Patient safety culture in hospitals within the nursing perspective

ABSTRACT

Objective

Evaluate the atmosphere regarding patient safety from the perspective of active nurses in hospitals in a country town of Rio Grande do Sul State.

Methods

Cross-sectional study with 637 nursing professionals from two hospitals. Data collection through Safety Attitudes Questionnaire, in the second half of 2014. Cutoff for positive assessment was ≥75 points.

Results

The scores for domains in the overall assessment were: 76 (team work atmosphere), 73 (safety atmosphere), 88 (job satisfaction), 59 (perceived stress), 66 (perception of unit management), 65 (perception of hospital management) and 80 (work conditions). When comparing averages between institutions, the private institution showed better working conditions.

Conclusions

Results can be used to plan and organize actions, given the low scores in relation to the safety atmosphere, management and stress perception.

Organizational culture; Nursing; Patient safety; Admitting department, hospital

RESUMO

Objetivo

Avaliar o clima de segurança do paciente na perspectiva dos profissionais de enfermagem atuantes em hospitais no interior do Estado do Rio Grande do Sul.

Métodos

Estudo transversal, com 637 profissionais de enfermagem de duas instituições hospitalares. Coleta de dados pelo Questionário de Atitude de Segurança, Safety Atitudes Questionnaire, no segundo semestre de 2014. Ponto de corte para avaliação positiva foi ≥75 pontos.

Resultados

Os escores por domínios na avaliação geral foram: 76 (clima de trabalho em equipe), 73 (clima de segurança), 88 (satisfação no trabalho), 59 (percepção do estresse), 66 (percepção da gerência da unidade), 65 (percepção da gerência do hospital) e 80 (condições de trabalho). Ao comparar médias entre as instituições, evidenciaram-se melhores condições de trabalho na instituição privada.

Conclusões

Os resultados podem servir para o planejamento e a organização das ações, tendo em vista os baixos escores em relação ao clima de segurança, gerência e percepção de estresse.

Cultura organizacional; Enfermagem; Segurança do paciente; Serviço hospitalar de admissão de pacientes

RESUMEN

Objetivo

Evaluar el clima de seguridad del paciente desde la perspectiva de las enfermeras que trabajan en hospitales en el interior del Estado de Rio Grande do Sul.

Método

Estudio transversal, con 637 profesionales de enfermería de dos hospitales. Para la recolección de datos se utilizó el Cuestionario de Actitud de Seguridad, Safety Atitudes Questionnaire, en el segundo semestre de 2014. El punto de corte para la evaluación positiva fue ≥75 puntos.

Resultados

Las calificaciones de dominios de la evaluación de conjunto fueron: 76 (clima de trabajo en equipo), 73 (clima de seguridad), 88 (satisfacción en el trabajo), 59 (estrés percibido), 66 (percepción de la gestión de la unidad), 65 (percepción gestión hospitalaria) y 80 (condiciones de trabajo). Al comparar los promedios entre las instituciones fue evidente mejores condiciones de trabajo en la institución privada.

Conclusión

Resultados pueden servir para la planificación y organización de acciones, de seguridad, gestión y percepción de estrés.

Cultura organizacional; Enfermería; Seguridad del paciente; Servicio de admisión en hospital

INTRODUCTION

Patient safety is defined as the reduction of risk of unnecessary harm associated with health care, to a minimum. The hospital provides assisted procedures and complex treatments, which enhances the chance of harm⁽¹⁾. This theme relates intrinsically to the quality of services, and has been discussed by managers of health service providers, professional associations and government agencies⁽²⁾.

Therefore, it is necessary to establish a culture of open communication related to errors, and to learn from mistakes ⁽³⁾. Through a non – punitive culture, the identification of causal factors makes it possible to invest in actions that reduce health care-related risks⁽⁴⁾. Strategies have been developed, so that the safety culture is disseminated. In this sense, the Brazilian Nursing and Patient Safety Network (REBRAENSP), established in 2008, has done work with national coverage through poles and cores, with repercussions for the health care practice, teaching and research⁽³⁾.

