Patient safety culture in hospital settingsMeasurements, health care staff perceptions and suggestions for improvement

Anna Nordin

Anna N

ordin | Patient safety culture in hospital settings | 2015:20

Patient safety culture in hospital settings

In health care, many patients are being harmed, with leads to suffering and financial costs. Health care staff’s patient safety culture reflects their attitudes towards safety for patients. The overall aim was to psychometrically test the questionnaires S-HSOPSC and HSOPSC for measuring patient safety culture, investigate health care staff’s perceptions of patient safety culture and their suggestions for improvement. In this thesis, respondents in the most common health care staff groups participated. Health care staff held a positive attitude towards patient safety culture within their own unit’s work. The perception of patient safety culture differed between professions and managers had a more positive attitude towards patient safety culture than others. Health care staff’s attitudes towards patient safety decreased during the measurement period for almost all aspects and they suggested many approaches to improve patient safety. Patient safety needs to be a responsibility for everyone. Supporting, committed managers, teamwork and collaboration are important for patient safety improvement. RNs have an important coordinating position in patient safety work.

DISSERTATION | Karlstad University Studies | 2015:20 DISSERTATION | Karlstad University Studies | 2015:20

ISSN 1403-8099

Faculty of Health, Science and TechnologyISBN 978-91-7063-634-9

Nursing Science

DISSERTATION | Karlstad University Studies | 2015:20

Patient safety culture in hospital settingsMeasurements, health care staff perceptions and suggestions for improvement

Anna Nordin

Print: Universitetstryckeriet, Karlstad 2015

Distribution:Karlstad University Faculty of Health, Science and TechnologyDepartment of Health SciencesSE-651 88 Karlstad, Sweden+46 54 700 10 00

© The author

ISBN 978-91-7063-634-9

ISSN 1403-8099

urn:nbn:se:kau:diva-35424

Karlstad University Studies | 2015:20

DISSERTATION

Anna Nordin

Patient safety culture in hospital settings - Measurements, health care staff perceptions and suggestions for improvement

WWW.KAU.SE

Patient safety culture in hospital settings Measurements, health care staff perceptions and suggestions for

improvement The aim was to psychometrically test the S-HSOPSC and HSOPSC, investigate health care staff’s perceptions of patient safety culture and their suggestions for improvement. Methods: A three-time cross-sectional study with data from health care staff (N= 3721) in a Swedish county council was conducted in 2009 (N = 1,023), 2011 (N = 1,228) and 2013 (N = 1,470) using the S-HSOPSC (I, II, III). Health care staff’s suggestions for patient safety improvement were analyzed in a qualitative content analysis study (IV). Results: The S-HSOPSC (14 dimensions, 51 items) is acceptable for measuring patient safety culture (I). Health care staff held a positive attitude towards dimensions of patient safety dealing with their own unit’s work, and a less favorable attitude towards hospital managers’ support for patient safety work (I). Managers held a more positive attitude towards patient safety than enrolled nurses (ENs), registered nurses (RNs) and physicians and ENs held a more positive attitude than RNs and physicians (II, III). Health care staff’s attitudes towards learning, nonpunitive response and staffing was positively associated with positive attitudes towards overall safety (II). Health care staff’s attitudes towards patient safety decreased during the measurement period for 12 out of 14 dimensions (III). A diversity of approaches, nuanced in relation to the informants’ profession was suggested to improve patient safety. The suggestions were distributed over nine categories for example ‘Increased staffing’ ‘Teamwork and collaboration’, ‘Improved feedback’ and ‘Committed management' (IV) Conclusions: The S-HSOPSC is suitable for measuring patient safety culture. Patient safety needs to be a responsibility for everyone. Supporting and committed managers, teamwork and collaboration are important for patient safety improvement. RNs have an important coordinating position in patient safety work, since they work in close proximity to the patients, and strategically in teams, where decisions of importance for patient safety are made. Health care staff’s attitudes towards communication, nonpunitive approach, feedback and learning from mistakes have deteriorated. To prevent from organizational fatigue, actions are needed. Keywords: patient safety culture, S-HSOPSC, HSOPSC, psychometric testing, managers, health care staff, nursing

Patientsäkerhetskultur i sjukhusmiljö Mätningar, sjukvårdspersonals uppfattningar och förslag på förbättring

Syftet var att psykometriskt testa S-HSOPSC och HSOPSC, undersöka sjukvårdspersonals attityder till patientsäkerhetskultur samt deras förslag till förbättringar. Metod: Tre tvärsnittsundersökningar genomfördes i ett landsting där sjukvårdspersonal (N=3721) besvarade den svenska versionen av Hospital Survey on Patient Safety Culture (S-HSOPSC) år 2009 (n=1023), 2011 (n=1228) och 2013 (n=1470) (I, II, III). Sjukvårdspersonalens förslag på förbättring av patientsäkerhet analyserades med kvalitativ innehållsanalys (IV). Resultat: S-HSOPSC (14 dimensioner, 51 frågor), är acceptabel för att mäta patientsäkerhetskultur (I). Sjukvårdspersonalen hade en positiv attityd till aspekter av patientsäkerhet som rörde arbete på den egna vårdenheten, men en mindre positiv attityd till högsta ledningens stöd för patientsäkerhetsarbetet (I). Chefer hade en mer positiv attityd till patientsäkerhet än undersköterskor, sjuksköterskor och läkare och undersköterskor hade en mer positiv attityd än sjuksköterskor och läkare (II, III). Förmågan att dra lärdom av misstag, en icke skuldbeläggande attityd vid misstag och personaltäthet var positivt associerad till en övergripande säkerhetsmedvetenhet (II). Sjukvårdspersonalens attityder till patientsäkerheten försämrades under mätperioden för 12 av 14 dimensioner (III). Sjukvårdspersonalen gav förslag till förbättring av patientsäkerheten som var fördelade på nio kategorier, bl.a. ’Ökad personaltäthet’, ’Teamwork och samverkan’, ’Förbättrad återkoppling’ och ’Engagerat ledarskap’. Förslagen var nyanserade i relation till informanternas egen profession (IV). Konklusioner: S-HSOPSC passar för att mäta patientsäkerhetskultur. Patientsäkerhet behöver vara ett ansvar för alla. Stöttande och engagerade chefer, teamwork och samverkan är viktigt för förbättrad patientsäkerhet. Sjuksköterskor har en viktig samordnande funktion i patientsäkerhetsarbetet, då de både arbetar nära patienterna och i team där det tas viktiga beslut som rör patientsäkerheten. Personalens attityd till kommunikation, icke bestraffande synsätt, återkoppling och lärande i samband med misstag har försämrats. För att förhindra en organisatorisk utmattning krävs åtgärder. Nyckelord: patientsäkerhetskultur, S-HSOPSC, HSOPSC, psykometrisk testning, chefer, sjukvårdspersonal, omvårdnad

TABLE OF CONTENT ABBREVIATIONS………………………………………………....………….… 3 ORIGINAL PAPERS……………………………………………..........………… 4 PREFACE……………………………………………………………...............….. 5 INTRODUCTION……………………………………………................................. 6 BACKGROUND………………………………......................………………..…… 8 Health Care Staff……………………………………..................…………..………..8 Policy documents…………………………………….....................………………….9 Teamwork…………………………………………………....................…………… 10 Professional ethics…………………………………….....….......................................... 11 Errors and adverse events in health care………………………………....................... 12 Patient Safety……………………………………………………………................... 16 Patient Safety Culture…………………………………………………….…............. 17 Instruments to measure health care staff’s attitudes towards patient safety……..........19 Studies of health care staff’s attitudes towards patient safety………………..…......... 22 Patient safety improvement…………………………………………......................… 24 Rationale for the thesis…………………………………………................................. 26 AIMS……………………………………………………..…....................................... 27 METHODS…………………………………..….......................................................... 28 Design………………………………................................................................................. 28 Participants….......................................................................................................................... 28 Data collection…………………………………………..…......................................... 30 Data analyses…………………………………………................................................... 32 Statistics (I-III) …………………………………….................................................…… 32 Qualitative Content analysis (IV) ………………………………........................................ 33 ETHICAL CONSIDERATIONS…………………………...................................... 35

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MAIN RESULT…………………………………………………………............... 36 Psychometric properties of the S-HSOPSC and HSOPSC (I) .......................... 36 Perceptions of patient safety culture (I) …………………………………......... 36 Comparisons of health care staff’s perception of patient safety culture (II, III)............................................................................................ 38 Managers’ perceptions of patient safety culture (II, III) …………………………....................38 Registered nurses’, enrolled nurses’ and physicians’ perceptions of patient safety culture (II, III)...... 40 Women’s and men’s perception of patient safety culture (II) ……………………...................... 42 Age groups and work experience and perception of patient safety culture (II).................................. 42 Workplace and perception of patient safety culture (II, III)………….......................... 44 Factors related to patient safety culture (II, III)……… …..……................................... 45 Patient safety culture change over time (III)...……… ……............................................ 46 Health care staff’s suggestions for patient safety improvement (IV)……… …........... 47 Summary of results…………………………………………….................................... 50 DISCUSSION…………………………………………............................................... 52 METHODOLOGICAL CONSIDERATIONS…...................................................... 62 CONCLUSIONS AND IMPLICATIONS FOR PRACTICE................................ 67 FUTURE RESEARCH…………………………...................................................... 69 ACKNOWLEDGEMENTS……………………........................................................ 70 REFERENCES……………………………………..................................................... 72 Appendix 1........................................................................................................................... 94

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ABBREVIATIONS

CFA Confirmatory factor analysis EFA Exploratory factor analysis EN Enrolled nurse HAI Hospital associated infections HRO High-reliability/risk organization HSOPSC Hospital Survey on Patient Safety Culture ICN International Council of Nurses ICU Intensive Care Unit NNF Northern Nurses Federation RN Registered nurse SALAR Swedish Association of Local Authorities and Regions S-HSOPSC Swedish version of Hospital Survey on Patient Safety Culture SMA Swedish Medical Association WHO World Health Organization WMA World Medical Association

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ORIGINAL PAPERS

I. Nordin, A., Wilde-Larsson, B., Nordström, G. & Theander, K. (2013).

Swedish hospital survey on patient safety culture -psychometric properties and health care staff’s perception. Open Journal of Nursing 3, 41-50. http://dx.doi.org/10.4236/ojn.2013.38A006

II. Nordin, A., Theander, K., Wilde-Larsson, B. & Nordström, G. (2013).

Health care staffs’ perception of patient safety culture in hospital settings and factors of importance for this. Open Journal of Nursing 3, 28-40. http://dx.doi.org/10.4236/ojn.2013.38A005

III. Nordin, A., Nordström, G., Wilde-Larsson, B., Hallberg, A. &

Theander, K. (201X). Patient safety culture over time–health care staff’s perceptions. Submitted.

IV. Nordin, A., Wilde-Larsson, B., Nordström, G. & Theander, K. (201X).

Improvements of patient safety – suggestions from health care staff. In manuscript.

Reprints were made with kind permission from the publishers.

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PREFACE

In my work as a registered nurse, I made mistakes. My fellow workers, registered nurses, enrolled nurses and physicians, also made mistakes. By the help of managers we put the mistakes in their context and together we learned from them. The worst were not the mistakes that were made, but the mistakes that were made and detected, yet remain untold because the person who made them, or detected them, was afraid of what would happen when the mistake was uncovered and exposed, for everyone to take part of. Many mistakes were kept secret out of guilt and shame. Had others known about them, everyone could have learned from them.

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INTRODUCTION

In spite of considerable advances in technology and skills in health care over the past decades, patients are still being affected by injuries caused by health care. The first measure of adverse events revealed that 3.7 % of all patients were affected (Brennan et al., 1991). The adverse events caused prolonged hospitalization, produced a disability at the time of discharge, or both (Brennan et al., 1991). The international interest in patient safety increased heavily after the report “To err is Human: Building a Safer Health System”, which stated that one of the leading causes of death and injury in the US was medical errors (Kohn et al., 2000). After this, improving health care became an important focus in all aspects of care. When the studies to measure hospital adverse events were internationally replicated, it was shown that they concerned approximately 9 % of all patients (de Vries et al., 2008). Adverse events lead to great human suffering, not only for patients (Baker et al., 2004), relatives (Vincent, 2003) and health care staff (Stangierski et al., 2012), but health organizations are also being negatively affected (Denham, 2007). Adverse events can lead to prolonged hospital care and costs thereafter. Costs in the US due to adverse events from drugs were estimated to $5.6 million (Bates et al., 1997) and adverse events in British hospitals led to costs of £290,268 (Vincent et al., 2001). The costs for adverse events in Swedish hospital care (Soop et al., 2009) has increased from 185.7 million SEK (Svensson et al., 2004) in 1995 to over 11 billion SEK in 2013 (Swedish Association of Local Authorities and Regions [SALAR], 2014a). In response to the many patients being harmed and costs following that, health care organizations started to realize that event reporting and learning from errors would improve the health care system and lead to patient safety, i.e. prevention of adverse events for patients (Aspden et al., 2014, SFS 2010:659). Error prevention, learning from errors and building a culture of safety which involves health care professionals, organizations and patients is important when health care aims towards patient safety improvement (Aspden et al., 2014; Clancy et al., 2005). It has also become apparent that health care organizations need to prioritize making safe systems in health care, thus creating an environment where a culture of safe practices will thrive. This has required a shift from the earlier widely used blame-and-shame individual perspective when errors occur, into a system perspective where individuals are seen as inheritors rather than creators of errors (Reason, 2000).

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Creating a culture of safety, i.e. "designing systems geared to preventing, detecting and minimizing hazards and the likelihood of error – not attaching blame to individuals" (Kohn et al., 2000, p 57) puts great demands on health care. A safety culture is created by changes in health care staff’s safety perspective and safe practices, and improving the patient safety culture in health care is a long-term process (Longo et al., 2005). Initially, Swedish authorities and health care organizations focused on retrospective measures (Carthey et al., 2001) of patient safety. Areas where patients often were injured were brought together in a joint effort for improved patient safety (SALAR, 2008). By examining how well routines worked for these areas; falls and fall injuries, health care associated infections (HAIs), pressure ulcer, malnutrition and drug-related errors in the gaps of health care, the systematic patient safety work in Swedish health care started. Steadily, the proactive focus became obvious and the perspective of patient safety culture in improving patient safety emerged. In order to improve safety in health care, it is important to understand how to create a culture in which safety thrives. It is also important to understand how accidents and threats against safety for patients occur. This thesis focuses on health care staff’s attitude towards patient safety; the patient safety culture.

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BACKGROUND

Health care staff

The health care system in Sweden is organized at three levels; national, regional and local. Nationally, policies for health care are established and launched by the Ministry of Health and Social Affairs. Regionally, the 21 health care regions, i.e. county councils, are responsible for financing and providing health care to citizens therein. Locally, the municipalities are responsible for social and elderly care. The health care system in Sweden is mainly financed by regional taxes. In addition, governmental grants and small patient fees finance health care services. Registered nurses (RNs), enrolled nurses (ENs) and physicians constitute the majority of staff in Swedish regional health care. Of these, RNs constitute the largest professional group (n = 72,163), followed by ENs (n = 50,624) and physicians (n = 31,399) (SALAR 2013b). In Sweden, students undergo a three-year education at a university or university college to become a RN. This education includes supervised hospital internships. It is completed with a professional certificate and an academic bachelor degree and allows for formal registration (SFS 2010:659). The education program for ENs is operated by the municipalities by proxy of secondary school/high school. ENs work without a specific ethical code to follow and without professional scientifically systematized knowledge, indicating that ENs do not belong to the classical professions in health care, e.g. RNs and physicians. However, after their degree, ENs are expected to work from a certain view on humanity (The Swedish National Agency for Education, 2015) and in accordance with policy documents for the specific workplace. The Swedish education program for physicians is conducted at a university and includes supervised hospital work. After five and a half year physicians receive a professional certificate and may also receive an academic bachelor or a master degree, depending on the educational establishment. A physician also becomes formally registered for service (SOSFS 1999:5; SFS 2010:659). All health care staff works under confidentiality, regardless of profession (SFS 2009:400). Health care in Sweden is often organized into units where managers are responsible for activities, employees and finances. Health care manager is the formal leader position at different health care organization levels, for example

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in a work unit, a health care division or a hospital. A manager in health care has responsibility to supervise employees at the unit. These health care staffs are often self-governing professionals (National Board of Health and Welfare, 2006), which puts the management in close proximity to the patients. Managers have the task to forward assignments and information from upper levels, for example politicians, the health care board or the upper management, to employees and to adapt this to the context where it is supposed to be used (Woods, 2004; National Board of Health and Welfare, 2006; Kean et al., 2011). Today, health care management is based on leadership and teamwork, reflecting collaborative and democratic approaches, in contrast to the previously more authoritarian management (Kean et al., 2011; Al-Sawai, 2013).

