High-reliability in healthcare : nurse-reported patient safety climate and its relationship with patient outcomes in Swiss acute care hospitals

Healthcare
is
a
high-­‐risk
industry.
Worldwide,
healthcare
systems
struggle
daily
to
keep
pa-­‐
tients
safe
and
protect
them
from
harm.
Still,
every
day,
countless
errors
occur.
Most
are
minor
and
pass
unnoticed;
however,
a
significant
proportion
result
in
adverse
events
such
as
pressure
ulcers,
patient
falls,
or
healthcare-­‐associated
infections,
with
consequences
for
patients
ranging
from
dis-­‐
comfort
to
mortality
[6-­‐10].
Today,
a
close
focus
on
patient
safety,
i.e.,
“the
continuous
identification,
analysis
and
management
of
patient-­‐related
risks
and
incidents
in
order
to
make
patient
care
safer
and
to
minimize
harm
to
patients”
[11,
p.
9],
is
a
key
component
of
high-­‐quality
care
[12,
13].
Con-­‐
versely,
as
in
other
high-­‐risk
industries,
such
as
aviation
or
nuclear
power,
adverse
events
should
be
viewed
not
as
failures
of
individual
healthcare
professionals
but
as
symptoms
of
system
vulnerability
[14-­‐16].
And,
as
experience
in
those
industries
has
shown,
the
majority
of
"human
error"
in
healthcare
originates
not
with
poorly
performing
individuals,
such
as
nurses,
physicians,
or
other
providers,
but
with
faulty
systems
/
processes
such
as
stressful
environments,
heavy
workloads
or
inadequate
communication
[17,
18].
To
overcome
such
systemic
defects,
a
growing
number
of
international
experts
agree
that
a
well-­‐developed
“culture
of
safety”
is
fundamental
to
understanding
patient
safety
mechanisms
and
preventing
adverse
events
[13,
19].
Other
high-­‐risk
industries
regularly
evaluate
and
improve
their
safety
cultures
via
workforce
surveys
designed
to
assess
and
monitor
safety
climate
(i.e.,
the
per-­‐
ceived
safety
culture
of
a
particular
group
at
a
particular
time)
[20].
Since
the
1999
publication
of
To
Err
is
Human
[21],
safety
culture
and
climate
have
attracted
increasing
interest
in
healthcare,
leading
to
major
advances
in
patient
safety
climate
research,
particularly
regarding
instrument
development
and
psychometric
evaluation
[22-­‐24].
To
date,
though,
few
studies
have
investigated
the
relationship
between
patient
safety
climate,
adverse
event
incidence
and
patient
outcomes
[24-­‐29].
SUMMARY
-­‐
10
-­‐
Overall,
this
dissertation's
aim
is
to
describe
the
results
of
4
studies
designed
first
to
test
nurse-­‐reported
patient
safety
climates
in
Swiss
acute-­‐care
hospitals,
then
to
analyze
for
relationships
with
possible
contributing
factors
(e.g.,
characteristics
of
Swiss
acute
care
hospitals)
and
conse-­‐
quences
(e.g.,
patient
outcomes).
Three
of
these
studies
used
survey
data
originally
collected
for
the
Swiss
RN4CAST
(Nurse
Forecasting:
Human
Resources
Planning
in
Nursing)
study,
including
data
from
1,633
nurses
and
997
patients
on
132
general
medical,
surgical
and
mixed
medical/surgical
units
in
35
Swiss
acute
care
hospitals.
The
dissertation
is
organized
in
7
chapters:
Chapter
1
introduces
the
problematic
issue
of
patient
safety
and
adverse
events,
as
well
as
of
human
contributions
to
error.
Emphasis
is
placed
on
the
importance
of
understanding
human
fac-­‐
tors,
including
organizational
safety-­‐related
behaviors
/
perceptions,
i.e.,
organizational
safety
cul-­‐
ture
/
climate,
regarding
understanding
and
minimizing
human
errors
and
their
underlying
system
defects.
An
overview
is
provided
of
the
state
of
safety
climate
research
in
healthcare,
and
the
concep-­‐
tual
framework
of
this
dissertation
project
is
presented.
In
the
final
part
of
the
introduction,
gaps
in
the
scientific
literature
are
summarized,
along
with
this
dissertation's
contribution
to
narrowing
those
gaps.
Chapter
2
describes
the
aims
of
this
dissertation,
including
the
translation
and
first
psy-­‐
chometric
testing
of
the
German,
French
and
Italian
versions
of
the
Safety
Organizing
Scale.
Findings
addressed
in
four
component
studies
are
reported
(Chapter
3
to
Chapter
6).
Chapter
3
presents
the
results
of
a
German
study
describing
the
translation
process
according
to
the
adapted
Brislin
translation
model
for
cross-­‐cultural
research
[30].
In
addition,
based
on
content
validity
rating
and
calculations
of
content
validity
indices
at
the
item
and
scale
levels,
the
content
valid-­‐
ity
testing
results
for
the
German
version
of
the
Safety
Organizing
Scale
(SOS)
are
described.
Chapter
4
presents
our
initial
evidence
regarding
the
validity
and
reliability
of
the
German-­‐,
French-­‐
and
Italian-­‐language
versions
of
the
SOS.
For
each
translation,
psychometric
evaluation
re-­‐
vealed
evidence
based
on
content
(scale-­‐content
validity
index
>
0.89),
response
patterns
(e.g.,
aver-­‐
age
of
missing
values
across
all
items
=
0.80%),
internal
structure
(e.g.,
comparative
fit
indices
>
0.90,
root
mean
square
error
of
approximation
<
0.08)
and
reliability
(Cronbach’s
alpha
>
0.79).
