interview of patients, active monitoring systems, and simulated patients were used with less frequency.

CONCLUSIONS

A lack of appropriate measurement tools has been suggested to limit the ability to monitor patient safety in primary care and to improve patient care. There is no evident "best" method of measuring patient safety in primary care. However, many of the measures are readily available, quick to administer, do not require external involvement, and are inexpensive. This synthesis of the literature suggests that it is possible for primary care physicians to take a proactive approach to measuring and improving safety.

Dimensions of safety culture: a systematic review of quantitative, qualitative and mixed methods for assessing safety culture in hospitals

BACKGROUND

The study of safety culture and its relationship to patient care have been challenged by variation in definition, dimensionality and methods of assessment. This systematic review aimed to map methods to assess safety culture in hospitals, analyse the prevalence of these methods in the published research literature and examine the dimensions of safety culture captured through these processes.

METHODS

We included studies reporting on quantitative, qualitative and mixed methods to assess safety culture in hospitals. The review was conducted using four academic databases (PubMed, CINAHL, Scopus and Web of Science) with studies from January 2008 to May 2020. A formal quality appraisal was not conducted. Study purpose, type of method and safety culture dimensions were extracted from all studies, coded thematically, and summarised narratively and using descriptive statistics where appropriate.

RESULTS

A total of 694 studies were included. A third (n=244, 35.2%) had a descriptive or exploratory purpose, 225 (32.4%) tested relationships among variables, 129 (18.6%) evaluated an intervention, while 13.8% (n=96) had a methodological focus. Most studies exclusively used surveys (n=663; 95.5%), with 88 different surveys identified. Only 31 studies (4.5%) used qualitative or mixed methods. Thematic analysis identified 11 themes related to safety culture dimensions across the methods, with 'Leadership' being the most common. Qualitative and mixed methods approaches were more likely to identify additional dimensions of safety culture not covered by the 11 themes, including improvisation and contextual pressures.

DISCUSSION

We assessed the extent to which safety culture dimensions mapped to specific quantitative and qualitative tools and methods of assessing safety culture. No single method or tool appeared to measure all 11 themes of safety culture. Risk of publication bias was high in this review. Future attempts to assess safety culture in hospitals should consider incorporating qualitative methods into survey studies to evaluate this multi-faceted construct.

Use of the Hospital Survey of Patient Safety Culture in Norwegian Hospitals: A Systematic Review

This review aims to provide an overview of empirical studies using the HSOPSC in Norway and to develop recommendations for further research on patient safety culture. Oria, an online catalogue of scientific databases, was searched for patient safety culture in February 2021. In addition, three articles were identified via Google Scholar searches. Out of 113 retrieved articles, a total of 20 articles were included in our review. These were divided into three categories: seven perception studies, six intervention studies, and seven reliability and validation studies. The first study conducted in Norway indicated a need to improve patient safety culture. Only one intervention study was able to substantially improve patient safety culture. The validity of HSOPSC is supported in most studies. However, one study indicated poor quality in relation to the testing of criteria related to validity. This review is limited to Norwegian healthcare but has several relevant implications across the research field, namely that intervention studies should (1) validate dimensions more carefully, (2) avoid pitfalls related to both factor analysis methods and criteria validity testing, (3) consider integrating structural models into multilevel improvement programs, and (4) benefit from applying different, new versions of HSOPSC developed in Norway.

Determinants of safety climate at primary care level in Ghana, Malawi and Uganda: a cross-sectional study across 138 selected primary healthcare facilities

BACKGROUND

Safety climate is an essential component of achieving Universal Health Coverage, with several organisational, unit or team-level, and individual health worker factors identified as influencing safety climate. Few studies however, have investigated how these factors contribute to safety climate within health care settings in low- and middle-income countries (LMICs). The current study examines the relationship between key organisational, unit and individual-level factors and safety climate across primary health care centres in Ghana, Malawi and Uganda.

METHODS

A cross-sectional, self-administered survey was conducted across 138 primary health care facilities in nine districts across Uganda, Ghana and Malawi. In total, 760 primary health workers completed the questionnaire. The relationships between individual (sex, job satisfaction), unit (teamwork climate, supportive supervision), organisational-level (district managerial support) and safety climate were tested using structural equation modelling (SEM) procedures. Post hoc analyses were also carried out to explore these relationships within each country.

