Assessing safety climate in acute hospital settings: a systematic review of the adequacy of the psychometric properties of survey measurement tools

Background: The perceived importance of safety culture in improving patient safety and its impact on patient outcomes has led to a growing interest in the assessment of safety climate in healthcare organizations; however, the rigour with which safety climate tools were developed and psychometrically tested was shown to be variable. This paper aims to identify and review questionnaire studies designed to measure safety climate in acute hospital settings, in order to assess the adequacy of reported psychometric properties of identified tools. Methods: A systematic review of published empirical literature was undertaken to examine sample characteristics and instrument details including safety climate dimensions, origin and theoretical basis, and extent of psychometric evaluation (content validity, criterion validity, construct validity and internal reliability). Results: Five questionnaire tools, designed for general evaluation of safety climate in acute hospital settings, were included. Detailed inspection revealed ambiguity around concepts of safety culture and climate, safety climate dimensions and the methodological rigour associated with the design of these measures. Standard reporting of the psychometric properties of developed questionnaires was variable, although evidence of an improving trend in the quality of the reported psychometric properties of studies was noted. Evidence of the theoretical underpinnings of climate tools was limited, while a lack of clarity in the relationship between safety culture and patient outcome measures still exists. Conclusions: Evidence of the adequacy of the psychometric development of safety climate questionnaire tools is still limited. Research is necessary to resolve the controversies in the definitions and dimensions of safety culture and climate in healthcare and identify related inconsistencies. More importance should be given to the appropriate validation of safety climate questionnaires before extending their usage in healthcare contexts different from those in which they were originally developed. Mixed methods research to understand why psychometric assessment and measurement reporting practices can be inadequate and lacking in a theoretical basis is also necessary

Understanding and responding when things go wrong: key principles for primary care educators

Learning from events with unwanted outcomes is an important part of workplace based education and providing evidence for medical appraisal and revalidation. It has been suggested that adopting a ‘systems approach’ could enhance learning and effective change. We believe the following key principles should be understood by all healthcare staff, especially those with a role in developing and delivering educational content for safety and improvement in primary care. When things go wrong, professional accountability involves accepting there has been a problem, apologising if necessary and committing to learn and change. This is easier in a ‘Just Culture’ where wilful disregard of safe practice is not tolerated but where decisions commensurate with training and experience do not result in blame and punishment. People usually attempt to achieve successful outcomes, but when things go wrong the contribution of hindsight and attribution bias as well as a lack of understanding of conditions and available information (local rationality) can lead to inappropriately blame ‘human error’. System complexity makes reduction into component parts difficult; thus attempting to ‘find-and-fix’ malfunctioning components may not always be a valid approach. Finally, performance variability by staff is often needed to meet demands or cope with resource constraints. We believe understanding these core principles is a necessary precursor to adopting a ‘systems approach’ that can increase learning and reduce the damaging effects on morale when ‘human error’ is blamed. This may result in ‘human error’ becoming the starting point of an investigation and not the endpoint

A cluster randomised controlled trial of a pharmacist-led collaborative intervention to improve statin prescribing and attainment of cholesterol targets in primary care