Still, in 2013 the Ministry of Health (MOH) established the National Patient Safety Program (PNSP) in order to provide feedback to individual and collective appeals of health professionals and the general population for safe care, free of incidents that may endanger one’s health⁽³⁾. In this sense, measuring the safety atmosphere through the perception of professionals, being considered a starting point for the institutions, because it is a measurable component of safety culture⁽⁵⁾. The diagnosis of this evaluation, with the perceptions and attitudes of professionals related to safety, allow the identification of problem areas, supporting the implementation of interventions⁽⁶⁾.

In hospitals, both for the administrative sector and for staff directly involved with the care for individuals, patient safety is a constant concern. However, thereis little scientific evidence on safety atmosphere among the professionals working in Brazilian hospitals⁽⁶⁾.

Studies that assess the safety atmosphere began in the 80s, and the literature indicates the Safety Attitudes Questionnaire (SAQ) as one of the tools to evaluate the safety culture, applied in a Chinese version within Taiwan hospitals⁽⁷⁾, Denmark⁽⁸⁾, and in Swedish hospitals^(9). In Brazil, the SAQ has been validated and applied in the State of São Paulo, showing itself to be reliable, and denotes that the punitive aspects dominate in relation to the error⁽¹⁰⁾.

In this perspective, the following research question was outlined: How is the atmosphere regarding patient safety from the perspective of active nurses in hospitals in a country town of Rio Grande do Sul State? And as the overall objective: Evaluate the atmosphere regarding patient safety from the perspective of active nurses in hospitals in a country town of Rio Grande do Sul State.

METHOD

This is a cross-sectional study carried out in two hospitals located in the northwest of Rio Grande do Sul State. One is a philanthropic general hospital, size IV, with 250 hospital beds. The other is a private hospital, size III, with 108 beds. The philanthropic hospital had about 599 nurses, and 276 private hospitals in the month of data collection, totaling 875 professionals.

Inclusion criteria were: professional nurse, technician or nursing assistant who has worked for at least one month in that sector, with 20 weekly working hours or more. Nursing professionals who were on sick leave or any other absence during data collection were excluded.

After applying the inclusion and exclusion criteria, 37 were excluded because they were on maternity or health leave, 53 were excluded because they had than 30 days in the unit, and two because they were part of the research team. We obtained 783 eligible professionals. Of these, 139 (18%) did not join the research and seven (1%) did not answer all questions. A rate of 81%, or 637 nursing professionals, participated in the research.

Data collection was conducted from June to September of 2014, by nursing students and two previously trained nurses. SAQ, validated for use in Brazil in 2011⁽¹⁰⁾, was used as a research tool. The approach to professionals took place at the nursing station units in both hospitals and, upon their acceptance to participate in the study, the professionals were asked to go to a private room to ensure privacy, answer the questionnaire and the interviewers remained next room to answer questions and receive the filled in questionnaire. It is noteworthy that each respondent received an envelope with two Free and Informed Consent Form (TCLE) and the questionnaire.

The instrument consists of two parts: the first part has 41 items that include six areas. The second part aims to collect data such as; sex, professional category, time as an active professional and the performance of the unit, adult or pediatric⁽¹¹⁾.

The six areas that aim to measure the perception of the safety atmosphere are: teamwork atmosphere, job satisfaction, perception of the unit and hospital management, working conditions and recognition of stress⁽¹²⁾. The answers to each of the questions follow a Likert scale of five points: I strongly disagree (A), I somewhat disagree (B), neutral (C) I somewhat agree (D), I strongly agree, and not applicable(E)⁽¹⁰⁾.

The final score of the instrument ranges from 0 to 100, where zero is the worst perception of the safety atmosphere and 100 is the best perception. The values are considered positive when the total score is greater than or equal to 75. The score is ordered as follows: I strongly disagree (A) is equal to 0 points; I somewhat disagree (B) is equal to 25 points; neutral (C) is equal to 50 points; I somewhat agree (D) is equal to 75 points; and I strongly agree (E) is equal to 100 points⁽¹⁰⁾.

The insertion and analysis were performed by the PASW Statistics® software (Predictive Analytics Software from SPSS Inc., Chicago – USA) 18.0 for windows. The evaluation of the global reliability and its respective dimensions was performed through the Cronbach’s alpha coefficient. The Mann-Whitney test was used to compare the means of the SAQ and the independent variables.

