The Relationship Between Perceptions of Patient Safety Culture, Nurse Advocacy, and Nurse Sensitive Patient Outcomes

The purpose of the study was to understand relationships between and among patient safety culture, nurse reported attitude toward patient advocacy and key patient outcomes. Nurses play an integral role in patient safety, providing care through constant interaction with the patient and clinical team. Advocating for patients is part of that role; however little research existed that explored how advocacy was related to the safety culture or specific patient outcomes. A correlational cross-sectional design was chosen for this secondary data analysis. Correlation and regression models were applied to medical/surgical unit data from seven facilities within one hospital system. Sources of data included the patient safety culture survey from the Agency for Healthcare Research and Quality (AHRQ), the Nurses’ Attitudes Toward Patient Advocacy (APAS) Acting on Behalf of Patients (ABP) subscale, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, patient falls and hospital acquired pressure ulcers (HAPU). Significant findings included a weak to moderate correlation between patient safety culture and attitude toward advocacy, and a moderate negative correlation between safety culture, advocacy and years of experience as a nurse. No significant correlations were found between safety culture and patient outcomes or advocacy and patient outcomes. Perceptions of experienced medical / surgical nurses within the participant hospitals were overall less positive about the patient safety culture and advocacy than their less experienced peers. These results raised questions as to whether adequate leadership attention was being given to the practice concerns of experienced medical/surgical nurses related to patient safety and advocacy

Organisational and systems factors impacting on patient safety in acute care organisations: lessons from four multi-site research studies

Background Patient safety is concerned with preventable harm in healthcare, a subject that became a focus for study in the UK in the late 1990s. How to improve patient safety, presented both a practical and a research challenge in the early 2000s, leading to the eleven publications presented in this thesis. Research question The overarching research question was: What are the key organisational and systems factors that impact on patient safety, and how can these best be researched? Methods Research was conducted in over 40 acute care organisations in the UK and Europe between 2006 and 2013. The approaches included surveys, interviews, documentary analysis and non-participant observation. Two studies were longitudinal. Results The findings reveal the nature and extent of poor systems reliability and its effect on patient safety; the factors underpinning cases of patient harm; the cultural issues impacting on safety and quality; and the importance of a common language for quality and safety across an organisation. Across the publications, nine key organisational and systems factors emerged as important for patient safety improvement. These include leadership stability; data infrastructure; measurement capability; standardisation of clinical systems; and creating an open and fair collective culture where poor safety is challenged. Conclusions and contribution to knowledge The research presented in the publications has provided a more complete understanding of the organisation and systems factors underpinning safer healthcare. Lessons are drawn to inform methods for future research, including: how to define success in patient safety improvement studies; how to take into account external influences during longitudinal studies; and how to confirm meaning in multi-language research. Finally, recommendations for future research include assessing the support required to maintain a patient safety focus during periods of major change or austerity; the skills needed by healthcare leaders; and the implications of poor data infrastructure

Exploring Resilience

Resilience has become an important topic on the safety research agenda and in organizational practice. Most empirical work on resilience has been descriptive, identifying characteristics of work and organizing activity which allow organizations to cope with unexpected situations. Fewer studies have developed testable models and theories that can be used to support interventions aiming to increase resilience and improve safety. In addition, the absent integration of different system levels from individuals, teams, organizations, regulatory bodies, and policy level in theory and practice imply that mechanisms through which resilience is linked across complex systems are not yet well understood. Scientific efforts have been made to develop constructs and models that present relationships; however, these cannot be characterized as sufficient for theory building. There is a need for taking a broader look at resilience practices as a foundation for developing a theoretical framework that can help improve safety in complex systems. This book does not advocate for one definition or one field of research when talking about resilience; it does not assume that the use of resilience concepts is necessarily positive for safety. We encourage a broad approach, seeking inspiration across different scientific and practical domains for the purpose of further developing resilience at a theoretical and an operational level of relevance for different high-risk industries. The aim of the book is twofold: 1. To explore different approaches for operationalization of resilience across scientific disciplines and system levels. 2. To create a theoretical foundation for a resilience framework across scientific disciplines and system levels. By presenting chapters from leading international authors representing different research disciplines and practical fields we develop suggestions and inspiration for the research community and practitioners in high-risk industries. This book is Open Access under a CC-BY licence. ; Explores different approaches for operationalization of resilience across scientific disciplines and system levels Creates a theoretical foundation for a resilience framework across scientific disciplines and system levels Develops suggestions and inspiration for the research community and practitioners in high-risk industries Presents chapters from leading international authors representing different research disciplines and practical field

