Study and promotion of safety culture using mixed methods research

Patient safety has been widely discussed by researchers and policy makers and is challenging for healthcare organizations.¹ At the same time, users expect high-quality, error-free care from health-service providers.

It has become clear that patient safety issues are more complex than initially understood since the health care system continues to operate with a low degree of reliability, indicating that patients often suffer harm that could have been avoided.^2,3 A recent study revealed that 1 out of every 10 patients developed an adverse condition during hospitalization. Furthermore, findings from this study showed that more than 12 million patients face diagnostic errors as outpatients each year. It is worth noting that more than 60% of health care errors are considered preventable.⁴

In Brazil, patient safety has been emphasized since 2013, with the creation of the National Patient Safety Program (NPSP),⁵ which advocates for the creation of patient safety teams in health establishments. The federal government initiative aims to encourage and support actions directed toward patient safety. One of the initial strategies of NPSP is the promotion of the patient safety culture, which encompasses a set of attitudes, perceptions, values, and individual and group competencies and behavioral standards that determine commitment, style, and proficiency in terms of issues related to patient safety and health management, thereby ensuring that healthcare institutions remain simultaneously profitable for the stakeholders and safe for the patients.⁶

Evaluating and understanding the culture of safety in healthcare facilities is essential, and, ideally, this assessment should be performed prior to planning actions that aim to provide safe care. One of the key benefits of this type of evaluation is to obtain a concrete indicator of the current state of the safety culture.⁷ This measurement can be performed using score-validated instruments, such as the Safety Attitudes Questionnaire (SAQ),⁸ which provides a temporal assessment of the institutional safety climate.

Evaluation research in this field has provided evidence of weaknesses in the safety climate in health institutions.^7,9,10,11 Similarly, a systematic review showed the existence of limited or even insufficient evidence to define strategies capable of obtaining definitive results in improving the safety climate.⁶

To study patient safety culture through mixed methods, research approaches contribute, in a way, to measure the safety climate and, more importantly, to identify factors that influence the quality of care and the safety culture.¹¹ In addition, the use of knowledge translation (KT) strategies, such as the use of the principles of deliberative dialogue (DD) during the implementation of the research, enables the participants to co-create and to identify priority actions to initiate processes of change.¹² This type of approach promotes a safety culture that is essential in the search for care that constantly endeavors to preclude all possibilities for harm.¹¹ Rationale for a mixed methods research approach is justified through the integration of quantitative and qualitative data providing a broader understanding of the research problem, going beyond the use of mono-method research.

Given these considerations and the relevance of patient safety, the following research question was studied: What are the safety culture and the respective strategies to improve the same, from the perspective of a multidisciplinary team? The study aimed (a) to analyze the patient safety culture from the perspective of the multidisciplinary team of a hospital in the southern region of Brazil; (b) to identify factors that influence the patient safety culture; and (c) to create/foster, jointly with the study participants, strategies to improve the processes of change in the patient safety culture at the study location.

The present study involved the use of a mixed methods research approach, with an explanatory sequential research design, which was denoted by QUAN → QUAL, wherein the uppercase letters indicate the phase that was prioritized—in this case, both phases had approximately equal priority—and the arrow indicates that the phases were performed sequentially.¹³ This method involves quantitative and qualitative data in a new framework to think about research in health services, with the potential to generate meta inferences and unique insights about phenomena that are expressed in a multifaceted way.^14,15,16 Attention to the integration of both databases, in the design stages of the study, in the method, and in the interpretation and presentation of the results, can improve the quality of mixed methods research studies in the health area and, therefore, generate important evidence to improve health care, services, systems, and policies.¹⁷ The STROBE guideline was used to develop the study.

The response rate to the SAQ was 89.6%. The literature suggests that adequate response rates for climate research should remain between 65% and 85% of the population.⁸ The internal consistency of the SAQ scores was assessed through Cronbach’s alpha, and the overall result was considered more than adequate (0.85), similar to other studies conducted in Brazil, suggesting that the measuring instrument yields valid scores for the proposed construct.^7,28

The results showed the predominance of women and the dominance of the category of nursing professionals among the study participants. In Brazil, the nursing team represents the largest contingent of professionals in hospitals, as well as the profession with the highest percentage of women. These data corroborate findings from other national studies that have been reported in recent years.^7,29

The total scores of the SAQ ranged from 59.1 to 88.7 per domain, with the overall average (75.1) reflecting a positive safety climate in the institution,⁸ differing from most of the other studies wherein the same questionnaire was used in Brazil.^7,11,19,28 The positive safety climate we found is probably related to the profile of the institution. It is a medium-sized hospital, and this can be considered a contributing factor to a positive safety climate, according to the findings of a study that assessed 18 types of services in Australia.³⁰ Gallego et al. revealed that smaller hospitals,³⁰ which provide fewer specialized services, tend to yield a more positive safety culture.

However, by analyzing the specific domains, individual negative scores were found in the areas of “safety climate,” “stress recognition,” and “working conditions.” Evidence suggests that these specific areas need strategies to promote safety in this institution.

