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Original Article Organizational Culture, Team Climate, and Quality Management in an Important Patient Safety Issue: Nosocomial Pressure Ulcers Marije Bosch, PhD, Ruud J.G. Halfens, PhD, Trudy van der Weijden, MD, PhD, Michel Wensing, PhD, Reinier Akkermans, MSc, Richard Grol, PhD ABSTRACT Background: Increasingly, policy reform in health care is discussed in terms of changing organizational culture, creating practice teams, and organizational quality management. Yet, the evidence for these suggested determinants of high-quality care is inconsistent. Aims: To determine if the type of organizational culture (Competing Values Framework), team climate (Team Climate Inventory), and preventive pressure ulcer quality management at ward level were related to the prevalence of pressure ulcers. Also, we wanted to determine if the type of organizational culture, team climate, or the institutional quality management related to preventive quality management at the ward level. Methods: In this cross-sectional observational study multivariate (logistic) regression analyses were performed, adjusting for potential confounders and institution-level clustering. Data from 1,274 patients and 460 health care professionals in 37 general hospital wards and 67 nursing home wards in the Netherlands were analyzed. The main outcome measures were nosocomial pressure ulcers in patients at risk for pressure ulcers (Braden score 18) and preventive quality management at ward level. Results: No associations were found between organizational culture, team climate, or preventive quality management at the ward level and the prevalence of nosocomial pressure ulcers. Institutional quality management was positively correlated with preventive quality management at ward level (adj. β 0.32; p < 0.001). Conclusions and Implications: Although the prevalence of nosocomial pressure ulcers varied con- siderably across wards, it did not relate to organizational culture, team climate, or preventive quality management at the ward level. These results would therefore not subscribe the widely suggested impor- tance of these factors in improving health care. However, different designs and research methods (that go beyond the cross-sectional design) may be more informative in studying relations between such complex factors and outcomes in a more meaningful way. KEYWORDS organizational culture, pressure ulcer, prevalence, quality of health care, institutional policies, team climate Worldviews on Evidence-Based Nursing 2010; x(x):1–11. Copyright ©2010 Sigma Theta Tau International Marije Bosch, Researcher, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; Ruud J.G. Halfens, Associate Professor, Department of Health Care and Nursing Science, Maastricht University, Maastricht, The Netherlands; Trudy van der Weijden, Professor, Implementation of Clinical Practice Guidelines, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands; Michel Wensing, Associate Professor, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; Reinier Akkermans, Statistician and Doctoral candidate, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; Richard Grol, Professor Quality of Care, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. This research was funded by the European Commission, Fifth Framework, Rebeqi project, contract no. QLRT-2001–00657. Address correspondence to Marije Bosch, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, PO. Box 9101, 6500 HB, Nijmegen, The Netherlands; [email protected] Accepted 18 January 2010 Copyright ©2010 Sigma Theta Tau International 1545-102X1/10 Worldviews on Evidence-Based Nursing xxxx 2010 1

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wvn_187_LROrganizational Culture, Team Climate, and Quality Management in an Important Patient Safety Issue: Nosocomial Pressure Ulcers
Marije Bosch, PhD, Ruud J.G. Halfens, PhD, Trudy van der Weijden, MD, PhD, Michel Wensing, PhD, Reinier Akkermans, MSc, Richard Grol, PhD
ABSTRACT Background: Increasingly, policy reform in health care is discussed in terms of changing organizational
culture, creating practice teams, and organizational quality management. Yet, the evidence for these suggested determinants of high-quality care is inconsistent.
Aims: To determine if the type of organizational culture (Competing Values Framework), team climate (Team Climate Inventory), and preventive pressure ulcer quality management at ward level were related to the prevalence of pressure ulcers. Also, we wanted to determine if the type of organizational culture, team climate, or the institutional quality management related to preventive quality management at the ward level.