A Configural Approach to Patient Safety Climate: The Relationship Between Climate Profile Characteristics and Patient Outcomes

Patient safety climate is defined as a holistic snapshot of enacted work environment practices and procedures related to patient safety, derived from shared perceptions of social and environmental work characteristics. While patient safety climate has been touted as a critical factor underlying safe patient care, our understanding of input factors influencing shared climate perceptions and, in turn, the effects of climate as a collective, group-level construct on important outcomes remains underdeveloped, both theoretically and empirically. Therefore, the current study examines (1) the antecedents that impact individual patient safety climate perceptions and (2) the relationships between hospital unit patient safety climate and two important unit level outcomes: patient willingness to recommend a facility to others and patient safety. This study also examines climate strength--the degree to which climate perceptions are shared--as a moderator of these relationships. While climate is conceptualized as a holistic description of the working environment, existing evidence has focused on relationships between the independent dimensions of patient safety climate and patient safety. No study to date has examined the configurations (i.e. patterns or profiles) among the multiple dimensions of patient safety climate or how these configurations are related to important employee and patient outcomes. This gap is redressed in the current study by examining patient safety climate in terms of three profile characteristics: (1) climate elevation (i.e., mean positive or negative valence across all dimensions), (2) climate variability (i.e., variance among dimensions), and (3) climate shape (i.e., the pattern of peaks and valleys among climate dimensions). Evidence from studies of general organizational climate suggests that the shape of the pattern among climate dimensions, the overall mean score across dimensions, and the degree to which dimension scores vary are predictive of employee attitudes, customer satisfaction, and organizational financial performance (Dickson et al., 2006; Joyce & Slocum, 1984; Jackofsky & Slocum, 1988; Gonzalez-Roma, Peiro, & Zornoza, 1999; Litwin & Stringer, 1968; Schulte et al., 2009). The current study, then, tests a theoretical model of patient safety climate examining the configural nature of the construct. An archival dataset collected from seven hospitals located in a metropolitan area of the southeastern United States was utilized to test study hypotheses. Data was collected from 3,149 individuals nested within 84 hospital units using the Hospital Survey on Patient Safety Culture (Sorra & Nieva, 2004). Unit level patient safety and patient willingness to recommend was collected by the hospital risk management and nursing administration departments. Hierarchical linear modeling (HLM7; Raudenbush, Bryk, Cheong, Congdon, & du Toit, 2011) was utilized to test hypotheses regarding antecedents of individual level perceptions of patient safety climate to account for the fact that individuals were nested within hospital units. Traditional multiple regression analyses were utilized to test unit level hypotheses examining the relationships between unit level patient safety climate and patient outcomes. Results indicated that unit membership was significantly related to individual climate perceptions--specifically, individual-level climate profile elevation. In turn, individual climate profile elevation and profile variability were related to employee willingness to recommend their organization to family and friends in need of care. At the unit level of analysis, climate profile variability was significantly related to patient willingness to recommend the organization to others, and climate shape was found to be related to patient safety. Furthermore, these results were not dependent on climate strength. The current study meaningfully contributes to the conceptual understanding of the patient safety climate construct by examining the degree to which configural aspects of the construct are predictive of important outcomes across multiple levels of analysis. In this way, it extends beyond existing studies of climate configurations to examine relationships at multiple levels of analysis and to also examine the moderating effects of climate strength. Practically, results provide insight into how the construct of patient safety climate can be used diagnostically and prescriptively to improve patient care and the working environment for providers. In addition to contributing to the theoretical understanding of the patient safety climate construct, this study also augments the evidence-base available to administrators, front-line providers, and regulators regarding how patient safety climate can be used to guide and align quality improvement efforts for greatest impact

