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Critical Care Nurses’ Perception towards Patient Safety Culture and Practices: A Descriptive Study

Hessa Raja Alanzi

Critical Care Nursing Department, Fakeeh College for Medical Sciences, Saudi Arabia

Abstract: Purpose: The study intended to evaluate perception of nurses towards patient safety culture and practices in the critical care units of Dr. Soliman Fakeeh Hospital. Background: In the healthcare setting, it is essential to promote a culture of security which involves performances related to patient safety. Patient safety culture is regarded as a crucial indicator of quality care and a vital tool of a successful healthcare organization. Consistency in the development of patient safety culture has become a foundation of a well-established and more advanced quality healthcare. Moreover, it has been confirmed that the influence of safety culture creates positive changes in the number of patient’s cases and re-hospitalization. Method: Quantitative descriptive design was utilized in the study and 113 nurses working in the critical care unit were selected using a non-probability convenience sampling technique. The Hospital Survey on Patient Safety Culture (HSPSC) 2.0: Items and Composite Measures was applied in the study. Result: The results of the study revealed that nurses rated communication about error (94.68%) and reported patient safety events (90.71%) were the highest priorities in the critical care unit. However, nurses rated staffing (63.83%) and workplace and handoffs and information exchange (67.55%) as the lowest priority in patient safety. Furthermore, the overall percent positive response across the composites of patient safety was rated 77.31% and majority of the nurses rated the hospital overall patient safety culture very good to excellent. Conclusion: The results indicated that the overall perception of staff nurses regarding patient safety culture in the hospital were very good to excellent. The study results may be recognized that the staff nurses at the critical care unit perceived the significance of patient safety culture but they need more teachings and workshops on upholding safety in their unit of assignment to prevent harm to their patents, as well as they still in a need of understanding that patient safety culture refers to the management as well as patient belief, values, and customs.

Keywords: patient safety culture, critical care, teamwork, patient safety, adverse event

Received September 17, 2022; Revised October 21, 2022; Accepted October 30, 2022

Citation: Hessa Raja Alanzi, Critical Care Nurses’ Perception towards Patient Safety Culture and Practices: A Descriptive Study. American Journal of Nursing Research, 10 (3). 90-97. January 2022. doi:10.12691/ajnr-10-3-3

1. Introduction

Patient safety is a worldwide concern for public health in the whole healthcare system, and the important role of patient safety culture is the reduction of medical errors, including patient safety enhancement at all levels of healthcare service delivery. So, WHO has urged its member states to improve the culture of patient safety and the quality of health care in a systematic way [1,2,3].

Intensive care units (ICUs) are known to be more susceptible to adverse events because of the complications of procedures and medical conditions handled in ICUs. Patients in the ICU are critically ill and more likely to be exposed to injuries as a result of their condition. Therefore, they need advanced life support care. Consequently, the ICU poses a risk to patient safety. Healthcare professionals, whether it is a physician, technician, or nurse, are the core component of the health system and their awareness of patient safety can affect the patients' health directly [4,5].

The perception of the importance of a safety culture may vary among units of a hospital [6]. Patient safety is crucial in intensive care units (ICUs). Patients in ICUs have a higher risk of being harmed by medical errors and the lack of a positive patient safety culture. The observers in a study on ICU units reported that 17% of the patients in these units were reported to have serious side effects [7,8,9]. So, patient safety culture is a key part of making the healthcare system safer for patients. It is also a challenge for health professionals, especially in intensive care units (ICUs), because of the nature of their jobs [10].

Patient safety remains a fundamental principle and an indicator of excellence in the healthcare setting. Patient safety stays at the top priority among systems in the healthcare department. Various efforts have been made over the last two decades to promote and integrate patient safety and quality care services, but a significant number of patients continue to suffer harm while being admitted to the hospital and receiving healthcare treatment. One of the reasons why there is still unsafe care for patients is that there isn't a strong safety culture [11].

1.1. The Aim of the Study

The study is intended to evaluate the perceptions of nurses towards patient safety culture and practices in the critical care units of Dr. Soliman Fakeeh Hospital. Patient safety culture is made up of each person's values, attitudes, perceptions, skills, and patterns of behavior. These things determine the organization's commitment, style, and skill in managing health and safety.

1.2. Research Questions

1. What is the nurse’s perception of patient safety culture and practices in the critical care units of Dr. Soliman Fakeeh Hospital?

