Employees’ perceptions of patient safety culture in Norwegian nursing homes and home care services

Background Most health care services are provided in the primary health care sector, and an increasing number of elderly is in need of these services. Nonetheless, the research on patient safety culture in home care services and nursing homes remains scarce. This study describes staff perceptions of patient safety culture in Norwegian home care services and nursing homes, and assesses how various patient safety culture dimensions contribute to explaining overall perceptions of patient safety. Methods Cross-sectional surveys were conducted among healthcare professionals in Norwegian home care services (N = 139) and nursing homes (N = 165) in 2018, response rates being 67.5% and 65%, respectively. A Norwegian version of the international recognized Nursing Home Survey on Patient Safety Culture was used. Descriptive statistics and t-tests were used to explore staff perceptions of patient safety culture. We used multiple regression analyses to explore the degree to which patient safety culture dimensions could explain overall perceptions of patient safety. Results The number of patient safety dimensions having an average score of more than 60% positive responses was seven out of 10 in nursing homes, and nine out of 10 in home care. Staffing had the lowest scores in both health care services. Home care services scored significantly higher than nursing homes on teamwork (eta squared = .053), while nursing homes scored somewhat higher on handover (eta squared = .027). In home care, total explained variance of overall perceptions of patient safety was 45%, with teamwork, staffing, and handoffs as significant predictors. The explained variance in nursing homes was 42.7%, with staffing and communication openness as significant predictors. Conclusions There are differences in perceptions of patient safety culture between nursing homes and home care services. Staffing is important for patient safety perceptions in both health care services. In home care, teamwork seems to be a significant contributing factor to patient safety, and building sound teams with mutual trust and collaboration should therefore be an essential part of managers’ work with patient safety. In nursing homes, the main focus when building a good patient safety culture should be on open communication, ensuring that staff’s ideas and suggestions are valued.publishedVersio

The Headaches of Case Study Research: A Discussion of Emerging Challenges and Possible Ways Out of the Pain

Case study research is a widely-used approach in qualitative research. The advantages of case study research include its ability to investigate complex social phenomena and to handle dense data. However, it has several drawbacks, such as defining the case and ensuring rigour. The large variety in descriptions of case study implementation makes the application of case study research a challenge for novice and experienced researchers alike. The aim of this paper is to describe a novice’s foray into case study research, illustrating advantages, drawbacks, and applications of case study research through examples from a previously conducted case study. By mapping consistencies and differences in the case study descriptions, this paper offers a way for novice researchers to familiarize themselves with the range of case study perspectives and with the choices and considerations that must accompany the choice of case study research. This paper shows the definitional and structural challenges that case study researchers may face. We identified 14 descriptions of case study research with unclear or overlapping distinctions. Despite the large number of variations in case study descriptions, we singled out one main distinction: the distinction between multiple and single case studies. The sheer proliferation of how case study research should be conducted underlines the great responsibility case study researchers have when choosing an analytical and methodological approach and ensuring rigour in their research.publishedVersio

Linking resilience and regulation across system levels in healthcare – a multilevel study

Background The Quality Improvement Regulation was introduced to the Norwegian healthcare system in 2017 as a new national regulatory framework to support local quality and safety efforts in hospitals. A research-based response to this, was to develop a study with the overall research question: How does a new healthcare regulation implemented across three system levels contribute to adaptive capacity in hospital management of quality and safety? Based on development and implementation of the Quality Improvement Regulation, this study aims to synthesize findings across macro, meso, and micro-levels in the Norwegian healthcare system. Methods The multilevel embedded case study collected data by documents and interviews. A synthesizing approach to findings across subunits was applied in legal dogmatic and qualitative content analysis. Setting: three governmental macro-level bodies, three meso-level County Governors and three micro-level hospitals. Participants: seven macro-level regulators, 12 meso-level chief county medical officers/inspectors and 20 micro-level hospital managers/quality advisers. Results Based on a multilevel investigation, three themes were discovered. All system levels considered the Quality Improvement Regulation to facilitate adaptive capacity and recognized contextual flexibility as an important regulatory feature. Participants agreed on uncertainty and variation to hamper the ability to plan and anticipate risk. However, findings identified conflicting views amongst inspectors and hospital managers about their collaboration, with different perceptions of the impact of external inspection. The study found no changes in management- or clinical practices, nor substantial change in the external inspection approach due to the new regulatory framework. Conclusions The Quality Improvement Regulation facilitates adaptive capacity, contradicting the assumption that regulation and resilience are “hopeless opposites”. However, governmental expectations to implementation and external inspection were not fully linked with changes in hospital management. Thus, the study identified a missing link in the current regime. We suggest that macro, meso and micro-levels should be considered collaborative partners in obtaining system-wide adaptive capacity, to ensure efficient risk regulation in quality improvement and patient safety processes. Further studies on regulatory processes could explore how hospital management and implementation are influenced by regulators’, inspectors’, and managers’ professional backgrounds, positions, and daily trade-offs to adapt to changes and maintain high quality care.publishedVersio

The role of organizational factors in how efficiency-thoroughness trade-offs potentially affect clinical quality dimensions – a review of the literature