Background: Small trials with short term follow up suggest pharmacists’ interventions targeted at healthcare professionals can improve prescribing. In comparison with clinical guidance, contemporary statin prescribing is sub-optimal and achievement of cholesterol targets falls short of accepted standards, for patients with atherosclerotic vascular disease who are at highest absolute risk and who stand to obtain greatest benefit. We hypothesised that a pharmacist-led complex intervention delivered to doctors and nurses in primary care, would improve statin prescribing and achievement of cholesterol targets for incident and prevalent patients with vascular disease, beyond one year.<p></p> Methods: We allocated general practices to a 12-month Statin Outreach Support (SOS) intervention or usual care. SOS was delivered by one of 11 pharmacists who had received additional training. SOS comprised academic detailing and practical support to identify patients with vascular disease who were not prescribed a statin at optimal dose or did not have cholesterol at target, followed by individualised recommendations for changes to management. The primary outcome was the proportion of patients achieving cholesterol targets. Secondary outcomes were: the proportion of patients prescribed simvastatin 40 mg with target cholesterol achieved; cholesterol levels; prescribing of simvastatin 40 mg; prescribing of any statin and the proportion of patients with cholesterol tested. Outcomes were assessed after an average of 1.7 years (range 1.4–2.2 years), and practice level simvastatin 40 mg prescribing was assessed after 10 years.<p></p> Findings: We randomised 31 practices (72 General Practitioners (GPs), 40 nurses). Prior to randomisation a subset of eligible patients were identified to characterise practices; 40% had cholesterol levels below the target threshold. Improvements in data collection procedures allowed identification of all eligible patients (n = 7586) at follow up. Patients in practices allocated to SOS were significantly more likely to have cholesterol at target (69.5% vs 63.5%; OR 1.11, CI 1.00–1.23; p = 0.043) as a result of improved simvastatin prescribing. Subgroup analysis showed the primary outcome was achieved by prevalent but not incident patients. Statistically significant improvements occurred in all secondary outcomes for prevalent patients and all but one secondary outcome (the proportion of patients with cholesterol tested) for incident patients. SOS practices prescribed more simvastatin 40 mg than usual care practices, up to 10 years later.<p></p> Interpretation: Through a combination of educational and organisational support, a general practice based pharmacist led collaborative intervention can improve statin prescribing and achievement of cholesterol targets in a high-risk primary care based population

Should GPs provide spiritual care?

No abstract available

Recovery from disability after stroke as a target for a behavioural intervention: Results of a randomised controlled trial

Purpose: Disability following stroke is highly prevalent and is predicted by psychological variables such as control cognitions and emotions, in addition to clinical variables. This study evaluated the effectiveness of a workbook-based intervention, designed to change cognitions about control, in improving outcomes for patients and their carers. Method: At discharge, stroke patients were randomly allocated (with their carers) to a 5-week intervention (n = 103) or control (normal care: n = 100). The main outcome (at 6 months) was recovery from disability using a performance measure, with distress and satisfaction as additional outcomes. Results: The intervention group showed significantly better disability recovery, allowing for initial levels of disability, than those in the control group, F(1,201) = 5.61, p = 0.019. Groups did not differ in distress or satisfaction with care for patients or carers. The only psychological process variable improved by the intervention was Confidence in Recovery but this did not mediate the effects on recovery. Conclusions: A large proportion of intervention participants did not complete the workbook tasks. This was perhaps associated with the fairly low level of personal contact with workbook providers. The modest success of this intervention suggests that it may be possible to develop effective behavioural interventions to enhance recovery from disability in stroke patients

Development and Evaluation of Four Week Attachments in General Practice at the University of Glasgow