Policy documents

Swedish health care staff’s work in health care is regulated in the Health Care Act (SFS 1982:763), an overall act outlining health care policies. Here it is stated that health care should be conducted in order to fulfil demands for good care, i.e. be of good quality with a good hygienic standard and meet the patient’s need for security, readily available, based on respect for the patient’s autonomy and integrity, promote good contacts between the patient and health care staff and meet the patient’s need for continuity and safety in health care. The care should also be delivered in consultation with the patient. In 2011, the Patient Safety Act (SFS 2010:659) was introduced. Here, the importance of safe care is stressed and the act underlines responsibilities for both employer and employees in patient safety work. Employers are responsible for conducting systematic patient safety work. This comprises that the employer should investigate events in the organization that caused or might have caused adverse events, provide patients and relatives with information in connection with adverse event and inform about the measures that have been taken to prevent recurrence. The health care provider should give patients and relatives opportunities to get involved in patient safety, but also provide information on how they can file a complaint. An annual patient safety report must also be written by the health care organizations. According to the act, all health care staff is obligated to report events and risks of harm. In addition, health care professionals deemed to pose a danger to patient safety should be reported to the National Board of Health and Welfare, and if necessary be taken off duty (SFS 2010:659). Compared to the previous system of liability, the

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Patient Safety Act focuses on supporting and supervising the health care professionals rather than handing out discipline penalties. The Patients Act (2014:821) is proposed in order to strengthen and clarify the patient’s position and to promote patient participation, self-determination and patient integrity. This act took effect on January 1st 2015 and is a clear shift of control over decision-making from the traditional, where health care providers decide about treatment and providers. Now, the patients themselves have a right to choose. In 2011, SALAR reached a national agreement for reducing adverse events in health care. The agreement, which was performance-based, aimed to encourage and strengthen patient safety work in the Swedish county councils using monetary incentives (SALAR, 2011). The following four requirements needed to be met for those county councils that wished to take part of the compensation: Establishing an annual patient safety report in accordance with the Patient Safety Act (SFS 2010:659), initiate the introduction of a national digital patient information system, initiate the introduction of a digital infection tracking tool and establish systematical review of patient medical records. For county councils that met the basic requirements, additional grants were allocated if patient safety culture, HAIs, pressure ulcers, overcrowding and relocation of patients and compliance to hygiene and work-wear regulations were monitored (SALAR, 2011). The county council under study here has, like many other county councils, had active representatives as a part of the team that developed the national agreement for increased patient safety.

Teamwork

An organization is primarily a system to accomplish a task (Perrow, 1967), which could mean to prevent, examine and treat patients suffering from different conditions (SFS 1982:763). When providing health care, health care staff must work in teams, i.e. two or more individuals who work together to achieve specified and shared goals, with task-specific competencies and specialized work roles, who use shared resources, and communicate to coordinate and to adapt to change (Brannick & Prince, 1997). In health care, inter-professional teamwork means that different professional groups have a common team identity and work together in an integrated manner in which they are mutually dependent on each other to solve problems (Reeves et al.,

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2010). Research indicates that factors contributing to adverse events in health care rather originate from flawed teamwork than from a lack of skills (Manser, 2009) and improved teamwork could have prevented many adverse events. Proper teamwork has been associated with improved patient safety and performance in the operating room (Catchpole et al., 2007; Neily et al., 2010; Wolf et al., 2010), improved quality of care for patients with chronic obstructive pulmonary disease (Zwar et al., 2012), reduced mortality for elderly in hospitals (Schraeder et al., 2001) and greater post-discharge survival for patients with chronic heart failure (Inglis et al., 2006). Teamwork as an important component in interventions for improved patient safety has been reported in relation to: health care staff’s attitude towards patient safety in obstetric care (Pettker et al., 2011), hospital mortality (Lipitz-Snyderman et al., 2011), fewer negative events in pediatric cardiac- and orthopedic-surgery (Catchpole et al., 2007) as well as reduced ventilator-associated pneumonia (Bigham et al., 2009) and catheter-associated bloodstream infections (Miller et al., 2010) in pediatric intensive care. Earlier studies among health care staff showed that leadership quality and communication openness were rated positively when perceptions of teamwork were examined (Miller, 2001; Flin et al., 2003). When comparing health care staff, differences in perceptions of teamwork was demonstrated, i.e. nurses indicated teamwork to be of lower quality than physicians (Hojat et al., 2003, Sexton et al., 2006). Cook et al. (2004) showed that health care also differed in the view of teamwork and responsibility in patient safety development, where a substantially small part of physicians considered nurses to be part of the team making decisions regarding patient safety.

Professional ethics

Within health care, professionals work to maintain or restore the patients’ health and to support their ability to develop resources for health. In the profession as RN, and in other professions in health care, marked by work together with and towards other people, professional ethics is fundamental (Christoffersen, 2007). ENs work from a view on humanity which emphasizes human equality, dignity, quality of life and well-being. There has been some societal discussions regarding ENs’ ethical regulations from the municipal workers union (Aromäki & Mouna, 2009), but so far ENs’ work is conducted in accordance with policy documents for the specific workplace e.g. the Health

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Care Act (SFS 1982:763), the Patient Safety Act (SFS 2010:659) and the Patient Act (SFS 2014:821). A dominant aspect of professional ethics is to make ethical responsibility and accountability a part of professional life, which is emphasized in ethical guidelines for RNs (International Council of Nurses [ICN], 2012) and for physicians (Swedish Medical Association [SMA], 2009). The two professions strongly emphasize to treat patients with empathy, attention and respect and to conduct work contributing to patients’ health. Additionally, both professions stress that work must be performed in accordance with science and proven experience and that workers should increase their competence (SMA, 2009; ICN, 2012). The ethical guidelines developed for RNs greatly emphasize moral responsibility (ICN, 2012). For RNs this could mean, but is not limited to, taking responsibility for competence through continuous learning and evaluation of their own profession and others’ skills. Additionally, RNs have a responsibility to act appropriately to safeguard patients when their health is endangered by another health care worker (ICN, 2012). Besides the strong protection of patients, physicians’ ethical code also includes a more prominent respect towards colleagues (SMA, 2009) which might lead to ethically problematic situations (Andrén-Sandberg et al., 2009). Historically, this collegial respect is already found in the wordings of the Hippocratic Oath (Edelstein, 1943). Hereby, the issue of different professional ethics (Kalkas & Sarvimäki, 1996) occurs as RNs and physicians must cooperate in the system of health care. In the context of patient safety culture, this might pose a challenge, since one cornerstone in patient safety culture, learning from mistakes, demands that committed errors resulting in adverse events are being openly discussed and shared in the organization in order for everyone to take part of (Manser, 2009; Sammer et al., 2010; Halligan & Zecevic, 2011).

Errors and adverse events in health care

In health care, errors may result in adverse events. An adverse event, first defined as an injury caused by medical management (rather than the underlying disease) which prolonged the hospitalization, produced a disability at the time of discharge, or both (Brennan et al., 1991) can be preventable or non-

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preventable. Errors can also result in near misses or risks which are incidents which did not reach the patient. Error includes those occasions when planned actions fail to achieve their preferred end, and when these failures cannot be attributed to involvement of other random events (Reason, 1990). Commonly, errors are classified either as mistakes, lapses or slips. Mistakes or lapses come from inappropriate choices, often due to insufficient knowledge, lack of experience or training, lack of information or decision-making based on the wrong set of rules. Slips occur as parts of a daily routine when a person is distracted or has a heavy work load. If an intention is inappropriate, it is a mistake, if an action is unintended it is a slip (Norman, 1983). There are a few models explaining human errors. The Swiss cheese model (Reason, 2000; Reason, 2009) has gradually been altered and developed for use in many contexts, such as aviation, nuclear power plants and for patient safety within health care. The Swiss cheese model is applicable in all complex and technological systems operating in high-risk environments. The model is based on the overall concepts risks, barriers and damages and postulates that barriers exist to prevent adverse events, but they are like slices of Swiss cheese with many holes (errors) in them. Adverse events happen when the holes in many layers temporarily line up. There are barriers (patient safety factors) stopping these errors from becoming adverse events. Unfortunately, these barriers sometimes allow errors to slip through and a bad outcome results. Another model explaining human error is the Individual-based and the System-based model (Reason, 2000; Reason, 2009) which represent two strongly contrasting approaches to the origin, nature and management of errors. Using the individual-based model, errors are seen as rising from unpredictable mental processes, and error management focuses on the individual; to blame, name, shame and retrain are common methods. This model is seen as comfortable from a legislation and employer perspective, since the organization gets disconnected from responsibility for the error. Using the system-based model, the person who committed the mistake is considered an heir of the mistake rather than a plotter (Perrow, 1999; Reason, 2009). Front line staff is thus seen as victims of a combination of factors induced by the system. This model does not ask “who made the mistake”?, it asks “what barriers snapped, and how may they be strengthened”? Both models might be criticized. The individual model

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since it is strongly connected to a culture of blame and the violations following that (Krizek, 2000), and the system model since it might lead to a taught helplessness, and in some cases that utterly clumsy staff will not be held responsible for their actions (Leape & Fromson, 2006; Wachter & Pronovost, 2009). Two important factors within error management are error-incidence limiting and the creation of systems that are able to tolerate the occurrence of error (Reason, 2000). High- reliability systems (HRO) operate in risky conditions, yet have fewer adverse events than expected (Reason, 2000) and are examples of systems with resilience. Resilient systems are characterized by complexity, dynamic, performance of tasks under time pressure and the capacity to carry out assignments with low rates of incidents and almost no catastrophic failures over long periods of time. In addition, the HRO are highly occupied with the possibility of making mistakes (Weick, 1987; Weick et al., 1999; Reason, 2000). It is expected that mistakes are made, and therefor staff are trained to recognize and recover errors. Scenarios with mistakes are being rehearsed and all levels in the organization participate to deal with mistakes (Reason, 2000). It is well-known that patients sometimes get harmed in connection with health care. In the early 1990s, it was shown that adverse events, caused by health care management (rather than the underlying disease), prolonging the hospitalization, producing a disability at the time of discharge, or both (Brennan et al., 1991) occurred for 3.7 % of all hospitalized patients. This study was followed by many other studies from countries all over the world, showing that 3 to 17 % of all patients were affected by one or more adverse events in connection with hospital care (Wilson et al., 1995; Thomas et al., 2000; Schiøler et al., 2001; Vincent et al., 2001; Davis et al., 2002; Baker et al., 2004; Soop et al., 2009; Zegers et al., 2009). Some adverse events are unavoidable consequences of care, such as an unanticipated reaction to antibiotics; however 37 % to 51 % were potentially preventable (Brennan et al., 1991; Leape et al., 1991; Wilson et al., 1995; Thomas et al., 2000; Davis et al., 2002; Vincent et al., 2001). Adverse events have been reported to occur more frequently for women than men (Davis et al., 2002), whereas other report the opposite (Soop et al., 2009). Adverse events have been reported to occur more frequently in teaching hospitals compared to rural hospitals (Brennan et al., 1991; Baker et al., 2004) and those patients experiencing an adverse event were older than those who did not have an adverse event (Leape et al., 1991; Gawande et al., 1999; Baker et al.,

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2004). Leape et al. (1991) showed that non-surgical adverse events were more common than surgical, and of these, infections were the most common adverse event. Later it was reported that adverse events due to drugs were the most common non-surgical events (Thomas et al., 2000). Swedish health care has been examined regarding adverse events using Global Trigger Tool (Health Quality & Safety Commission, 2013). Data was collected in 18 consecutive months beginning in 2013 and was analyzed using reviews of medical records from nearly 30 000 patients (SALAR, 2014b). The review shows that adverse events occur in 8.3 % of all care episodes. Men were more likely to be affected, older patients also. Adverse events were more likely to occur at teaching hospitals in comparison to county council hospitals. The most common field for adverse events was in orthopedic care, followed by surgical care. Internal medicine and cardiology had the lowest frequencies of adverse events. More than half (50.5 %) of the events were categorized as minor, 44.3 % led to prolonged hospitalization and 5.2 % caused permanent injury or death. Among those events categorized as causing death, the most common adverse event was septicemia, surgical injuries and drug-related injuries. Among minor adverse events the most common adverse event was pressure ulcer, urinary tract infection and injuries due to falls (SALAR, 2014b). Research regarding relatives’ experiences of adverse events is scarce, but Vincent (2003) argues that relatives suffer when patients are affected by adverse events, first from the incident itself, secondly from the manner in which the event is subsequently handled, and thirdly from a prolonged bereavement. Relatives take legal actions towards health care providers to help prevent similar incidents in the future and for health care organizations to take account for their actions (Vincent et al., 1994). Further, relatives needed explanations of how and why the injury happened and finally they wanted compensation for loss or pain, or to provide care in the future (Vincent et al., 1994). Health care staff involved in care processes where adverse events have occurred report emotional distress (Scott et al., 2009; Gazoni et al., 2012; Stangierski et al., 2012), insufficient support from the organization (Waterman et al., 2007; Edrees et al., 2011; Ullström et al., 2014) and insufficient support from coworkers (Aasland & Forde, 2005; Rassin et al., 2005). Health care staff react with feelings of fear, guilt, shame and disappointment following an adverse event, and the impacts of adverse events have led to long-lasting effects on

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health care staff (Seys et al., 2013). Female health care staff involved in an adverse event tends to report more distress and fear of confidence-loss than male health care staff, and they experience more loss of reputation from their colleagues (Seys et al., 2013). The term second victim was introduced in 2000 (Wu, 2000) to shed light on the experiences of physicians involved in an adverse event. A more specific definition was proposed by Scott et al. (2009) as health care providers involved in an unanticipated adverse patient event become victimized in the sense that the provider is traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient (Scott et al., 2009). Regardless of gender, profession or work experience, adverse events is a life-altering experience for health care staff, leaving a permanent imprint of the individual. As said by Don Berwick, former administrator for the Center for Medicare and Medicaid Services (CMS):

‘‘Health care workers who get wrapped up in error and injury, as almost all someday will, get seriously hurt too. And if we’re really healers, then we have a job of healing them too. That’s part of the job. It’s not an elective issue, it’s an ethical issue’’ (Denham, 2007, p 109).

Patient Safety

Patient safety is described as prevention of adverse events for patients (Aspden et al., 2014; SFS 2010:659). Error prevention, learning from errors and building a culture of safety involving health care professionals and patients are important factors when health care aims towards patient safety improvement (Aspden et al., 2014; Clancy et al., 2005). In early research, safe patient practice was described as “a type of process or structure whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures” (Shojanja et al., 2001, p 29). Patient safety can be established by interactions in the system of health care. Assessment of system safety can be done using reactive and proactive indicators (Reason, 2009; Reiman & Pietikäinen, 2012). Reactive safety indicators are conclusions we draw from past events, for example rates of infection, surgical injuries, falls, pressure ulcers and malnourished patients. Safety is assessed in retrospect and this requires safety management systems

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which are able to give accurate pictures of weaknesses within the organization. Proactive safety indicators consist of regular scrutiny and identification of entities known to have an impact on an organizations’ state of safety, such as communication, cooperation, routines, guidelines, scheduling, documentation and conflict between production versus safety (Reason, 2009; Reiman & Pietikäinen, 2012).

Patient Safety Culture

On Saturday, April 26, 1986, two explosions blew off the 1,000 ton concrete ceiling in the Ukrainian nuclear power plant reactor Chernobyl-4. The explosions released molten core fragments in the surrounding area and fission products in the atmosphere. This was the worst accident in history of commercial nuclear power generation, costing many lives and contaminating approximately 400 square miles around the plant. This was an entirely man-made disaster and the investigation showed that safety culture or “dedication and personal responsibility of all those involved in any safety-related activity” (INSAG 3, p 84) was lacking in all levels, from the highest spheres of administration to those involved in the operational stage. “Safety Culture” was presented. Culture as a concept has often been disputed (Keesing, 1981) and early anthropologists claimed that there is no culture without humans, but more importantly no humans without culture (Geertz, 1973). Culture may be considered a collective memory of a group, and by applying memory to culture, it indicates that culture is learned (Hofstede, 2001). There has been considerable debate about the differentiation of the terms culture and climate (Guldenmund, 2000; Hale, 2000), due to their small but important differences. Climate comprises perceptions concerning procedures, practices and behavior and is related to low-management concerns (Hofstede, 1991; Schneider et al., 2013). Culture resides at a deeper level and includes elementary assumptions, values and beliefs (Davis et al., 2000), characterizing an environment, and reflects functions related to the highest management in organizations (Hofstede, 1991; Schneider et al., 2013). Still, there are substantial overlaps between the two terms and they should be considered as different layers of the same phenomena (Schein, 1990) instead of two different phenomena (Garavan & O’Brien, 2001). Organizational culture and organizational climate was developed throughout the 1970s and 1980s

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(Guldenmund, 2000). Similar to organizational climate, organizational culture conceptualizes how people experience and describe their work setting (Ekvall, 1983; Halligan & Zecevic, 2011; Schneider et al., 2013) and derived from this is the concept of safety culture. There are several definitions of safety culture. A short and native understanding of safety culture is “the way things have to be done around here” (Davis et al., 2000; Guldenmund, 2010) and Cox and Cox (1991) presented safety culture as attitudes, beliefs, perceptions and values in relation to safety shared by employees. A more detailed definition of safety culture is the result of values, attitudes, perceptions, competencies and behaviors, shared by all individuals and all groups, which determine the devotion to and skills in an organization’s management of health and safety (Glendon & McKenna, 1995). In order to understand the differences in depth, the definition from Guldenmund (2000) can be used, which suggests that in the extension of safety climate, which refers to attitudes, comes safety culture which concerns the beliefs and convictions of those attitudes. Safety climate may be seen as an entity perceived by employees at a certain point in time, or an indicator of the organization’s safety culture (Cox & Flin, 1998). Depending on where in the organization the employees are, they will see things very differently, even though they are subject to the same law and procedures (Payne, 1996). Safety culture is thus the prevailing values of attitudes towards safety in a work group (Guldenmund, 2000). Patient safety culture is an aspect of the organizational culture within health care. A dynamic and conscious definition of patient safety culture was presented by the European Society for Quality in Health Care in 2006 and reflects safety culture where actions are taken to reduce risk or harm to patients within the trajectory of care. This definition reads: “An integrated pattern of individual and organisational behavior, based upon shared beliefs and values that continuously seeks to minimise patient harm, which may result from the processes of care delivery” (European Society for Quality in Health Care, 2010, p. 4). Characteristic properties of patient safety culture have been identified by Sammer et al. (2010) as a leadership acknowledging the environments as highly risky and determined in transferring resources to the frontline staff, a collaborative spirit among staff, where relations are open, respectful and flexible, where the environment allows all health care staff to speak up on the

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patient’s behalf, and where all staff value learning from mistakes as a way to improve their performance. Further, practice is based on evidence, errors are considered as system failures rather than individual failures and simultaneously individuals are held responsible for their actions, and care is centered on the patient (Sammer et al., 2010).

