The effect of executive walk rounds on nurse safety climate attitudes: A randomized trial of clinical units

BACKGROUND: Executive walk rounds (EWRs) are a widely used but unstudied activity designed to improve safety culture in hospitals. Therefore, we measured the impact of EWRs on one important part of safety culture – provider attitudes about the safety climate in the institution. METHODS: Randomized study of EWRs for 23 clinical units in a tertiary care teaching hospital. All providers except physicians participated. EWRs were conducted at each unit by one of six hospital executives once every four weeks for three visits. Providers were asked about their concerns regarding patient safety and what could be done to improve patient safety. Suggestions were tabulated and when possible, changes were made. Provider attitudes about safety climate measured by the Safety Climate Survey before and after EWRs. We report mean scores, percent positive scores (percentage of providers who responded four or higher on a five point scale (agree slightly or agree strongly), and the odds of EWR participants agreeing with individual survey items when compared to non-participants. RESULTS: Before EWRs the mean safety climate scores for nurses were similar in the control units and EWR units (78.97 and 76.78, P = 0.458) as were percent positive scores (64.6% positive and 61.1% positive). After EWRs the mean safety climate scores were not significantly different for all providers nor for nurses in the control units and EWR units (77.93 and 78.33, P = 0.854) and (56.5% positive and 62.7% positive). However, when analyzed by exposure to EWRs, nurses in the control group who did not participate in EWRs (n = 198) had lower safety climate scores than nurses in the intervention group who did participate in an EWR session (n = 85) (74.88 versus 81.01, P = 0.02; 52.5% positive versus 72.9% positive). Compared to nurses who did not participate, nurses in the experimental group who reported participating in EWRs also responded more favorably to a majority of items on the survey. CONCLUSION: EWRs have a positive effect on the safety climate attitudes of nurses who participate in the walk rounds sessions. EWRs are a promising tool to improve safety climate and the broader construct of safety culture

Providing Feedback Following Leadership Walkrounds is Associated with Better Patient Safety Culture, Higher Employee Engagement and Lower Burnout

Background There is a poorly understood relationship between Leadership WalkRounds (WR) and domains such as safety culture, employee engagement, burnout and work-life balance. Methods This cross-sectional survey study evaluated associations between receiving feedback about actions taken as a result of WR and healthcare worker assessments of patient safety culture, employee engagement, burnout and work-life balance, across 829 work settings. Results 16 797 of 23 853 administered surveys were returned (70.4%). 5497 (32.7% of total) reported that they had participated in WR, and 4074 (24.3%) reported that they participated in WR with feedback. Work settings reporting more WR with feedback had substantially higher safety culture domain scores (first vs fourth quartile Cohen’s d range: 0.34–0.84; % increase range: 15–27) and significantly higher engagement scores for four of its six domains (first vs fourth quartile Cohen’s d range: 0.02–0.76; % increase range: 0.48–0.70). Conclusion This WR study of patient safety and organisational outcomes tested relationships with a comprehensive set of safety culture and engagement metrics in the largest sample of hospitals and respondents to date. Beyond measuring simply whether WRs occur, we examine WR with feedback, as WR being done well. We suggest that when WRs are conducted, acted on, and the results are fed back to those involved, the work setting is a better place to deliver and receive care as assessed across a broad range of metrics, including teamwork, safety, leadership, growth opportunities, participation in decision-making and the emotional exhaustion component of burnout. Whether WR with feedback is a manifestation of better norms, or a cause of these norms, is unknown, but the link is demonstrably potent

A new look at an old well-being construct: evaluating the psychometric properties of 9, 5, and 1-item versions of emotional exhaustion metrics

ObjectiveTo compare the relative strengths (psychometric and convergent validity) of four emotional exhaustion (EE) measures: 9- and 5-item scales and two 1-item metrics.Patients and methodsThis was a national cross-sectional survey study of 1409 US physicians in 2013. Psychometric properties were compared using Cronbach’s alpha, Confirmatory Factor Analysis (CFA), Exploratory Factor Analysis (EFA), and Spearman’s Correlations. Convergent validity with subjective happiness (SHS), depression (CES-D10), work-life integration (WLI), and intention to leave current position (ITL) was assessed using Spearman’s Correlations and Fisher’s R-to-Z.ResultsThe 5-item EE scale correlated highly with the 9-item scale (Spearman’s rho = 0.828), demonstrated excellent internal reliability (alpha = 0.87), and relative to the 9-item, exhibited superior CFA model fit (RMSEA = 0.082, CFI = 0.986, TLI = 0.972). The 5-item EE scale correlated as highly as the 9-item scale with SHS, CES-D10, and WLI, and significantly stronger than the 9-item scale to ITL. Both 1-item EE metrics had significantly weaker correlation with SHS, CES-D10, WLI, and ITL (Fisher’s R-to-Z; p < 0.05) than the 5- and 9-item EE scales.ConclusionThe 5-item EE scale was repeatedly found equivalent or superior to the 9-item version across analyses, particularly with respect to the CFA results. As there is no cost to using the briefer 5-item EE scale, the burden on respondents is smaller, and widespread access to administering and interpreting an excellent wellbeing metric is enhanced at a critical time in global wellbeing research. The single item EE metrics exhibited lower convergent validity than the 5- and 9-item scales, but are acceptable for detecting a signal of EE when using a validated EE scale is not feasible. Replication of psychometrics and open-access benchmarking results for use of the 5-tem EE scale further enhance access and utility of this metric