2. How many patient safety events have been reported in the past 12 months in the critical care units of the hospital?

3. What is the overall patient safety rating given by the nurses working in the critical care units of the hospital?

4. Is there a significant difference between the demographic characteristics of the respondents and their perception of patient safety culture and practices in the critical care units?

2. Materials and Method

2.1. Materials

Research design; this study employed a quantitative descriptive research design to evaluate the perspective of the nurses on patient safety culture in the critical care units of Dr. Soliman Fakeeh Hospital.

Settings; the study was conducted at Dr. Soliman Fakeeh Hospital located in Jeddah, Saudi Arabia. The study selected 3 critical care units including ICU, CCU, and ER.

Subjects; The study included 113 nurses working in the critical care units such as the critical care unit (ICU), coronary care unit (CCU), and emergency room (ER) of Dr. Soliman Fakeeh Hospital. Convenient sampling was utilized to select the sample size to be included in the study from the total population.

Tools; The study used an adopted questionnaire developed by the Agency for Healthcare Research and Quality (AHRQ) [6] in 2004, which is the most widely used instrument internationally. The “SOPS Hospital Survey 2.0: Items and Composite Measures” is a self-administered survey with 32 questions that cover 10 different areas.

The tool consisted of two parts: Part I covered the demographic characteristics of the respondents, including gender, age, nationality, length of experience, and unit of assignment.

Part II covered the perspective of the nurses on patient safety, which comprises 32 items across 10 dimensions utilizing a 5-point Likert scale. The HSOPSC questionnaire comprises both positive and negative items. All items in the 10 dimensions were answered by (5) strongly agree, (4) agree, (3) either agree or disagree, (2) disagree, and (1) strongly disagree. The mean percent positive response was used to report the results. The positive responses for each item were defined as the percentage of strongly agreed and agreed (always and most of the time) responses for direct-worded items and strongly disagreed and disagreed (never and rarely) for reverse-worded items. The tool also measures the number of events reported (D3), which was answered by (none, 1 to 2, 3 to 5, 6 to 10, 11 or more) regarding the number of patient safety events in the past 12 months and the overall patient safety rating (E1) were answered using this scale: (5) excellent, (4) very good, (3) good, (2) fair, and (1) poor.

2.2. Method

Data collection began after the approval of the Institutional Review Board of Fakeeh College for Medical Sciences. The researcher sent a letter to the chief nursing officer of the hospital and asked for permission to collect data in the ICU, CCU, and ER. Then, the researcher visited the study place and the target population, and the sample size was selected based on the standards discussed in the inclusion criteria. The purpose of the study, including the rights of every respondent, was clearly explained at the beginning of the consent. The researcher made sure that the respondents understood the terms and consent had been secured before the data collection. Informed consent is a vital principle to protect the rights of respondents while conducting a study. Obtaining consent from the study respondents is the basic step prior to beginning research, and the researcher ensured that consent was voluntary and informed. Data collection was done by the researchers for 3 months from February 2022 to April 2022.

2.3. Data Collection

For this study, all study respondents were provided with informed consent before the study. In addition, respondents were given a study information package explaining their responsibilities and the likely risks and benefits incurred by their participation. The nature of the data needed for study purposes was explained to respondents, and they have the right to enroll in this study without coercion and to withdraw from the study at any point. A printed copy of the questionnaire was distributed to the respondents by the researcher itself. The researcher spent 7 days visiting the setting of the study to obtain the desired number of respondents. The respondents were given 2-3 days to answer the questionnaire, and they were given the choice to answer it in the unit or take it home. On the last day, 113 questionnaires were returned back for analysis. The data was organized, and the data was coded and encoded in an excel sheet and submitted to the statistician.

2.4. Statistical Analysis

The data gathered was analyzed using IBM SPSS Statistics 20. The data analysis used descriptive and inferential statistical tests that were appropriate to answer the research questions. Statistical analysis was done according to the most reliable and valid statistical methods currently available. Frequency and percentage were utilized in analyzing the demographic characteristics of the respondents in terms of gender, age, educational qualifications, nationality, length of experience, and unit of assignment of the respondents as well as the patient safety culture dimension/element ratings and safety results (patient safety grade and the number of reported events). Furthermore, t-test and ANOVA were utilized to evaluate the significant differences between the demographic characteristics of the respondents and their perspectives on patient safety culture, which is comprised of the 10 dimensions.