Instruments to measure health care staff’s attitudes towards patient safety

A number of instruments have been developed to measure health care staff’s attitudes towards issues related to patient safety. The Safety Attitudes Questionnaire (SAQ) has been developed (Sexton et al., 2006) to measure patient safety climate using the factors ‘Teamwork Climate’, ‘Safety Climate’, ‘Perceptions of Management’, ‘Job Satisfaction’, ‘Working Conditions’, and ‘Stress Recognition’. The Patient Safety Climate in Healthcare Organizations Survey (PSCS) (Singer et al., 2007) developed from the Patient Safety Cultures in Healthcare Organizations (PSCHO) constitutes nine constructs; Organization level ‘Senior managers’ engagement’, ‘Organizational resources’ and ‘Overall emphasis on safety’, Unit level ‘Unit safety norms’ and ‘Unit recognition & support for safety’, Individual ‘Fear of shame’, ‘Fear of blame’, and ‘Learning, and the additional ‘Provision of safe care’. The PSCS measures patient safety culture and patient safety climate. The Manchester Patient Safety Assessment Framework (MaPSaF) is developed as a tool for organizations to qualitatively work with nine dimensions of patient safety culture in five organizational levels of safety; ‘Pathological’, ‘Reactive’, ‘Calculative’, ‘Proactive’ and ‘Generative’ (Parker, 2009). The Hospital Survey on Patient Safety Culture (HSOPSC) is developed by the Agency for Healthcare Research and Quality (AHRQ) (Colla et al., 2005; Flin et al., 2006; Singla et al., 2006; Halligan & Zecevic, 2011) to measure patient safety culture and is used in the present thesis. These instruments have been developed to conduct more specific surveys, for example the Safety Attitudes Questionnaire—Ambulatory (SaQ-A), measuring patient safety climate for ambulatory settings (Modak et al., 2007), the MapSaF-offspring Pharmacy Safety Climate Questionnaire (PSCQ) for safety climate in pharmacies (Ashcroft & Parker, 2009). Furthermore, the HSOPSC has also been developed for measuring patient safety culture in critical care transport

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(Erler et al., 2013), in nursing homes (Handler et al., 2006), and for general practice (Zwart et al., 2011). One of the most applied instruments is the HSOPSC, which measures patient safety culture from a health care staff perspective. The HSOPSC was thoroughly developed (Sorra & Nieva, 2004) by 1) a review of the literature pertaining to safety, accidents, medical error, error reporting, safety climate and culture, and organizational climate and culture, 2) a review of existing published and unpublished safety culture surveys and 3) in-person and telephone interviews with hospital staff. Thereafter, the survey was pre-tested by hospital staff to ensure the items were easily understood and relevant to patient safety culture in a hospital setting. Finally, the survey was pilot-tested with more than 1,400 hospital employees from 21 hospitals across the United States. The HSOPSC showed sound psychometric properties by means of exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) (Sorra & Nieva, 2004). The original HSOPSC (12 dimensions, 44 items) consists of unit-level aspects of patient safety collected in seven dimensions (24 items): ‘Manager Promoting Safety’, ‘Organizational Learning’, ‘Teamwork Within Hospital Units’, ‘Communication Openness’, ‘Feedback and Communication’, ‘Nonpunitive Response To Error’ and ‘Staffing’. Hospital-level aspects are collected in three dimensions (11 items): ‘Hospital Management Support’, ‘Teamwork Across Hospital Units’ and ‘Hospital Handoffs & Transitions’. Two outcome measures (7 items): ‘Frequency of Event Reporting’ and ‘Overall Perceptions of Safety’ and two single-item measures also constitute the HSOPSC: ‘Patient Safety Grade’ and ‘Number of Events Reported’. Internal consistency reliability for the 12 dimensions showed Cronbach’s alpha values ranging from 0.63 to 0.84. Except for two items using a six-point frequency scale, most patient safety culture items are answered using a five-point response scale of agreement, where a higher score indicates a more positive attitude towards patient safety, i.e. strengths in patient safety (Sorra & Nieva, 2004). In later research, the original structure of the HSOPSC was supported, but the dimension ‘Number of Events Reported’ was recommended to be best used as a descriptive measure (Sorra & Dyer, 2010) instead of as an outcome, as it initially was. The HSOPSC is one of the most frequently cited tools (Halligan & Zecevic, 2011) with sound and comprehensively reported psychometric testing (Colla et al.,

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2005). Moreover, HSOPSC users are provided an extensive benchmark database for comparisons (Singla et al., 2006). The psychometric properties of the HSOPSC were further tested in Asia, the United States, Europe and the Middle East. In Table 1, a chronological selection of developmental and/or psychometric studies of HSOPSC is displayed. Table 1. Chronological display of selected studies using the HSOPSC. First author, country, year Dimensions, Items Cronbach’s α Sorra, USA, 2004 12 dimensions, 42 items 0.63 to 0.84 Kim, Korea, 2007 ------------------------ ------------- Hellings, Belgium, 2007 12 dimensions, 41 items 0.58 to 0.85 Olsen, Norway, 2008 12 dimensions, 41 items 0.51 to 0.82 Smits, Netherland 2008 11 dimensions 40 items 0.58 to 0.79 Blegen, USA, 2009 12 dimensions, 42 items 0.58 to 0.81 Bodur, Turkey, 2010 10 dimensions, 42 items 0.57 to 0.86 Chen, Taiwan, 2010 12 dimensions, 42 items 0.51 to 0.84 Pfeiffer, Switzerland, 2010 8 dimensions, 40 items 0.61 to 0.88 Waterson, UK, 2010 9 dimensions, 27 items > 0.7 for 7/9 dimensions Ito, Japan, 2011 12 dimensions, 42 items 0.46 to 0.88 Sarac, Scotland, 2011 12 dimensions, 42 items 0.60 to 0.84 Arabloo, Iran, 2012 ------------------------- ------------- Brborovic´, Croatia, 2013 11 dimensions, 42 items 0.35 to 0.91 Naijar et, 2013 11 dimensions, 38 items 0.41 to 0.87 Occelli, France, 2013 10 dimensions, 40 items 0.55 to 0.84 Robida, Slovenia, 2013 12 dimensions, 42 items 0.36 to 0.88 Zhu, China, 2014 9 dimensions, 34 items 0.59 to 0.88 Within the national initiative in Sweden for improved patient safety, six county councils and the National Board for Health and Welfare decided to develop a method for assessing patient safety culture. From the six county councils’ network of safety practitioners and researchers, the choice fell on the HSOPSC, which was translated into Swedish by the National Board for Health and Welfare (2009). Two dimensions; ‘Information to Patient/Relatives’ and ‘Information to Staff’ were added to adapt this version (S-HSOPSC) to a Swedish health care context. Dimensions, items, and response alternatives of the S-HSOPSC and HSOPSC are shown in Appendix 1.

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Studies of health care staff’s attitudes towards patient safety

Patient safety culture measured using the HSOPSC describes areas of patient safety culture strength and areas in need of improvement. In Table 2, dimensions are displayed which were scored high and low in different studies. Table 2. Studies displaying HSOPSC dimensions with high and low patient safety culture scores at different levels. Dimensions scored high

Dimensions scored low

Unit level Teamwork Within Hospital Unit

Hellings et al., 2007; Bodur & Filiz, 2010; Smit et al., 2009; Snijders et al., 2009; Wagner et al., 2009; Alahmadi, 2010; Chen & Li, 2010; El Jardali et al., 2010; Sarac et al., 2011; Arabloo et al., 2012; Ballangrud et al., 2012; Vlayen et al., 2012

Nonpunitive Response To Error

Hellings et al., 2007; Bodur & Filiz 2010; Wagner et al., 2009; Alahmadi 2010; Chen & Li 2010; El Jardali et al., 2010; Arabloo et al., 2012; Vlayen et al., 2012

Manager Promoting Safety

Castle et al., 2007; Hellings et al., 2007; Wagner et al., 2009; Chen & Li 2010; Sarac et al., 2011; Arabloo et al., 2012; Ballangrud et al., 2012; Vlayen et al., 2012

Staffing Castle et al., 2007; Hellings et al., 2007; Wagner et al., 2009; Alahmadi, 2010; Chen & Li, 2010; El-Jardali et al., 2010; Sarac et al., 2011; Arabloo et al., 2012; Vlayen et al., 2012

Hospital level Hospital Management Support

Castle et al., 2007; Wagner et al., 2009; Alahmadi 2010; El-Jardali et al., 2010

Teamwork Across Hospital Units

Smit et al., 2009; Snijders et al., 2009; Alahmadi, 2010; El Jardali et al., 2010; Sarac et al., 2011; Arabloo et al., 2012; Ballangrud et al., 2012; Vlayen et al., 2012

Teamwork Across Hospital Units

Castle et al., 2007; Chen & Li, 2010

Hospital Handoffs and Transitions

Castle et al., 2007; Hellings et al., 2007; Bodur & Filiz, 2010; Wagner et al., 2009; Chen & Li, 2010; El Jardali et al., 2010; Sarac et al., 2011; Vlayen et al., 2012

Outcome measures Frequency of Event Reporting

Sarac et al., 2011 Frequency of Event Reporting

Smit et al., 2009; Snijders et al., 2009; Chen & Li, 2010; Ballangrud et al., 2012

Overall Perceptions of Safety

Castle et al., 2007; Bodur & Filiz, 2010; El Jardali et al., 2010

Overall Perceptions of Safety

Snijders et al., 2009; Wagner et al., 2009, Alahmadi, 2010

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When studies of patient safety culture have been conducted, differences between staff groups have been displayed. Managers scored patient safety culture higher than non-managers in several studies (Kim et al., 2007; Singer et al., 2008; Wagner et al., 2009; de Wet et al., 2012). Differences between professions were also reported where RNs scored higher than physicians (Huang et al., 2007; Scherer & Fitzpatrick, 2008; Blegen et al., 2010; El-Jardali et al., 2010). Higher scores were also reported for RNs with longer experience in the current unit compared to those with shorter experience (Kim et al., 2007; Wagner et al., 2009) and for RNs aged 40-49 years compared to those younger than that (Kim et al., 2007). Patient safety culture perception has also shown to differ due to context, where respondents working in internal medicine and obstetric units reported higher scores considering communication openness when compared to those in other kinds of units (Kim et al., 2007). Studies have shown positive associations between patient safety culture strengths and measures of safety performance (Sorra & Nieva, 2004). Ballangrud et al. (2012) reported a model consisting of the 12 original HSOPSC dimensions showing an explained variance of 28 % for the outcome measures ‘Overall Perception of Safety’ and ‘Frequency of Incident Reporting’ respectively. Pfeiffer & Manser (2010) showed an explained variance of 54 % for ‘Overall Perception of Safety’ and 35 % for ‘Frequency of Incident Reporting’ using a modified HSOPSC version consisting of nine of the 12 original dimensions. Also Alahmadi (2010) used a modified HSOPSC version consisting of seven of the 12 original dimensions. This model showed an explained variance of 32 % for ‘Overall Perception of Safety’ (Alahmadi, 2010). A positive association between the HSOPSC dimensions and safety outcome measures was also shown by Agnew et al. (2013), using a modified Hospital Safety Questionnaire Package. Early conducted research (Shortell et al., 2000) on positive safety culture, safety management and positive patient outcome showed only small effects. Subsequent research has shown relations between a strong patient safety culture and positive patient outcomes, such as shorter length of stay (Pronovost et al., 2005), fewer falls among elderly in nursing homes (Vogus & Sutcliffe, 2007) and lower rates of in-hospital complications, e.g. pneumothorax, infection due to care and postoperative sepsis (Mardon et al., 2010). Willingness of treatment error reporting has also been shown (Naveh et al., 2006).

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A strong patient safety culture has also been shown to be associated with higher employee engagement and workplace safety longitudinally (Thorp et al., 2012). Another longitudinal study showed significant reduction of serious events, a variety of hospital-acquired infections, and hospital mortality three years after implementing a patient safety culture changing program in a pediatric hospital (Brilli et al., 2013).

Patient safety improvement

The interest for patient safety confirms that this area is a major problem in health care, a problem that contributes to costs and suffering. Improving safety in health care calls for knowledge from many disciplines (Batalden et al., 2011) and the establishing of systems to detect and eradicate threats to patient safety is essential when health care organizations aim for patient safety improvement. The core in improvement of health care safety is three-pronged; reducing the burden of illness for individuals, improving safety of the system and developing and maintaining professional competence (Batalden, 2010). In later years there have been successful interventions within health care aiming for patient safety improvements in hospitals in general (Parand et al., 2013), and in special areas such as intensive care (Pronovost et al., 2004; Ballard et al., 2007; Pronovost, 2008; Lipitz-Snyderman et al., 2011), obstetrics (Pettker et al., 2009; Iverson & Heffner, 2011; Pettker et al., 2011), medicine-oncology (Kalisch et al., 2007) and pediatric intensive care (Bigham, et al., 2009; Miller et al., 2010; Muething et al., 2012).

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In these, interventions for patient safety improvements were related to significantly reduced falls (Kalish, 2007), mortality (Lipitz-Snyderman et al., 2011), catheter-associated bloodstream infections (Miller et al., 2010) ventilator-associated pneumonia (Bigham et al., 2009), obstetric adverse events (Pettker et al., 2009; Iverson & Heffner., 2011) and serious safety events resulting in harm for pediatric patients (Muething et al., 2012). Positive patient safety outcomes from the interventions were significantly improved teamwork (Kalisch et al., 2007; Pettker et al., 2011), patient safety culture (Pronovost et al., 2004; Pettker et al., 2009; Pettker et al., 2011; Muething et al., 2012) and reduced staff turnover (Kalisch et al., 2007). Interventions in these mentioned studies are presented in table 3. Patient safety improvement is complex and needs support from many disciplines (Batalden et al., 2011) to succeed. Interventions to improve patient safety have been conducted in many areas and have resulted in significantly reduced harm and less mortality rates for patients. The successful interventions were multi-faceted with engagement of staff in all organizational levels, including managers, clear procedures and staff trained in safety and teamwork. Further, systems for event reporting, feedback and learning were established. Table 3. Interventions in studies for improved patient safety. Intervention

Engaging managers and physicians Kalish, 2007; Bigham et al., 2009; Pettker et al., 2011

Clarification of procedures and guidelines

Ballard et al., 2007; Pronovost, 2008; Bigham et al., 2009; Miller et al., 2009; Iverson & Heffner, 2011; Lipitz-Snyderman et al., 2011; Pettker et al., 2009; Pettker et al., 2011; Muething et al., 2012

Education and training of safety and teamwork

Pronovost et al., 2004; Ballard, 2007; Kalish, 2007; Pronovost, 2008; Iverson & Heffner, 2011; Pettker et al., 2009; Pettker et al., 2011; Lipitz-Snyderman et al., 2011; Muething et al., 2012

Creating and clarifying systems for risk and event management

Pronovost et al., 2004; Ballard et al., 2007; Kalish, 2007; Bigham et al., 2009; Pettker et al., 2009; Pettker et al., 2011; Muething et al., 2012

Limiting overtime tenure Iverson & Heffner, 2011

Distinct distribution of responsibilities

Pronovost et al., 2004; Ballard et al., 2007; Pronovost, 2008; Bigham et al., 2009; Miller et al., 2009; Iverson & Heffner, 2011; Lipitz-Snyderman et al., 2011; Pettker et al., 2011; Muething et al., 2012

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Rationale for the thesis

Promoting patient safety is a very important area in health care. Over time, more attention has been given to the patient safety culture. Health care staff’s patient safety culture is related to patient outcomes, and measurements of patient safety culture have come to form the basis of health care organizations’ structured methods to gain an understanding of health care staff’s and managers’ perceptions of safety. Studies of patient safety culture from a Swedish health care perspective are scarce, both from a bedside health care staff and a managerial perspective. Measuring patient safety culture is crucial when managers in health care aim to improve safety by handling adverse events and benchmark towards other health care organizations, thus it is important that the questionnaire is valid, reliable and adapted to the context where it is intended to be used. Since staff teamwork and communication and the organization’s ability to learn and improve as well as managers’ actions are important components in patient safety culture, it is important to gain knowledge about staff’s perception of patient safety culture. Differences have been reported regarding variations in potential predictors for patient safety culture. Studying factors related to health care staff’s attitude towards patient safety can contribute to knowledge about patient safety. Patient safety culture measurements can be used to detect areas of weak patient safety or to track changes over time. In order to gain a better understanding of managers’ and staff’s perception of patient safety culture and the factors potentially of importance for this, these relations need further examination. Health care organizations can benefit from using staff’s suggestions when improving patient safety. Since health care staff is involved in direct contact with patients, it may be beneficial to study their suggestions for improvement of patient safety.

