An educational intervention to enhance nurse leaders' perceptions of patient safety culture

Health Services Research, August, 2005 by Liane Ginsburg, Peter G. Norton, Ann Casebeer, Steven Lewis

Patient safety and medical error have emerged as important quality and public policy issues in health care. Studies of the incidence of adverse events (AEs) in acute care hospitals have been reported internationally (e.g., Brennan et al. 1991; Wilson et al. 1995; Vincent, Neale, and Woloshynowych 2001; Baker et al. 2004). These studies indicate that between 5 and 20 percent of patients admitted to a hospital experience an AE (defined in the Australian study as an unintended injury or complication which results in disability, death, or prolonged hospital stay and is caused by health care management rather than the patient's underlying disease [Wilson et al. 1995]) and that roughly 50 percent of these AEs are judged to be preventable, and that AEs cost health care systems millions of dollars in additional hospital days. These incidence data, together with the release of the Institute of Medicine's (IOM 1999) report To Err is Human, prompted several national policy documents with comprehensive plans and direction for policymakers, health care leaders, clinicians, and regulators about system changes necessary to improve patient safety (AGPS 1996; Department of Health 2000; IOM 2001).

From the literature it is clear that most AEs are the result of cumulative effects of small errors involving both human errors and latent failure--failures arising from organizational and administrative processes and systems (Reason 1990). They tend to emerge from the interactions of multiple, related components within complex systems (IOM 1999). Accordingly, the potential for error and AE reduction exists at all levels of the health care system. However, although research to measure the incidence of AEs continues to grow, there has been less in the way of empirical research into strategies for helping front-line providers reduce AEs and improve patient safety. It has been suggested that more targeted studies of potential interventions to reduce AEs are needed (Leape et al. 1998; Davis et al. 2001). Moreover, in a recent study of various health-related organizations in Canada, nearly half of all organizations surveyed indicated that they were not able to effectively improve patient safety (Baker and Norton 2002).

This study involved the design of a training intervention and a test of its effect on nurse leaders' perceptions of patient safety culture. The relationship between senior leadership support and perceived safety culture was also investigated. Nurses in clinical leadership roles were chosen as the focus for this study because they are high leverage actors in the quality improvement (QI) process because of their ability to lead change (Munro 2002; Batalden et al. 2003; Currie and Brown 2003). Our literature review revealed no controlled studies of patient safety interventions with this group. Additionally, a recent international study reported that nurses feel the quality of care is deteriorating and that AEs related to such things as medication errors and falls occur regularly (Aiken et al. 2001), suggesting the area of AE reduction will be seen as relevant to this group.

LITERATURE

Few intervention studies to improve patient safety have been reported in the literature, although some do exist. Most of the reported studies are on the effects of computerized physician order entry systems for reducing AEs (e.g., Bates et al. 1998). Other studies on the adaptation of Crew Resource Management in Emergency Departments found that observed clinical errors were reduced in teamwork trained EDs (Morey et al. 2002). Finally, the literature includes descriptive accounts of error reduction processes undertaken in individual units or organization (e.g., Brown, Riippa, and Shaneberger 2001).

Thus far, most assessments of QI initiatives do not use randomization or nonequivalent control groups (Samsa and Matchar 2000). However, randomized-controlled studies (RCTs) are needed--a recent study revealed that while most QI studies based on before-and-after observations reported positive findings, three published RCTs of QI suggested no impact on clinical outcomes and no evidence of organization-wide improvement in clinical performance (Shortell, Bennett, and Byck 1998).

The literature also shows that interventions tend to be aimed at intermediate outcomes expected to reduce AEs rather than AE reduction itself. For instance, the Institute for Healthcare Improvement breakthrough collaboratives ultimately targeted at reducing adverse drug events actually used the implementation and development of various medication error prevention practices as the outcome measure (Leape et al. 2000). A more recent study by Pronovost et al. (2003) described a strategic plan aimed at improving intermediate outcomes of patient safety culture and safety climate. Patient safety interventions often focus on these kinds of intermediate or upstream outcome measures because testing models where reduction in AEs is the dependent variable poses serious challenges. First, such studies are vulnerable to problems associated with confounding. Second, the kinds of changes in systems and culture that many suggest as being required to reduce AEs and improve patient safety are likely to be observed only after long periods of time--witness the case of anesthesia where evidence from safety interventions implemented in the early 1990s to reduce preventable deaths are only now being seen in the published literature (Runciman and Moiler 2001).