Variation in staff perceptions of patient safety climate across work sites in Norwegian general practitioner practices and out-of-hour clinics

Designing an Intervention to Improve Medication Safety for Nursing Home Residents Based on Experiential Knowledge Related to Patient Safety Culture at the Nursing Home Front Line: Cocreative Process Study

BACKGROUND

Despite years of attention, avoiding medication-related harm remains a global challenge. Nursing homes provide essential health care for frail older individuals, who often experience multiple chronic diseases and polypharmacy, increasing their risk of medication errors. Evidence of effective interventions to improve medication safety in these settings is inconclusive. Focusing on patient safety culture is a potential key to intervention development as it forms the foundation for overall patient safety and is associated with medication errors.

OBJECTIVE

This study aims to develop an intervention to improve medication safety for nursing home residents through a cocreative process guided by integrated knowledge translation and experience-based codesign.

METHODS

This study used a cocreative process guided by integrated knowledge translation and experience-based co-design principles. Evidence on patient safety culture was used as an inspirational source for exploration of medication safety. Data collection involved semistructured focus groups to generate experiential knowledge (stage 1) to inform intervention design in a multidisciplinary workshop (stage 2). Research validation engaging different types of research expertise and municipal managerial representatives in finalizing the intervention design was essential. Acceptance of the final intervention for evaluation was aimed for through contextualization focused on partnership with a municipal advisory board. An abductive, rapid qualitative analytical approach to data analysis was chosen using elements from analyzing in the present, addressing the time-dependent, context-bound aspects of the cocreative process.

RESULTS

Experiential knowledge was represented by three main themes: (1) closed systems and gaps between functions, (2) resource interpretation and untapped potential, and (3) community of medication safety and surveillance. The main themes informed the design of preliminary intervention components in a multidisciplinary workshop. An intervention design process focused on research validation in addition to contextualization resulted in the Safe Medication in Nursing Home Residents (SAME) intervention covering (1) campaign material visualizing key roles and responsibilities regarding medication for nursing home residents and (2) "Medication safety reflexive spaces" focused on social and health care assistants.

CONCLUSIONS

The cocreative process successfully resulted in the multifaceted SAME intervention, grounded in lived experiences shared by some of the most important (but often underrepresented in research) stakeholders: frontline health care professionals and representatives of nursing home residents. This study brought attention toward closed systems related to functions in medication management and surveillance, not only informing the SAME intervention design but as opportunities for further exploration in future research. Evaluation of the intervention is an important next step. Overall, this study represents an important contribution to the complex field of medication safety.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/43538.

Patient Safety Climate in Danish Primary Care: Adaption and Validation of the Danish Safety Attitudes Questionnaire (SAQ-DK-PRIM)

Background

A lack of instruments to assess patient safety climate within primary care exists. The objectives of this study were as follows: 1) To adapt the Danish hospital version of the Safety Attitudes Questionnaire (SAQ-DK) for use in primary care; 2) Test the internal consistency and the construct validity of this version; 3) Present benchmark data; and 4) Analyze variance.

Methods

The SAQ-DK was adapted for use in Danish primary care settings (SAQ-DK-PRIM) and distributed to healthcare staff members from nursing homes (N = 11), homecare units (N = 4) and healthcare units (N = 2), within the municipality of Aarhus, Central Denmark Region, Denmark. Face- and content validity were assessed. The construct validity was evaluated by a set of goodness-of-fit indices. The internal reliability was evaluated using the item-rest correlations, the inter-item correlations, and Cronbach's alpha (α).

Results

The adaptation process resulted in a questionnaire of 10 items. Eight hundred and thirty healthcare staffs participated (78% of the eligible respondents). In total 586 (70.6%) responses were complete and were included in the analysis. Goodness-of-fit indices from the confirmatory factor analysis showed: Chi2=46.90CFI=0.97, RMSEA = 0.063 (90% CI: 0.044-0.084), Probability RMSEA (p close)=0.12. Internal reliability was high (Cronbach's α=0.76). Proportions of participants with a positive attitude was 41.1% and did not differ between the healthcare services. Scale mean score was 70.19 (SD: 18.05) and differed between healthcare services. The safety climate scale scores did not vary according to healthcare service type. ICC was 0.68% indicating no clustering of scores by healthcare service type.

Conclusion

Considering the questionnaire's applicability, short length, strengthened focus on one area of interest and validity, the SAQ-DK-PRIM can serve as a valuable tool for measuring patient safety climate within primary care settings in Denmark.