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AIMS

The overall aim of this thesis was to psychometrically test the S-HSOPSC and the HSOPSC, investigate health care staff's perceptions of patient safety culture and their suggestions for improvement. The specific aims were:

I. To examine the psychometric properties of the S-HSOPSC and the HSOPSC within a Swedish hospital setting and to describe health care staff’s perceptions of patient safety culture.

II. To compare managers’ and health care staff’s perceptions of patient

safety culture and to explore factors potentially influencing patient safety culture in hospital settings.

III. To examine and compare health care staff’s perceptions of patient

safety culture over time. A further aim was to examine factors that have had an effect on patient safety culture.

IV. To describe health care staff’s suggestions for improvement of

patient safety.

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METHODS

Design

This thesis consists of four papers (I-IV). To address the overall aim a descriptive and explorative design (Polit & Beck, 2012) was used, combining quantitative (I-III) and qualitative (IV) methods (Table 4). Table 4. Overview of papers in the thesis. Paper Design Participants Data collection Data analysis

I Descriptive Cross-sectional

1,023 health care staff

S-HSOPSC2 as a web survey

Descriptive, inferential and psychometric statistics

II Descriptive Explorative Cross-sectional

1,023 health care staff

S-HSOPSC2 as a web survey

Descriptive and inferential statistics

III Descriptive Explorative Three-time cross sectional1

3,721 health care staff

S-HSOPSC2 as a web survey

Descriptive and inferential statistics

IV Descriptive 684 health care staff

An open-ended question in S-HSOPSC2 as a web survey

Qualitative content analysis

1 Data collected in 2009, 2011 and 2013 2 S-HSOPSC= Swedish version of the Hospital Survey on Patient Safety Culture

Participants

The studies were conducted in a county council with three hospitals in central Sweden. The largest hospital has approximately 560 beds and besides the large elective and acute medical and surgical areas, it provides several subspecialties, including gynecology, nephrology and oncology. In total, approx. 3,700 are employed at this central county hospital. The two smaller county hospitals are due to their geographical positions covering the need of health care for inhabitants in other parts of the county. The two smaller hospitals have approximately 90 beds each and approximately 570 and 500 employees respectively. Here, surgery and medicine are supplemented with specialist receptions including oncology and nephrology. The county council has organizationally divided the health care into nine divisions, of which three were in focus in the studies presented here. The medical and the surgical health care divisions, including staff and senior management board, span over two hospitals. The mixed medical-surgical health care division is comprised of staff employed at one of the smaller hospitals, led

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by a hospital manager. Each health care division is led by a senior manager with a varying number of upper managers at intermediate level responsible for a number of collected workplace units. The health care divisions are divided into a varying number of workplace units led by operative managers.

Data was collected in October to November 2009 (I-III), March 2011 (III), and October to November 2013 (III) using the S-HSOPSC as a cross-sectional web-survey. The survey was disseminated through a link attached in an e-mail to each employee who fulfilled the following criteria: being an RN, EN or physician, having an extent of service of 50 percent or more, having been employed for three months or more and not being on extended sick or parental leave (I-III). Written information about the study was sent out via the staff newspaper and digitally on the staff intranet. Survey aim, information about voluntary participation and confidentiality was emphasized both at information meetings held at the health care divisions as well as in the e-mail message containing the link to the questionnaire. Once the respondent had answered the questionnaire in the link by clicking “send”, the link ceased to exist (I-IV). Names and e-mail addresses of eligible respondents (N = 2,120) were obtained from nurse managers and personnel officers (I, II). In 2011 and 2013, names and e-mail addresses of eligible respondents (N = 2,172 and N = 2,561, respectively) were obtained from the county council’s computerized catalogue to which all health care staff are connected (III). The names and addresses were reviewed thoroughly and if necessary adjusted in order to ensure that questionnaires were sent out to the correct recipients. Data was collected by an external partner (Indikator) commissioned by the county council (I, II, III). In total, 6,853 questionnaires were sent and 3,713 valid questionnaires were returned, yielding a response rate of 54 %. The participants, response rates over time and respondent characteristics are presented in Table 5.

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Table 5. Respondent characteristics and response rates over time. 2009 2011 2013 Sent Returned Sent Returned Sent Returned

n n (%) n n (%) n n (%) Health care division

Medical 999 439 1,008 540 1,139 658

Surgical 821 409 873 523 1,164 641

Mixed medical-surgical 300 175 291 165 258 171 Total 2,120 1,023 (48) 2,172 1,228 (57) 2,561 1,470 (57) Sex Female 871 (85) 1,027(84) 1,132 (77) Male 152 (15) 176 (14) 253 (17) Unknown 0 25 (2) 85 (6) Age -24 17 (2) 24 (2) 31 (2) 25-34 126 (12) 195 (16) 268 (18) 35-44 247 (24) 295 (24) 285 (19) 45-54 357 (35) 395 (32) 425 (29) 55-64 210 (20) 275 (22) 384 (26) 65- 7 (1) 3 (1) 7 (1) Unknown 56 (6) 38 (3) 70 (5)

Total work experience (years) 0-5 83 (8) 153 (12) 206 (14) 6-10 114 (11) 159 (13) 174 (12) 11-15 90 (9) 137 (11) 186 (13) 16-20 90 (9) 121 (10) 121 (8) 21-50 579 (56) 636 (52) 706 (48) Unknown 67 (7) 22 (2) 77 (5) Staff group Managers 51 (5) 44 (4) 64 (4) Registered Nurse* 617 (60) 743 (60) 789 (53) Enrolled Nurse* 293 (29) 302 (24) 364 (25) Physician* 62 (6) 119 (10) 174 (12) Unknown 0 20 (2) 81 (6) *Non manager

Data collection

The HSOPSC (12 dimensions, 44 items) was developed in the US to measure patient safety culture. The HSOPSC was translated into Swedish and further adapted to the Swedish health care context by adding seven items of importance to Swedish patient safety (National Board of Health and Welfare,

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2009). In total, the Swedish version, the S-HSOPSC, (14 dimensions, 51 items) consists of the unit-level aspects of patient safety culture measured with seven dimensions (24 items) and the hospital-level aspects measured with three dimensions (11 items). A single item serves as a descriptive measure regarding number of events reported over the past 12 months. Two dimensions and one single-item (8 items) serve as patient safety measures. For the S-HSOPSC, one dimension (four items) reflecting information and support to patients/relatives in connection to adverse events and one dimension (two items) reflecting information and support to staff in connection to adverse events were added. Furthermore one single-item regarding number of risks reported over the past 12 months reflecting patient safety within a Swedish health care context were also added. Most items are answered using a five-point response scale of agreement (1 = “Strongly Disagree” to 5 = “Strongly Agree”), frequency (1 = “Never” to 5 = “Always”), or quality (1 = “Failing” to 5 = “Excellent”) where a higher score indicates a more positive attitude towards patient safety, i.e. strengths in patient safety. Two items use a six-point frequency scale from “No Event” to “21 Events or more” or “No Risk” to “21 risks or more”. Dimensions, items, and response alternatives of the S-HSOPSC and HSOPSC are shown in Appendix 1. In addition to the patient safety culture dimensions, a demographic section asks questions about sex, age, staff group (i.e. RN, EN, physician, or manager), total experience within health care and in the hospital work unit. In this section, the respondents also have the opportunity to state whether they have direct contact with patients and to provide the length of time they have worked in their current specialty or profession. In addition to the quantitative part (51 items of the S-HSOPSC), an open-ended question about the informants’ suggestions for safety improvement was also included (IV). The informants were asked to “please give suggestions for improvement and comments regarding patient safety and patient safety work in your work unit”. These digital notes varied in length from a few words to approximately one complete page of typewritten notes.

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Data analyses

Statistics (I-III)

The data were summarized as frequencies and percentages (nominal and ordinal data), mean and standard deviation (interval data) (Field, 2009) (I-III). A confirmatory factor analysis (CFA) was used to examine the psychometric properties of the S-HSOPSC and the HSOPSC (I). In order to fulfil the criteria for CFA used in this study, respondents who had answered all patient safety culture items in the S-HSOPSC, i.e. 569 respondents were included for these analyses: i.e. listwise deletion (Hair et al., 2006, Harrington, 2009). Factors were estimated using the maximum likelihood method (I). To asses fit for the 14 dimensional S-HSOPSC and the 12 dimensional HSOPSC models in Swedish data, the index Root Mean Square Error of Approximation (RMSEA), χ 2 statistic, degrees of freedom (df), Goodness-of-Fit Index (GFI), Comparative Fit Index (CFI), and Tucker Lewis Index (TLI) were used (Hair et al., 2006). In accordance with the developers’ instructions, composite scores for all 14 dimensions (composites) were calculated, making up a possible score ranging from 0 to 100, with higher scores indicating a more positive assessment of patient safety culture (Sorra & Nieva, 2004). Areas with mean percentage values of 75 and above were considered as patient safety strengths and those not reaching values of 50 were considered as areas in need of improvement (Sorra & Nieva, 2004) (I). The dimensional patient safety culture mean was calculated, i.e. the percentage of respondents who answered the item by clicking “strongly agree” and “agree” or “always” and “most of the time” (II). Differences in patient safety culture between two unrelated groups (i.e. managerial function, sex) were analyzed using Students T-test. Levene’s test was used to analyze differences in variance between two groups (Field, 2009) (II). Differences in patient safety culture between three unrelated groups (i.e. staff group, total experience within health care, age, health care division) were tested using Analysis of Variance (ANOVA) (Field, 2009) (II). To examine which factors that were statistically significantly associated with health care staff’s perception of patient safety culture, a multiple regression analysis (Field, 2009) was conducted. Dependent variables were the two outcome dimensions ‘Frequency of Event Reporting’ and ‘Overall Perceptions of Safety’. Independent variables were the patient safety culture dimensions on

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unit level (7 dimensions), hospital level (3 dimensions) and Swedish added dimensions (2 dimensions). Further, respondent characteristics (staff group, health care division, sex, managerial function and total health care experience) served as additional independent variables. Two models were created, one for each dependent variable where all independent variables were entered simultaneously (Field, 2009) (II). A four-way analysis of variance (ANOVA) was performed to examine a systematic change (Montgomery, 2013) in patient safety culture due to the factors staff group (RN, EN, physician, manager), the health care division to which one belongs (medical, surgical, mixed medical-surgical), the year of measurement (2009, 2011, 2013), and sex (female/male) (III). The interactions between these factors were also assessed. Sex was kept as a control variable due to varying theoretical support of having effect on patient safety culture (III). Significant F-values were followed by post-hoc comparison (Tukey) to further analyze differences between the groups (II-III). Internal consistency was calculated using Cronbach’s alpha coefficient (I-III) (George & Mallery, 2003). Significance levels were set to <0.05 (I) and < 0.01 (II, III). Statistical analyses were conducted using IBM Statistical Package for Social Sciences (SPSS) Statistics version 18.0, 19.0, 20.0 (I, II, III) and SPSS Analysis of moment structures (SPSS Amos) (I).

Qualitative Content Analysis (IV)

The texts underlying the analysis are written comments answering an open- ended question in a questionnaire, and are suitable to be analyzed using qualitative content analysis (Krippendorrf, 2004). Thus, qualitative content analysis was chosen to describe health care staff’s suggestions for improvement of patient safety. The text from the informants varied from a few words making up a sentence, to approximately one complete page of typewritten notes, making up approximately 12,000 words. Perceptual wholes were formed from text with common and disparate meanings using manually conducted clustering (Krippendorrf, 2004). First, all informants’ answers to the open-ended question were read to obtain a sense of the whole. Next, meaning units with reference to the informants’ suggestions for improvements were identified. A meaning unit could consist of a few words, one or more sentences or paragraphs of a narrative. Thereafter, meaning units with similarities with respect to words were grouped into clusters. Subsequently, clusters with similarities were grouped in categories. The main author (AN) went back and forth between the steps

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during this process. The co-authors read the author’s initial analysis and critical discussions were conducted within the research group resulting in modifications of the clusters and categories. The analysis was conducted separately for the different professions. After reading the analysis as a whole, all the authors discussed the findings until agreement was reached.

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ETHICAL CONSIDERATIONS

These studies were conducted in accordance with ethical principles and guidelines drawn in ‘Ethical guidelines for nursing research in the Nordic Countries’ (Northern Nurses Federation [NNF], 2003), aligned with the ‘Declaration of Helsinki’ (World Medical Association [WMA], 2013). Before the studies were carried out, the project underwent ethical review and approval by the local ethics committee (Dnr. C 2009/304). In addition, the County Council Manager and each health care division’s senior management board gave their approval. Data was handled according to the Swedish Personal Data Act (1998), supervised by the Data Inspection Board. All material for the research underpinning the thesis is stored in accordance with guidelines for Preservation and sorting out research material (Dnr. 230/02, Karlstad University). The principle of autonomy was ensured by voluntary and confidential participation, informed consent and the right to withdraw from the project. Invitation to participate and information including study rationale, aim of the project, methods, researchers and contact persons in the county council and in the research group were given to participants in writing and verbally by the author in meetings, via the staff newspaper and via the staff intranet. Further, it was stressed that the participation was voluntary and that participants could withdraw from the project at any time without any negative consequences (NNF, 2003; WMA, 2013). The principle of beneficence was safeguarded by all health care units, all managers and the county council managers receiving their results with regard to positive composite scores on the S-HSOPSC dimensions (NNF, 2003). This may contribute to patient safety improvement in the health care decisions. To ensure the principle of non-maleficence, the researchers offered opportunities for participants to consult with them and ask questions if required. This was enabled by thorough contact information in writing and verbally. Consultations by mail, telephone and in person were made by respondents from all professions. The principle of justice was ensured by inviting all RNs, ENs and physicians in all work units at the three health care divisions to participate in the project (NNF, 2003).

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MAIN RESULT

Results from the studies are shown in six sections: psychometric properties of the S-HSOPSC and HSOPSC (I), perceptions of patient safety culture (I), comparisons of health care staff’s perception of patient safety culture (II, III), factors related to patient safety culture (II, III), patient safety culture change over time (III) and health care staff’s suggestions for patient safety improvement (IV). Lastly, the results are being summarized.

Psychometric properties of the S-HSOPSC and HSOPSC (I)

A confirmatory factor analysis (CFA) was conducted to examine the psychometric properties and Cronbach’s alpha was used to examine analysis of internal consistency of the S-HSOPSC and the HSOPSC (I). The construct validity was tested by means of CFA which showed that the six fit indices of the proposed 14 dimensional S-HSOPSC model and the 12 dimensional HSOPSC model were acceptable. The fit index RMSEA, which was primarily used to test the model fit, revealed a value of 0.082 for the factor structure in the S-HSOPSC and 0.085 for the HSOPSC, which indicated acceptable fit for both models. Internal consistency reliability for the dimensions in the S-HSOPSC and the HSOPSC showed Cronbach’s alpha values ranging from .60 to .87. In total nine dimensions in the S-HSOPSC reached an alpha value > 0.70. Of these, three dimensions displayed alpha values > 0.80. These were ‘Information to Patient/Relatives’, ‘Frequency of Event Reporting’ and ‘Hospital Management Support’. Six dimensions displayed alpha values > 0.70, yet below 0.80. These were by ‘Overall Perceptions of Safety’, ‘Manager Promoting Safety’, ‘Feedback and Communication’, ‘Nonpunitive Response To Error’, ‘Hospital Handoffs & Transitions’ and ‘Information to Staff’. The dimensions ‘Organizational Learning’, ‘Communication Openness’, ‘Staffing’, ‘Teamwork Within Hospital Units’ and ‘Teamwork Across Hospital Units’ displayed alpha values ≥0.60, yet below 0.70.

Perceptions of patient safety culture (I)

Composite scores for the dimensions in the S-HSOPSC indicated that health care staff had favorable attitudes towards those aspects of patient safety that dealt with their own unit’s work. The Unit Level dimensions ‘Teamwork Within

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Hospital Units’ (M=86.1, SD=22.4), ‘Communication Openness’ (M=79.0, SD= 28.6) and ‘Feedback and Communication’ (M=78.5, SD= 29.7) displayed a mean percentage > 75. Those dimensions indicating a less favorable attitude towards patient safety were scattered on the three remaining levels. The dimensions ’Hospital Management Support’ (M= 35.5, SD= 39.9), ‘Information to Patients/Relatives (M=47.7, SD= 36.8) and ‘Frequency of Event Reporting’ (M=48.7, SD= 40.9) displayed mean percentages below 50 and were considered as areas in need of improvement accordingly. These dimensions reflect the upper management’s dedication to patient safety work, information to patients and relatives in connection with events and staff’s propensity to report events, respectively. Health care staff’s attitudes towards overall safety in their own work unit were considered positive by 58.9 % of the respondents. Of these, 53.0 % considered the overall safety to be ‘Very good’ and 5.9 % considered the overall safety to be ‘Excellent’. The majority (67.1 %) of the respondents had also written down and reported at least one event in the past 12 months. Of the respondents, 40.9 % had reported 1-2 events in the past year and 19.5 % of the respondents had reported 3-5 events in the past year. Of all respondents, 32.9 % had not written any events during the last year.