Study approved by the Research Ethics Committee (CEP) of the Northwest Regional University of Rio Grande do Sul State (UNIJUI) under Opinion No. 652 976, on 09/05/2014. Participants signed the Free and Informed Consent Form in two counterparts. The study met the guidelines of Resolution. 466/2012.

RESULTS

The study enrolled 637 nursing professionals. Among them, assistants or or technicians (83.5%) prevailed, female (89.3%), working primarily with adults (53.7%) and working in that specialty for more than three years (65.1%).

Table 1 presents the participants’ answers for questions in the fields of teamwork atmosphere, safety atmosphere and job satisfaction. It is emphasized that, in the descriptive analyzes by issue, options DT and DP, and CP and CT were grouped in order to obtain clarity on descriptive statistics.

Table 1
– Descriptive analysis per question of SAQ of the domains teamwork atmosphere, safety atmosphere and job satisfaction of nurses who are active in hospitals in the northwest of the State of Rio Grande do Sul, Brazil. 2014

Questions by domain	DT/DP N (%)	N N (%)	CP/CT N (%)	NA N (%)
Teamwork atmosphere
1. Suggestions of the nurse are well received in this area;	31(4.9)	40(6.3)	563(88.3)	3(0.5)
2. (R) It is difficult to talk openly if I notice a problem with patient care in this area;	309(49)	71(11)	235(37)	22(3)
3. The disagreements are resolved in an appropriate manner in this area	62(9.7)	82(12.9)	485(76.3)	7(1.1)
4. I have the support I need from other members of staff to care for patients;	40(6.2)	34(5.3)	545(85.5)	18(3)
5. It is easy for professionals working in this area to ask questions when there is something they do not understand;	37(5.8)	31(4.9)	564(88.5)	5(0.8)
6. The doctors and nurses here work together as a well-coordinated team;	101(15.9)	82(12.9)	450(70.6)	4(0.6)
Safety atmosphere
7. I would feel safe if I were treated here as a patient;	51(8)	71(11.1)	510(80.1)	5(0.8)
8. Errors are handled appropriately in this area;	82(12.9)	71(11.1)	475(74.5)	9(1.4)
9. I know the appropriate means to forward issues related to patient safety in this area;	32(5)	49(7.7)	545(85.6)	11(1.7)
10. I get appropriate feedback on my performance;	119(18.7)	88(13.8)	423(66.4)	7(1.1)
11. (R) It is difficult to discuss mistakes in this area;	271(42.6)	91(14.3)	271(42.6)	4(0.5)
12. I am encouraged by my colleagues to report any concern I may have regarding the safety of the patient;	49(7.6)	55(8.6)	524(82.2)	9(1.4)
13. The culture in this area makes it easy to learn from the mistakes of others;	122(19.1)	144(22.0)	348(54.6)	23(3.6)
Job satisfaction
15. I like my job;	6(0.9)	7(1.1)	622(97.7)	2(0.3)
16. Working here is like being part of a large family;	39(6.2)	41(6.4)	554(87)	1(0.2)
17. This is a good place to work;	12(1.9)	30(4.7)	592(92.9)	2(0.3)
18. I am proud to work in this area;	9(1.4)	15(2.4)	608(95.4)	4(0.6)
19. The moral in this area is high;	64(10)	106(17)	460(72)	6(0.9)

• Source: Research data, 2014.
• Notes: (R) Reverse items; DT – I strongly disagree DP – I somewhat disagree; N – neutral; CP – I somewhat agree; CT – I strongly agree; NA – Not applicable. Question 14 of the instrument was excluded for not constituting any domain.

Table 2 shows the responses of nursing professionals per question of the questionnaire in the areas of stress, perception, perception of management and hospital unit and working conditions.

