Nurses perception of patient safety culture in operating rooms

 

Mrs. Ramya K R*

Asst Professor, Jubilee Mission College of Nursing and Lead, Quality Cell, Jubilee Mission Medical College & Research Institute, Thrissur, Kerala

 

ABSTRACT:

Operating room (OR) is a specialized area of hospital with inherent multiple risks and hazards to both patients and staff. There are an estimated 200 million surgeries  performed worldwide each year. Recent reports reveal that the adverse event rates for surgical conditions remain unacceptably high, despite wide spread patient safety initiatives over the past decade. Each year 7 million surgical patients are estimated to suffer from serious complications from adverse events and up to 1million die. Evidences in the field of health care quality shows that nurturing a culture of safety can reduce adverse events and improve patient safety. The aim of the present study was to explore the perception of patient safety culture among nurses working in operating rooms. The study utilized a quantitative  cross sectional survey deign using safety attitude questionnaire (SAQ).SPSS version 20 was used to analyze the data. The total number of participants in the study was 131. Results revealed that the mean experience of study participants in the present institution was 2.56 ±1.19 years, while the mean total professional experience was 4.19±4.96 years. The mean overall rating of the OR was 3.43±.785. The total score of the SAQ ranged from 40.90 to 80.56, with a mean 61.44 ±9.06.The mean score was found to be highest in safety climate while least in stress recognition. Only 4.7% of the study participants perceived a favorable climate for patient safety culture. Years of experience in the current institution was significantly associated with perception towards team work climate and patient safety culture at .05 and at .01 level resp. Years of total professional experience was significantly associated with perceptions of management and stress recognition at .05 level. Years of total professional experience was also significantly associated with safety climate at .01 level. Study recommends interventions to promote working conditions, job satisfaction, team work, communication, and conflict resolution to provide a safe environment for nurses and thereby for patients.

 

 

 

INTRODUCTION:

Operating room (OR) is a specialized area of hospital with inherent multiple risks and hazards to both patients and staff. However, until the 1999 Institute of Medicine(IOM) report 'To Err Is Human' it was unaware of the number of surgery associated injuries, deaths, and near misses.

 

There are an estimated 200 million surgeries performed worldwide each year and recent reports reveal that adverse event rates for surgical conditions remain unacceptably high, despite widespread patient safety initiatives over the past decade.¹ The world health organisation report 2009 recognizes that complications of surgical procedure including that of anesthesia have become a major cause of death and disability worldwide. Each year 7 million surgical patients are estimated to suffer from serious complications from adverse events and up to 1million die.² Studies in developing countries suggest a death rate of 5–10% associated with major surgery^3,4 and Aranaz JM et al estimated that the presence of adverse events in a surgical intervention to be 37.6%.⁵

 

Though preventable surgical errors happen secondary to medication errors, its incidence is still increasing. Surgical errors or harms can have devastating effect on both patient and health care workers. The complexity of procedures,  interaction of multidisciplinary teams, work under pressure and use of technology makes operating theaters a high risk environment. Therefore preventing a surgical error requires a systems approach involving a team effort by all individuals participating in the surgical process. Recent studies have proved that though the operating room is more likely to pose risks, but most of them can be avoided.^6,7

 

Advancements in the field of health care quality show that nurturing a culture of safety can reduce adverse events and improve patient safety. The concept of ‘safety culture’ draw the attention following the Chernobyl nuclear disaster as it was suggested that organisations can reduce accidents and safety incidents by developing a ‘positive safety culture.’ Safety culture refers to the way patient safety is thought about and implemented within an organisation and the structures and processes in place to support this. Patient safety culture has been shown to be related to healthcare clinician behaviors, such as reporting adverse incidents⁸, to patient outcomes such as fewer adverse events in hospitals⁹ and patient mortality in intensive care units¹⁰, and to positive assessments of care by patients.¹¹ The IOM report (1999) recommended that “errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing. Having a system in place to prevent them from occurring, and remedying them when they do occur, improves overall patient safety in the health care environment. 

 

Strategies for improving the quality of healthcare services require systematic evaluations. These go beyond the methodological debates on the purpose and utility of the evaluation in decision-making, recognition of pluralism of values and distinct points of view of the interest groups about the evaluation process.¹² Thus, it is important that organization measures patient safety culture and attitude to monitor, implement changes over time.

 

MATERIALS AND METHODS:

The present study utilized a quantitative approach and cross sectional survey deign. The aim was to identify perception of patient safety culture among nurses working in operating rooms. Data was collected during the month of November 2016. Study was carried out in a tertiary care hospital, Kerala, South India after obtaining permission from the concerned authorities. Using convenient sampling method 150 nurses who were working morning and evening shift in operating rooms were asked to complete the questionnaire. 131 nurses completed the survey. The research followed all the ethical principles and informed consent was obtained from study participants.