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Comparisons of health care staff’s perception of patient safety culture (II, III)

Managers’ perceptions of patient safety culture (II, III)

When managers were compared with non- managers (II), the results showed that managers scored higher for all but three dimensions, ‘Overall Perceptions of Safety’, ‘Manager Promoting Safety’ and ‘Hospital handoffs and Transitions’ indicating that managers had a more favorable attitude towards most aspects of patient safety (Table 6).

Table 6. Comparisons of patient safety culture scores between managers and non-managers. Only statistically significant differences are shown.

Managers

(n=51)

Non-managers (n=972)

p1

Patient Safety Culture Dimensions Mean (SD) Mean (SD) Outcome Measures

Frequency of Event Reporting 3.69 (0.79) 3.35 (0.85) ** Unit Level

Organizational Learning 3.92 (0.59) 3.58 (0.65) *** Teamwork Within Hospital Units 4.27 (0.45) 4.05 (0.54) ** Communication Openness 4.24 (0.50) 3.94 (0.65) *** Feedback and Communication 4.16 (0.56) 3.90 (0.75) ** Nonpunitive Response To Error 4.27 (0.68) 3.78 (0.80) *** Staffing 3.76 (0.67) 3.44 (0.68) ***

Hospital Level Hospital Management Support 3.54 (0.80) 3.04 (0.84) *** Teamwork Across Hospital Units 3.70 (0.56) 3.45 (0.62) **

Swedish Added Dimensions Information to Patient/Relatives 3.68 (0.72) 3.38 (0.77) ** Information to Staff 4.15 (0.51) 3.63 (0.87) ***

1Tukey post-hoc ** = p <.01, *** = p ≤ .001

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Managers’ perceptions of patient safety culture (II, III) (cont.)

In paper III, when comparing managers and RNs, ENs and physicians, the results again showed that the former held a more favorable attitude towards patient safety. Managers scored significantly higher for all 14 dimensions compared with RNs, ENs, and physicians (Table 7).

Table 7. Comparisons of patient safety culture between health care staff. Only statistically significant differences are shown. Registered

Nurses (1) (n=2,113)

Enrolled Nurses (2) (n=941)

Physicians (3)

(n=342)

Managers (4)

(n=159) p1

Patient Safety Culture Dimensions Mean (SD) Mean (SD) Mean (SD) Mean (SD) Outcome Measures Frequency of Event Reporting 3.26 (.04) 3.53 (.04) 2.91 (.06) 3.55 (.07) 1>3; 2>1, 3; 4>1, 3*** Overall Perceptions of Safety 3.62 (.03) 3.77 (.04) 3.31 (.05) 3.92 (.07) 1>3; 2>1, 3; 4>1, 3*** Unit Level Manager Promoting Safety 3.67 (.02) 3.88 (.03) 3.59 (.05) 4.0 (.07) 2>1, 3; 4>1, 3*** Organizational Learning 3.47 (.02) 3.59 (.05) 3.41 (.04) 3.82 (.07) 2>1, 3; 4>1, 2, 3*** Teamwork Within Hospital Units 4.00 (.02) 4.02 (.04) 3.93 (.05) 4.20 (.06) 1>3; 2>3; 4>1, 2, 3*** Communication Openness 3.67 (.02) 3.70 (.02) 3.65 (.04) 4.00 (.05) 1>3; 2>3**; 4>1, 2, 3*** Feedback and Communication 3.70 (.04) 3.83 (.07) 3.44 (.07) 4.00 (.08) 1>3; 2>3; 4>1, 3*** Nonpunitive Response To Error 3.69 (.03) 3.74 (.06) 3.53 (.05) 4.28 (.08) 2>1, 3, 4; 4>1, 2, 3*** Staffing 3.43 (.02) 3.29 (.02) 2.96 (.06) 3.66 (.06) 1>2, 3; 2>3; 4>1, 2, 3*** Hospital Level Hospital Management Support 2.98 (.02) 3.28 (.03) 3.10 (.07) 3.59 (.07) 2>1, 3; 4>1, 2, 3*** Teamwork Across Hospital Units 3.39 (.04) 3.52 (.04) 3.51 (.05) 3.70 (.06) 2>1, 3; 4>1, 3*** Hospital Handoffs and Transitions 3.55 (.03) 3.66 (.05) 3.17 (.05) 3.56 (.07) 1>3; 2>1, 3; 4>3*** Swedish Added dimensions Information to Patient/Relatives 3.32 (.03) 3.7 (.04) 3.67 (.05) 3.81 (.07) 2>1; 3>1; 4>1*** Information to Staff 3.52 (.02) 3.84 (.03) 3.52 (.08) 4.12 (.08) 2>1, 3; 4>1, 2, 3*** 1Tukey post-hoc ** = p <.01, *** = p ≤ .001

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Registered nurses’, enrolled nurses’ and physicians’ perceptions of patient safety culture (II, III)

When comparisons between the staff groups RNs, ENs and physicians were made, the results showed that the professions had different attitudes towards patient safety (II). ENs scored significantly higher than RNs for ten dimensions and physicians for six dimensions out of 14, indicating a more favorable attitude towards patient safety (Table 8).

Table 8. Comparisons of patient safety culture scores between different staff groups. Only statistically significant differences are shown.

Registered Nurses (1) (n=660)

Enrolled Nurses (2) (n=294)

Physicians (3)

(n=69) p1

Patient Safety Culture Dimensions Mean (SD) Mean (SD) Mean (SD) Outcome Measures Frequency of Event Reporting 3.30 (0.82) 3.62 (0.87) 3.01 (0.79) 2>1, 3*** Overall Perceptions of Safety 3.67 (0.76) 3.86 (0.68) 3.44 (0.78) 2>1, 3*** Unit Level Manager Promoting Safety 3.73 (0.77) 3.96 (0.72) 3.70 (0.81) 2>1*** Organizational Learning 3.55 (0.66) 3.74 (0.57) 3.53 (0.72) 2>1*** Feedback and Communication 3.91 (0.75) 4.00 (0.69) 3.60 (0.83) 1>3**; 2>3*** Nonpunitive Response To Error 3.75 (0.80) 3.93 (0.75) 3.73 (0.88) 2>1** Staffing 3.51 (0.66) 3.40 (0.68) 3.25 (0.86) 1>3** Hospital Level Hospital Management Support 2.98 (0.82) 3.31 (0.82) 2.91 (0.94) 2>1, 3*** Teamwork Across Hospital Units 3.43 (0.58) 3.57 (0.62) 3.30 (0.81) 2>1, 3** Hospital Handoffs and Transitions 3.57 (0.64) 3.74 (0.62) 3.14 (0.70) 1>3*** 2>1, 3*** Swedish Added Dimensions Information to Patient/Relatives 3.26 (0.78) 3.65 (0.69) 3.63 (0.68) 2>1*** 3>1*** Information to Staff 3.56 (0.89) 3.89 (0.75) 3.60 (0.84) 2>1*** 1Tukey post-hoc ** = p <.01, *** = p ≤ .001

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When comparisons between staff groups were made (III), ENs showed a more positive attitude towards patient safety than RNs for ten out of 14 dimensions and physicians for 13 out of 14 dimensions. Physicians showed a more positive attitude than RNs in ‘Information to Patient/Relatives’, indicating a more favorable attitude to informing patients/relatives in connection to adverse events (III). In Figure 1, the differences in perception between RNs, ENs and physicians are depicted. See also Table 8 for comparisons of patient safety culture between health care staff.

Figure 1. Differences between health care staff’ attitudes towards patient safety. The higher the score (1-5), the more positive an attitude towards patient safety. In order to clarify the differences, only range 2 to 4.5 are visualized in the figure.

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Women’s and men’s perceptions of patient safety culture (II)

Comparisons in attitude towards patient safety between men and women were conducted. The analyses showed that female respondents reported higher patient safety culture scores than male respondents for four dimensions, indicating a more positive attitude towards patient safety (Table 9).

Age groups and work experience and perception of patient safety culture (II)

When differences in attitude towards patient safety for respondents of different age were examined, differences occurred. Health care staff aged ≥56 years scored higher, indicating a more positive attitude towards patient safety, for several dimensions (Table 10).

Table 9. Comparison of patient safety culture scores between sex. Only statistically significant differences are shown. Female

(n=871) Male (n=152) p1

Patient Safety Culture Dimensions Mean(SD) (n=871)

Mean(SD) (n=152)

Outcome Measures Frequency of Event Reporting 3.4 (0.8) 3.2 (0.8) *** Unit Level Feedback and Communication 3.9 (0.7) 3.7 (0.7) *** Hospital Level Hospital Management Support 3.1 (0.8) 2.9 (0.8) ** Hospital Handoffs & Transitions 3.6 (0.6) 3.4 (0.7) *** 1Students T-test ** = p <.01, *** = p ≤ .001

Table 10. Patient safety culture scores in different age groups. Only statistically significant differences are shown. ≤40 years

(1) (n=271)

41-55 years (2)

(n=508)

≥56 years (3)

(n=185) p1

Patient Safety Culture Dimensions Mean (SD) Mean (SD) Mean (SD) Outcome Measures

Frequency of Event Reporting 3.10 (0.86) 3.45 (0.80) 3.47 (0.85) 2>1; 3>1*** Overall Perceptions of Safety 3.46 (0.77) 3.76 (0.72) 3.95 (0.70) 2>1; 3>1***

3>2** Unit Level

Organizational Learning 3.47 (0.70) 3.62 (0.64) 3.74 (0.58) 2>1**; 3>1*** Nonpunitive Response To Error 3.68 (0.80) 3.86 (0.78) 3.82 (0.85) 2>1** Staffing 3.33 (0.69) 3.50 (0.68) 3.59 (0.69) 2>1**, 3>1***

Hospital Level Hospital Management Support 2.75 (0.76) 3.12 (0.81) 3.39 (0.85) 2>1; 3>1, 2*** Teamwork Across Hospital Units

3.30 (0.64) 3.49 (0.58) 3.59 (0.63) 2>1; 3>1***

Swedish Added Dimensions Information to Patient/Relatives 3.19 (0.81) 3.40 (0.75) 3.67 (0.68) 2>1; 3>1, 2*** Information to Staff 3.42 (0.95) 3.73 (0.83) 3.83 (0.77) 2>1; 3>1***

1Tukey post-hoc ** = p <.01, *** = p ≤ .001

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Health care staff with a total work experience within healthcare >10 years scored higher, indicating a more positive attitude towards patient safety than those with shorter experience for several dimensions (Table 11).

Table 11. Comparisons of patient safety culture scores between respondents in relation to total work experience within health care. Only statistically significant differences are shown.

0-5 years

(1) (n=81)

6-10 years (2)

(n=114)

≥ 10 years (3)

(n=759) p1

Patient Safety Culture Dimensions Mean (SD) Mean(SD) Mean(SD) Outcome Measures

Frequency of Event Reporting 3.05 (0.83) 3.19 (0.83) 3.43(0.83) 3>1*** Overall Perceptions of Safety 3.37 (0.79) 3.45 (0.81) 3.80(0.72) 3>1, 2***

Unit Level Staffing 3.25 (0.72) 3.23 (0.66) 3.53(0.68) 3>1, 2***

Hospital Level Hospital Management Support 2.70 (0.76) 2.75 (0.83) 3.16(0.83) 3>1, 2*** Teamwork Across Hospital Units 3.23 (0.64) 3.34 (0.63) 3.51(0.60) 3>1***

Swedish Added Dimensions Information to Staff 3.50 (1.04) 3.45 (0.94) 3.72(0.82) 3>2**

1Tukey post-hoc ** = p <.01, *** = p ≤ .001

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Workplace and perception of patient safety culture (II, III)

Health care staff in the three health care divisions held different attitudes towards patient safety. Differences were seen at all hospital level dimensions and one Swedish added dimension (II), indicating that health care staff in the mixed medical-surgical division held a more favorable attitude towards the upper management’s dedication to patient safety work, to teamwork with staff outside the own work unit and to transfer of patients and information (Table 12).

When comparing the results between health care divisions, health care staff at the mixed medical-surgical health care division scored higher than those in the medical and the surgical health care divisions. In addition to the differences mentioned above, another six dimensions differed. Differences were later scattered on all levels (Table 13).

Table 12. Patient safety culture scores in different health care divisions. Only statistically significant differences are shown.

Medical (1) (n=439)

Surgical (2) (n=409)

Mixed (3) (n=175) p1

Patient Safety Culture Dimensions Mean (SD) Mean (SD) Mean (SD) Hospital Level Hospital Management Support 2.91 (0.82) 3.04 (0.81) 3.53 (0.80) 3>1, 2*** Teamwork Across Hospital Units 3.40 (0.57) 3.40 (0.62) 3.75 (0.63) 3>1, 2*** Hospital Handoffs and Transitions 3.72 (0.63) 3.50 (0.67) 3.77 (0.64) 3> 2*** Swedish Added Dimensions Information to Patient/Relatives 3.31(0.79) 3.56 (.073) 3.59 (0.71) 3>1*** 1Tukey post-hoc ** = p <.01, *** = p ≤ .001

Table 13. Health care division grand mean scores of patient safety culture. Only statistically significant differences are shown.

Medical (1) (n=1,637)

Surgical (2) (n=1,573)

Mixed (3) (n=511) p1

Patient safety Culture Dimensions Mean (SD) Mean (SD) Mean (SD) Outcome Measures Frequency of Event Reporting 3.28 (.03) 3.29 (.03) 3.36 (.08) 3>2*** Overall Perceptions of Safety 3.55 (.03) 3.66 (.03) 3.76 (.08) 3>1**; 3>2*** Unit Level Organizational Learning 3.60 (.03) 3.52 (.03) 3.59 (.04) 1>2** Communication Openness 3.74 (.02) 3.76 (.02) 3.77 (.03) 3>1** Feedback and Communication 3.75 (.03) 3.73 (.04) 3.95 (.08) 1>2; 3>1, 2*** Staffing 3.25 (.03) 3.32 (.03) 3.46 (.05) 3>1, 2** Hospital Level Hospital Management Support 3.02 (.03) 3.02 (.03) 3.65 (.06) 3>1, 2*** Teamwork Across Hospital Units 3.39 (.03) 3.37 (.03) 3.83 (.06) 3>1, 2*** Hospital Handoffs and Transitions 3.42 (.03) 3.34 (.03) 3.69 (.05) 1>2; 3>1, 2*** Swedish Added Dimensions Information to Patient/Relatives 3.52 (.03) 3.60 (.03) 3.75 (.08) 3>1, 2*** Information to Staff 3.70 (.04) 3.67 (.04) 3.89 (.07) 3>1**; 3>2*** 1Tukey post-hoc ** = p <.01, *** = p ≤ .001

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Factors related to patient safety culture (II, III)

A regression model was conducted to analyze which factors could explain the variance in attitudes towards patient safety. For ‘Overall Perceptions of Safety’ the regression model, i.e. the 14 patient safety culture dimensions and sample characteristics, including staff group, health care division, sex, managerial function and total experience within health care was significantly associated with health care staff’s attitudes towards an overall perception of safety and together explained a variance of 49 %. In the model, the three unit level dimensions ‘Organizational Learning’, ‘Nonpunitive Response To Error’ and ‘Staffing’ were positively associated with health care staff’s attitude towards an overall perception of safety, i.e. the more positive attitude towards learning, non-punitive response and staffing, the more an positive attitude towards overall safety. Further, the hospital level dimensions ‘Hospital Management Support’ and ‘Hospital Handoffs and Transitions’ were also positively associated i.e. the more positive attitude towards the upper management support and hospital transitions, the more the health care staff had a positive attitude towards overall safety. Moreover, managerial function and Total work experience within health care >10 years were also positively associated, indicating that managers and health care staff with a work experience >10 years had a more favorable attitude towards overall safety in their unit (II). For ‘Frequency of Incident Reporting’, the regression model was significantly associated with health care staff’s attitude towards incident reporting and explained a variance of 26 %. Two unit level dimensions; ‘Organizational Learning’ and ‘Feedback and Communication’ and one of the Swedish added dimensions; ‘Information to Patient/Relatives’ was positively associated with propensity to report adverse events, i.e. the more positive attitude towards learning, and open communication with feedback and information to patients or relatives in connection with adverse events, the more the health care staff had a positive attitude towards reporting events (II). The factors having main effect and interaction effect on the 14 patient safety culture dimensions were further analyzed (III). Staff group had a significant main effect on all 14 dimensions. Health care division had a significant main effect on the eight dimensions ‘Overall Perceptions of Safety’, ‘Organizational Learning’, ‘Teamwork Within Hospital Units’, ‘Staffing’, ‘Hospital Management Support’, ‘Teamwork Across Hospital Units’, ‘Hospital Handoffs & Transitions’ and ‘Information to Patient/Relatives’. Year of measurement had a

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significant main effect on the eight dimensions ‘Frequency of Event Reporting’, ‘Overall Perceptions of Safety’, ‘Teamwork Within Hospital Units’, ‘Communication Openness’, ‘Staffing’, ‘Hospital Management Support’, ‘Teamwork Across Hospital Units’, ‘Hospital Handoffs & Transitions’ and ‘Information to Patient/Relatives’.

Patient safety culture change over time (III)

Health care staff’s perceptions of patient safety culture measured over time showed significant deteriorations. Patient safety culture score decreased significantly over time for 12 dimensions, indicating a deteriorating attitude over time for most aspects of patient safety. Patient safety culture increased significantly over time for the dimension ‘Information to Patients/Relatives’, indicating an improved attitude towards informing patients and relatives in connection with an adverse event. For the dimension ‘Information to Staff’, no significant change was detected, indicating that health care staff’s attitudes towards information and support to staff affected by an adverse event remained similar over time. Mean scores for the 14 dimensions over time are shown in Table 14.