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

OBJECTIVES: Key validated clinical metrics are being used individually and in aggregate (Baby-MONITOR) to monitor the performance of neonatal intensive care units (NICUs). The degree to which perceptions of key components of safety culture, safety climate, and teamwork are related to aspects of NICU quality of care is poorly understood. The objective of this study was to test whether NICU performance on key clinical metrics correlates with caregiver perceptions of safety culture. STUDY DESIGN: Cross-sectional study of 6253 very low-birth-weight infants in 44 NICUs. We measured clinical quality via the Baby-MONITOR and its nine risk-adjusted and standardized subcomponents (antenatal corticosteroids, hypothermia, pneumothorax, healthcare-associated infection, chronic lung disease, retinopathy screen, discharge on any human milk, growth velocity, and mortality). A voluntary sample of 2073 of 3294 eligible professional caregivers provided ratings of safety and teamwork climate using the Safety Attitudes Questionnaire. We examined NICU-level variation across clinical and safety culture ratings and conducted correlation analysis of these dimensions. RESULTS: We found significant variation in clinical and safety culture metrics across NICUs. Neonatal intensive care unit teamwork and safety climate ratings were correlated with absence of healthcare-associated infection (r = 0.39 [P = 0.01] and r = 0.29 [P = 0.05], respectively). None of the other clinical metrics, individual or composite, were significantly correlated with teamwork or safety climate. CONCLUSIONS: Neonatal intensive care unit teamwork and safety climate were correlated with healthcare-associated infections but not with other quality metrics. Linkages to clinical measures of quality require additional research

Correction: The effect of executive walk rounds on nurse safety climate attitudes: A randomized trial of clinical units [ISRCTN85147255]

Eric J. Thomas is with the Department of Internal Medicine, The University of Texas Medical School at Houston, Houston, TX, USA -- J. Bryan Sexton is with the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Quality and Safety Research Group, The Johns Hopkins University School of Medicine, Baltimore, USA -- Torsten B. Neilands is with the Center for AIDS Prevention Studies (CAPS), University of California, San Francisco, San Francisco, CA, USA -- Allan Frankel is with the Partners Healthcare System, Prudential Tower, Boston, MA, USA -- Robert L. Helmreich is with the Department of Psychology, The University of Texas at Austin, Austin, TX, USAFollowing publication of this article [1], the study was included in the International Standard Randomised Controlled Trial Number (ISRCTN) Register and assigned the number [email protected]

The language of healthcare worker emotional exhaustion: A linguistic analysis of longitudinal survey

ImportanceEmotional exhaustion (EE) rates in healthcare workers (HCWs) have reached alarming levels and been linked to worse quality of care. Prior research has shown linguistic characteristics of writing samples can predict mental health disorders. Understanding whether linguistic characteristics are associated with EE could help identify and predict EE.ObjectivesTo examine whether linguistic characteristics of HCW writing associate with prior, current, and future EE.Design, setting, and participantsA large hospital system in the Mid-West had 11,336 HCWs complete annual quality improvement surveys in 2019, and 10,564 HCWs in 2020. Surveys included a measure of EE, an open-ended comment box, and an anonymous identifier enabling HCW responses to be linked across years. Linguistic Inquiry and Word Count (LIWC) software assessed the frequency of one exploratory and eight a priori hypothesized linguistic categories in written comments. Analysis of covariance (ANCOVA) assessed associations between these categories and past, present, and future HCW EE adjusting for the word count of comments. Comments with <20 words were excluded.Main outcomes and measuresThe frequency of the linguistic categories (word count, first person singular, first person plural, present focus, past focus, positive emotion, negative emotion, social, power) in HCW comments were examined across EE quartiles.ResultsFor the 2019 and 2020 surveys, respondents wrote 3,529 and 3,246 comments, respectively, of which 2,101 and 1,418 comments (103,474 and 85,335 words) contained ≥20 words. Comments using more negative emotion (p < 0.001), power (i.e., references relevant to status, dominance, and social hierarchies, e.g., own, order, and allow) words (p < 0.0001), and words overall (p < 0.001) were associated with higher current and future EE. Using positive emotion words (p < 0.001) was associated with lower EE in 2019 (but not 2020). Contrary to hypotheses, using more first person singular (p < 0.001) predicted lower current and future EE. Past and present focus, first person plural, and social words did not predict EE. Current EE did not predict future language use.ConclusionFive linguistic categories predicted current and subsequent HCW EE. Notably, EE did not predict future language. These linguistic markers suggest a language of EE, offering insights into EE’s etiology, consequences, measurement, and intervention. Future use of these findings could include the ability to identify and support individuals and units at high risk of EE based on their linguistic characteristics