Methods: In this cross-sectional observational study multivariate (logistic) regression analyses were performed, adjusting for potential confounders and institution-level clustering. Data from 1,274 patients and 460 health care professionals in 37 general hospital wards and 67 nursing home wards in the Netherlands were analyzed. The main outcome measures were nosocomial pressure ulcers in patients at risk for pressure ulcers (Braden score ≤ 18) and preventive quality management at ward level.
Results: No associations were found between organizational culture, team climate, or preventive quality management at the ward level and the prevalence of nosocomial pressure ulcers. Institutional quality management was positively correlated with preventive quality management at ward level (adj. β
0.32; p < 0.001). Conclusions and Implications: Although the prevalence of nosocomial pressure ulcers varied con-
siderably across wards, it did not relate to organizational culture, team climate, or preventive quality management at the ward level. These results would therefore not subscribe the widely suggested impor- tance of these factors in improving health care. However, different designs and research methods (that go beyond the cross-sectional design) may be more informative in studying relations between such complex factors and outcomes in a more meaningful way.
KEYWORDS organizational culture, pressure ulcer, prevalence, quality of health care, institutional policies, team climate
Worldviews on Evidence-Based Nursing 2010; x(x):1–11. Copyright ©2010 Sigma Theta Tau International
Marije Bosch, Researcher, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; Ruud J.G. Halfens, Associate Professor, Department of Health Care and Nursing Science, Maastricht University, Maastricht, The Netherlands; Trudy van der Weijden, Professor, Implementation of Clinical Practice Guidelines, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands; Michel Wensing, Associate Professor, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; Reinier Akkermans, Statistician and Doctoral candidate, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; Richard Grol, Professor Quality of Care, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
This research was funded by the European Commission, Fifth Framework, Rebeqi project, contract no. QLRT-2001–00657.
Address correspondence to Marije Bosch, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, PO. Box 9101, 6500 HB, Nijmegen, The Netherlands; [email protected]
Accepted 18 January 2010 Copyright ©2010 Sigma Theta Tau International 1545-102X1/10
Worldviews on Evidence-Based Nursing xxxx 2010 1
Organizational Factors in Pressure Ulcer Prevention
INTRODUCTION
There is a growing belief that one of the keys to im- proved health care practice and better patient safety
is structural support at different organizational levels (Sol- berg 2000; Ferlie & Shortell 2001). Such support enables the implementation of systems to facilitate clinical deci- sion making (Moss et al. 1998; Solberg 2000). To secure the gains in quality, it has been suggested that changes in culture are needed alongside the structural changes (Scott et al. 2003a). Different types of organizational cultures have been found to relate to health care performance out- comes including quality improvement activities (Shortell et al. 1995), team functioning (Strasser et al. 2002), care process indicators (Shortell et al. 2000), perceived orga- nizational performance (Gerowitz 1998), and evidence- based practices (Shortell et al. 2001). Few studies have demonstrated a link to such patient outcomes as patient satisfaction (Meterko et al. 2004) or physical and men- tal health outcomes (Shortell et al. 2000). In addition, the importance of effective health care teams in attaining safe and high-quality care has been stressed (Institute of Medicine 2001). Teamwork provides a means to reduce care fragmentation, widen professional skills, and han- dle the complexity of modern care (Firth-Cozens 1998; Friedman & Berger 2004). Higher levels of teamwork have been found to produce improved outcomes in terms of overall clinical performance, (Haward et al. 2003) ab- sence of hospital physicians due to sickness (Kivimaki et al. 2001), and patient outcomes (Campbell et al. 2001; Bower et al. 2003; Wheelan et al. 2003). For instance, a study in American intensive care units found that staff members of units with mortality rates that were lower than predicted perceived their teams as functioning at higher stages of group development. They perceived their team members as less dependent and more trusting than did staff mem- bers of units with mortality rates that were higher than predicted (Wheelan et al. 2003).