The safety climate domain yielded a negative score in our study (72.7), which also was noted in three hospitals in Portugal³¹ and two hospitals in northeastern Italy.³² Other Brazilian studies also have produced negative results for this domain.^19,33,34 These negative safety climate scores suggest a lack of a successful systemic approach to promoting harm-free care.⁴ Indeed, this result points to the need for changes in management errors and incidents systems, understanding them from a systematic approach for professionals to feel free to expose weaknesses in their work processes without fear of punitive measures or retaliation.⁶ Efforts should be directed to improving organizational commitment and adherence to professional guidelines and rules because they are also among the effective measures to improve the safety climate in multidisciplinary teams.³⁵ To encourage staff to report errors by creating a non-punitive environment where errors are examined and potentially solved is widely acknowledged to be an important step toward safety culture environments and in improving patient safety.

The low score found in the working conditions domain indicates that the study participants recognized the need for improvement in this area with a view to a more secure and positive practice environment. Similar results were found in studies conducted in Brazil.^11,36,37 The weakness identified in this area points to the need for interventions that promote the training of professionals, availability of necessary information for diagnostic and therapeutic discussions, and efficient equipment and proper maintenance and quality infrastructure. In addition, the lack of staffing, work overload, lack of resources, and lack of materials and supplies compromise the quality of care and contribute to professionally reduced job satisfaction and burnout.³⁵ For health systems to improve excellence in care, working conditions need to be a priority.

The stress recognition domain yielded the lowest score in the study, 59.1, as noted by other researchers using the same instrument.^34,38 These results show that professionals do not recognize that tension and stress can harm their performance. One example is the study by Taylor et al.,³⁹ wherein the stress was associated with an increase of 1.5–3 times the likelihood of accidents, such as falls, medication errors, and pressure injuries.

Factors related to human resources, such as fatigue of professionals due to excessive workload, barriers in communication, ineffective interpersonal relationships, distractions, and the emotional factor of the professionals, are closely linked to the recognition of stress and might negatively affect the development of safe care.⁶ Thus, it is important that health professionals recognize stress as a factor detrimental to their health and impacting patient safety.

Results from the qualitative approach support and sustain the results of the quantitative approach. During the discussions in the FGs, participants were able to discuss factors that exercised a negative influence on patient safety culture. Some punitive actions were mentioned as a factor contributing to the underreporting of adverse events. A study of 7 Brazilian hospitals revealed that the open discussion of adverse events was considered to be a positive factor in the search for improvements, as a consequence of cultivation of the understanding among staff that the detection of these events can serve as a basis for decision-making and planning for improvements in patient safety through the analysis, monitoring, minimizing, and preventing of incidents that cause adverse events.⁴⁰

Ineffective communication in the multidisciplinary team, manifested by the difficulty of professionals to express themselves in front of their peers or leaders, also was a factor that corroborated the negative score in the safety climate domain. A study investigating the concerns that arise between doctors and nurses during the work revealed that they often failed to share problems related to job performance, their knowledge gaps, their relationship problems, and the occurrence of adverse events. As in our study, while acknowledging that such an attitude jeopardizes patient safety, health care workers preferred to remain silent for fear of leaving their current position or being transferred from the sector.⁴¹

Research indicates that inadequate communication has been one of the main factors contributing to the occurrence of adverse events and, consequently, decrease in the quality of care.⁴² To improve communication processes, we recommend the use of tools available in the literature, such as structured communication protocols, briefing (before) and debriefings (after) the implementation of certain procedures, standardization of information about the patient (SBAR), and read back, which constitute effective ways to overcome the barriers to ineffective communication.

The use of DD is an innovative perspective in health research and allows the connection between the empirical evidence and the tacit knowledge of the participants to initiate and implement intentional changes in practice, and to explore a new way of building scientific knowledge.¹² An example of this was the beginning of actions proposed in the FG meeting, which began even before the end of the research. Among them, the meeting of the patient safety team with leaders was conducted to publicize the NPSP of the institution, and in this meeting, all participants pledged to make the necessary disclosures to all professionals on their respective teams. Also noteworthy was the meeting of the nursing management during all shifts of nursing coordinators to present the results of existing safety indicators in the institution to identify potential threats and to help prioritize actions to prevent harm.

The findings revealed a positive safety culture in this healthcare organization, as identified by the multidisciplinary team.

Participants in the FG meeting contributed substantially to produce an explanation concerning aspects that resonated negatively in the score domains, safety climate, stress recognition, and working conditions. Among these aspects, ineffective communication stood out, as did a lack of commitment and adherence to protocols and the non-recognition of stress and errors. The participants also mentioned weaknesses in infrastructure, such as the lack of human, financial, and material resources.

The strategy of using a mixed methods research approach made it possible to explain aspects of safety culture that could not be understood using only one approach, and describes the processes of change or reformulation identified by professionals to improve the culture of patient safety in the institution. The use of the DD principles in the study as an IKT strategy enabled us to identify and plan joint actions to generate improvements in safety culture, based on tacit knowledge and the local context of the stakeholders and the integration and interpretation of scientific evidence.

For these reasons, we believe that the analysis of safety culture in an integrated manner using a mixed methods research approach, coupled with the application of the principles of DD, can be the basis for management and policy makers in developing and implementing effective strategies to improve patient safety. Furthermore, this study also shows the need for further research in the area, making it possible to explore the phenomenon in different contexts. In addition, more research is needed to determine whether changes are sustainable and to change the culture of safety with a reduction in adverse events. From a policy or practice perspective, this study provides important information for managers in that these methods might be useful in the implementation of strategies that aim to consolidate a safety culture in health care institutions.