Table 2
– Descriptive analysis per question of the SAQ on the domains perception of stress, perception of unit-hospital management and working conditions of active nurses in hospitals in the northwest of Rio Grande do Sul State, Brazil. 2014

Questions by domain	DT/DP N (%)	N N (%)	CP/CT N (%)	NA N (%)
Stress perception
20. When my workload is excessive, my performance is impaired;	127(20)	62 (9.7)	438(68.7)	9(1.4)
21. I am less efficient at work when tired;	182(28.5)	58(9.1)	393(61.4)	4(0.6)
22. I’m more likely to make mistakes in tense or hostile situations;	212(33.3)	66(10.4)	348(54.6)	11(1.7)
23. Tiredness affects my performance during emergency situations;	302(48)	69(10.8)	239(37)	27(4.2)
Perception of unit/hospital management
24. UNIT The management supports my daily efforts;	89(14.1)	140(22.1)	398(62.7)	6(0.9)
24. HOSPITAL The administration supports my daily efforts;	105(16.5)	212(33.3)	305(48)	14(2.2)
25. UNIT Management does not consciously compromise patient safety;	177(27.9)	177(27.9)	258(41)	22(3.5)
25. HOSPITAL Management does not consciously compromise patient safety;	166(26.1)	219(34.4)	231(36.3)	20(3.1)
26. UNIT The administration is doing a good job;	57(9)	99(15.6)	474(74.7)	4(0.6)
26. HOSPITAL The administration is doing a good job;	57(8.9)	136(21.3)	439(69)	4(0.6)
27. UNIT Troubled team professionals are treated in a constructive manner;	134(21.1)	156(24.6)	329(51.9)	15(2.4)
27. HOSPITAL Troubled team professionals are treated in a constructive manner;	113(17.7)	206(32.4)	296(46.5)	21(3.3)
28. UNIT I receive adequate and timely information about events that may affect my work;	65(10.3)	118(18.6)	437(69)	13 (2.1)
28. HOSPITAL I receive adequate and timely information about events that may affect my work;	74(11.7)	167(26.3)	374(58.9)	20(3.1)
29 In this area, the number and qualification of the professionals are sufficient to handle the number of patients;	238(37.3)	65(10.2)	321(50.4)	13(2)
Work conditions
30. This hospital does a good job in training new team members;	65(10.2)	65(10.2)	506(79.4)	1(0.2)
31. All necessary information for diagnostic and therapeutic decisions are routinely available to me;	83(13.1)	116(18.2)	416(65.3)	22(3.5)
32. Interns of my profession are properly supervised.	60(9.4)	83(13)	308(48.4)	186(29.2)

• Source: Research data, 2014.
• Notes: DT – I strongly disagree; DP – I somewhat disagree, N –neutral, CP – somewhat agree, CT – I strongly agree, and NA – not applicable. Questions 33 to 36 were excluded from the analysis because they do not constitute a specific area.

In Table 3, the averages of the overall assessment were revealed, showing that the areas teamwork atmosphere, job satisfaction and working conditions were satisfactory. The reliability of the SAQ was measured by the Cronbach Alfa estimator. Its use expresses the degree of reliability of the responses arising from the evaluated questionnaires. In this research, the value of the overall Cronbach alpha was 0.628.

Table 3
– Breakdown of average scores per area of the SAQ and Cronbach Alpha, Rio Grande do Sul State, Brazil. 2014

SAQ Areas	Score Mean (DP)	Mean (DP)	Cronbach Alpha
Teamwork atmosphere	76 (14.77)	4.06 (0.60)	0.504
Safety atmosphere	73 (15.17)	3.91 (0.52)	0.567
Job satisfaction	88 (13.06)	4.52 (0.52)	0.700
Perceived stress	59 (28.02)	3.36 (1.12)	0.774
Unit management	66 (18.84)	3.64 (0.75)	0.649
Hospital management	65 (19.87)	3.59 (0.85)	0.688
Work conditions	80 (21.38)	4.21 (0.86)	0.518

• Source: Research data, 2014.

Table 4 presents mean comparisons of the areas, according to professional category and hospital. It was evident that compared to private institutions, it offers better working conditions for nurses (p = 0.000).