The development of pressure ulcers constitutes a preva- lent and serious health care problem. Patients remain longer in hospital than otherwise might be needed and of- ten require intensive treatment. Studies show a wide range of prevalence rates from less than 5% (Lyder 2001) to over 40% (Thomson & Brooks 1999). The total cost of pressure ulcers have been estimated to be around £1.4–£2.1 bil- lion (4% of total NHS expenditure) annually in the United Kingdom (Bennett et al. 2004), around US$11 billion in 2006 in the United States (Russo et al. 2008), and the most conservative estimate of a Dutch study was 1% of the total health care budget (Severens et al. 2002). However, most pressure ulcers can be prevented with high-quality care, and they therefore constitute an important quality-of-care
indicator (Lyder 2003). For example, in 2003, pressure ul- cers were introduced as a quality indicator by the Nether- lands Health Care Inspectorate.
The prevention of pressure ulcers requires concerted action on the part of health care professionals. Effective communication and careful coordination of tasks and re- sponsibilities are thus necessary. This means that the team- work and organizational culture within an institution may certainly influence the way the pressure ulcer preventive care is organized and structured at ward level and, perhaps, the prevalence of nosocomial pressure ulcers directly. With the increasing demand for transparency in patient safety issues, it is of utter importance for policy makers to identify factors that may contribute to low prevalence figures.
In this study, we aimed to determine if the type of or- ganizational culture, team climate, and preventive qual- ity management at ward level related to the prevalence of nosocomial pressure ulcers in patients at risk for pressure ulcers. Also, we wanted to determine if the type of organi- zational culture, team climate, or the institutional quality management related to preventive quality management at the ward level.
METHODS
Design and Population Since 1998, the prevalence of pressure ulcers has been an- nually measured in the Netherlands via standardized point prevalence screening (Bours et al. 2002) on a prespecified day. In 2005, each Dutch health care organization was in- vited to participate on April 4. In participating wards, all patients that handed in informed consent were included in the measures. Adult patients at risk for pressure ulcers (Braden score ≤ 18; age ≥ 18 years) were included in the analyses. Besides patient outcomes, various structural fac- tors and indicators to measure pressure ulcer preventive quality management at ward and organizational level were scored.
In this study, a secondary analysis of data collected dur- ing the 2005 national prevalence study for those patients at risk of pressure ulcers was performed. All of the 61 gen- eral hospitals and 92 nursing homes, which participated in April 2005, were invited to complete an additional ques- tionnaire on team climate and organizational culture. The questionnaires were sent to the managers of two randomly selected wards per institution in May and June of 2005 for distribution to one doctor and four nurses or nursing assistants from the same patient care team on a ward.
Four hundred ninety-four respondents from 117 wards in 25 hospitals and 36 nursing homes returned our ques- tionnaire for team climate and organizational culture.
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Organizational Factors in Pressure Ulcer Prevention
Response rates were 41% for the hospital wards and 39% for the nursing home wards; 25% of the nonresponse was caused because the surveys could not be allocated to a specific ward. Of 2,686 patients, who handed in informed consent, 1,322 patients were excluded because they did not meet our patient inclusion criteria (Braden score ≤ 18; age ≥ 18 years). Furthermore, when less than three care providers of a ward returned our team climate and organi- zational culture questionnaires (8 wards, 15 respondents), the patients from this particular ward were excluded as well (n = 90). Therefore, the analyses included a total of 1,274 patients on 104 wards with measures derived from 460 health care providers. The prevalence screening was approved by the Maastricht University Medical Centre ethics committee, and all included patients handed in writ- ten informed consent.
Measures Our clinical outcome was the case-mix-adjusted point prevalence of nosocomial pressure ulcers (grade II or worse) in risk patients per ward. Patients’ risk for pressure ulcer development was assessed using the Braden Scale (Bergstrom et al. 1987), which encompasses six subscales that conceptually reflect degrees of sensory perception, moisture, activity, mobility, nutrition, and friction and shear. All subscales are rated from 1 (worst) to 4 (best), apart from friction and shear, which is rated from 1 to 3. The subscales were summed for a total score, ranging from 6 to 23. In this study, a cut-off point of 18 was cho- sen, since this is recommended for all settings (Bergstrom et al. 1998). Pressure ulcers were assessed according to the European Pressure Ulcer Advisory Panel (EPUAP) grading system (EPUAP 2008). Grade I ulcers were not counted as it is difficult to accurately diagnose nonblanchable dis- coloration (Bergstrom et al. 1996). And only nosocomial pressure ulcers were counted as this means that the ul- cers developed in the current institution and therefore represent quality of care. In order to standardize mea- surements, prior to measurement, health care personnel involved were trained by the coordinator in each institu- tion and the research project team. Each patient was scored by a health caregiver working on the patients’ ward, and by a health care provider working on a different ward. Disagreements were discussed and solved with an inde- pendent third trained care provider (please refer to Bours et al. 2002 for more information).