RESULTS

Our model including all countries explained 55% of the variance in safety climate. In this model, safety climate was most strongly associated with teamwork (β = 0.56, p < 0.001), supportive supervision (β = 0.34, p < 0.001), and district managerial support (β = 0.29, p < 0.001). In Ghana, safety climate was positively associated with job satisfaction (β = 0.30, p < 0.05), teamwork (β = 0.46, p < 0.001), and supportive supervision (β = 0.21, p < 0.05), whereby the model explained 43% of the variance in safety climate. In Uganda, the total variance explained by the model was 64%, with teamwork (β = 0.56, p < 0.001), supportive supervision (β = 0.43, p < 0.001), and perceived district managerial support (β = 0.35, p < 0.001) all found to be positively associated with climate. In Malawi, the total variance explained by the model was 63%, with teamwork (β = 0.39, p = 0.005) and supportive supervision (β = 0.27, p = 0.023) significantly and positively associated with safety climate.

DISCUSSION/CONCLUSIONS

Our findings highlight the importance of unit-level factors-and in specific, teamwork and supportive supervision-as particularly important contributors to perceptions of safety climate among primary health workers in LMICs. Implications for practice are discussed.

A comparative assessment of two tools designed to support patient safety culture in UK general practice

BACKGROUND

The NHS has recognised the importance of a high quality patient safety culture in the delivery of primary health care in the rapidly evolving environment of general practice. Two tools, PC-SafeQuest and MapSaf, were developed with the intention of assessing and improving patient safety culture in this setting. Both have been made widely available through their inclusion in the Royal College of General Practitioners' Patient Safety Toolkit and our work offerss a timely exploration of the tools to inform practice staff as to how each might be usefully applied and in which circumstances. Here we present a comparative analysis of their content, and describe the perspectives of staff on their design, outputs and the feasibility of their sustained use.

METHODS

We have used a content analysis to provide the context for the qualitative study of staff experiences of using the tools at a representative range of practices recruited from across the Midlands (UK). Data was collected through moderated focus groups using an identical topic guide.

RESULTS

A total of nine practices used the PC-SafeQuest tool and four the MapSaf tool. A total of 159 staff completed the PC-SafeQuest tool 52 of whom took part in the subsequent focus group discussions, and 25 staff completed the MapSaf tool all of whom contributed to the focus group discussions. PC-SafeQuest was perceived as quick and easy to use with direct questions pertinent to the work of GP practices providing useful quantitative insight into important areas of safety culture. Though MaPSaF was more logistically challenging, it created a forum for synchronous cross- practice discussions raising awareness of perceptions of safety culture across the practice team.

CONCLUSIONS

Both tools were able to promote reflective and reflexive practice either in individual staff members or across the broader practice team and the oversight they granted provided useful direction for senior staff looking to improve patient safety. Because PC SafeQuest can be easily disseminated and independently completed it is logistically suited to larger practice organisations, whereas the MapSaf tool lends itself to smaller practices where assembling staff in a single workshop is more readily achieved.

Variations in Workplace Safety Climate Perceptions and Outcomes Across Healthcare Provider Positions

EXECUTIVE SUMMARY

Injury rates reported among healthcare practitioners tend to vary depending on position. Nurses and healthcare aides report different rates of injury, which suggests that position and job duties may be key injury antecedents. The outcomes related to workplace safety climate perceptions (e.g., injury rates, job satisfaction, turnover) require reflection to identify antecedents of safety perception. The purpose of this study was to examine workplace safety perceptions and well-being (e.g., stress, job satisfaction) of healthcare practitioners by position. A cross-sectional survey of care teams (e.g., nurses, healthcare aides, allied health professionals) was conducted across three inpatient units. Data (N = 144) were analyzed using hierarchical linear regression and binomial logistic regression to examine the relationship between safety climate and self-reported injuries and ANOVA to determine variations in safety climate perceptions by position. Results indicated that nurses, healthcare aides, and allied health professionals report differing levels of workplace safety climate perceptions. Nurses reported the poorest safety perceptions, lowest job satisfaction, and highest stress, while allied health professionals reported the highest safety perceptions and job satisfaction and the lowest stress. Safety climate perceptions were found to be significantly related to care practitioner reported stress, turnover intent, and job satisfaction. Considering the importance of safety climate perceptions for the well-being of care practitioners, healthcare organizations need to prioritize workplace safety to optimize practitioners' perceptions. This study makes a unique contribution to the safety climate literature by identifying the variation in safety climate perceptions by care practitioner position. Practical implications are offered for enhancing workplace safety perceptions.

Thirst for change in a challenging environment: healthcare providers' perceptions of safety culture in a large Irish teaching hospital

BACKGROUND

The Irish healthcare system is currently recognised as being understaffed and under-resourced due to historic underfunding and the aftermath of the 2008 global financial crisis. This descriptive study investigated healthcare providers' perceptions of the safety culture in a large Irish teaching hospital.