Table 14. Patient safety culture mean score over time. Only statistically significant differences are shown.

2009 (1)

N= 1,023

2011 (2)

N=1,228

2013 (3)

N=1,470 p1

Patient Safety Culture Dimensions Mean (SD) Mean (SD) Mean (SD) Outcome Measures Frequency of Event Reporting 3.38 (0.85) 3.38 (0.82) 3.22 (0.87) 1>3***; 2>3*** Overall Perceptions of Safety 3.72 (0.75) 3.56 (0.79) 3.47 (0.84) 1>2, 3*** 2>3** Unit Level Manager Promoting Safety 3.78 (0.76) 3.67 (0.85) 3.76 (0.83) 1>2*** Organizational Learning 3.60 (0.65) 3.55 (0.69) 3.47 (0.72) 1>3*** Teamwork Within Hospital Units 4.06 (0.54) 3.99 (0.58) 3.97 (0.61) 1>2**; 1>3*** Communication Openness 3.94 (0.65) 3.93 (0.67) 3.15 (0.71) 1>3***; 2>3*** Feedback and Communication 3.94 (0.74) 3.89 (0.75) 3.63 (0.77) 1>3***; 2>3*** Nonpunitive Response To Error 3.78 (0.80) 3.71(0.80) 3.76 (0.85) 1>2** Staffing 3.44 (0.70) 3.27 (0.74) 3.21 (0.80) 1>2***; 1>3*** Hospital Level Hospital Management Support 3.16 (0.84) 3.05 (0.86) 3.07 (0.91) 1>2***; 1>3** Teamwork Across Hospital Units 3.51 (0.62) 3.42 (0.66) 3.46 (0.68) 1>2***; 1>3*** Hospital Handoffs and Transitions 3.62 (0.65) 3.53 (0.70) 3.52(0.73) 1>2***; 1>3*** Swedish Added Dimensions Information to Patient/Relatives 3.43 (0.77) 3.38 (0.80) 3.65 (0.82) 3>2***; 3>1*** 1Tukey post-hoc ** = p <.01. *** = p ≤ .001

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Health care staff’s suggestions for patient safety improvement (IV)

The qualitative content analyses resulted in nine categories showing that health care staff suggests a diversity of approaches to improve patient safety. In general, health care staff expressed similar manners to improve patient safety, but their suggestions were nuanced in relation to their professions. The categories in relation to health care staff professions are shown in Table 15.

The category ‘Increased staffing’ described health care staff’s suggestions to increase staffing levels in general, during sick-leave and during heavy workload. Health care staff claims that with increased staffing levels, duties that are beneficial for patient safety including mobilizing patients recovering from trauma or major surgery can be performed to a greater extent. It is also suggested that staff shortages should be taken seriously due to the organizational drainage which occurs when hard-to-replace valuable knowledge and competence follow staff that leaves. By retaining permanent staff patient safety would improve according to health care staff’s suggestions. ‘Hard and soft resources’ describes health care staff’s suggestions for utilizing resources to improve patient safety. Hard resources such as alarms were suggested for monitoring patients prone to get up from bed and fall. Facilities for undisturbed preparation of potent drugs and advanced medical equipment as well as for conversations without violation of confidentiality were also suggested. Soft resources such as appropriately planned schedules making it possible to work consecutively and care for the same patients over a period of time, time for recovery after heavy workloads and restrains on overtime work that jeopardizes safety were other suggestions to improve patient safety. Other suggestions were appointing adequate competence and prioritizing health care staff with responsibilities for patient safety work, so they are given time to conduct their work.

Table 15. Distribution of the categories in relation to the various health care staff. Increased

staffing Hard and soft resources

Look beyond finances

Clarity and follow procedures

Right patient at the right place

Teamwork and collaboration

Improved feedback

Systematic event processing

Committed management

RNs X X X X X X X X X ENs X X X X X X X X Physicians X X X X X X X X Managers X X X X X X X

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The category ‘Look beyond finances’ described how health care staff from all professions suggests that the health care organization should focus beyond cost savings. The suggestions dealt with how the county council should focus more on safety and quality in the long run, instead of on immediate cost savings, since cut-backs were believed to lead to patient safety impairment. And in order to improve safety, the flow of patients sometimes needs to slow down. Health care staff also suggested that the health care should be given in accordance with patients’ needs, not after last year’s budget, and that patient safety work needs to be prioritized. Regarding the category ‘Clarify and follow procedures’, health care staff from all professions suggested that procedures should be well-known, easily accessed and followed by everyone for patient safety to be improved. Training in safety practices, i.e. education, use of check-lists, tests and follow-ups of health care staff’s compliance to procedures should be introduced. Procedures including transferring patients between units, documentation of venous catheters, drug management, correctly filled out notification for surgeries and tools to ensure that procedures truly are followed were examples of suggestions. Placing patients at the right place where health care staff holds the right competence to improve patient safety was suggested by health care staff in the category ‘Right patient at the right place’. The patient should be placed and cared for at a unit where all staff has the right competence, since taking care of patients with serious conditions but not having the specific competence was described as irrational and risky. Moreover, it was suggested not to relocate patients to other, non-specialized units due to shortage of beds, as this is seen as a patient safety risk. In the category ‘Teamwork and collaboration’, enhanced teamwork by interprofessional and multiprofessional cooperation, collaboration between units and with other organizations were suggested to improve safety for patients through the whole trajectory of care. Enhanced communication, clinical rotations and clinical audits in other professions’ daily work and sharing of experiences were proposed to counteract hierarchical structures as a way to improve patient safety. Increased cooperation with patients to improve patient safety was also suggested.

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In the category ‘Improved feedback’, increased positive and negative feedback, given promptly in close connection to the event was suggested as an approach to learn from mistakes and thus a way to improve patient safety. The feedback was suggested to be structured in accordance with the different areas, e.g. drug errors events, administrative deviations and risk reports. By continuously presenting and openly discussing health care staff’s event reports, this approach was suggested to improve patient safety. In the category ‘Systematic event processing’, it was suggested that reporting risks ought to be given a more prominent position as a way to eliminate what later could result in an adverse event. Event reporting needs time allocated to be more frequently conducted and the systems for reporting ought to be more user-friendly. To enhance staff’s willingness to report, it was proposed a shift from the individual sneaky-shame attitude to a systematic open no-blame attitude towards events. The manager’s position for patient safety improvement was pointed out in the category ‘Committed management’. The nearest managers were seen as receptive to suggestions for patient safety improvement, but it was suggested that more upper managers should attend meetings when patient safety issues were discussed and participate in work conducted in close connection to patients to receive input and fully understand the efforts and character of work. Moreover, managers were suggested to show courage, to give operational, hands-on support to staff in periods of heavy workload and to promote the work units as attractive work places.

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Summary of results

The construct validity was tested using CFA which showed that the proposed 14 dimensional S-HSOPSC model and the 12 dimensional HSOPSC model was acceptable. Internal consistency reliability for the S-HSOPSC and the HSOPSC showed Cronbach’s alpha values ranging from 0.60 to 0.87 (I).

Health care staff had favorable attitudes towards those aspects of patient

safety dealing with their own unit’s work. The dimensions ‘Teamwork Within Hospital Units’ and ‘Communication Openness’ were scored the highest. Those dimensions indicating a less favorable attitude towards patient safety were ’Hospital Management Support’, and ‘Information to Patients/Relatives (I).

Patient safety culture is perceived differently in perspective to the

profession. Managers held a favorable attitude towards patient safety for all 14 dimensions compared to RNs, ENs and physicians indicating a more positive attitude to patient safety (II, III).

ENs showed generally more positive perceptions to patient safety

compared to both RNs and physicians. RNs held a more positive attitude towards patient safety than physicians (II).

Health care staff in units prone to learn from mistakes and with appropriate staff levels, had a more positive attitude towards support and feedback from managers as well as structure for patient transferring and event information. They also had a more positive attitude towards safety and a greater propensity to report adverse events. Personal traits such as managerial function and work experience > 10 years did also affect positively to health care staffs attitude towards safety (II).

Health care staff working in the mixed medical-surgical health care

division had a more favorable attitude towards patient safety for several dimensions compared with those working in the medical and surgical health care division (II, III).

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Health care staff’s attitude towards patient safety decreased significantly for 12 out of 14 dimensions from 2009 to 2013. The only dimension to increase was ‘Information to Patients/Relatives’, indicating a positive attitude towards informing patients and relatives in connection with an adverse event (III).

Health care staff suggested several approaches to improve patient safety.

The areas where suggestions were given were similar, but suggestions for improvement were nuanced in relation health care staff’s profession. Increased staffing levels, work schedules allowing recovery after heavy workload, focus on safety instead of cost savings, adherence to procedures as well as restrictions regarding relocation of patients would improve patient safety. Furthermore, staff teamwork, quick and direct feedback when mistakes were made, and a structured event reporting process from committed managers were also suggested to improve patient safety (IV).

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DISCUSSION

The results showed that the S-HSOPC and HSOPC were acceptable for measuring health care staff’s attitudes towards patient safety. Health care staff’s attitudes towards patient safety vary with respect to managerial function, profession, sex, age, total work experience and the health care division to which they belonged. Managerial function and the health care division they belonged to were factors of importance for positive attitudes towards patient safety. Further, the results showed that health care staff’s attitude’ towards patient safety deteriorated over time for most dimensions. Suggestions for improvement of patient safety varied in connection to their work roles. The confirmatory factor analysis was conducted to test fit of the S-HSOPSC 14 dimensional model and the original HSOPSC 12 dimensional model in the Swedish context. This enabled comparisons with the results of the developers (Sorra & Nieva, 2004). The RMSEA and other fit indices reached acceptable levels (Hair et al., 2006), indicating that the S-HSOPSC is a valid questionnaire to measure patient safety culture in a Swedish hospital context. However, the S-HSOPSC and HSOPSC showed fit less favorable than reported in other studies (Sorra & Nieva, 2004; Pfeiffer & Manser, 2010; Waterson et al., 2010; Sarac et al., 2011; Eiras et al., 2014). The reasons for these differences might be methodological and are discussed in the methodological section. The dimensions ‘Teamwork Within Hospital Units’, ‘Communication Openness’ and ‘Feedback and Communication about Error’ received the highest percentage positive responses from health care staff (I). These results, which are similar to those earlier reported (Smits et al., 2008; Ballangrud et al., 2012; Eiras et al., 2014; Perneger et al., 2014), indicate a positive attitude towards the parts of patient safety which involves teamwork, communication in situations that might threat patient safety and feedback after adverse events. This attitude is beneficial for further patient safety work since teamwork, open communication and feedback in connection to errors are essential for patient safety (Singer et al., 2007; Sammer et al., 2010). The dimension ‘Hospital Management Support’, ‘Information to Patient/Relatives’ and ‘Frequency of Event Reporting’ showed the lowest percentage positive responses (I). These results also show similarities with earlier studies (Hellings et al., 2007; Snijders et al., 2009; Sarac et al., 2011), indicating a less positive attitude towards these parts of patient safety. Altogether, these results mirror the state of patient safety and patient safety work knowledge at the time of data collection. Patient safety

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development and improvement were in its early stages and regulations and procedures had recently been implemented (SFS 2010:659, SOSFS 2011:9). However, well thought-out and established systems for patient safety work with known information paths was at the time of the study in its infancy in the county council in question. Managers held a more positive attitude than non-managers towards patient safety for eleven dimensions (II), an attitude which persisted when all staff groups later were compared (III). Being a manager or holding a positive attitude towards the upper manager’s support for patient safety was also positively related to an overall positive attitude towards safety (II). That managers have a more positive attitude towards patient safety is shown in several earlier studies (Singer et al., 2003; Kim et al., 2007; Wagner et al., 2009; Feng et al., 2012; Gallego et al., 2012; de Wet et al., 2012) and might be related to the managers’ responsibility in patient safety work. These results (II, III) regarding managers’ positive attitudes towards patient safety may be due to the fact that managers consider the regulations related to patient safety to be well-implemented and that they feel familiar and up-to-date with the current patient safety work at the workplace. On the other hand, these results may reflect that managers are more distant from front-line service and direct contact with patients, unaware and unknowing of all situations when the safety of patients is put at risk, thus giving them a more optimistic view of patient safety. This difference in attitude towards patient safety between managers and non-managers might also mirror a propensity from health care staff to smooth over safety problems when informing managers (Wagner et al., 2009), leading to managers being uninformed regarding the current status of patient safety. Patient safety is largely created and developed by managers at all levels in an organization (Sammer et al., 2010) and effective management has shown to be important for creating a positive safety environment (Firth-Cozens & Mowbray, 2001; Feng et al., 2012: Parand et al., 2013). Evidence of the efficacy in interventions to promote safety culture is emerging (Frankel et al., 2003), and it is becoming clear that the manager’s role in achieving patient safety is essential (Hughes & Lapane, 2006; Pettker et al., 2011; Öhrn et al., 2011). RNs, ENs and physicians have different views on patient safety culture (II, III). ENs displayed a more positive attitude towards patient safety than physicians and RNs for multiple dimensions. These results support finding from earlier studies where ENs scored higher than RNs concerning patient safety (Hughes

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& Lapane, 2006; Yoon et al., 2014) as well as for organizational climate and quality of care (From et al., 2013). The results in the present studies might be explained by the fact that ENs are more frequently involved in direct patient care. Thus the score represents an assessment of one’s own labor and proneness to prioritize safety. The results may also reflect that RNs and physicians are more schooled in critical thinking, hence they score lower. Further focus on developing ENs’ commitment to patient safety could be beneficial for safety improvements, since further education for staff members can lead to, among other things, lower fall rates among patients (Bonner et al., 2007). This indicates that ENs have an important role to play in patient safety improvement. RNs indicated a more positive attitude towards patient safety than physicians in several dimensions (II, III). One of these dimensions was ‘Hospital Handoffs and Transitions’, regarding transferring patients and information between units and shifts. This result may reflect that RNs are more aware of these aspects of hospital care, since these tasks, e.g. transferring and reporting about patients, is carried out to a large extent by RNs. RNs also held a more positive attitude than physicians in the dimension ‘Communication Openness’ (III). This dimension deals with aspects of speaking up and communicating when health care staff becomes aware of something that might negatively affect the patients or to intervene when persons in higher hierarchical positions make decisions or perform in a manner that might negatively affect the patients. The less positive attitude of physicians towards this may indicate that physicians as a group are less prone to speaking up when something goes wrong, which is contra productive to a positive culture of patient safety (Feng et al., 2008; Sammer et al., 2010; Halligan & Zecevic, 2011). This kind of introversion was been shown in earlier research, where physicians for example displayed disinclination towards intervening in potential patient safety threats when they were questioned about safe practices (Davis et al., 2014). Physicians have also been shown to support hierarchies where junior surgeons do not question senior surgeons (Sexton et al., 2000). Another example of how complex ethical decision-making and teamwork can be in health care is reported by Josse-Eklund et al. (2012). Here, RNs showed strongly positive attitudes towards reporting misconduct and whistleblowing as parts of patient advocacy, yet RNs were least positive towards supporting patients’ decisions over the plans of physicians. To achieve open communication, beneficial for patient safety, interventions such as Patient Safety Dialogues (Öhrn et al., 2011) or trans-

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collegial discussions aiming to engender an open culture could increase awareness about these areas of patient safety. These discussions could also create an atmosphere where personal revisions are normalized and seen as common practice. In order to get physicians and RNs to speak openly about mistakes, an attitude shift needs to start already during education and then continue during supervised hospital internship where more experienced colleagues share their experiences and talk about how they have made mistakes themselves. In the present studies, physicians indicated a more positive attitude than RNs regarding the aspect of informing the patient and/or relatives when an adverse event had happened (II, III). The task of informing and managing patients and relatives in connection to adverse events traditionally falls to the physicians, giving them an understanding of the situation. A more positive attitude among physicians was also reported by Verbeek-Van Noord et al. (2014) and Weaver et al. (2015), showing a complexity in health care staff’s attitude towards the safety of patients. Here, physicians and RNs exhibited similar perceptions regarding the propensity to report adverse events and upper managers’ support in patient safety work, but when further analyzed, interactions showed that physicians held a more favorable attitude than RNs towards these aspects of patient safety (Verbeek-Van Noord et al., 2014). Physicians also held a more positive attitude towards teamwork for patient safety than RNs, but simultaneously seemed to be unaware of problems connected to teamwork (Weaver et al., 2015). Another illustration of the diversity regarding transparency when adverse events occur is reported by Pukk Härenstam et al. (2009) showing that a majority (53 %) of Swedish health care managers were reluctant to publicly share anonymized patient safety incidents and 59 % were convinced that patients and relatives should be informed about negative events only when the patients had been harmed as a result. Physicians’ and RNs’ as well as other health care staff’s divergent attitudes towards patient safety might pose threats to patient safety if they give rise to difficulties in cooperation and teamwork. Teamwork is described as one pillar of patient safety (Kohn et al., 2000; Feng et al., 2008; Sammer et al., 2010; Halligan & Zecevic, 2011) and lack of teamwork with additional lack of communication have been proposed to cause adverse events in health care (El-Dawlatly et al., 2004; Lingard et al., 2004; Suresh et al., 2004; Pronovost et al., 2006; Seiden & Barach, 2006; Catchpole et al., 2007; Wiegmann et al., 2007).