The second outcome was the sum score of eight indi- cators for preventive quality management at ward level, which was measured by a checklist completed by the head of each participating ward (Bours et al. 2002; Halfens et al. 2005) (see Figure 1; Cronbach’s alpha 0.69).
The first independent variable was the sum score for the 11 indicators of quality management at the institutional level (Bours et al. 2002; Halfens et al. 2005) (see Figure 1; Cronbach’s alpha 0.62), measured by a checklist that was completed by the coordinator in each participating organi- zation. The quality indicators included in this study were formulated by a team of Dutch experts in the pressure ulcer field, and were based on (inter)national guidelines (EPUAP 1998; Dutch Institute for Healthcare Improvement [CBO] 2002), and expert opinion.
To measure organizational culture, we used the Com- peting Values Framework (CVF). The framework dis- tinguishes two dimensions: “internally oriented” versus “externally oriented,” and “stability” versus “flexibility and change,” resulting in four ideal types of culture (see Figure 2). The framework encompasses five questions re- ferring to particular aspects of organizational life: overall character, leadership style, institutional bonding, strategic emphasis, and reward system. For each of these questions, respondents are asked to distribute a total of 100 points across four sets of statements in such a manner that the organizational nature of the institution is best represented (Quinn & Kimberly 1984). For each of the five questions, nonblank respondent errors were corrected for by propor- tionally adjusting the responses to add to 100. The number of points allocated to each type of organizational culture was then averaged across the five questions. Cronbach’s alphas were 0.69 for group culture, 0.56 for developmen- tal culture, 0.51 for hierarchical culture, and 0.41 for the rational culture statements. The scores reported for the group, developmental and hierarchical types of organiza- tional culture were somewhat lower than those reported in other studies in health care settings (Shortell et al. 2001; Meterko et al. 2004) but still considered acceptable in light of the low number of items (5) within the concepts. For each ward, the mean scores for the four types of organi- zational culture were determined. The data were opera- tionalized in two manners, which have been described in previous studies (Shortell et al. 2000; Meterko et al. 2004). First, the separate scores for the different types of organi- zational cultures were treated as a continuous variable. Second, for each ward the dominant type of culture (the type that received the highest mean score) was determined, which led to a categorical variable.
Teamwork was measured with the short version of the Team Climate Inventory (TCI) (Anderson & West 1994; Loo & Loewen 2002). The underlying theory as- sumes that effective team performance often results from team activities, which are characterized by: (1) a focus on clear and realistic objectives (vision), (2) a participa- tory and nonthreatening climate for team interaction (par- ticipative safety), (3) commitment to high standards of
Worldviews on Evidence-Based Nursing xxxx 2010 3
Organizational Factors in Pressure Ulcer Prevention
Figure 1. Indicators of the pressure ulcer quality management at the level of the institution and at the level of the ward.
performance (task orientation), and (4) support for at- tempts at innovation (support for innovation). The in- strument uses 14 statements or questions reflecting the underlying factors, and 5-point Likert scales ranging from 1 (strongly disagree, indicating a “poor” team climate) to 5 (strongly agree, indicating high levels of team climate). Overall Chronbach’s alpha for the 14 questions was 0.87. For each subscale, mean scores were calculated per indi- vidual and then averaged to ward-level scores. We then combined these to one overall ward score (Campbell et al. 2001).