Review: application of the Safety Attitudes Questionnaire (SAQ) in primary care - a systematic synthesis on validity, descriptive and comparative results, and variance across organisational units

Patient safety research has focused mostly on the hospital and acute care setting whereas assessments of patient safety climate in primary health care settings are warranted. Valid questionnaires as e.g., the Safety Attitudes Questionnaire (SAQ) may capture staff perceptions of patient safety climate but until now, an overview of the use of SAQ in primary care has not been systematically presented. Thus, the aim of this systematic review is to present an overview of SAQ used in primary care.Methods The electronic databases: PubMed, Embase, Cinahl, PsycInfo and Web of Science were used to find studies that used any version of SAQ in primary care. Studies were excluded if only abstract or poster was available, as the information in abstract and posters was deemed insufficient. Commentaries and nonempirical studies (e.g., study protocols) were excluded. Only English manuscripts were included.Results A total of 43 studies were included and 40 of them fell into four categories: 1) validation analysis, 2) descriptive analysis, 3) variance assessment and 4) intervention evaluation and were included in further analyses. Some studies fell into more than one of the four categories. Seventeen studies aimed to validate different versions of SAQ in a variety of settings and providers. Twenty-five studies from fourteen different countries reported descriptive findings of different versions of SAQ in a variety of settings. Most studies were conducted in primary health care centres, out-of-hours clinics, nursing homes and general practice focusing on greatly varying populations. One study was conducted in home care. Three studies investigated variance of SAQ scores. Only five studies used SAQ to assess the effects of interventions/events. These studies evaluated the effect of electronic medical record implementation, a comprehensive Unit-based Safety Program or COVID-19.Conclusion The synthesis demonstrated that SAQ is valid for use in primary care, but it is important to adapt and validate the questionnaire to the specific setting and participants under investigation. Moreover, differences in SAQ factor scores were related to a variety of descriptive factors, that should be considered in future studies More studies, especially variance and intervention studies, are warranted in primary care.Trial registration This systematic review was not registered in any register.

Exploring the role of leaders in enabling adaptive capacity in hospital teams - a multiple case study

BACKGROUND

Resilient healthcare research studies how healthcare systems and stakeholders adapt and cope with challenges and changes to enable high quality care. Team leaders are seen as central in coordinating clinical care, but research detailing their contributions in supporting adaptive capacity has been limited. This study aims to explore and describe how leaders enable adaptive capacity in hospital teams.

METHODS

This article reports from a multiple embedded case study in two Norwegian hospitals. A case was defined as one hospital containing four different types of teams in a hospital setting. Data collection used triangulation of observation and interviews with leaders, followed by a qualitative content analysis.

RESULTS

Leaders contribute in several ways to enhance their teams' adaptive capacity. This study identified four key enablers; (1) building sufficient competence in the teams; (2) balancing workload, risk, and staff needs; (3) relational leadership; and (4) emphasising situational understanding and awareness through timely and relevant information.

CONCLUSION

Team leaders are key actors in everyday healthcare systems and facilitate organisational resilience by supporting adaptive capacity in hospital teams. We have developed a new framework of key leadership enablers that need to be integrated into leadership activities and approaches along with a strong relational and contextual understanding.

Psychometric Properties of the Greek Version of the Medical Office on Patient Safety Culture in Primary Care Settings

Background: Safety culture is considered one of the most crucial premises for further development of patient care in healthcare. During the eight-year economic crisis (2010–2018), Greece made significant reforms in the way the primary health care system operates, aiming at the more efficient operation of the system without degrading issues of safety and quality of the provided health services. In this context, this study aims to validate a specialized tool—the Medical Office Survey on Patient Safety Culture (MOSPSC)—developed by the Agency for Healthcare Research and Quality (AHRQ) to evaluate primary care settings in terms of safety culture and quality. Methods: Factor analysis determined the correlation of the factor structure in Greek data with the original questionnaire. The relation of the factor analysis with the Cronbach’s coefficient alpha was also determined, including the construct validity. Results: Eight composites with 34 items were extracted by exploratory factor analysis, with acceptable Cronbach’s alpha coefficients and good construct validity. Consequently, the composites jointly explained 62% of the variance in the responses. Five items were removed from the original version of the questionnaire. As a result, three out of the eight composites were a mixture of items from different compounds of the original tool. The composition of the five factors was similar to that in the original questionnaire. Conclusions: The MOSPSC tool in Greek primary healthcare settings can be used to assess patient safety culture in facilities across the country. From the study, the patient safety culture in Greece was positive, although few composites showed a negative correlation and needed improvement.

Variation in Perception of Safety Culture in Out-of-hours Family Medicine Service in Croatia

Introduction

The Safety Attitudes Questionnaire (SAQ) is among the most frequently cited tools for measuring safety culture in healthcare settings. Its ambulatory version was used in this study. The aim was to assess safety culture in out-of-hours (OOH) family medicine service and its variation across job positions, regions, and respondents’ demographic characteristic.

