Patient safety culture in an intensive care unit : the perspective of the nursing team *

A survey was conducted with the goal of identifying and comparing the dimensions of patient safety culture from the perspective of nursing workers in two intensive care units. The Hospital Survey on Patient Safety Culture was applied between April and June 2011. It was answered by 86 workers, who were 83.49% of the nursing workers in the two intensive care units. The dimensions with the highest positive evaluations were teamwork within the units (62.8%), supervisors’/managers’ expectations and actions for safety promotion (49%) and organizational learning (46,1%). The dimensions with the lowest assessments were management support for safety (13.6%), nonpunitive responses to errors (17.5%) and general perception of safety (25.9%). The results indicate that safety culture must be developed at the study sites, with special attention to the dimensions with lower safety culture evaluations. Descriptors: Patient Safety; Culture; Intensive Care Units; Nursing. INTRODUCTION Patient safety has been a focus of health organizations when improving service quality. In response to the recommendations of the Institute of Medicine (an NGO in the United States) for improvement of patient safety in 2000, patient safety became an important worldwide health policy; it is seen as a paradigm, practice and movement uniting various communities as they move toward a common goal. Various strategies aiming for patient safety have been implemented in order to reduce errors in health care. However, it is recognized that the main barrier to safe practice is not lack of data, knowledge or experience among workers, but the fact that many health organizations have fragile cultures that reinforce * Article extracted from the Master’s Thesis “Patient safety culture at intensive care units, the nursing perspective”, presented to the Nursing Graduate Program of the Federal University of Santa Catarina, Santa Catarina, Brazil. 1 Nurse, Master of Nursing. Professor of the Nursing Graduate Program, Doctorate Level, of the Federal University of Santa Catarina. Nurse of the University Hospital of the Federal University of Santa Catarina. Florianopolis, Santa Catarina, Brazil. Email: janeidef@gmail.com. 2 Nurse, PhD in Health Sciences. Adjunct professor of the Federal University of Santa Catarina. Florianopolis, Santa Catarina, Brazil. Email: sayonara.barbosa@ufsc.br. Received: 08/18/2016. Accepted: 12/08/2016. Published: 05/04/2017. Suggest citation: Mello JF, Barbosa SFF. Patient safety culture in an intensive care unit: the perspective of the nursing team. Rev. Eletr. Enf. [Internet]. 2017 [cited __/__/__];19:a07. Available from: http://dx.doi. org/10.5216/ree.v19. 38760. Mello JF, Barbosa SFF. Rev. Eletr. Enf. [Internet]. 2017 [cited __/__/__];19:a07. Available from: http://dx.doi. org/10.5216/ree.v19. 38760. 2 negative behaviors. These cultures hamper high-quality and effective care that is efficient and profitable. The cultures of health organizations are unable to adapt to satisfy needs and overcome limitations and offer stimulating and safe work environments The development of patient safety culture was one of the measures recommended by the Institute of Medicine to help health institutions promote safety. Safety culture in an organization is the values shared among members about what is important, beliefs about how things work in the organization, and interactions with work facilities, structures and organizational systems, which together produce behavior standards that promote safety. There are emerging trends that correlate patient safety culture to positive results for patients, such as decreases in readmission and mortality rates, patient satisfaction and pressure ulcers. When it comes to patient safety culture in intensive care units (ICUs), mortality and family satisfaction present even higher correlations. Moreover, positive safety culture can also be related to a lower rate of adverse events. In this sense, safety culture in healthcare environments contributes to quality and patient safety. The main elements of safety culture involve effective leadership, teamwork, learning from mistakes and establishment of an environment of trust. However, most health organizations have outdated hierarchical structures that inhibit communication, compromise full participation and harm teamwork. In this context, assessing patient safety culture is the first step toward improving patient safety in health organizations. It enables: a clear view of patient safety aspects that require urgent attention; identification of strong and weak points in safety culture; detection of patient safety problems in the units; and comparative evaluation of their scores against scores from other institutions. Various instruments have been developed to assess safety culture. They usually employ quantitative questionnaires based on a combination of various dimensions of patient safety culture. The most frequent dimensions are: the