Both the CVF and the TCI were translated into Dutch, following the guidelines for cross-cultural adaptation (Beaton et al. 2000). Items were translated from English to Dutch by a bilingual researcher, followed by back trans- lation from Dutch to English by a second bilingual re- searcher. Discrepancies between the original questionnaire items and the back translation were identified and solved with a third bilingual researcher and all researchers were
familiar with the theoretical constructs. A pilot test was performed to measure acceptation, item response, and ter- minology, on the basis of which one small adaptation in wording was made. While the measures were administered at the individual level, the climate and culture variables re- quired shared perceptions. Analyses of variance verified that the individual responses for team climate and organi- zational culture could be validly aggregated at the level of the team. That is, the within-team variability was clearly less than the between-team variability (F-values ranging from 1.9 to 2.3, p < 0.001).
The following—possibly confounding—variables (Bours et al. 2004) were also included in the analyses: age, derived from the medical records; and type of ward, derived from the ward checklist and malnutrition. The definition of malnutrition was based on the literature and consultation of experts in the field of malnutrition in Europe, and was operationalized by one of the three following criteria: (1) a Body Mass Index (BMI) less than
4 xxxx 2010 Worldviews on Evidence-Based Nursing
Organizational Factors in Pressure Ulcer Prevention
Figure 2. Competing values framework.
18.5 with age <85, or a BMI of less than 24 with age ≥85; (2) unintentional weight loss (6 kg during the last 6 months or 3 kg during the last month); or (3) a BMI between 18.5 and 20 with age <85, and between 24 and 26 with age ≥85 in combination with no nutritional intake for 3 days or reduced intake for more than 10 days (Meijers et al. 2009). If any one of these three criteria could be confirmed, the patient was diagnosed as malnourished (Halfens et al. 2006).
Statistical Analyses Descriptive statistics were calculated for the patients and the wards. Bivariate correlations were examined to check for particularly high intercorrelations. Univariate associa- tions between the different variables were examined using SPSS 12.0.1 (SPSS Inc., Chicago, IL; ANOVAs, t-tests, Pear- son’s correlation, and Chi-square test). Multilevel logistic regression analyses were performed using the Glimmix procedure in SAS for Windows V8.2 (SAS Institute, Cary, NC) with patients (level 1) nested within institutions (level 2) to explore associations between organizational culture, team climate, and preventive quality management at ward level on the one hand and the prevalence of pressure ulcers on the other. It was hard to attain a good estimate of the random ward effect due to the small number of wards per institution. The random effect was therefore distributed to the level of the institution. Since we were interested in the effect of each of our variables of interest separately (culture, team climate, and quality management), we used separate models with one of these variables at a time. The four types
of organizational culture could not be examined together within a single model as the scores were not independent. Seven separate models were thus created for the prevalence of pressure ulcers: four models for the four organizational cultures, one for the dominant organizational culture, one for the team climate and, finally, one for preventive qual- ity management at ward level. In each model, the effects of patient age, malnutrition, and type of ward were con- trolled for. Adjusted odds ratios (adj. OR) were calculated to describe the associations between the determinants and the outcome. An OR > 1 means a positive associa- tion with the outcome. Two-sided p-levels of <0.05 were considered statistically significant. Finally, the influences of organizational culture, team climate, and institutional quality management on preventive quality management at ward level were examined. General Linear Model regres- sion analysis was performed using SPSS 12.0.1, and the type of ward was controlled for.