Purpose The purpose of this paper is to increase knowledge of the role organizational factors have in how health personnel make efficiency-thoroughness trade-offs, and how these trade-offs potentially affect clinical quality dimensions. Design/methodology/approach The paper is a thematic synthesis of the literature concerning health personnel working in clinical, somatic healthcare services, organizational factors and clinical quality. Findings Identified organizational factors imposing trade-offs were high workload, time limits, inappropriate staffing and limited resources. The trade-offs done by health personnel were often trade-offs weighing thoroughness (e.g. providing extra handovers or working additional hours) in an environment weighing efficiency (e.g. ward routines of having one single handover and work-hour regulations limiting physicians' work hours). In this context, the health personnel functioned as regulators, balancing efficiency and thoroughness and ensuring patient safety and patient centeredness. However, sometimes organizational factors limited health personnel's flexibility in weighing these aspects, leading to breached medication rules, skipped opportunities for safety debriefings and patients being excluded from medication reviews. Originality/value Balancing resources and healthcare demands while maintaining healthcare quality is a large part of health personnel's daily work, and organizational factors are suspected to affect this balancing act. Yet, there is limited research on this subject. With the expected aging of the population and the subsequent pressure on healthcare services' resources, the balancing between efficiency and thoroughness will become crucial in handling increased healthcare demands, while maintaining high-quality care.publishedVersio

Reflexive Spaces: Leveraging Resilience Into Healthcare Regulation and Management

Healthcare is increasingly seen as a complex, adaptive system in which resilience is a key factor in creating patient safety. A need exists to understand how organizations are able to perform with success under varying conditions, that is, to be resilient. So far, the attention in resilience research has been on the sharp end of the system, such as emergency departments and clinicians’ adaptation of work practices to constantly varying conditions. However, we have limited knowledge about the role of regulators and managers in creating and supporting environments that cultivate resilience.1,2 In this article, we argue that (a) regulators and managers need to understand and acknowledge reflexivity as a foundation for resilience in healthcare organizations and that (b) creating and supporting reflexive spaces are a key for leveraging resilience into healthcare regulation and management.publishedVersio

How do contextual factors influence quality and safety work in the Norwegian home care and nursing home settings? A qualitative study about managers’ experiences

Objective Although many contextual factors can facilitate or impede primary care managers’ work with quality and safety, research on how these factors influences the managers’ continuous improvement efforts is scarce. This study explored how primary care managers experience the impact of a variety of contextual factors on their daily quality and safety work. Design The study has a qualitative design. Nine semistructured qualitative interviews were conducted at the participants’ workplaces. Systematic text condensation was used for analysis. Setting Five nursing homes and three home care services in Norway. Participants Female primary care managers at different levels, working in different units and municipalities varying in size and location. Results The participants cited the lack of time and money as a significant impediment to quality and safety, and these resources had to be carefully allocated. They emphasised the importance of networks and competence for their quality and safety work. Delegation of responsibility among employees helped create engagement, improved competence and ensured that new knowledge reached all employees. External guidelines and demands helped them to systematise their work and explain the necessity of quality and safety work to their employees, if they were compliant with daily clinical practice in the organisation. Conclusions Numerous contextual factors influence the managers by determining the leeway that they have in quality and safety work, by setting the budgetary constraints and defining available competence, networks and regulation. At first glance, these factors appear fixed, but our findings underscore the importance of primary care managers acting on and negotiating the environment in which they conduct their daily quality and safety work. More research is needed to understand how these managers strategise to overcome the impediments to quality and safety.publishedVersio

The effect of full-time culture on quality and safety of care – a literature review

Purpose The purpose of this study is to increase knowledge and understanding of the relationship between full-time-culture and the outcome for quality and safety of care. Design/methodology/approach The paper is a literature review with a qualitatively oriented thematic analysis concerning quality or safety outcomes for patients, or patients and staff when introducing a full-time culture. Findings Identified factors that could have a positive or negative impact on quality and patient safety when introducing full-time culture were length of shift, fatigue/burnout, autonomy/empowerment and system/structure. Working shifts over 12 h or more than 40 h a week is associated with increased adverse events and errors, lower quality patient care, less attention to safety concerns and more care left undone. Long shifts give healthcare personnel more flexibility and better quality-time off, but there is also an association between long shifts and fatigue or burnout. Having a choice and flexibility around shift patterns is a predictor of increased wellbeing and health. Originality/value A major challenge across healthcare services is having enough qualified personnel to handle the increasing number of patients. One of the measures to get enough qualified personnel for the expected tasks is to increase the number of full-time employees and move towards a full-time culture. It is argued that full-time culture will have a positive effect on work environment, efficiency and quality due to a better allocation of work tasks, predictable work schedule, reduced sick leave, and continuity in treatment and care. There is limited research on how the introduction of full-time culture will affect the quality and safety for patients and staff, and few studies have been focusing on the relationship between longer shift, work schedule, and quality and safety of care.publishedVersio

Why adopt ISO 9001 certification in hospitals? A case study of external triggers and sensemaking in an emergency department in Norway