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Many activities in health care are communicative and team-based, but consideration must be taken to the varying perspectives on patient safety among different professional groups. Group-specific interventions could be patient safety-beneficial parts of an improvement package and conducting multiprofessional collaborative rounds (Dutton, 2003) or multidisciplinary teamwork training, for example the Triad for Optimal Patient Safety (TOPS) (Seghal et al., 2008) could also raise awareness about the importance of teamwork in the trajectory of care and improve patient safety. Staff in the smaller, mixed medical-surgical health care division exhibited a more positive attitude towards patient safety than staff in the larger medical and surgical health care divisions (II, III). Support from upper managers, teamwork with other units and hospital transitions were areas where staff at the smaller division showed a more positive attitude. These results might indicate that staff at the smaller division perceive that communication and cooperation with other hospital units works well, and that the senior managers and hospital manager are accessible (Ginsburg et al., 2010), committed to patient safety work and able to communicate the importance of safe behavior. Early research claiming that larger organizations were more likely to be less responsive to employees’ needs and concerns and have a less developed organizational culture (Nahavandi & Ali, 1993) support these results (II, III). The results were further confirmed by Sorra et al. (2011) and El-Jardali et al. (2014), showing that health care staff in small organizations have a more positive attitude towards those aspects concerning the patient safety work of managers. Health care staff’s attitudes towards patient safety was examined for change over time (III), showing a deteriorating attitude towards patient safety for all but two dimensions; information to patients or relatives and staff in connection with mistakes. The county council under study, as well as national authorities with great impact on health care, have made many efforts to improve patient safety (SALAR, 2011; SALAR, 2012; SALAR, 2013a). The fact that the attitude towards patient safety did not improve despite the efforts taken from 2009 to 2013 further underlines the challenges in complex interventions (Dixon-Woods et al., 2011; AbuAlRub & Alhijaa, 2014) and the time-consuming process that patient safety improvement is. Successful interventions to improve patient safety have been shown in earlier research with targeted actions, for example commitment of managers, determining a clinical study coordinator and conducting education in safety and training (Pronovost et al., 2004; Ballard,

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2007; Kalisch, 2007; Bigham et al., 2009; Miller et al., 2009; Iverson & Heffner, 2011; Pettker et al., 2011; Muething et al., 2012). Furthermore, teamwork training and a clinical study board with clear responsibilities therewithin (Pronovost et al., 2004; Ballard et al., 2007; Kalisch, 2007; Pronovost, 2008; Bigham et al., 2009; Miller et al., 2009; Iverson & Heffner, 2011; Lipitz-Snyderman et al., 2011; Pettker et al., 2011; Muething et al., 2012) were activities resulting in successful inventions. In the present study (III), the agreement for improved patient safety was implemented on a national basis, with all county councils compelled to accede in order to be eligible to monetary incentives. In the light of the postulated goals for improved patient safety in Swedish hospitals (SALAR, 2011; SALAR, 2012; SALAR, 2013a), results from the present studies might mirror difficulties to efficiently implement the national actions in the county council under study. The activities that the initiative was based on were annual patient safety reports, national digital patient information systems, digital infection tracking tools and systematic reviews of patient medical records. In addition, county councils were compelled to monitor patient safety culture, HAIs, pressure ulcer, overcrowding and relocation of patients and compliance to hygiene and workwear regulations to be eligible for additional grants. The results may also be explained by the fact that the structured work to improve patient safety in the county council was in its infancy and the many changes in procedures, equipment, attitudes and training (Leape et al., 2002) were not yet fully implemented at the time of measurement. When health care staff was asked to give suggestions to improve patient safety (IV), informants gave many similar suggestions, but the suggestions were nuanced in relation to the informants’ professions. For example, in the category ‘Increased staffing’, increased staffing levels were suggested in order to keep up with mobilization of the very ill patients in the ICU department (IV). Due to the low staffing levels, patients needed to be sedated, machine-ventilated and immobilized. Considering the high cost per 24-hours in the ICU (Dasta et al., 2005; Moerer et al., 2007; Halpern & Pastores, 2010), and studies indicating cost-savings (Lord et al., 2013) and reduction of hospital mortality (McWilliams, 2015) due to early ICU rehabilitation, these suggestions should be taken under consideration. Not only health care staff perceives pressure due to staff shortages. It is also reported by patients and relatives (Jangland et al., 2009), indicating that increased staffing levels has a bearing for both care supplier and consumer, to speak in financial terms. The focus on cost-savings instead of

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quality needs to be shifted, according to the informants (IV), since cut-backs and savings were seen as opposites of patient safety. There has also been previous research showing that, despite doubts (Canadian Patient Safety Institute, 2011), patient safety improvement leads to cost-savings (Waters et al., 2011; Etchells et al., 2012). To improve patient safety, enhanced teamwork was suggested from health care staff from all professions. By cooperation with other health care staff, managers and secretaries, as well as with different hospital units, physicians suggested that patient safety would improve. These suggestions are supported by earlier research (Quick, 2011, West et al., 2012, Reeves et al., 2013), showing that interprofessional teamwork and discussions are important for efficient workflow and improved patient safety. But apart from one physician, the perspective of teamwork where the patient is put in the center is not clearly articulated. Collaborating with patients by providing patient-centered care is intertwined with patient safety (Wagner et al., 2001; The Joint Commission, 2010; World Health Organization [WHO], 2011) and engagement of patients in their own care in order to improve patient safety is recommended (The Joint Commission, 2010; WHO, 2011; The Joint Commission, 2014). Today this might be discussed as providing a care adjusted to the patient, i.e. person centered care (Ekman et al., 2011), which also has shown to have a bearing on improved health, wellbeing and satisfaction for patients and health care staff (McCormack & McCance, 2006) as well as an organizations’ culture (Alharbi & Ekman, 2012). For person-centered care, which involves a focus om patients to participate in their own care, the organizations need a culture where the patient as an individual is in focus and not the health care staff, nor the organization (The Swedish Society of Nursing & The Swedish Society of Medicine, 2013). The importance of patients being in focus and strong participants in their own care is also clearly formulated in the Patient Act (SFS 2014:821), which was to be implemented shortly after the last data collection in the present studies. Since collaboration with the patient was not suggested by many health care staff members (IV), the act might not have had an impact yet. Another explanation might be that the content of and meaning of the act may have been interpreted as largely directed towards physicians. Given the perspective of the informants in the present study, it entails a challenge for patient safety to make health care staff allow patients to take part in their own care. Educating health care staff and managers about patients’ rights to be part of the planning and implementing of their care might thus benefit patient safety.

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Systematic event processing and improved feedback was suggested by health care staff to improve patient safety (IV). The informants were highly aware of the importance of reporting events and risks, and they also expressed a wish for preventive patient safety work and that reporting risks should be more prominent. The computerized event reporting system in the county council under study was upgraded and reintroduced in 2011, since it was previously criticized as being too time-consuming. Despite this, health care staff working close to patients emphasized that event and risk reporting is troublesome and that health care staff is forced to choose between the performance of patient care and event reporting. Current acts and regulations regarding patient safety and systematic quality work (SFS 2010:659, SOSFS 2011:9) claim that the systematic work must be characterized by continuously conducted reviews and subsequent actions to prevent events and risks. Besides from clearly pronouncing the health care organizations’ and employers’ responsibilities, the acts also underline that employees have responsibilities as a result of their registration following education (RNs and physicians). The willingness to grow and learn from events is critical to patient safety improvement (Wiegmann et al., 2004). The importance of giving feedback in connection with mistakes and after event reports to promote learning is known from earlier research (Bagian et al., 2001, Wiegmann et al., 2004, McCarthy & Blumenthal, 2006). Feedback needs to be relevant, given promptly to the relevant individual, but also disseminated as information to the whole work group (Benn et al., 2009, D’Lima, 2015). In the present research (IV), health care staff expressed that they also wanted feedback when organizational improvements were made, a finding supported by Pinto et al. (2011). This might be interpreted as the health care staff’s need for acknowledgement when they do good. Based on the informants’ suggestions regarding adverse event management and feedback, there is reason to doubt whether this fundamental principle of patient safety actually is put into place at the divisions under study. Several answers indicated that the informants’ workplace completely or partially lacks this kind of feedback and learning in connection to adverse events. The findings (IV) are troublesome, since it might indicate low compliance to legal incentives (SFS 2010:659; SOFS 2011:9), but also that health care staff despair and cease to report events (Gunnarsdottir et al., 2009, Jackson et al., 2013).

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An approach to patient safety work from a qualitative, group-perspective is the Manchester Patient Safety Framework (Parker, 2009) where patient safety culture is assessed and improved within the organization as a part of a risk management program. Patient safety culture is assessed to reside in five levels; ‘Pathological’, ‘Reactive’, ‘Calculative’, ‘Proactive’ and ‘Generative’ (Parker, 2009). Given the answers from health care staff in the present studies (I-IV), the patient safety culture in the county council resides at a calculative level, which is the third level out of five according to Parker (2009). In the calculative level, there is a lot of information from patients, staff and the organization, but it is inefficiently used, leading to information overload and that little is actually done with the information. Results from the national study of patient safety culture (SALAR, 2015), showed that health care staff are critical to upper managers support for patient safety work, adverse events are still being underreported, systems for safety management are insufficient and that workload is heavy (SALAR, 2015). To move forwards to the fourth level, proactive safety culture or to the fifth level, generative, where everybody communicates safety issues and learns from experiences from others, and where the patients are included in safety management, further work to improve patient safety is needed in the Swedish health care organization. Swedish health care organizations in general have been forced to major cut-backs. In the 1990s, extensive cost-cuttings were made, resulting in lower levels of staff. Serious staff shortages for the coming 10-20 years were predicted already in 2002 (Statistics, 2002), and the supply of RNs and physicians in health care is still insufficient (National Board of Health and Welfare, 2015). This demand for RNs and physicians and health care staff will also increase the coming three years (National Board of Health and Welfare, 2015). The lack of health care staff has rendered a situation where the current staff works under great pressure to perform their duties, with the knowledge that they are obliged to report adverse events, but are unable to do so because of a lack of time and underperforming systems (Jeffe et al., 2004). The combination of knowing what is right, but being hindered by institutional obstacles, has been defined as moral stress (Jameton, 1984) and the role of organizational obstacles in relation to developing moral stress has been reported earlier (Lützén et al., 2003, Hanna, 2004, Glasberg, 2007). Burnout defined as health care staff’s psychological response to work-related stress consists of exhaustion of work-related emotional resources, pulling away from others associated with the job (Maslach & Jackson, 1981). The occurrence of burnout among health care staff has

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become an important issue for health care organizations, since there are negative consequences, such as increased turnover (Lichtenstein, 1984; Shanafelt et al., 2002), job dissatisfaction (Aiken et al., 2002; Kalliath & Morris, 2002; Piko, 2006; Poncet et al., 2006) and impaired performance (Parker & Kulik, 1995; Shanafelt et al., 2002) connected to the phenomena. Burnt-out also affects patient safety, since for example burnt-out health care staff reports a less favorable attitude towards patient safety (Shanafelt et al., 2002; Halbesleben, 2008) and are less prone to report events with possibility to harm the patients (Spence Laschinger & Leiter, 2006, Halbesleben, 2008). Given the resignation expressed by the informants in relation to event reporting as patient safety improvement, this should be taken under consideration in order to prevent the development of exhaustion and burnout. Review of staffing and recruiting to adequate levels, as well as active, committed and supportive leadership, may serve as a way to improve patient safety.

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METHODOLOGICAL CONSIDERATIONS

In this thesis, quantitative (I-III) and qualitative (IV) methods were used. Hence, the quality of the research needs to be assessed with different criteria to which validity, reliability and trustworthiness belong (Polit & Beck, 2012). Validity concerns how conclusions drawn from the research building analyses are correct and solid. Statistical conclusion validity concerns the empirical relationship between the independent and dependent variables (Polit & Beck, 2012). Internal validity concerns the design of the studies, and the degree to which the results can be assigned to the independent variables therein. According to Polit & Beck (2012), threats to the internal validity include selection, history, and attrition. External validity concerns the conclusions we draw based on variations in population, participants and settings. Construct validity was secured using confirmatory factor analysis to test fit of the S-HSOPSC 14 dimensional model and the original HSOPSC 12 dimensional model (I). This enabled comparisons with the results of the developers (Sorra & Nieva 2004). Fit tested using the index RMSEA reached 0.082 for the S-HSOPSC and 0.085 for the HSOPSC. RMSEA values below 0.10 are considered acceptable (Hair et al., 2006). Thus, fit of the S-HSOPSC and HSOPSC reached acceptable levels, however less favorable than reported in other studies (Sorra & Nieva, 2004, Pfeiffer & Manser, 2010, Waterson et al., 2010, Sarac et al., 2011, Hedsköld et al., 2013; Eiras et al., 2014). A reason for this discrepancy can be sample size, which is a known source of effect on fit indices. Many fit indices have positive associations with sample size, i.e. a large sample will more likely exhibit fit values indicating good fit than a small sample (Hu & Bentler, 1998). To examine the psychometric properties and fit for the S-HSOPSC and the HSOPSC, the statistical analyses were performed on 569 respondents (I) who had answered all patient safety culture items in the S-HSOPSC. This sample size is sufficient for performing CFA according to Kaiser (1960) and MacCallum et al. (2001), but produces a lower subject-to-variable ratio (11:1) than the developers had (32:1), which might explain their more preferable fit values (Sorra and Nieva, 2004). The sample required to conduct CFA depends on different aspects, including technique to estimate the model and complexity of the model (Hair et al., 2006; Harrington, 2009). Maximum likelihood technique, which was used as estimation procedure, has shown sensitivity to detect almost all differences in samples > 400, which is

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below the sample in the present research (Hair et al., 2006). The fit-index RMSEA as primary index (I) was chosen since RMSEA represents how well a model fits a population, not just a sample used for estimation, and the index also tries to correct for model complexity and sample size (Hair et al., 2006). Fit for the S-HSOPSC 14 dimension model was also analyzed by Hedsköld et al. (2013) using CFA and RMSEA for 21,099 respondents in hospital settings. Here, the S-HSOPSC was found to have acceptable construct validity, thus the clinical usability remains similar, yet a more favorable RMSEA in Hedsköld et al.’s study (2013). Empirical relationship between the variables was tested using descriptive (I, II, III) inferential (I, II, III) and psychometric (I) statistics (Hair et al., 2006, Polit & Beck, 2012), which were based on the research question. A significance level of p < 0.05 was initially used (I) for tests in this thesis, but this level of significance was later adjusted to ≤ 0.01 to avoid the risk of type I errors due to the many tests (II, III). The use of a known questionnaire obviates the threats to statistical conclusion, although some Cronbach’s alpha values were low in the S-HSOPSC. Regarding reliability, nine dimensions had an alpha value between 0.70 and 0.87, which is to be considered acceptable to good (George & Mallery, 2003). The dimension ‘Frequency of Event Reporting’ showed the highest Cronbach’s alpha value (α = 0.87), which is similar to the value (α = 0.84) for the same dimension presented by the developers (Sorra & Nieva, 2004). The dimension ‘Staffing’ showed a Cronbach’s alpha value of 0.60. This dimension was also reported to exhibit similar alpha values in other studies (Sarac et al., 2011; Blegen et al., 2009; Bodur & Filiz, 2010). This indicates that the items in this dimension may be vaguely formulated or that the items vary in importance for patient safety culture depending on country or organization and might benefit from a review in order to strengthen the internal consistency (Field, 2009). Thus, the results of this dimension must be interpreted with caution. In total, the psychometric properties for the S-HSOPSC model are considered to be acceptable. However, the model might face changes due to second-time response in the national Swedish database for patient safety culture, which might lead to further development of the questionnaire.

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Regarding external validity, i.e. generalizability, one methodological reflection concerns the selection (I, II, III) (Polit & Beck, 2012). Two reminders were sent in accordance with Dillman (2007), resulting in a response rate over time of 48 % in 2009, 57 % in 2011 and 57 % in 2013. This response rate is similar to other studies of patient safety culture (Olsen, 2008; Halbesleben et al., 2008; Smits et al., 2008; Wagner et al., 2009; Pfeiffer & Manser, 2010). The threshold effect, that longer questionnaires had lower response rates than shorter questionnaire (Jepson et al., 2005), and the fact that the systematic Swedish patient safety movement was in its infancy when the first studies (I, II,) were conducted may have had a dampening effect on the recipients. A national study of patient safety culture sent to approximately 180,000 respondents, also including paramedical and administrative staff in Swedish health care, exhibited response rates of 64 % (SALAR, 2015). The number of items and time required to respond in connection with high workloads might have had a negative impact on the respondents’ ability to answer. However, our response rate can be seen as average for a web survey (Baruch 1999). This indicates that it might be difficult to achieve higher response rates in these types of studies. Another methodological reflection concerns the history, or the external events taking place in parallel to the study and affecting the outcome (Polit & Beck, 2012). Patient safety is highly interesting for employers, unions, patient organizations and the surrounding community, and media reports about the topic on a weekly basis. In the three-time cross-sectional study (III), the respondents could have been affected by the societal events regarding patient safety and demonstrated a positively or negatively developed attitude towards different aspects of patient safety beyond knowledge of the study. In methodological terms, attrition refers to when participants drop out, for instance due to death or illness, and the risk is particularly great when a long period of time passes between the time points for measurement (Polit & Beck, 2012). In the present study (III), total response rate increased over time, which indicates that the issue of attrition is less applicable. This might be due to the county council’s major efforts to focus on the importance of safe behavior, adverse events, event reporting and health care staff’s attitudes towards safety. Health care staff turnover rates also showed steadily increasing numbers of RNs and physicians between 2010 and 2013 (County council employee report, 2015). However, a closer review shows that between 2010 and 2011, rates decreased for several RNs with specialist education for example nurse anesthetist and emergency room nurse (County council employee report, 2015).

