Date Published: April 10, 2019
Publisher: Public Library of Science
Author(s): Ellen Catharina Tveter Deilkås, Dag Hofoss, Elisabeth Holm Hansen, Gunnar Tschudi Bondevik, Iratxe Puebla.
Measuring staff perceptions with safety climate surveys is a promising approach to addressing patient safety. Variation in safety climate scores between work sites may predict variability in risk related to tasks, work environment, staff behavior, and patient outcomes. Safety climate measurements may identify considerable variation in staff perceptions across work sites.
To explore variation in staff perceptions of patient safety climate across work sites in Norwegian General Practitioner (GP) practices and Out-of-hours clinics.
The Norwegian Safety Attitudes QuestionnaireAmbulatory Version (SAQ A) was used to survey staff perceptions of patient safety climate across a sample of GP practices and Out-of-hours clinics in Norway. We invited 510 primary health care providers to fill out the questionnaire anonymously online in October and November 2012. Work sites were 17 regular GP practices in Sogn & Fjordane County, and seven Out-of-hours clinics, of which six were designated as “Watchtower Clinics”. Intra–class correlation coefficients were calculated to identify what proportion of the variation in the five factor scores (Teamwork climate, Safety climate, Job satisfaction, Perceptions of management, and Working conditions) were at work site-level.
Of the 510 invited health care providers, 266 (52%) answered the questionnaire. Staff perceptions varied considerably at the work site level: intra–class correlation coefficients (ICCs) were 12.3% or higher for all factors except for Job satisfaction–the highest ICC value was for Perceptions of management: 15.5%.
Although most of the score variation was at the individual level, there was considerable response clustering within the GP practices and OOH clinics. This implies that the Norwegian SAQ A is able to identify GP practices and OOH clinics with high and low patient safety climate scores. Patient safety climate scores produced by the Norwegian version of the SAQ A may, thus, guide improvement and learning efforts to work sites according to the level of their scores.
For more than a decade, the landmark report, “An organisation with a memory,” has emphasised how the mindset, values and priorities of employees and management influence patient safety . The report acknowledged that adverse events must be valued as sources of useful information for health care organisations to learn and improve. It concluded that improvement in patient safety depends on how healthcare organisations are able to encourage staff to speak up about hazards, risks and adverse events. This requires that staff feel safe and trust that admitting mistakes and adverse events will not be held against them . Since the report was published, widespread efforts to address safety culture in healthcare organisations have emerged [3, 4]. Most have been related to hospital care, but efforts to address safety culture in primary care have also been noted [5–9].
Of the 510 invited health care providers, 266 (52%) answered the questionnaire: 72% of the support staff (n = 139) and 39% of the medical doctors (n = 124). Three respondents did not provide information on their professional status. The response rate was higher amongst medical doctors in GP practices (55%), than medical doctors in OOH clinics (33%). Corresponding rates for support staff were 73% and 71%, respectively. Basic characteristics of the sample have been previously reported . One work site was excluded from the multilevel analysis, as it returned only one questionnaire.
In addition to a large variation at the individual level, all patient safety climate scores varied noticeably at the work site level. Since our model is simple, the estimated ICCs are less likely to be biased . The result is consistent with results from a Scottish study that showed significant variation in safety climate between practice teams in primary care . For all five patient safety climate dimensions in our study the two level models produced lower AIC values than the models ignoring the possibility of factor score variation across work sites. This indicates that the two level models fit better to the data. The results suggest that the Norwegian version of the SAQ A is able to identify variation in staff perceptions of patient safety climate across work sites in Norwegian General Practitioner practices and Out-of-hour clinics. Accordingly, some work sites may be more promising candidates for patient safety improvement interventions than others, for example, work sites where employees feel reluctant to speak up if they experience problems in patient care or perceive that their input is not wanted. The results reveal opportunity for leaders to improve behavior and results in their organisation by facilitating dialogue to strengthen trust, mutual values and relationships within groups of employees at work sites, and not only by influencing individuals[7, 30]. Although staff attitudes are strongly modified by work place culture, individual characteristics may also contribute. Therefore, we explored individual characteristics related to patient safety climate scores in a previous paper . Older health professionals scored higher than younger professionals, and female GPs scored significantly lower than male GPs. Knowing that patient safety climate perceptions are perceived significantly more positively by staff in leadership positions than their subordinates it is not unreasonable to think that age may have a similar effect [6, 22, 32]. Age may be associated with more experience, qualifications and confidence, which may influence staff to respond more positively to items like: “It is easy for personnel in this clinic to ask questions when there is something that they do not understand”, and “I know the proper channels to direct questions regarding patient safety in this clinic”. A potential strategy to encourage younger staff to be open about hazards and adverse events could be senior staff offering to arrange regular dialogue meetings and expose their own experiences of vulnerability in relation to hazards and adverse events. It is possible that female GPs scored significantly lower than male GPs because female GPs may identify more risks than male GPs . The interpretation is supported by a German study that found that female medical doctors cared better for type 2 diabetes patients than male medical doctors . A study from the US found that elderly hospitalised patients had lower mortality and readmission rates when treated by female internists compared to those treated by male medical doctors . In trying to explain the gender difference, listening and communication skills, as well as spending more time with patients, were suggested as possible factors. Such characteristics may also be relevant to explore in dialogue meetings where patient safety climate scores are discussed for improvement purpose.
Our results show that there was quite a bit of response clustering within the GP and OOH units. This implies that the Norwegian SAQ A is able to identify GP practices and OOH clinics with high and low patient safety climate scores. Patient safety climate scores produced by the Norwegian version of the SAQ A may, thus, guide improvement and learning efforts to work sites according to the level of their scores. Some units scored better, others scored worse. By discussing patient safety climate survey results, staff in lowscoring units and their leaders may identify opportunities for improvement and develop their understanding of how to reduce risks of adverse events and to improve patient safety.