 

Data were collected using Safety Attitudes Questionnaire (SAQ), operating room version. Permission was also obtained to use and modify the instrument. Minor changes were made in the SAQ with the instrument composed of two parts: the first part contains 58 questions on patient safety perception and the second part contained questions about the overall rating of OR (5point likert scale), duration of experience in the present OR, and total duration of professional experience. The 30 items of the SAQ are grouped into six domains: 1) Teamwork climate (TC): quality of the relationship and collaboration between the members of a team (6 items); 2); Safety Climate (SC): professionals’ perception about the organizational commitment to patient safety (7 items); 3) Job Satisfaction (JS): positive view of the workplace (5 items); 4) Stress Perception (SP): recognition of the influence of stress factors in the performance of work (4 items); 5) Management Perception (MP),relating to the approval of management or administrative actions (4 items); and 6) Working Conditions (WC): perception of the work environment quality (4 items). The other items were not part of any domain in the original instrument. Each item of the SAQ follows a five-point likert scale, organized and scored as follows: strongly disagree (0 points), disagree (25 points), neutral (50 points), agree (75 points) and strongly agree (100 points); the “not applicable” option does not score. In the final score, 0 corresponds to the worst perception of the climate of security and 100 to best perception. The calculation is made by adding the answers of the items of each domain and dividing the result by the number of items of each domain, after inversion of reverse items. Scores are reported as the percentage of respondents who have positive attitudes toward each factor (score≥75). These percentages are equivalent to scores 4 or 5 on the likert scale (agree or strongly agree).

 

The data were coded and transferred into SPSS 20.0 Version and was analyzed. The descriptive analysis was carried out using the mean, standard deviation (SD), frequency, and percentage of responses to items, calculated for each domain. Chisquare test was used for inferential statistics.

 

 

RESULTS:

 

Figure 1: Distribution study participants based on experience in the present institution.

 

 

The total number of participants in the study was 131. Figure 1 shows the distribution study participants based on experience in the present institution. The mean experience of study participants in the present institution was 2.56 ±1.19years, while the mean total professional experience was 4.19±4.96 years. The mean overall rating of the OR was 3.43±0.785 (Minimum score was 1 and maximum score was 5). Table 1 shows the mean score

 

, standard deviations and frequency (percentage) with positive attitude for each domain of SAQ. The total score of the SAQ ranged from 40.90 to 80.56, with a mean of 61.44 ± 9.06 The mean score was found to be highest in safety climate while least in stress recognition. Only 4.7%of the study participants perceived a favorable climate for patient safety culture. Years of experience in the current institution was significantly associated with perception towards team work climate and patient safety culture at .05 and at 0.01 level resp. Years of total professional experience was significantly associated with perceptions of management and stress recognition at 0.05 level. Years of total professional experience was significantly associated with safety climate at 0.01 level.

 

 

Table1: Percentage (frequency) of study participant’s providers with positive safety attitudes and mean scale scores by domains

 

 

Table 2: Frequency and percentage of study participants with positive safety attitudes towards other items of scale

Items	Frequency	Percentage
High levels of workload are common in OR	27	20.6
Briefings are common in OR	100	76.4
Briefing OR Nurse/surgeon is important for patient safety	81	61.8
Hospital management does not knowingly compromise the safety of patients.	40	30.5
Decision making in this OR utilizes input from relevant staff	84	64.1
Medical equipments in this OR is adequate	40	30.6
I have seen other’s make mistakes that had the potential to harm the patient.	51	38.9
Stress  from personal problems adversely affect my performance	59	45
Disruptions in the continuity of care (shift changes, patient transfer, phone calls )can be detrimental to patient safety here	83	63.4
During emergencies I can predict what others are going to do next	34	25.9
I am frequently unable to express disagreement with staff/doctors	24	18.3
Truly professional persons can leave personal problems behind when working	109	83.2
I know the names of the staff I worked with during my last shift	32	34.5
I have made errors that had the potential to harm the patients	95	72.5
All staff in the OR takes responsibility for patient safety.	39	29.8
Staff/doctors in the OT are doing a good job	40	30.5
I feel fatigued when I get up in the morning and have to face another day on the job	80	61.1
Patient safety is constantly reinforced as the priority in this OR	20	15.3
I feel stressed out from my work	90	58.7
All important issues/informations are well communicated in shift changes	69	52.7
There is widespread adherence to clinical guidelines regarding patient safety here	45	34.4
I feel frustrated at my job	44	54.2
I feel like I am working too hard on my job	71	54.2
Information obtained through incident report is used to make patient care safer in OR	46	35.1
During emergency situations my performance is not affected by working with inexperienced or less capable staff.	76	58
The surgeon should be formally in charge of OR during surgical procedure	89	67.9
Communication breakdown leading to delays in care are common	60	45.8

 

 

Table 3: Association between experience in the current institution and domains of patient safety culture

* Significant at .05 level, ** Significant at .05 level

 

Table 4: Association between total professional experience in the current institution and domains of patient safety culture