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The generalizability concerns the extent to which findings in research are applicable to other groups and other settings (Polit & Beck, 2012). Health care staff’s perceptions of patient safety culture were examined over a four-year period using three repeated cross-sectional measurements in the same health care divisions, and the same professions were measured. This, in combination with conducting the studies (I-III) in medical and surgical surroundings where adverse events are prone to occur, gives strength to validity of the studies. Further, participants from both genders, different age groups and with different experiences, were invited to participate and provide variation in information regarding the phenomena. This also meant that managers and health care staff from different educational backgrounds and professions constituted the sample. In this thesis, the RNs, ENs, physicians and managers constituting the participants are distributed in a manner corresponding rather well with the population in the county council as well as the national distribution (SALAR, 2013b), which also make the results applicable to other organizations with similar staff arrangements. The results in the present studies (I-III) are strengthened by the similar results recently reported by the National survey of patient safety culture in Sweden (SALAR, 2015), which was also conducted as a repeated cross-sectional study of patient safety culture, using the same measurement (National Board of Health and Welfare, 2009) but in a larger sample. The results (I) are also strengthened by the results from Hedsköld et al. (2013). Health care staff with workplace experience of > 3 months was eligible to take part in the studies (Nieva & Sorra, 2003). Health care staff’s attitudes towards patient safety have shown to vary in relation to experience (Kim et al., 2007; Wagner et al., 2009). The knowledge in this area may be broadened if health care staff with short experience is allowed to express their attitudes. However, this calls for a different research method, where interviews might be useful. In qualitative research, trustworthiness concerns evaluation of quality in the study. In this thesis, Lincoln & Guba’s criteria for trustworthiness were used (Lincoln & Guba, 1986). To start with, the recognized method content analysis according to Krippendorrf (2004) was used to enhance trustworthiness (IV). The informants were asked to write down their answers to a question which was proposed to all informants, and informants could add as much text as they

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desired. By doing so, credibility and dependability was enhanced. In addition to the categories, quotations from all professions were provided, in order to assist the reader to establish confirmability of the content. Furthermore, the categories are consistent with other studies of earlier conducted research of health care staff’s attitudes towards patient safety and the properties of health care staff’s attitudes towards patient safety, i.e. patient safety culture. This, in combination with a broad description of the research context, enhances the transferability.

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CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The questionnaire S-HSOPSC can be considered valid and reliable and can be used for measuring patient safety culture in the context of Swedish hospital settings.

Health care staff from different professions has different attitudes towards patient safety. In order to improve, patient safety needs to be a responsibility for everyone, at all organizational levels.

There is a gap in perceptions of patient safety between managers and the other health care staff. Managers are encouraged to approach health care staff and participate in patient safety work in close proximity to patients. Health care managers have access to valuable information from health care staff, which can be used to improve safety.

The more positive attitude health care staff had towards upper managers’ support for patient safety, the more positive attitude they had towards overall safety. This indicates that committed and supportive managers might affect patient safety in a positive way.

Health care staff suggests that patient safety would improve with teamwork and collaboration. This further stresses the importance of allowing patients to participate in their own care and creating venues for health care staff to discuss patient safety together with staff from other professions. RNs have an important coordinating position in patient safety work, since they work in close proximity to the patients, and strategically in teams, where decisions of importance for patients are made.

Health care staff’s attitudes towards open communication, nonpunitive approach, feedback and learning from mistakes have deteriorated. Staff state that care actions are being overridden due to insufficient staff levels. To prevent organizational fatigue, actions are needed.

Health care staff state that they want, and are compelled, to perform care that is safe. Supportive and committed management, a well-

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function system for patient safety and adequate staff levels are important organizational preconditions for health care staff to provide safe care.

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FUTURE RESEARCH

Further research of interest in the area of patient safety culture is to:

› Further develop and psychometrically test the S-HSOPSC within other Swedish care contexts including municipality care.

› Study associations between improved patient safety and improved patient safety culture for the most exposed patients in hospitals and nursing homes.

› Describe patient safety culture from newly employed health care staff’s

point of view.

› Study the association between patient safety culture and quality of care from patients’ perspectives.

› Explore whether patient safety culture, quality of care and patient advocacy are affected by educational interventions aiming to enhance health care staff’s competence.

› Study the association between patient safety culture and interventions on

organizational and occupational level, for example structure in schedule, staffing levels and improvement of collaboration between health care staff from different professions.

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ACKNOWLEDGEMENT

Även om jag står som författare, är denna avhandling ett arbete som i likhet med patientsäkerhetskultur skapas av flera individer i ett sammanhang. Denna avhandling skulle inte kunna ha genomförts utan stöd och hjälp från olika håll. Landstinget i Värmland och Karlstads universitet som skapade ramen för en avhandling i ämnet patientsäkerhetskultur. Stort tack till all personal som öppnat dörren till era attityder och tankar om det som påverkar säkerheten för de patienter som vårdas på sjukhus. Jag riktar mitt innerliga tack till de som har fört mig framåt som blivande forskare. Till De tre Visa Kvinnorna, mina tre vulkaner, vill jag vända mig först: Gun; Du är makalös i ditt sätt att få mig att prestera, att tänka nytt men även tänka på de basala delarna i forskningen (”the Devil is in the details!”). Varje handledning har fört mig framåt, ibland så mycket som vi har tänkt, ibland mindre. Min frustration över utebliven insikt och frånvarande kapacitet har du hanterat på det sätt som bara en mycket erfaren handledare kan. Myndigt, generöst och mjukt. Bodil; Du har rört dig runt mina tankar om statistik som en delfin simmar kring fören på en båt. Gracilt, snabbt och med lätthet har du fört diskussioner om statistiska termer så jag har hängt med fast jag inte trott mig om detta. När jag har hittat ett okänt ”något” har du snabbt kommit ikapp och förbi även om jag inte ens kunnat berätta vilken kurs mina tankar har. Du har en fantastisk förmåga att lyfta människor till högre och högre nivåer. Kersti; Du är snabbtänkt som en pil, skarp som ett rakblad, helt orädd och har med falkblick upptäckt när jag inte haft koll på mina begrepp. Du har med intresse och stor värme diskuterat mod, hur jag återfår mitt när det saknats, men även övermodet när det gått (för) bra. Dessutom uppskattar jag närheten till någon som värdesätter en schysst surdeg och blir ilsken över dåliga råvaror. Nu ska jag besöka Artisanen! Att bli handledd av en trojka som denna är en ynnest. Tack för allt. Jari Appelgren som suveränt har guidat mig och gett mig stöd när jag utrustad med smörkniv började ta mig fram i statistikens djungel. Du hjälpte mig att uppgradera till machete. Ve den faktoranalys, regression eller fyrvägsANOVA som står i vägen för mig! Annelie Ekberg-Andersson; för mer än tio år sedan visade du hur jag skaffade mig svart bälte i databassökning, detta hjälpte mig senare i forskningsprocessen. Tack för alla diskussioner, om allt från sömnstörningar till patientsäkerhetskultur. För alla givande resonemang under de gångna åren om allt inom och bortom en forskarutbildning, för alla kreativa diskussioner och all värdefull kritik under seminarier vill jag tacka de fantastiska kollegorna i forskarutbildningen; Kaisa Bjuresäter, Mona Persenius, Carina Bååth, Angelica Fredholm-Nilsson, Randi Tosterud, Randi Ballangrud, Vigdis Abrahamsen Gröndahl, Sigrid Wangensteen, Oyfrid Larsen Moen, Hege S Kletthagen, Bente Weimand, Anne-Kjersti Myhrene

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Stefenak, Anne Karin Helgessen, Ingrid From, Catharina Wallengren-Gustavsson, Sepideh Olausson, Mia Henricsson, Kristina Rosengren, Patrice Anderberg, Anna Abelsson, Ann-Chatrin Blomberg, Lena German-Millberg, Karin Ängeby, Hanne Söberg-Finnbråten, Tuva Sandsdalen, Marie Dahlen Granrud, Annika Skoogh och Maria Andersson. Stort tack till er alla! Ett särskilt tack vill jag rikta till mina kära kollegor Anna Josse Eklund, Cecilia Olsson och Anna Willman. Vi har kommit att lära känna varandra på ett sätt som man inte ofta gör som vuxen. Att förbehållslöst kunna slänga sig ner i en bekväm pinnstol och delge spännande fynd från en väl genomförd faktoranalys, och detta tas emot med samma intresse som att det kommit en ny choklad till sta’n är inte alla förunnat. Ni är ju så förbenat bra! Min stora familj har under avhandlingen funnits högst närvarande på praktiska sätt och som diskussionspartners. Att vara småbarnsförälder, renovera hus, och samtidigt disputera är en ekvation som kan verka omöjlig att lösa - men med er hjälp har det gått. Tack Charles och Gunilla för allt ert stöd under alla år, ni har odiskutabelt varit de ultimata svärföräldrarna till en doktorand! Till mina föräldrar Lars och Greta riktar jag min stora kärlek och varma tack. Att kärleksfullt tvingas ut på bärplockning, att lasta ved, baka tunnbröd och i mörkret starta en gammal moped utstirrad av tre älgar samt styra en gammal snöskoter över vårisar rustade mig väl för eskapader längre fram i livet. Tack för allt ert stöd och all kärlek! Mattias R Gustavsson. För 13 år sedan fattade du ett beslut som var så rätt. Du vet inget om mig längre, men förmodligen kommer framtidens patienter skörda frukter från det frö du vattnade. Mina många vänner utanför forskarvärlden som med vin, böcker, choklad, skidåkning i fjällen, resor, tjejmilen, matlagning och allt annat som hör livet till har berikat tiden som doktorand och hjälpt till att göra den njutbar. Även om ni lessnat på mitt snack om analysmetoder och svåra överväganden har ni stannat kvar. Många är de män som har bidragit, men fler är kvinnorna; speciellt Maria, Anna och Anna, mina medsystrar och älskade vänner. ”Låtom oss fröjdas och aldrig skiljas” sa vi som sjuksköterskestuderande för 23 år sedan. Livet har givit stort och tagit brutalt, men vi har alltid funnits för varandra. Nu kan jag finnas mer för er och det blir inget annat än tillfyllest, på vårt sätt. P.I.L. ! Mina älskade döttrar Aprilia och Livia; ni har tvingat mig att tänka på annat än statistik och patientsäkerhetskultur. Varje önskad godnattsaga har gett min överhettade doktorandhjärna chans till ”reset” och varje hård kram från era barnarmar har bidragit till återhämtning. På sluttampen har ni även varit mina strängaste och vänligaste coacher. Jag älskar er så! Min älskade Teo; utan dig hade detta varit omöjligt att genomföra. Vi har så här långt i livet klarat av fler utmaningar än jag ibland tycker att någon ska behöva göra. Den här avhandlingen bär jag dock med glädje och stolthet som en av juvelerna på livets halsband. Tillsammans klarar du och jag allt!

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Appendix 1.

Appendix 1. Hospital Survey on Patient Safety Culture (HSOPSC) and the Swedish version (S-HSOPSC), level of measurement, dimensions, items, and response alternatives.

PATIENT SAFETY CULTURE DIMENSIONS- UNIT-LEVEL Supervisor/manager expectations & actions promoting safety1 B1. My supervisor/manager says a good word when he/she sees a job done according to established patient safety procedures. B2. My supervisor/manager seriously considers staff suggestions for improving patient safety. B3. Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking shortcuts (reverse worded). B4. My supervisor/manager overlooks patient safety problems that happen over and over (reverse worded). Organisational Learning - Continous improvement1 A6. We are actively doing things to improve patient safety. A9. Mistakes have led to positive changes here. A13. After we make changes to improve patient safety, we evaluate their effectiveness. Teamwork Within Hospital Units1 A1. People support one another in this unit. A3. When a lot of work needs to be done quickly, we work together as a team to get the work done. A4. In this unit, people treat each other with respect. A11. When one area in this unit gets really busy, others help out. Communication Openness2 C2. Staff will freely speak up if they see something that may negatively affect patient care. C4. Staff feels free to question the decisions or actions of those with more authority. C6. Staff are afraid to ask questions when something do not seem right (reverse worded). Feedback and Communication About Error2 C1. We are given feedback about changes put into place based on event reports. C3. We are informed about errors that happen in this unit. C5. In this unit, we discuss ways to prevent errors from happening again. Nonpunitive Response To Error1 A8. Staff feel like their mistakes are held against them (reverse worded). A12. When an event is reported, it feels like the person is being written up, not the problem (reverse worded). A16. Staff worry that mistakes they make are kept in their personnel file (reverse worded). Staffing1 A2. We have enough staff to handle the workload. A5. Staff in this unit work longer hours than is best for patient care (reverse worded). A7. We use more agency/temporary staff than is best for patient care (reverse worded). A14. We work in "crisis mode," trying to do too much, too quickly (reverse worded). PATIENT SAFETY CULTURE DIMENSIONS- HOSPITAL-LEVEL Hospital Management Support for Patient Safety1 F1. Hospital management provides a work climate that promotes patient safety. F8. The actions of hospital management show that patient safety is a top priority. F9. Hospital management seems interested in patient safety only after an adverse event happens (reverse worded). Teamwork Across Hospital Units1

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F4. There is good cooperation among hospital units that need to work together. F10. Hospital units work well together to provide the best care for patients. F2. Hospital units do not coordinate well with each other (reverse worded). F6. It is often unpleasant to work with staff from other hospital units (reverse worded). Hospital Handoffs & Transitions1 F3. Things "fall between the cracks" when transferring patients from one unit to another (reverse worded). F5. Important patient care information is often lost during shift changes (reverse worded). F7. Problems often occur in the exchange of information across hospital units (reverse worded). F11. Shift changes are problematic for patients in this hospital (reverse worded). PATIENT SAFETY CULTURE DIMENSIONS AND SINGLE ITEMS Overall Perceptions of Safety1 A15. Patient safety is never sacrificed to get more work done. A18. Our procedures and systems are good at preventing errors from happening. A10. It is just by chance that more serious mistakes don't happen around here (reverse worded). A17. We have patient safety problems in this unit (reverse worded). Frequency of Event Reporting2 D1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported? D2. When a mistake is made, but has no potential to harm the patient, how often is this reported? D3. When a mistake is made that could harm the patient, but does not, how often is this reported? Patient Safety Grade3, 6 E1. Please give your work unit in this hospital an overall grade on patient safety. Number of Events Reported4, 6 G1. In the past 12 months, how many event reports have you filled out and submitted? DIMENSIONS AND ITEMS ADDED FOR THE S-HSOPSC Number of Risks Reported5, 6 G2. In the past 12 months, how many risks have you reported? Information and Support to Patient/Relatives at Adverse Event 1 α=0.81 G3. In this unit, persons affected by an adverse event will receive an apology from what has happened. G4. In this unit, persons affected by an adverse event will receive information on what happened, consequences, and what is being done to prevent such from happening again. G5. In this unit, persons affected by an adverse event will receive support and assistance to work through and deal with what happened. G6. In this unit, persons affected by an adverse event will receive information about seeking compensation from patient insurance scheme. Information and Support to Staff at Adverse Event1 G7 In this unit, staff who has been affected by an adverse event will receive information on what is being done to prevent such from happening again. G8 In this unit, staff who has been affected by an adverse event receives support and assistance to work through and deal with what happened. 1 Response alternative from 1= strongly disagree to 5=strongly agree 2 Response alternative from 1= never to 5=always 3 Response alternative from 1= failing to 5= excellent 4 Answer categories: no events, 1-2 events, 3-5 events, 6-10 events, 11-20 events, and 21 events or more 5 Answer categories: no risk, 1-2 risks, 3-5 risks, 6-10 risks, 11-20 risks, and 21 risks or more 6 Not included in confirmatory factor analysis

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Patient safety culture in hospital settingsMeasurements, health care staff perceptions and suggestions for improvement

Anna Nordin

Anna N

ordin | Patient safety culture in hospital settings | 2015:20

Patient safety culture in hospital settings

In health care, many patients are being harmed, with leads to suffering and financial costs. Health care staff’s patient safety culture reflects their attitudes towards safety for patients. The overall aim was to psychometrically test the questionnaires S-HSOPSC and HSOPSC for measuring patient safety culture, investigate health care staff’s perceptions of patient safety culture and their suggestions for improvement. In this thesis, respondents in the most common health care staff groups participated. Health care staff held a positive attitude towards patient safety culture within their own unit’s work. The perception of patient safety culture differed between professions and managers had a more positive attitude towards patient safety culture than others. Health care staff’s attitudes towards patient safety decreased during the measurement period for almost all aspects and they suggested many approaches to improve patient safety. Patient safety needs to be a responsibility for everyone. Supporting, committed managers, teamwork and collaboration are important for patient safety improvement. RNs have an important coordinating position in patient safety work.

DISSERTATION | Karlstad University Studies | 2015:20 DISSERTATION | Karlstad University Studies | 2015:20

ISSN 1403-8099

Faculty of Health, Science and TechnologyISBN 978-91-7063-634-9

Nursing Science