3. Results

Table 1 shows the distribution of the nurses according to their socio-demographic data. As a result, 85.8% of those polled were females. In relation to age, the majority of the respondents were in the age range of 25–35 years old. Regarding the length of experience, the majority of the respondents have 4-6 years of experience in the critical care unit. As for the nationality of the respondents, the majority of the respondents were Filipino nurses. Table 1 also shows that 57.5% of the respondents were nurses working in the intensive care unit. Table 2 shows the perspective of the nurses on patient safety. In relation to teamwork, the average percent positive response across the 3 items was 80.62%. Regarding staffing and work pace, the average percent positive response across the 4 items was 62.83%. As for the organizational learning—continuous improvement, the average percent positive response across the 3 items was 77.28%. For the response to error, the average percent positive response across the 4 items was 73.89%. Regarding supervisor, manager, or clinical leader support for patient safety, the average percent positive response across the 3 items was 71.68%. In relation to communication about errors, the average percent positive response across the 3 items was 94.68%. For communication openness, the average percent positive response across the 3 items was 72.12%. As regards reporting patient safety events, the average percent positive response across the 2 items was 90.71%. In relation to hospital management support for patient safety, the average percent positive response across the 3 items was 81.71%. Lastly, as for handoffs and information exchange, the average percent positive response across the 3 items was 67.55%. Table 3 shows the number of events reported in the past 12 months. The table showed that the majority of the respondents reported that there were 11 or more patient safety events in the past 12 months in the hospital. Table 4 shows the overall patient safety rating given by the respondents. 47.8% of the respondents rated it as very good, and 46.0% of the respondents rated the patient’s safety as excellent. Table 5 displays the percent positive response of the respondents to patient safety culture in its 10 composite measures. The table displayed that the overall average percent positive response across the composites was 77.31%. Table 6 displays the relation between nurses’ socio-demographic characteristics and their composite measures. The table displayed that there were no statistically significant relations between all the nurses’ socio-demographic characteristics and their composite measures, except in organizational learning and continuous improvement; hospital management support for patient safety; handoffs and information exchange with their working unit; and supervisor, manager, or clinical leader support for patient safety with gender and working units.

Table 1. Distribution of the of the respondents according to their demographic data

Table 2. Distribution of perspective of the nurses on patient safety

Table 3. Distribution of the Number of Events Reported in the Past 12 Month

Table 4. Distribution of the Patient Safety Rating

Table 5. Patient Safety Culture Score per Composite Measures

Table 6. The relation between nurses’ socio demographic characteristics and their composite measures

4. Discussion

The study is intended to evaluate nurses' perceptions of patient safety culture in the critical care units. It was reported that nurses rated communication about errors and reporting patient safety events as the highest priorities in the critical care unit. However, nurses rated staffing and workplace handoffs and information exchange as the lowest priority in patient safety. Additionally, it also revealed that there are differences in terms of handoffs and information exchange depending on the critical care unit. It is also reported that hospital management support for patient safety differs by nationality. It also implies that a supervisor, manager, or clinical leader's support for patient safety varies on their age and their unit of assignment. Also, 77.31% of all the questions about patient safety got a positive answer, and most of the nurses said that the hospital's overall culture of patient safety was very good to excellent.

In hospitals, nurses' views of patient safety culture were as follows: “frequency of events reported” had the highest number of positive responses (90.6%), which was higher than the results from the Agency for Healthcare Research and Quality in the U.S. (67%), Lebanon (68.2%), and Saudi Arabia (64.3%) [12].

Saudi Arabia is a predominantly interesting setting to study patient safety culture as more than half of its healthcare workers are from overseas [13]. People think that staff that speak more than one language and come from different cultures contribute a lot to medical mistakes [14,15] and may be a major threat to patient safety.

Another important area that achieved a low positivity score is “hospital handoff and transition”. The presence of a handover process between the different professional groups is vital in this department, which deals with critically ill patients [15].

Furthermore, a study showed that the patient safety culture of the nurses can be affected by various factors such as: characteristics of employees and units; working day or night shifts; workload and nurses’ fatigue and stress; administrative factors in units; and structures and properties of the hospitals [9,16].

This claim is also supported by the study findings of Farzi et al. (2017) [17] that patient safety culture was found to be poor in the dimension of “handoffs and transitions” in the present study (40.1%), when transferring patients from ICU to other wards requires exchange of the clinical information of patients to other healthcare providers at the time of transfer. Lack of this information may lead to an increased occurrence of errors in treatment procedures and threaten patient safety. Additionally, a low score in this dimension indicated the staff lacked enough knowledge of what patient safety is and how it could help in error and adverse event reduction processes.