Table 4
– Average comparison of domains, according to professional category and hospital, State of Rio Grande do Sul, Brazil. 2014

Domains
Variable	Teamwork atmosphere		Safety atmosphere		Job satisfaction		Perceived stress		Hospital management		Unit management		Work conditions
	M	p	M	P	M	p	M	p	M	p	M	p	M	p
Category		0.588		0.282		0.449		0.652		0.916		0.310		0.565
Ass. /Tecn.	75		72		88		58		64		65		80
Nurs.	81		75		90		63		67		72		83
Institution		0.491		0.934		0.726		0.348		0.064		0.330		0.000
Philanthropic	77		73		88		58		64		66		74
Private	76		73		88		60		66		67		91

• Source: Research data, 2014.
• M = Average

DISCUSSION

Female professionals prevail in this investigation. This feature is due to the construction of gender roles, which direct the professional choice influenced by family, social history, conditioning childhood ideas, behavioral stereotypes and a career choice consistent career with femininity⁽¹³⁾.

In this space where care is offered to patients, nursing is the professional area that works directly with patients, developing actions ranging from disease prevention and health promotion to rehabilitation, therefore, we highlight the importance of this work being carried out with the nursing staff.

It should be highlighted that quality care involves quality service with the use of protocols, a multidisciplinary team, effectiveness, efficiency, safety, innovation and technology. But, beyond these characteristics, it involves strategic management, with well – defined goals⁽¹⁴⁾, and the appreciation of employees by team members and managers⁽⁴⁾, as this will imply a direct association with the reduction of adverse events and quality of care⁽¹⁵⁾.

The results of this research denote that in all areas, the majority of respondents agreed partially or totally with the issues presented. It is noteworthy that 97.7% of professionals said they liked the work they did, and 95.4% were proud to work in the field.

Another study, using the same instrument, carried out in medical and surgical wards of a teaching hospital located in the city of Ribeirão Preto – SP, denoted that the area with the highest score was job satisfaction⁽¹⁵⁾. The satisfaction of the professional is considered a positive factor because it directly involves quality of care⁽¹⁵⁾.

Dissatisfied professionals have high turnover rates, and turnover is associated with adverse events such as medication errors, nosocomial infections and falls. A survey held with nurses in two surgical inpatient units of auniversity hospital in Florianópolis, SC, Brazil, corroborates similar results in the statement “I like my job,” revealing 92.9%, noting that satisfied professionals can transform the workplace into a safer place⁽¹⁶⁾.

Factors that predispose to job satisfaction include liking the profession, recognition, opportunity to help others and relationships in the job environment. For nurses, the autonomy, individual and team work, and job responsibilities, leading to satisfaction and endorse the meaning of this word as being close to the customer, providing quality care, feeling recognized and value⁽¹⁷⁾.

Job satisfaction is related to working conditions in the institutions, occupational health, as well as in team relations, resulting in a more humane environment. Greater professional satisfaction constitutes a relevant factor for improving the quality of health care and patient satisfaction, implying directly in better clinical outcomes of patients⁽¹⁸⁾.

Teamwork is the association of a harmonious relationship, interaction and cooperation between individuals in the same space. Research shows the area teamwork atmosphere as satisfactory, a positive aspect in the studied institutions. The literature informs that the good relationship is used as an aid structure in solving team problems⁽¹⁷⁾.

In a study with nurses in a hospital in the countryside, the same authors mentioned above who assessed the items considered satisfaction generators by order of priority, corroborate evidence that 77.8% included teamwork, among others, as the contributing factor to job satisfaction⁽¹⁷⁾. Furthermore, the factors that also contribute to worker satisfaction are the power of resolution, recognition, appreciation, compensation, autonomy and professional growth⁽¹⁸⁾.

In addition, for the due progress of work, it is necessary to have respect, harmony, consideration for different opinions, collective chemistry, in order to maintain a work environment conducive to the safety of both the professional and the patient that is treated. The area safety atmosphere presented scores considered below the cutoff point used as reference in this research, as well as in another study⁽¹¹⁾. This result indicates that this involvement and respect among workers happens, but needs to be strengthened.

This area depends not only on management or the institutional work proposal, for, in addition to the conditions and workload, this result may vary depending on the subjectivity of the human being. The safety atmosphere varies from person to person, how these workers see themselves in light of care, and the time of their lives⁽¹⁹⁾.