Hospital discharge of the elderly: an observational case study of functions, variability and performance-shaping factors

Background: Understanding and improving hospital discharge has assumed major importance since it represents an error-prone transition in care. One barrier to improvement is the lack of detailed understanding of how hospital discharge is organized, including its interdependencies and influential performance-shaping factors (PSFs). This study examines the discharge of elderly patients using the Functional Resonance Analysis Method, developed to analyze performance variability in complex systems. Our main aim was to identify hospital discharge functions, variability, and PSFs that may explain the variability and different outcomes in discharge practices by incorporating multiple-stakeholder perceptions (health-care providers, patients, next of kin). Methods: The data consisted of moderate participant observations of 20 elderly patients (>75) discharged from hospital to primary health care. The data comprised 90 hours’ observations at hospital wards, including 173 conversations with patients, next of kin, and health-care personnel involved in discharge. Results: We identified 10 common functions in the discharge of elderly patients to primary health care. We found substantial variability in terms of timing, duration, and precision. Duration is a significant source of variability, primarily determined by the time of day the patient was determined medically fit for discharge. Precision issues related to (1) decision-making criteria concerning the medical fitness decision and appropriate level of care, (2) quality of discharge planning, (3) degree of patient involvement, and (4) quality of information transfer. PSFs were temporal conditions (degree of time pressure), individual and team characteristics, patient factors, organizational factors (unit, specialization, leadership, institutionalized routines), work environment factors (bed availability, availability in municipal services, quality of discharge planning, familiarity with the patient, pressure from next of kin, doctor’s specialization) and regulatory influences (financial incentives). Conclusions: The study provides a detailed understanding of the discharge of elderly patients by describing common functions and variability in performance caused by multiple PSFs. Our findings indicate the necessity for studying multiple factors related to discharge, interdependencies, and their effects on a range of discharge outcomes incorporating a multiple-stakeholder perspective. We argue that the existing sequential approaches to the complexity surrounding hospital discharge are inadequate. Given the interdependencies among functions, there is a need for corresponding multi-factorial interventions

Quality and coordination in home care: a national cross-sectional multicenter study – SPOTnat