Sharing of values, attitudes, and beliefs linked to the patient’s safety culture impacts the outcome and organizational traits [18,19]. A higher culture of patient safety has been shown to be associated with better patient outcomes. Quality in hospital services simply means providing the patient with multidisciplinary care at minimal risk. Hence, progress and advancement in organizational and safety culture heightens quality [20, 19]. Moreover, nurses are responsible and accountable for the delivery of safe patient care and ensure no harm occurs to the recipient of their care. Recently, patient safety has become a high priority healthcare system issue due to the high potential of adverse events occurring, indicating the challenges of a weak patient safety culture. Therefore, the issue should be integrated into all policymakers' and managerial initiatives in our health system as a number one priority [21,22].

Safety is a critical and essential component of quality patient care. A wide range of actions, including performance improvement, infection control, safe use of medicines and equipment, safe clinical practice, and environmental safety, are needed to ensure safety in healthcare. A comprehensive, multifaceted approach from all healthcare disciplines and actors is considered to be the key for identifying and managing potential risks to patient safety [23].

In a study conducted in Saudi Arabia, it was disclosed that 58.0% of the respondents reported that mistakes should be corrected before affecting the patient [20]. Furthermore, hospital handoffs and transitions were one of the lowest-rated composites for patient safety culture. This finding is consistent with the results of studies carried out in Lebanon [24], Jordan [12], Japan [25], and Ethiopia [26]. Besides, a systematic review showed that in 36% of the reviewed studies, the “handoffs and transitions” dimension was rated as weak ([9].

The ability of nurses to understand the concept of patient safety culture and act accordingly is known to influence the quality of care rendered to patients. Previous research has found that there are a few things that hurt patient safety culture, such as a lack of communication between nurses and administrators and a punitive environment around mistakes, which makes people less likely to report mistakes or bad things that happen [27].

The WHO also stated that improving communication in the clinical setting will improve patient safety, quality of care, length of hospital stay, patient outcomes, and satisfaction among patients and their families [26, 27]. An aspect of an organizational culture, safety culture is referred to as the common knowledge, ideals, actions, and norms regarding security shared among the staff of an organizational medical facility. The safety culture influences the individual’s actions and attitude [28]. “Culture has an effect on how a staff sees the attitudes and actions that are needed to keep patients safe, and it gets them to do those things [18,29].

5. Recommendations

Based on the results of the study, the researcher recommends the following action plan as a basis for the development of patient safety guidelines and protocols and other quality improvement measures that ensure patient safety in the hospital:

• Professional development programs must be initiated and include all nurses in the critical care units to understand the values, beliefs, and standards about what is important in an organization and what attitudes and behaviors related to patient safety are necessary.

• Hospital administration, particularly nursing administrators, should establish standards for patient safety programs and conduct regular assessments of effective safety culture practices among nurses.

• Nursing administrators should maintain a positive working environment with an appropriate number of staff nurses by following the recommended nurse-patient ratio in the critical care units of the hospital.

• Train nurses and other healthcare providers to support blame-free reporting of safety events and ensure that healthcare IT solutions are functioning at all times.

5.1. Limitations of the Study

The current study was limited to evaluating the perception of nurses towards patient safety culture on its 10 dimensions, namely: teamwork; staffing and workplace; organizational learning-continuous improvement; response to error; supervisor, manager, or clinical leader support for patient safety; communication about error; communication openness; reporting patient safety events; hospital management support for patient safety; and handoffs and information exchange. The study was conducted in the critical care units of Dr. Soliman Fakeeh Hospital, located in Saudi Arabia, and included ICU, CCU, and ER. The data collection was limited to questionnaire distributions to the research respondents. As a sample of the whole population, 113 critical care nurses were chosen for the study. A convenient sampling method was used. 

5.2. Ethical Consideration

The study adheres to the ethical principles set forth by the research ethical committee of Fakeeh College for Medical Sciences Institutional Review Board. The respondents were informed that they were free to participate and withdraw from the study at any point in time. The informed consent, including the purpose, benefits, and risks of the study, was explained, and the respondents were requested to sign it before they answered the questionnaires. The respondents were also informed that their participation would remain anonymous and that the details would be kept confidential. The researcher also ensures that physical and psychological harm are kept to an outright minimum.

References

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