AIM

The aim of this study was to investigate healthcare workers' perceptions of the safety culture in a large Irish teaching hospital in a climate of national under-resourcing of healthcare.

METHODS

Seventeen semi-structured interviews were carried out with patient-attending staff between February and June 2019. Interviews were transcribed verbatim and analysed using thematic analysis.

RESULTS

Two predominant themes emerged from the interviews: (1) challenging environment and (2) thirst for change. Study participants described the poor working conditions in the hospital, but also recognised the importance of teamwork and communication in maintaining patient safety and had a strong appetite for change regarding the safety culture in the hospital.

CONCLUSION

This study highlights the complex relationship between working conditions and safety culture. Hospital staff were committed to providing the best possible care for their patients but struggled to provide safe care in a challenging work environment. A clear appetite for change was identified amongst HCPs regarding patient safety culture in Irish healthcare.

Achieving and Maintaining Safety in Healthcare Requires Unwavering Institutional and Individual Commitments

In 2000, "To Err Is Human" brought to light the fact that the estimated number of people dying from medical errors occurring in hospitals exceeded those that die from motor vehicle accidents (MVAs), breast cancer, or acquired immunodeficiency syndrome (AIDS) - three causes receiving far more public attention. The report prompted the gradual adoption of safety processes developed in the nuclear and aviation industries. However, sophisticated engineering solutions to operations are not enough. High and low mortality hospitals have similar processes and procedures, but low-mortality hospitals are more proficient at recognizing and managing serious complications as they unfold. This ability to rescue a deteriorating situation (resilience) reflects a healthier safety culture. Organizations move within the safety space in the direction of either more or less resilience depending on the fluctuation of their safety culture. Improving resilience requires transforming learned safety practices into a "habit" in conjunction with accepting accountability. Personal accountability means commitment to safe practices along with effective and transparent reporting of near misses/close calls and adverse events (AEs). Institutional accountability means putting safety first by ensuring the availability of appropriate resources, role leadership modeling, and effective management of sentinel events (SEs) to reduce harm occurrence and re-occurrence. This requires a more robust root cause analysis (RCA) process to guarantee that action plans produce strong and effective corrective measures. Synergistic coaching interventions include instilling the awareness that failure can and will happen, mapping team talents, and assessing gaps. These interventions will optimize group expertise, reaffirming the concept of institutional and personal accountability. The unending performance of drills will sustain the group resilience under both expected and unexpected conditions. Given the strong correlation between practice environment and outcomes, sustained improvement of the safety climate will produce more robust safety behaviors and ultimately better outcomes.

What do we really assess with organisational culture tools in healthcare? An interpretive systematic umbrella review of tools in healthcare

Introduction

A toxic organisational culture (OC) is a major contributing factor to serious failings in healthcare delivery. Poor OC with its consequences of unprofessional behaviour, unsafe attitudes of professionals and its impact on patient care still need to be addressed. Although various tools have been developed to determine OC and improve patient safety, it remains a challenge to decide on the suitability of tools for uncovering the underlying factors which truly impact OC, such as behavioural norms, or the unwritten rules. A better understanding of the underlying dimensions that these tools do and do not unravel is required.

Objectives

The aim of this study is to provide an overview of existing tools to assess OC and the tangible and intangible OC dimensions these tools address.

Methods

An interpretive umbrella review was conducted. Literature reviews were considered for inclusion if they described multiple tools and their dimensional characteristics in the context of OC, organisational climate, patient safety culture or climate. OC tools and the underlying dimensions were extracted from the reviews. A qualitative data analysis software program (MAX.QDA 2007) was used for coding the dimensions, which resulted in tangible and intangible themes.

Results

Fifteen reviews met our inclusion criteria. A total of 127 tools were identified, which were mainly quantitative questionnaires covering tangible key dimensions. Qualitative analyses distinguished nine intangible themes (commitment, trust, psychological safety, power, support, communication openness, blame and shame, morals and valuing ethics, and cohesion) and seven tangible themes (leadership, communication system, teamwork, training and development, organisational structures and processes, employee and job attributes, and patient orientation).

Conclusion

This umbrella review identifies the essential tangible and intangible themes of OC tools. OC tools in healthcare do not seem to be designed to determine deeper underlying dimensions of culture. We suggest approaching complex underlying OC problems by focusing on the intangible dimensions, rather than putting the tangible dimensions up front.