Homecare services include a wide range of medical treatments and therapies, basic care (e.g., personal hygiene), domestic services (e.g., household support) and social services. However, it has been neglected in most countries compared to hospitals and nursing homes, especially regarding healthcare research. As a result, while many countries see high-quality, sustainable care at home as a high-value goal, there are many knowledge gaps in the homecare setting. For agencies, challenges include an increasing demand combined with a workforce shortage, constant cost pressure, and issues with both care coordination and care quality. Problematically, owing to a long shortage of research, knowledge of these elements is scant. In this sector, large-scale studies that consider macro-, meso-, and micro-level factors and incorporate multiple perspectives and measurements to capture coordination and quality of care are extremely rare. When the SPOTnat study (Spitex Koordination und Qualität - eine nationale Studie (homecare coordination and quality – a national study)) began, no published study had examined how homecare agencies perform regarding care coordination. More importantly, though, none had determined which factors are associated with care coordination in the homecare setting. Moreover, across the entire health sector, no clear, accepted concept was available either of what exactly constitutes coordination, or of what it entails. This dissertation is embedded in the SPOTnat study. Preparing it, the overall goal was to deepen our understanding of the homecare sector regarding care coordination and quality. Therefore, a preliminary goal was to clarify the concept of care coordination. Later goals included describing the various financial and regulatory mechanisms operating in the Swiss homecare setting. That information made it possible to explore how those factors relate to homecare agencies’ structures, processes, and working environments, how system and agency factors are related to care coordination, and ultimately how care coordination is related to quality of care. CHAPTER 1 presents the background, the target research gap and the rationale behind this dissertation. We look closely at the unique challenges of the homecare setting, particularly regarding coordination and care quality. In CHAPTER 2 we establish a theoretical basis for care coordination and explain how the concept of coordination can be understood and measured. Our newly-constructed COORA (care coordination) framework differentiates clearly between coordination as a process—i.e., tasks people perform to coordinate versus coordination as a state, i.e., the desired outcome of the coordination process. Applying this distinction to both measurement and interpretation of results helps avoid misleading conclusions. The COORA theoretical framework is based on the full range of influential coordination literature. Iteratively developed in consultation with healthcare professionals, patients and their relatives, it considers the complex relationships between the many factors influencing coordination (as an outcome), and is applicable not only to homecare but across healthcare settings. However, measurement of both care coordination and quality of care remains a challenge. Further research will be necessary to develop and validate a questionnaire that reliably measures care coordination as an outcome. CHAPTER 3 presents the research protocol for the SPOTnat study, a national multi-center cross-sectional survey in Swiss homecare settings. That study included 88 homecare agencies. Using public records and data from questionnaires sent to those agencies’ 3323 employees (including managers and homecare staff), 1508 clients and 1105 relatives of those clients, the SPOTnat research team gathered data on homecare financing mechanisms, agency characteristics and homecare employees' working environments and coordination activities, as well as staff- and patient-level perceptions of coordination and quality of care. CHAPTER 4 discusses our analyses of how regulatory and financial mechanisms explain differences in agency structures, processes and work environments. Based on the mechanisms acting on the participating agencies, we divided them into four groups. Our analyses showed considerable inter-group differences, especially in the range and volume of services provided, but also regarding their employment conditions and cost structures. The most prominent inter-group differences related to the conditions of their cantonal and municipal service agreements. Alongside such details, financial incentives must harmonize the care goals, i.e., achieving and maintaining accessible, high-quality homecare, with the regulatory goals, i.e., assuring the quality and financial sustainability of that care. CHAPTER 5 includes an analysis of how selected explicit and implicit agency-level coordination (process) mechanisms are linked to successful coordination (as an outcome). The results revealed that several implicit mechanisms, i.e., communication/information exchange, role clarity, mutual respect/trust, accountability/predictability/common perspectives, and knowledge of the health system, all correlate with employee-perceived coordination ratings. We also found that certain coordination mechanisms mediated the effects both of agency characteristics (i.e., staffing/ workload and overtime) and of external factors (i.e., regulations). In CHAPTER 6, the final included study gives insights regarding how both homecare employees’ and clients’ coordination-relevant perceptions relate to one another’s quality-of-care ratings. Our analyses indicate that employee-perceived care coordination ratings correlate positively with their own ratings of their quality of care, while client-perceived care coordination problems correlated inversely with client-reported quality of care. Client-perceived coordination problems also correlated positively with hospitalizations and unscheduled urgent medical visits, but not significantly with emergency department visits. No associations were found between employee-perceived coordination and either healthcare service utilization or client quality-of-care ratings. Alongside these relationships, various coordination deficiencies, for example, poor information flow, also became apparent. To conclude, CHAPTER 7 provides a synthesis of the main findings and discusses the results in relation to practical, political and research implications. While contributing further to the understanding of care coordination via the COORA framework, this dissertation also raises various methodological issues. From a practical perspective, measuring and operationalizing both coordinating processes and quality of care outcomes remain challenging issues. While our qualitative results suggest that improving coordination will lead to higher-quality care, testing and ultimately exploiting any such relationship will require not only improved financial and technical structures, but the abandonment of outmoded siloed attitudes regarding the entire homecare sector