We
differ-­‐
entiated
the
SOS
regarding
one
related
concept
(implicit
rationing
of
nursing
care).
At
the
individual
level,
higher
SOS
scores
correlated
with
supportive
leadership
and
fewer
nurse-­‐reported
medication
errors,
but
not
with
nurse-­‐reported
patient
falls.
The
results
suggest
that
the
SOS
offers
a
valuable
measurement
of
engagement
in
safety
practices
that
might
influence
patient
outcomes,
including
adverse
events.
Further
analysis
using
more
reliable
outcome
measures
(e.g.,
mortality
rates)
will
be
necessary
to
confirm
concurrent
validity.
SUMMARY
-­‐
11
-­‐
Chapter
5
reports
on
our
study
describing
nurse
reports
of
patient
safety
climate
and
nurses’
engagement
in
safety
behaviors
in
Swiss
acute
care
hospitals,
exploring
relationships
between
unit
type,
hospital
type,
language
region,
and
nurse-­‐reported
patient
safety
climate.
Of
the
120
units
in-­‐
cluded
in
the
analysis,
only
on
33
(27.5%)
did
at
least
60%
of
the
nurses
rate
their
patient
safety
cli-­‐
mates
positively.
The
majority
of
participating
nurses
(51.2-­‐63.4%,
n=1,564)
reported
that
they
were
“consistently
engaged”
in
only
three
of
the
nine
measured
patient
safety
behaviors.
Our
multilevel
regression
analyses
revealed
both
significant
inter-­‐unit
and
inter-­‐hospital
variability.
Of
our
three
variables
of
interest
(hospital
type,
unit
type
and
language
region)
only
language
region
was
consist-­‐
ently
related
to
nurse-­‐reported
patient
safety
climate.
Nurses
in
the
German-­‐speaking
region
rated
their
patient
safety
climates
more
positively
than
those
in
the
French-­‐
and
Italian-­‐speaking
language
regions.
This
study's
findings
suggest
a
need
to
improve
individual
and
team
skills
related
to
proac-­‐
tively
and
preemptively
discussing
and
analyzing
possible
unexpected
events,
detecting
and
learning
from
errors,
and
thinking
critically
about
everyday
work
activities/processes.
Chapter
6
presents
the
results
of
our
explorative
study
of
the
associations
between
nurse-­‐
reported
patient
safety
climate,
nurse-­‐related
organizational
variables
and
selected
patient
outcomes.
In
none
of
our
regression
models
was
patient
safety
climate
a
significant
predictor
for
medication
er-­‐
rors,
patient
falls,
pressure
ulcers,
bloodstream
infections,
urinary
tract
infection,
pneumonia,
or
pa-­‐
tient
satisfaction.
However,
from
the
nurse-­‐related
organizational
variables,
implicit
rationing
of
nurs-­‐
ing
care
emerged
as
a
robust
predictor
for
patient
outcomes.
After
controlling
for
major
organizational
variables
and
hierarchical
data
structure,
higher
levels
of
implicit
rationing
of
nursing
care
resulted
in
a
significant
decrease
in
the
odds
of
patient
satisfaction
(OR
=
0.276,
95%CI
=
0.113
to
0.675)
and
a
sig-­‐
nificant
increase
in
the
odds
of
nurse
reported
medication
errors
(OR
=
2.513,
95%CI
=
1.118
to
5.653),
bloodstream
infections
(OR
=
3.011,
95%CI
=
1.429
to
6.347),
and
pneumonia
(OR
=
2.672,
95%CI
=
1.117
to
6.395).
Overall,
our
findings
did
not
confirm
our
hypotheses
that
PSC
is
related
to
improved
patient
outcomes.
Given
the
current
state
of
research
on
patient
safety
climate,
then,
the
direct
impact
of
PSC
improvements
on
patient
outcomes
in
general
medical
/
surgical
acute-­‐care
settings
should
not
be
overestimated.
As
a
structural
component
of
the
work
environment,
PSC
might
influence
the
care
process
(by
calling
attention
to
rationing
of
nursing
care)
and
thus
have
only
an
indirect
effect
on
pa-­‐
tient
outcomes.
Testing
this
possibility
will
require
further
analyses.
Finally,
in
Chapter
7,
major
findings
of
the
individual
studies
are
synthesized
and
discussed,
and
methodological
strengths
and
limitations
of
this
dissertation
are
discussed.
Furthermore,
impli-­‐
cations
for
further
research
and
clinical
practice
are
suggested.
The
findings
of
this
dissertation
add
to
the
existing
literature
the
first
evidence
regarding
validity
and
reliability
of
the
German,
French
and
Italian
versions
of,
the
Safety
Organizing
Scale,
a
patient
safety
climate
measurement
instrument.
Our
findings
did
not
confirm
the
underlying
theoretical
assumption
that
higher
safety
climate
levels
are
related
to
improved
patient
safety
and
quality.
Although
these
findings
suggest
the
need
to
im-­‐
SUMMARY
-­‐
12
-­‐
prove
of
patient
safety
climate
on
general
medical,
surgical
and
mixed
medical/surgical
units
in
Swiss
hospitals,
it
remains
unclear
whether
improving
nurses’
engagement
in
safety
behaviors
will
lead
to
improved
patient
safety
outcomes
(e.g.,
reduced
occurrence
of
adverse
events).
This
disserta-­‐
tion
will
contribute
to
the
further
development
of
safety
culture
and
climate
theory
and
raises
meth-­‐
odological
issues
that
will
require
consideration
in
future
studies.