There is an increasing consensus that a considerable proportion of undergraduate clinical medical education could be shifted into community settings, primarily general practice. This would help to solve many of the difficulties facing hospital teaching of medical students, and enable the aims of the Education Committee of the General Medical Council to be reached more fully. Against this background, it was decided to introduce a compulsory four week attachment in general practice, at the University of Glasgow, for the first time, starting in April 1992, for students undergoing their final clinical rotation. The aims of this thesis are: firstly, to describe the organisation of the attachments, the tutors and practices involved, the course objectives and tasks, the effect of the attachments on student attitudes, and its effect on patient attitudes; secondly, to examine in detail an experiment in problem based learning and an audit project which were used as teaching methods during the attachment and; finally, to evaluate all aspects of the attachments in order to produce recommendations, to improve the future learning opportunities for students. The methods used to complete this research were: detailed postal questionnaires applied to the general practitioner tutors, before and after the attachments, and face-to-face discussions with large groups of tutors; detailed questionnaires applied to the students, at the start and at the end of the attachments, and tape recorded interviews with 25% of the class and; simple questionnaires applied to patients three months before the attachments, immediately before a consultation and immediately after a consultation, where a student was present. 111 [90%] of the tutors, who had expressed an interest in the attachments, replied to an initial questionnaire, before the attachment, and 72 [72%] of those, who taught the course, replied to a follow-up questionnaire, after the attachment. Two hundred students [97.1% of the class] completed an initial student questionnaire, at the start of the attachment, and 190 [92.2%] completed the follow-up questionnaire, at the end. Evaluative questionnaires about the attachment, the problem based learning and the audit project were completed by 89.3%, 65% and 85.6%, respectively, of the students who took part. 25% of the class contributed to semi-structured, tape recorded interviews. 681 patients completed a questionnaire three months before the attachments started. 469 patients completed a questionnaire immediately before a consultation with their general practitioner, where a student would be present, and 759 patients completed a questionnaire immediately after a consultation, where a student was present. It was found that there is a large pool of enthusiastic tutors willing to teach medical students in the community. However, it is recommended that these tutors receive adequate support to enable high standards of clinical teaching to be maintained. The objectives for the attachment were found to be appropriate and it was recommended that the possibility of producing common general objectives, for undergraduate teaching in general practice, should be explored by United Kingdom medical schools. The tasks of the attachment were found to be useful and relevant, and it was possible to produce a profile of the content of an ideal attachment according to student opinion. The attachment promoted a positive attitude among students, towards general practice, and acted as a positive vocational opportunity. However, it is recommended that this cohort of students should be followed up to discover if their stated preference for general practice, as a career, is maintained. Patient opinion was generally favourable towards the presence of medical students in the consulting room. It was therefore recommended that educators in medical schools could be reassured about the case-mix seen in general practice, and general practitioner tutors reassured about the acceptability to patients, of students in the consulting room. The problem based learning group work was a qualified success, according to student opinion. It was therefore recommended that this method of learning should be refined for further use in this course, and its use promoted in United Kingdom medical schools. The audit project increased students' self-reported knowledge about audit but it was recommended that, in order to produce a more Interesting and useful learning experience, the students should be given more ownership of the project in the future. It is further recommended that teaching about audit should be promoted in the general practice setting, in the United Kingdom. The advantages and shortcomings of the methods, which were used to assess the students, are discussed and it is recommended that a more objective measure, such as a modified essay question or an observer structured clinical examination, should be included in the future assessment of students undergoing this attachment. The evaluative information given by the students about their attachment provided evidence that the majority of them enjoyed it very much. They found it useful for learning about general medicine, psychiatry and communication skills, and many of them were impressed by the standard of teaching received. However, they wanted to conduct more personal consultations and practical procedures, and they also suggested improvements to the Department course. Information from this research can be used to shape a course which is responsive to the requirements of Glasgow medical students, the University of Glasgow and the recommendations of the General Medical Council, and to support the shift of more undergraduate medical education into the setting of general practice, in the United Kingdom

Incidence of unipolar and bipolar depression, and mania in adults with intellectual disabilities: prospective cohort study

Background: Incidence and determinants of affective disorders among adults with intellectual disabilities are unknown. Aims: To investigate affective disorder incidence, and determinants of unipolar depression, compared with general population reports. Method: Prospective cohort study measuring mental ill health of adults with mild to profound intellectual disabilities living within a defined community, over 2 years. Results: There was 70% cohort retention (n = 651). Despite high mood stabiliser use (22.4%), 2-year incident mania at 1.1% is higher than the general population; 0.3% for first episode (standardised incident ratio (SIR) = 41.5, or 52.7 excluding Down syndrome). For any bipolar episode the SIR was 2.0 (or 2.5 excluding Down syndrome). Depression incidence at 7.2% is similar to the general population (SIR = 1.2), suggesting more enduring/undertreatment given the higher prevalence. Problem behaviours (odds ratio (OR) = 2.3) and life events (OR = 1.3) predict incident unipolar depression. Conclusions: Depression needs improved treatment. Mania has received remarkably little attention in this population, despite high prevalence and incidence (similar to schizophrenia), and given the importance of clinician awareness for accurate differential diagnosis from attention-deficit hyperactivity disorder and problem behaviours

Prevalence of physical conditions and multimorbidity in a cohort of adults with intellectual disabilities with and without Down syndrome: cross-sectional study