Additionally, in regards to the area of safety atmosphere, 80% shared the idea that they would feel safe being treated in this unit as patients. In contrast, studies that used the same instrument denoted that 83% of professionals surveyed would feel safe being treated as patients in their clinical field⁽¹⁵⁾. On the same scale, 85.6% knew the appropriate means to forward issues related to patient safety in this area, and 82.2% said they were encouraged by colleagues to report any concerns regarding patient safety.

In the area that evaluates the “perception of stress,” the highest percentage of responses was in the “somewhat agree” option. This area had the lowest average among all, which showed that professionals had low perception of stressful situations at work. It is necessary that the nursing professionals understand that to provide patient care, they must first take care of themselves, and avoid feelings of stress and anxiety that lead to abandoning their jobs, affecting the care provided to the patient.

Studies conducted with nursing staff related to stress reinforce the work in the hospital sometimes awakens feelings that are confusing and can represent both balance and satisfaction, tension and disagreements, with consequent worker illness⁽²⁰⁾. Moreover, the longer the work experience, the lower the worker stress, due to the greater technical assurance and control of everyday occurrences, no longer seen as stressful⁽²⁰⁾. health institutions must maintain a balance between caregiving and the care worker, to contribute to the positive perception of this individual worker, which will contribute positively to their satisfaction.

It is noteworthy that the perceptions of nursing professionals regarding the hospital and unit management had low scores. The professionals who participated in the study identified the unit and hospital management as a major weakness. This is a factor that deserves attention, as reflected in the quality of care provided. This area refers to the perception of professionals regarding the safety attitudes developed by the administration⁽¹¹⁾. From the results and the author quoted above, we see the need for managers to focus on these issues, for there will be no changes in the culture, if the unit and the hospital management do not adhere to this purpose. This result corroborates such fact, indicating that there is a distance between the nurses and his superiors in relation to the discussion of patient safety issues⁽¹⁵⁾.

Each institution has its rules to be followed and respected. These factors influence the actions and how professionals act and interact within the organization and, thus, collaborate with the formation of the organizational culture and climate⁽¹¹⁾. The area Working Conditions had a satisfactory score. Proper and effective training of professionals is considered key to the quality of the institution’s health service⁽¹⁶⁾. The same authors showed an average of 40 for this area in their research, stating the need to conduct training for professionals and improve staff problems⁽¹⁶⁾.

Regarding working conditions, the private institution had the best score. This may be related to the public health crisis in the country, which required changes in health organizations, especially in public hospitals, interfering negatively in working conditions.

The evidence found points to several aspects that were identified as weak in the study and need to be developed to achieve safe care. This study contributes to the hospitals, educational and scientific community, it depicts the safety culture of two hospitals located within the State of Rio Grande do Sul, a gap identified in the literature.

CONCLUSION

The study showed satisfactory scores in the areas of teamwork atmosphere, job satisfaction and working conditions. Poor results were found for the areas of safety atmosphere, perceived stress, unit and hospital management. In this sense, it is important for the manager to identify the elements that need to be qualified in order to aggregate actions with the intention of improving these scores, since a change of culture is embedded in satisfactory results in all areas.

When comparing the average between the two institutions, it was possible to identify that the private institution offers better working conditions, in the perception of the nursing team. The results can help managers of hospitals undertake the planning and organization of actions in order to change the displayed context.

Still, there is need to include patient safety discussions with all professionals involved in care, with the creation of multidisciplinary committees to implement actions and practices aimed at collective involvement, with free and safe communication, which contributes to better patient safety culture. Given this scenario, the need for educational institutions to encourage the inclusion of the specific discipline of patient safety in technical, undergraduate and graduate courses should be highlighted.

We also recommend the development of new studies in institutions related to patient safety, for a more detailed and focused look at the different areas, covering a multidisciplinary team, as the study was limited due to its evaluation restricted to the nursing staff, and for not performing correlations between the number of patients assisted with the areas, as well as sociodemographic characteristics.

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Publication Dates

• Publication in this collection
  2016

History

• Received
  20 Sept 2015
• Accepted
  10 June 2016