RESULTS
Patient and Ward Characteristics Table 1 shows patient and ward characteristics. The to- tal number of patients with nosocomial pressure ulcers (grade II or worse) was 129. The mean point preva- lence of nosocomial pressure ulcers (grade II or worse) in risk patients was higher in the general hospitals as com- pared to the nursing homes (14.2% and 9.7%, respectively, p = 0.02). We distinguished 7 different types of wards: in general hospitals 12 surgery wards, 15 internal wards,
Worldviews on Evidence-Based Nursing xxxx 2010 5
Organizational Factors in Pressure Ulcer Prevention
TABLE 1 Characteristics of patient population (N = 1,274) and wards (N = 104)
GENERAL HOSPITAL NURSING HOME PATIENTS (N = 235) PATIENTS (N = 1,039)
Age (mean, SD) 73.5 (14.3) 81.0 (11.6) Male (mean %) 48.5% 27.5% Braden score (mean, SD) 14.8 (2.7) 14.5 (2.6)
GENERAL HOSPITAL WARDS (N = 37) NURSING HOME WARDS (N = 67)
Prevalence of nosocomial pressure ulcers (grade II or worse) (mean %, SD)
14.2 (0.0–25.0)a 9.7 (0.0–12.5)a
Malnutrition (mean %, SD) 31.2 (29.3) 18.6 (0.0–29.6)a
Preventive pressure ulcer quality management at ward level (0–8) (mean, SD)
4.8 (1.9) 5.2 (1.8)
Organizational culture (mean, SD) Group (0–100) 28.6 (8.6) 32.3 (11.9) Developmental (0–100) 18.1 (6.4) 18.3 (5.8) Hierarchical (0–100) 31.9 (8.0) 29.2 (9.4) Rational (0–100) 21.4 (5.6) 20.2 (7.3)
Dominant culture (%) Group 37.8% 53.0% Developmental 5.4% 1.5% Hierarchical 51.4% 40.9% Rational 5.4% 4.5%
Team climate overall score (1–5) (mean, SD) 3.71 (0.24) 3.75 (0.34) Institutional quality management (0–11) (mean, SD) 8.5 (2.0) 6.3 (2.6) aDue to skewed distributions: 25th and 75th percentiles presented.
and 10 other wards were included, and in nursing homes 36 psychogeriatic, 7 somatic reactivation, 18 somatic long stay, and 6 other wards. In 51.4% of the general hospital wards, hierarchical culture scored highest (mean across wards of 31.9); in 53% of the nursing hospital wards, group culture scored highest (mean across wards of 32.3). The team climate scores were 3.71 for general hospitals and 3.75 for nursing homes. The general hospitals scored bet- ter with respect to the institutional quality management than the nursing homes (8.5 vs. 6.3).
Multivariate Associations with Prevalence of Nosocomial Pressure Ulcers Table 2 shows the associations between different types of organizational cultures, team climate, and preventive quality management at ward level on the one hand and prevalence of nosocomial pressure ulcers on the other. Prevalence did not relate to any of the variables. Overall, the pooled dominant culture variable was not significantly related to pressure ulcers (p = 0.17), although it showed a tendency in favor of a predominantly rational ward as compared to predominantly group or hierarchical culture
TABLE 2 Influences of different types of organizational cultures, team climate, and preventive pressure ulcer quality management at ward level or dominant type of organizational culture on prevalence of nosocomial pressure ulcers adjusted for patient age, malnutrition, and type of ward
ADJ. OR 95% CI
culture (0–100) 1.02 0.98, 1.06
Hierarchical culture (0–100) 0.99 0.97, 1.02 Rational culture (0–100) 0.99 0.96, 1.02 Team climate (1–5) 1.00 0.50, 2.02 Preventive pressure ulcer
quality management at ward level (0–8)
0.96 0.88, 1.06
Dominant culture (categorical)∗
Group 4.21 1.20, 14.79 Developmental 4.03 0.66, 24.83 Hierarchical 4.00 1.13, 14.23 Rational 1.00 –
∗p = 0.17
Organizational Factors in Pressure Ulcer Prevention
TABLE 3 Influences of different types of organizational cultures, team climate, institutional quality management, or dominant type of organizational culture on preventive pressure ulcer quality management at ward level adjusted for type of ward
ADJ. B 95% CI
Group culture (0–100) −0.01 −0.04, 0.03 Developmental culture (0–100) −0.02 −0.08, 0.05 Hierarchical culture (0–100) 0.01 −0.03, 0.06 Rational culture (0–100) 0.01 −0.05, 0.06 Team climate (1–5) 0.86 −0.32, 2.04 Institutional quality management (0–11) 0.32 0.18, 0.47∗
Dominant culture type Group −0.04 −1.77, 1.69 Developmental 1.03 −1.66, 3.72 Hierarchical 0.27 −1.46, 1.99 Rational – –
∗p < 0.001
wards (adj. OR 4.2; p = 0.03 and adj. OR 4.0; p = 0.03, respectively).