commitment of leadership to safety; trust-based, open communication; organizational learning; nonpunitive approaches to adverse event reports; teamwork; and shared beliefs about the importance of safety. Given the importance of assessing patient safety culture, the present study applied the Hospital Survey on Patient Safety Culture (HSOPSC), an assessment instrument for safety culture created by the Agency for Healthcare Research and Quality of the United States. This instrument was utilized with the objective of identifying and comparing dimensions of patient safety culture in the eyes of nursing workers in two adult ICUs. METHOD A quantitative cross-sectional survey study conducted in two adult ICUs of public hospitals in southern Brazil from April to June 2011. The Brazilian standards for research on human subjects were adopted. The project was approved by the human research ethics committees of both institutions under protocol numbers 59/10 of 10/25/2010 and 1.111 of 11/29/2010. Mello JF, Barbosa SFF. Rev. Eletr. Enf. [Internet]. 2017 [cited __/__/__];19:a07. Available from: http://dx.doi. org/10.5216/ree.v19. 38760. 3 Convenience sampling was used to select the participants. The study’s population consisted of 109 nursing workers. The inclusion criterion was at least six months of employment in the ICUs where the study was conducted. Of the 109 professionals, five were excluded from the study because they were away from work during the data collection period and one refused to participate in the study. Therefore, 103 participants received the forms, and 97 returned them. Data collection consisted of applying the HSOPSC, an instrument that was transculturally adapted and validated for Brazilian Portuguese in 2013. Since the chosen instrument was still in process of validation, the authors decided to use the version translated into Portuguese, which was pretested by five professionals. Comparison of the study’s version and the version that was submitted for adaptation and validation found no differences in language that would compromise comprehension of the instrument, which could have the result of affecting the assessment conducted by the professional. The HSOPSC has been available in the public domain since 2004, and it has been widely employed due to its favorable psychometric properties, which are evidenced by its reliability and validity attributes. The instrument contains 42 questions grouped under 12 dimensions: teamwork within units; supervisor/manager expectations and actions promoting patient safety; organizational learning, continuous improvement; feedback and communication about errors; communication openness; staffing; nonpunitive response to errors; management support for patient safety; teamwork across units; handoffs and transitions; overall perceptions of patient safety; and frequency of events reported. Each of the 12 dimensions of the HSOPSC includes three or four items scored according to a five-point Likert scale, with response categories in terms of agreement (nine responses) or frequency (three responses). The score for each dimension is expressed as a percentage of positive responses, obtained by calculating the combined scores of the two highest response categories for each dimension. Higher percentage values indicate positive attitudes in relation to patient safety culture. After signing the free and informed consent form, participants learned about the study’s objectives. Then the completed surveys were put in a ballot box separately, with no identification except for the HSOPSC’s demographic data. Sociodemographic data were analyzed through descriptive statistics, with frequency rates calculated, both absolute and percentage, for each category of nursing workers. For analysis and interpretation of results, the AHRQ guidelines were employed. Some of these guidelines were the combination of the two highest response categories (“strongly agree/agree” and “most of the time/always”) for items described positively, and the two lowest response categories (“strongly disagree/disagree” and “never/rarely”) for items written negatively or reversed. Then the percentage for each item was calculated. The highest percentage values indicate positive attitudes regarding patient safety culture. Areas of strength for patient safety are defined by the AHRQ for items and dimensions in which over 75% of interviewees responded with “strongly agree/agree” and “most of the time/always” for items described positively, or with “strongly disagree/disagree” and “never/rarely” for items written negatively. Mello JF, Barbosa SFF. Rev. Eletr. Enf. [Internet]. 2017 [cited __/__/__];19:a07. Available from: http://dx.doi. org/10.5216/ree.v19. 38760. 4 Areas with potential for improvement are identified as items or dimensions with percentages of positive responses below 50%, while neutral areas are those in which the percentages of positive responses are below 75% and above 50%. Assessment percentages for safety culture were calculated for each of the ICUs a