* Significant at .05 level, ** Significant at .05 level

 

DISCUSSION:

It was found that majority of the study participants 34.35% and 30.53% respectively had experience ranging from 6 months to 1year in the present institution. Taylor JA et al found that the increased turnover of staff in the unit has increased the risk of injury in nurses, while its decrease has reduced the chances of patient falls.¹³

 

The total score of the SAQ ranged from 40.90 to 80.56, with a mean of 61.44 ±9.06. The average score shows that the perception of the safety culture among nurses is below international recommendations, which is 75 for a good perception of safety culture. Low total score of the SAQ below 75 was found among professionals by Carvalho PA et al. It was ranged from 34.4 to 74.8, per domain, with average of 53.5.¹⁴ Study by Lee WC et al revealed a similar low total mean score of 61.5.¹⁵

 

 

Team work is a spirit of collegiality, collaboration, and cooperation among staff. With increasing complexity of disease, use of high technologies and multidisciplinary care team work forms an integral component in patient safety culture. Study conducted by Raftopoulos V et al¹⁶ found a mean score of 74.1 for team work climate which was higher than the present study findings.

 

Singer S et al has found that hospitals with better overall safety climate had lower relative incidence of patient safety outcomes, as did hospitals with better scores on safety climate dimensions measuring interpersonal beliefs regarding shame and blame.¹⁸

 

Perception of safety culture is a specific component of safety culture of an organization and highlights the role of interpersonal, work unit, and organizational contributions in forming shared basic assumptions that individuals working in organizations develop over time. Regarding the climate of security the average was found too be 48.9±19.6 by 69.4 by Carvalho REFL. ¹⁹

 

A quality improvement program of the American Nurses Association reported that nurses job satisfaction can significantly improve patient outcomes. In the present study the mean job satisfaction score was found to be 68.47± 15.74.Studies conducted by Carvalho PA et al¹⁴  and Lee WC et al¹⁵  revealed a higher score compared to the present findings while Shie HG et al²⁰ revealed a low score.

 

Characteristics of the health care environment, including time pressure, lack of control over work processes, role conflict, and poor relationships between groups and with leadership, combine with personal predisposing factors and the emotional intensity of clinical work put nurses at high risk for stress and burnout. In the present study stress perception score was found to be the lowest compared to all the other domains with a mean of 47.37±21.41. Azimi L et al²¹ also found low stress recognition ranging from 20.9 to 27.3. But Carvalho PA et al¹⁴  found a mean score of 74.8±25.64 which was higher than the present study findings. A Swiss study of burnout in 54 ICUs link burnout to both safety perspectives and standardized mortality ratios.²²

 

The mean score of Working condition was 63.69±14.87 and only 29% of study participants had favorable attitude towards working conditions. In the operating room, the perceptions about working conditions were less favorable among nurses (mean=57) than among surgeons (mean=75). ²³ Within the context of the ongoing healthcare worker shortage (especially associated with nurses), clinicians, hospital administrators, and policymakers are looking for ways to improve working conditions while providing high quality, safe care, efficiently. A large body of evidence has shown clear linkages between workplace conditions and employee satisfaction and stress in a wide variety of organizational and industry settings.^{24 Error! Bookmark not defined.}Stone PW et al has found that improving nurse working conditions can improve patient safety outcomes.

 

Management and administration has a key role in designing, fostering, and nurturing a culture of safety. Blake et al identified administrative leadership as one of the most significant facilitators for establishing and promoting a culture of safety.²⁵ The perceptions of management score ranged from 18.75 to 100 with a mean of 52.43 ±15.95. Low perception in relation to the unit’s management, hospital management and working conditions suggests that professionals working in healthcare do not notice any commitment from the institution’s management with the latent factors of safety culture.

 

The limitations of this study include the use limited sample size from a single setting. Use of perceptions rather than personal behavior is another limitation. It is suggested that follow-up surveys on safety culture can be used to assess the progress in the implementation of processes to improve the surgical care and patient safety, as well as studies on adverse events and incidents.

 

CONCLUSION:

Preventable errors in OR are often not related to failure of technical skill, training, or knowledge but represent cognitive, system, or teamwork failures. Nontechnical skills such as communication, cooperation, coordination, and leadership are critical components of teamwork.²⁶ The results of this study points out a deficiency or weakness in the perception towards patient’s safety culture among nurses. Heavy workload, long working hours, night shift and sleep deprivation, fatigue from handling the patients, and stress on managing the very sick patients are the occupational hazards that can have adverse effect on mental skill and reaction time, vigilance, and interpersonal relationship among the OR personnel. These can have a negative influence on the surgical team and therefore on patient safety. Study recommends interventions to promote working conditions, job satisfaction, team work, communication, and conflict resolution to provide a safe environment for nurses and thereby for patients.

 

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Received on 29.11.2016          Modified on 15.12.2016

Accepted on 13.01.2017        © A&V Publications all right reserved