Background Certification and accreditation are widely used to achieve quality and safety in health care but are also questioned regarding their assumed effects. This is a challenge for policymakers and managers, since adoption of these regimes can have a circumstantial impact upon organizations. This study’s aim was to explore how external conditions catalyzed and triggered organizational change and internal sensemaking processes as part of an ISO 9001 certification process. Methods The study applied an explanatory single-case design, using a narrative approach, to retrospectively follow a sensemaking process in an emergency department in a Norwegian hospital undergoing ISO 9001 certification. The certification process was a pilot initiated by a Regional Health Authority, which ran from autumn 2008 until spring 2012. Nine semi-structured, qualitative interviews were conducted, and documents in the form of minutes and reports were collected. The data was analyzed according to an organized sensemaking framework. Results The adoption of the ISO 9001 certification did not follow a comprehensive decision-making process. Our study shows two external situational triggers that initiated adoption. First, a countrywide supervision conducted by the Norwegian Board of Health Supervision concluded that inadequate management and leadership negatively affected the day-to-day running of Norwegian emergency departments. This external disruption visualized longstanding organizational challenges that threatened the managers’ shared identity. A search for meaning became prominent. Second, an occasional, externally initiated certification project was a plausible solution that would lead to an immediate action that would reduce uncertainty. Institutional requirements and concepts in the international ISO 9001 standard and in the national health regulations were unfamiliar and ambiguous for the project group involved in the certification. These issues became the institutional external triggers for intra-organizational sensemaking processes that made ISO certification possible. External assessments were acknowledged as useful for making improvements. Conclusions By combining institutional theory with sensemaking theory, this case study contributes to a better understanding of how external pressure meets micro-level change processes. These understandings are important because environments give rise to adoption of different management tools, such as certification, but organizations adopting new management tools seldom abandon others. This can lead to even more complex health care.publishedVersio

Health Care Personnel’s Perspective on Potential Electronic Health Interventions to Prevent Hospitalizations for Older Persons Receiving Community Care: Qualitative Study

Background: The use of electronic health (eHealth) interventions is suggested to help monitor and treat degenerative and chronic diseases through the use of sensors, alarms, and reminders and can potentially prevent hospitalizations for home-dwelling older persons receiving community care. It is increasingly recognized that the health care personnel’s acceptance of a technological application remains a key challenge in adopting an intervention, thus interventions must be perceived to be useful and fit for purpose by the actual users. Objective: The aim of this study was to identify and explore the perspectives of managers and health care personnel in community care regarding the use of eHealth interventions in terms of prevention of hospitalizations for home-dwelling older persons receiving community care. Methods: A case study with a qualitative approach was carried out in community care in a Norwegian municipality, comprising individual interviews and focus group interviews. A total of 5 individual interviews and 2 focus group interviews (n=12) were undertaken to provide the health care personnel’s and managers’ perspective regarding the use of eHealth interventions, which could potentially prevent hospitalizations for home-dwelling older persons receiving community care. Data were analyzed by way of systematic text condensation, as described by Malterud. Results: The data analysis of focus group interviews and individual interviews resulted in 2 categories: potential technological applications and potential patient groups. Discussions in the focus groups generated several suggestions and wishes related to technical applications that they could make use of in their day-to-day practice. The health care personnel warranted tools and measures to enhance and document their clinical observations in contact with patients. They also identified patient groups, such as patients with chronic obstructive pulmonary disease or dehydration or urinary tract infections, for whom hospitalizations could potentially have been prevented. Conclusions: We have shown that the health care personnel in community care warrant various technological applications that have the potential to improve quality of care and resource utilization in the studied municipality. We have identified needs and important matters in practice, which are paramount for acceptance and adoption of an intervention in community care.publishedVersio

What are the key contextual factors when preparing for successful implementation of assistive living technology in primary elderly care? A case study from Norway

Objective To identify contextual factors at different organisational levels to guide the implementation of an assistive living technology intervention in Norwegian primary home care. Design A single embedded case study design was carried out in an urban municipality in Western Norway to get an overview of key contextual factors from the municipality’s perspective. Data collection and analysis The data collection was based on a triangulation of methods involving document analysis, semi-structured individual interviews and focus group interviews to get a broad insight when preparing for an intervention. Data were collected on three levels of the healthcare system: (1) national policy documents and regulations (macro), (2) five individual interviews with senior managers and municipal strategy documents (meso) and (3) two focus group interviews with nurses and nurse managers in direct patient care (micro). The Model for Understanding Success in Quality framework was used as a guide in the data analysis. Results The main contextual factors identified were external motivators and project sponsorship (macro level); leadership, workforce focus and maturity (meso level);and motivation to change and maturity (micro level). Strategies developed in policy documents affected upper management in the municipality, but healthcare personnel at the micro level were not so familiar with strategies and emphasis on assistive living technologies. Healthcare personnel in our study were motivated to use technological solutions, but lack of data infrastructure and resource availability hindered this. Conclusions Aligning interests across multiple stakeholders remain a challenge when planning for an assistive living technology intervention in primary care. In the studied municipality, integration of technological solutions into healthcare services was more a vision than a reality because of a low level of organisational readiness.publishedVersio