Multivariate Associations with Pressure Ulcer Preventive Quality Management at Ward Level The different types of organizational cultures and team climate were not associated with preventive quality man- agement at ward level (Table 3). However, institutional quality management was strongly associated with preven- tive quality management at ward level (p < 0.001) and accounted for 17.2% of the 23.1% explained variance.
DISCUSSION
Although organizational culture, team climate, and qual- ity management have all been argued to potentially con- tribute to the improvement of patient care, the present re- sults show only the quality of pressure ulcer management at institutional level to strongly contribute to preventive quality management at ward level. However, contrary to our expectations, a significant link to the prevalence of nosocomial pressure ulcers was not detected.
Strengths and Weaknesses of the Study and Comparison with Other Studies There are several possible explanations for the absence of associations with the outcome variables in this study. First, the relations between the organizational factors and out- comes may be much more complex than we suggested. It is possible that other aspects of an institution or team medi- ate or moderate these relationships, such as the perceived level of external accountability, the way a team learns from mistakes, team characteristics such as size, compo-
sition and workload, and human recourse management. To identify important issues, it is important to go beyond the cross-sectional quantitative studies. Further research might benefit from combining qualitative and quantitative methods, and also study the interrelations between differ- ent factors in the system. For instance, a recent review on linkages between organizational factors, medical errors, and patient safety (Hoff et al. 2004) suggests that stud- ies should take a “systems perspective” (Shortell & Singer 2008). In addition to a variable such as “teamwork,” a larger, more interconnected web of organizational dynam- ics should be considered in the analyses based on several different theoretical models. However, the multilevel de- sign of this type of quantitative studies implies that one can study only a limited number of factors at cluster level. So, other designs such as qualitative studies are needed to study a broad range of interconnected factors. A recent review on teamwork within the psychological literature suggested that since teamwork is dynamic, its manifesta- tion can vary based on a vast number of variables, such as team environment, type of task, individual difference, and perceived workload (Salas et al. 2005). Therefore, to fully understand such a construct, the authors argued that it is insufficient to take a single snapshot of team perfor- mance. Instead, it should be sampled during a variety of conditions and situations, including both laboratory and applied research settings (Salas et al. 2005).
Also, we may have found relationships if we had selected outcomes that are more closely linked to culture and cli- mate such as job satisfaction of caregivers. Although the selection of a clinical outcome is important to distinguish between process and outcome variables, one might run the risk with the selection of such a specific variable of becoming too narrow to reflect the complexity of modern patient care (Horn 2006). Also, the prevention of pressure ulcers requires an ongoing, continuous care delivery pro- cess by several caregivers, compliant with guideline rec- ommendations. It is likely that there is a considerable gap between what is recorded in medical records or in policy documents and protocols, and what is actually done in practice (Bates-Jensen et al. 2003b). Although, for health care management and policy makers, it is still very im- portant to know whether preventive quality management at ward level indeed leads to better safety outcomes for patients, it would have been informative if we also had the information regarding the actual preventive care pro- vided to each patient. Therefore, the results of this study would benefit from additional research using preferably other methods such as practice observations to register the actual implementation of recommendations at patient level (Bates-Jensen et al. 2003a) in addition to our sum score of preventive quality management at ward level.