Methods

A cross-sectional observational study was carried out targeting 358 health professionals working in the 29 largest Croatian healthcare centres providing out-of-hours family medicine service. The response rate was 51.7% (185 questionnaires). The questionnaire comprised 62 Likert items with 5 responses (fully disagree to fully agree). Scores of negatively worded items were reversed before analysis. Scores on the total scale and subscales were calculated as additive scores. The study included demographic data on gender, age, working experience, and job position. Repeated measurement analysis of variance was used to assess variation of Safety Attitudes Questionnaire – Ambulatory Version (SAQ-AV) sub-scales.

Results

Nurses assessed safety culture higher than did physicians and residents. Teamwork climate had higher scores than Ambulatory process of care and Organizational climate. Stress recognition and Perceptions of workload had the lowest overall scores. Variation across gender, age, working experience, and region was not statistically significant.

Conclusions

SAQ-AV can be used to identify areas for improvement in patient safety at OOH GPs. There is a need to improve staffing and support for OOH GP residents. Further research is needed in order to gain better understanding of factors influencing observed variations among job positions.

Patient safety culture in Italian out-of-hours primary care service: a national cross-sectional survey study

Background

Out-of-hours (OOH) services in Italy provide >10 million consultations every year. To the authors' knowledge, no data on patient safety culture (PSC) have been reported.

Aim

To assess PSC in the Italian OOH setting.

Design & setting

National cross-sectional survey using the Safety Attitudes Questionnaire — Ambulatory Version (SAQ-AV).

Method

The SAQ-AV was translated into Italian and distributed in a convenience sample of OOH doctors in 2015. Answers were collected anonymously by Qualtrics. Stata (version 14) was used to estimate Cronbach’s alpha, perform exploratory and confirmatory factor analysis, correlate items to doctors’ characteristics, and to do item descriptive analysis.

Results

Overall, 692 OOH doctors were contacted, with a 71% response rate. In the exploratory factor analysis (EFA), four factors were identified: Communication and Safety Climate (14 items); Perceptions of Management (eight items); Workload and Clinical Risk (six items); and Burnout Risk (four items).

These four factors accounted for 68% of the total variance (Kaiser–Meyer–Olkin [KMO] statistic = 0.843). Cronbach’s alpha ranged from 0.710–0.917. OOH doctors were often dissatisfied with their job; there is insufficient staff to provide optimal care and there is no training or supervision for new personnel and family medicine trainees. Service managers are perceived as distant, with particular issues concerning the communication between managers and OOH doctors. A large proportion of OOH doctors (56.8%) state that they do not receive adequate support.

Conclusion

These findings could be useful for informing policies on how to improve PSC in Italian OOH service.

The safety attitudes questionnaire - ambulatory version: psychometric properties of the Norwegian version for nursing homes

BACKGROUND

Patient safety culture involves leader and staff interaction, routines, attitudes, practices and awareness that influence risks of adverse events in patient care. The Safety Attitudes Questionnaire (SAQ) is an instrument to measure safety attitudes among health care providers. The instrument aims to identify possible weaknesses in clinical settings and motivate quality improvement interventions leading to reductions in medical errors. The Ambulatory Version of the SAQ (SAQ-A) was developed to measure safety climate in the primary care setting. The original version of the SAQ includes six major patient safety factors: Teamwork climate, Safety climate, Job satisfaction, Perceptions of management, Working conditions, and Stress recognition. Patients in nursing homes are particularly vulnerable to adverse events. We present the psychometric properties of the Norwegian translation of the SAQ-A for the nursing home setting.

METHODS

The study was conducted in five nursing homes in Tønsberg, Norway, in February 2016. A total of 463 employees working more than 20% received a paper version of the translated SAQ-A adapted to the Norwegian nursing home setting and responded anonymously. Filled-in questionnaires were scanned and transferred to an SPSS file. SPSS was used to estimate Cronbach alphas, corrected item-total correlations, item-to-own and item-to-other correlations, and item-descriptive statistics. The confirmatory factor analysis was done by AMOS.

RESULTS

Of the 463 health care providers, 288 (62.2%) responded to the questionnaire. The confirmatory factor analysis showed that the total model of the six factors Teamwork climate, Safety climate, Job satisfaction, Perceptions of management, Working conditions, and Stress recognition had acceptable goodness-of-fit values in the nursing home setting.

CONCLUSIONS

The results of our study indicate that the Norwegian translated version of the SAQ-A, with the confirmed six factor model, is an appropriate tool for measuring patient safety climate in the nursing home setting. Future research should study whether there is an association between patient safety climate in nursing homes and occurrence of adverse events among the patients.