Dimensions analysis of the Hospital Survey on Patient Safety Culture questionnaire in Iran: Psychometric properties

AIM

The present study aimed to investigate the possible alternative factorial structure of the patient safety culture model in Iran.

METHODS

This study was performed based on data collected by Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire from 420 staff in four hospitals. Internal consistency reliability and construct validity were evaluated by Cronbach's alpha and correlation analysis. Exploratory factor analysis (EFA), confirmatory factor analysis (CFA) and structural equation modeling (SEM) were used to investigate the possible alternative factorial structure, examine and confirm the obtained structure, alternatively. Kaiser-Meyer-Olkin measure and Bartlett test were calculated to determine the factor ability of sample and fit of the factor analysis, alternatively. SPSS and AMOS version 25 were used.

RESULTS

EFA identified 12 dimensions which one dimension has been also created from a new question. Distribution of items in all dimensions differed from the original HSOPSC questionnaire except two dimensions. The obtained structure was a proportional model. The calculation of Cronbach's alpha (∝ = .8) showed that, the internal consistency reliability was appropriate for all items in the questionnaire. Also, construct validity was acceptable for all factors.

CONCLUSIONS

The structure of the dimensions obtained in this study was not consistent with the structure of the original HSOPSC model.

HIGHLIGHTS

Provide a model for assessing patient safety culture with relative stability with respect to the native culture of the region. Good content and construct validity. Differences in the distribution of items in dimensions. Formation of new dimensions. Performing a psychometric analysis of the instrument using EFA, CFA and SEM to examine the disagreement on the validity, reliability and dimensions of patient safety culture in previous studies in Iran. Numerous discrepancies in item wording comply with the approach advocated by the translation guideline for AHRQ survey on patient safety.

Assessing Patients' Perceptions of Safety Culture in the Hospital Setting: Development and Initial Evaluation of the Patients' Perceptions of Safety Culture Scale

OBJECTIVES

Both patient satisfaction and hospital safety culture have been recognized as key characteristics of healthcare quality and patient safety. Thus, both characteristics are measured widely to support quality and safety improvement efforts. However, because safety culture surveys focus exclusively on the perspective of hospital staff, the complimentary information to be gained from patients' perceptions of safety culture has received little research attention so far. We aimed to develop a measure explicitly focusing on patients' perceptions of safety culture in the hospital setting and perform an initial evaluation of its measurement properties.

METHODS

We employed a multistep development approach including (a) literature review of survey instruments for patient experience and safety culture and (b) item categorization and selection. We evaluated the measurement properties of the final item set focusing on factor structure, internal consistency, item difficulty, and discrimination. Data were collected from June to December 2015 via an online patient survey conducted routinely by a health insurer.

RESULTS

Overall, 112,814 insured persons participated in the online survey (response rate = 19.7%). The final 11-item set formed a single scale that was named Patients' Perceptions of Safety Culture scale. Its measurement properties were deemed satisfactory based on this initial evaluation.

CONCLUSIONS

The Patients' Perceptions of Safety Culture scale contributes to both a more comprehensive view of patients' experience of healthcare and a more balanced approach to safety culture measurement in healthcare. It contributes to an increased recognition of patients' views on safety-relevant aspects of their care that provide important inputs to patient safety improvement.

Assessment of patient safety climate by nurses in Slovak Public and private hospitals

AIM

To examine variations in the safety climate reported by nurses in Slovak hospitals and to analyse the association between dimensions of the patient safety climate and demographic and organisational factors.

BACKGROUND

A deeper understanding of how safety climate varies across hospitals can be useful in determining areas with a potential for improvement. Staffing and non-punitive response to errors were identified in recent research syntheses as the weakest dimensions of safety climate that require strengthening.

METHODS

The sample consisted of 1,429 nurses working in public and private hospitals in Slovakia. The Hospital Survey on Patient Safety Culture questionnaire was used for data collection, and descriptive analysis was carried out to examine relationships between variables.

RESULTS

Nurses working in general private hospitals with a bed capacity of less than 500 beds were more positive about their hospital safety climate than other nurses working in differently organised hospitals. The lowest number of positive responses was scored in the domain of 'Non-Punitive Response to Error'. This result came from a blame-free error-reporting atmosphere.

CONCLUSIONS

Nurses perceived a higher level of patient safety when they had experienced better sharing of information on event reporting and had better learning opportunities.

IMPLICATIONS FOR NURSING MANAGEMENT

The results revealed strengths and weaknesses of the patient safety climate in the network of Slovak hospitals from the perspective of nurses working in these hospitals. This knowledge can enable nurse managers to instigate supportive strategies for just reporting, and learning from events, within an enhanced safety culture.