Worldviews on Evidence-Based Nursing xxxx 2010 7
Organizational Factors in Pressure Ulcer Prevention
A second possible explanation may be that the measure- ment instruments were unsuitable for finding the relation- ships we explored. We selected the instruments we used in this study because they had been validated previously, and had been used in numerous other studies. By using the same instruments, one allows for better comparison between the different studies, which is important to gain insight into the relevance of these constructs. A review (Scott et al. 2003a) on the association between organiza- tional culture and health care performance concluded that in 4 out of 10 studies that used the CVF, significant asso- ciations were found. However, these studies were mostly concerned with performance as perceived by managers. The observed associations were also found for only those aspects of performance, which were clearly valued by the dominant culture. Since the prevention of pressure ulcers relies on a concerted action between different caregivers with clear responsibilities, one could argue that the more “social” cultures, which tend to enhance team function- ing and creativity (the flexible group and developmental types) show positive associations with preventive efforts and the prevalence of pressure ulcers. However, prevent- ing ulcers also requires a strict adherence to the evidence- based protocol. Therefore, on the other hand, one could also argue that the more control-orientated rational or hi- erarchical culture types with a focus on policies, proce- dures, and production might be just as useful in attaining safety in patient care. However, our findings did not sub- scribe to either of these ideas, although an earlier study on the relations between the CVF, the extent of quality improvement, and pressure ulcers in nursing homes did find that quality improvement implementation was greater in those nursing homes with an organizational culture that emphasizes innovation and teamwork (Berlowitz et al. 2003). However, like in our study, no significant associa- tion was found between quality improvement implemen- tation and either adherence to guideline recommendations as reported in patient records or the rate of pressure ulcer development.
We also failed to find significant associations between teamwork and the outcomes. Previous studies that used the TCI explored associations between team climate and performance showed mixed results. For instance, a study in primary care identified team climate as a key part of pro- viding high-quality care across a range of areas (Campbell et al. 2001). Gibbon et al. used the TCI to examine whether team-coordinated approaches could improve staff attitudes to team working in stroke care. They concluded that at- titudes did not significantly improve; teams appeared to take a long time to establish cohesion and develop shared values (Gibbon et al. 2002). The absence of associations
in our study thus contributes to the debate concerning the meaning of the concepts of organizational culture and team climate (Scott et al. 2003b), and the measurement of these complex constructs (Colla et al. 2005). For instance, since climate and culture are considered to be shared attributes, individual measures are aggregated to ward level. Yet, this ignores the fact that different subgroups (e.g., nurses and doctors within a team) may have different opinions and re- duces variation that may exist between individuals (Scott et al. 2003b). Other studies have raised concerns about the suitability of using survey-based scales to show the link be- tween such complex factors and clinical patient outcomes (Colla et al. 2005). Future research would probably bene- fit from qualitative research methods and the exploration of instruments that are more sensitive to measure these complex constructs.
Third, other methodological limitations could have played a role. For instance, in order to minimize the bur- den on the participating teams, the number of respondents for the organizational culture and team climate question- naires was small (between 3 and 5) while the number of respondents for a team or group variable ideally should be as high as possible. The Cronbach’s alphas for the orga- nizational culture subscales, for example, were quite low, which shows low internal consistency for the subscales, which may have diluted potential relations. Also, response bias may have influenced the results. For instance, we asked the ward managers to distribute the questionnaires among members of the same patient care team at their ward. It is possible that respondents who were asked to complete the questionnaires could have been more in- clined to assign higher scores on team climate as com- pared to others who were not asked to participate in the study. However, scores on team climate were in line with previous studies (Dackert & Brenner 2002; Loo 2003). Mean culture scores tend to vary considerably between several studies so it is hard to compare our scores to scores of studies conducted previously. Finally, response rates were quite low, and therefore we may have lacked the power to find associations. The wide confidence inter- vals in Table 3 for the categorical dominant culture vari- able show that this point may, at least partly, limit our results.
CONCLUSIONS
Despite the possible limitations on this study, to our knowledge, it is the first Dutch study in hospitals and nursing homes to explore the associations between orga- nizational culture, teamwork, and quality management for an important patient safety issue measured in an objective
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manner. The absence of significant associations for our fac- tors of interest and the prevalence of nosocomial pressure ulcers contributes to the ongoing discussion of the poten- tial of these constructs to improve patient care. Additional research is needed to determine if, under what conditions, and exactly how these variables can be meaningfully mea- sured and to learn about their potential contribution to safer and higher quality patient care. Mixed methods as well as methods to generate knowledge within a context of application may contribute to future knowledge develop- ing.
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