Abstract: Objectives To investigate the prevalence of multimorbidity in adults with intellectual disabilities with and without Down syndrome. Design: Large, population-based cross-sectional study. Setting: The geographical area of one Health Board, Scotland. Participants: All adults (aged 16+ years) known to general practitioners to have intellectual disabilities and adults receiving services provided or paid by intellectual disabilities health or social work services. 1023/1562 potential participants took part (65.5%); 562 (54.9%) men and 461 (45.1%) women, aged 43.9 years (16–83 years). 186 had Down syndrome and 837 did not. Main outcome measures: The prevalence of International Statistical Classification of Diseases, 10th revision, physical health conditions and multimorbidity detected at a comprehensive health assessment. Results: The mean number of physical health conditions/participant was 11.04, and 98.7% had multimorbidity. The most prevalent conditions are painful and/or disabling and, in some cases, life threatening. The five most prevalent were visual impairment, obesity, epilepsy, constipation and ataxic/gait disorders. The pattern of multimorbidity differs from that seen in the general population and is spread across the entire adult life course. The extent of multimorbidity in the adults with Down syndrome was similar to that of the adults without Down syndrome, while the prevalence of individual conditions differed. Conclusions: This robustly designed study with a large population found an extremely high prevalence of multimorbidity in adults with intellectual disabilities across the entire adult life course. This increases complexity of medical management that secondary healthcare services and medical education are not yet geared towards, as these tend to focus on single conditions. This is in addition to complexity due to limitations in communication and understanding. As the physical conditions within their multimorbidity also differ from that seen in the older general population, urgent attention is needed to develop the care pathways and guidelines that are required to inform and so improve their healthcare

Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised controlled trial

Background: Cognitive behavioural therapy (CBT) is an effective treatment for people whose depression has not responded to antidepressants. However, the long-term outcome is unknown. In a long-term follow-up of the CoBalT trial, we examined the clinical and cost-effectiveness of cognitive behavioural therapy as an adjunct to usual care that included medication over 3–5 years in primary care patients with treatment-resistant depression. Methods: CoBalT was a randomised controlled trial done across 73 general practices in three UK centres. CoBalT recruited patients aged 18–75 years who had adhered to antidepressants for at least 6 weeks and had substantial depressive symptoms (Beck Depression Inventory [BDI-II] score ≥14 and met ICD-10 depression criteria). Participants were randomly assigned using a computer generated code, to receive either usual care or CBT in addition to usual care. Patients eligible for the long-term follow-up were those who had not withdrawn by the 12 month follow-up and had given their consent to being re-contacted. Those willing to participate were asked to return the postal questionnaire to the research team. One postal reminder was sent and non-responders were contacted by telephone to complete a brief questionnaire. Data were also collected from general practitioner notes. Follow-up took place at a variable interval after randomisation (3–5 years). The primary outcome was self-report of depressive symptoms assessed by BDI-II score (range 0–63), analysed by intention to treat. Cost-utility analysis compared health and social care costs with quality-adjusted life-years (QALYs). This study is registered with isrctn.com, number ISRCTN38231611. Findings: Between Nov 4, 2008, and Sept 30, 2010, 469 eligible participants were randomised into the CoBalT study. Of these, 248 individuals completed a long-term follow-up questionnaire and provided data for the primary outcome (136 in the intervention group vs 112 in the usual care group). At follow-up (median 45·5 months [IQR 42·5–51·1]), the intervention group had a mean BDI-II score of 19·2 (SD 13·8) compared with a mean BDI-II score of 23·4 (SD 13·2) for the usual care group (repeated measures analysis over the 46 months: difference in means −4·7 [95% CI −6·4 to −3·0, p<0·001]). Follow-up was, on average, 40 months after therapy ended. The average annual cost of trial CBT per participant was £343 (SD 129). The incremental cost-effectiveness ratio was £5374 per QALY gain. This represented a 92% probability of being cost effective at the National Institute for Health and Care Excellence QALY threshold of £20 000. Interpretation: CBT as an adjunct to usual care that includes antidepressants is clinically effective and cost effective over the long-term for individuals whose depression has not responded to pharmacotherapy. In view of this robust evidence of long-term effectiveness and the fact that the intervention represented good value-for-money, clinicians should discuss referral for CBT with all those for whom antidepressants are not effective