Hospital survey on patient safety culture (HSOPSC): a multi-method approach for target-language instrument translation, adaptation, and validation to improve the equivalence of meaning for cross-cultural research

Background

The Hospital Survey on Patient Safety Culture (HSOPSC) is widely utilized in multiple languages across the world. Despite culture and language variations, research studies from Latin America use the Spanish language HSOPSC validated for Spain and the United States. Yet, these studies fail to report the translation method, cultural adaptation process, and the equivalence assessment strategy. As such, the psychometric properties of the HSOPSC are not well demonstrated for cross-cultural research in Latin America, including Peru. The purpose of this study was to develop a target-language HSOPSC for cross-cultural research in Peru that asks the same questions, in the same manner, with the same intended meaning, as the source instrument.

Methods

This study used a mixed-methods approach adapted from the translation guideline recommended by Agency for Healthcare Research and Quality. The 3-phase, 7-step process incorporated translation techniques, pilot testing, cognitive interviews, clinical participant review, and subject matter expert evaluation.

Results

The instrument was translated and evaluated in 3 rounds of cognitive interview (CI). There were 37 problem items identified in round 1 (14 clarity, 12 cultural, 11 mixed); and resolved to 4 problems by round 3. The pilot-testing language clarity inter-rater reliability was S-CVI/Avg = 0.97 and S-CVI/UA = 0.86; and S-CVI/Avg = 0.96 and S-CVI/UA = 0.83 for cultural relevance. Subject matter expert agreement in matching items to the correct dimensions was substantially equivalent (Kappa = 0.72). Only 1 of 12 dimensions had a low Kappa (0.39), borderline fair to moderate. The remaining dimensions performed well (7 = almost perfect, 2 = substantial, and 2 = moderate).

Conclusions

The HSOPSC instrument developed for Peru was markedly different from the other Spanish-language versions. The resulting items were equivalent in meaning to the source, despite the new language and different cultural context. The analysis identified negatively worded items were problematic for target-language translation. With the limited literature about negatively worded items in the context of cross-cultural research, further research is necessary to evaluate this finding and the recommendation to include negatively worded items in instruments. This study demonstrates cross-cultural research with translated instruments should adhere to established guidelines, with cognitive interviews, based on evidence-based strategies.

Safety climate: Systematic literature network analysis of 38 years (1980-2018) of research

The objective of this paper is to examine the safety climate knowledge epistemology using bibliometric and systematic literature network analysis. For this purpose, bibliometric information of research article published on safety climate topic was retrieved from Scopus databases. In total, 494 articles published between 1980 and 2018 were retrieved. These articles cover 1373 authors, 203 journals and 2511 keywords. Information collected was analyzed employing bibliometric and network analysis approach using an open source computer program R and VOSviewer. The main findings of the study reveal the publication trends in safety climate literature since 1980 to present, identifies most productive authors, and most influential research work. Our findings suggest that Huang and Zohar are the top publishing authors in safety climate domain. Zohar's work has the highest citations. The most influential articles have been published in Journals such as Accident Analysis and Prevention, Journal of Applied Psychology, Safety Science and Journal of Safety Research. Network analysis of these articles yielded co-citation networks of most influential works, bibliographical coupling network and keywords co-occurrence network yielded the structure of safety climate knowledge. Findings of our research have theoretical and practical implications in the area of safety climate.

Patient safety culture in Hungarian hospitals

PURPOSE

The Hospital Survey on Patient Safety Culture (HSOPSC) is a rigorously designed tool for measuring inpatient safety culture. The purpose of this paper is to develop a cross-cultural HSOPSC for Hungary and determine its strengths and weaknesses.

DESIGN/METHODOLOGY/APPROACH

The original US version was translated and adapted using existing guidelines. Healthcare workers (n=371) including nurses, physicians and other healthcare staff from six Hungarian hospitals participated. Answers were analyzed using exploratory factor analyses and reliability tests.

FINDINGS

Positive responses in all dimensions were lower in Hungary than in the USA. Half the participants considered their work area "acceptable" regarding patient safety. Healthcare staff worked in "crisis mode," trying to accomplish too much and too quickly. The authors note that a "blame culture" does not facilitate patient safety improvements in Hungary.

PRACTICAL IMPLICATIONS

The results provide valuable information for promoting a more positive patient safety culture in Hungary and for evaluating future strategies to improve patient safety.

ORIGINALITY/VALUE

Introducing a validated scale to measure patient safety culture in Hungary improves healthcare quality.