Methodological aspects in the assessment of safety culture in the hospital setting: a review of the literature.

A thematic literature review was undertaken to identify methodological aspects in the assessment of safety culture and critically examine how these have been addressed in hospital-based studies of safety culture, for the period 1999-2012. The literature search included an electronic database search (BNI, CINAHL, EMBASE, MEDLINE and PsycINFO), access to websites of organizations dedicated to the enhancement of patient safety, and a manual search of reference lists of the papers included. The analysis of the 43 records included in the review revealed that discussion regarding the measurement of safety culture in the hospital setting revolves around three methodological areas, namely: research approaches; survey tools for data collection; and levels of data aggregation. To advance these discussions, robust research is needed to clarify what dimensions belong to the core of safety culture and what the main sources of safety culture variability are. Studies using a mixed methods approach to assess safety culture would be useful, since they permit the in-depth research necessary to depict the multiple components of this construct.

Collaboration: a SWOT analysis of the process of conducting a review of nursing workforce policies in five European countries.

AIM: This paper critically reviews the literature on international collaboration and analyses the collaborative process involved in producing a nursing workforce policy analysis. BACKGROUND: Collaboration is increasingly promoted as a means of solving shared problems and achieving common goals; however, collaboration creates its own opportunities and challenges. Evidence about the collaboration process, its outcomes and critical success factors is lacking. METHODS: A literature review and content analysis of data collected from six participants (from five European countries) members of the European Academy of Nursing Science Scholar Collaborative Workforce Workgroup, using a SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis template. RESULTS: Two major factors affecting scholarly collaboration were identified: Facilitators, which incorporated personal attributes and enabling contexts/mechanisms, including individual commitment, responsibility and teamwork, facilitative supportive structures and processes. The second, Barriers, incorporated unmet needs for funding; time; communication and impeding contexts/mechanisms, including workload and insufficient support/mentorship. CONCLUSIONS: The literature review identified a low level of evidence on collaboration processes, outcomes, opportunities and challenges. The SWOT analysis identified critical success factors, planning strategies and resources of effective international collaboration. IMPLICATIONS FOR NURSING MANAGEMENT: Collaboration is an important concept for management. Evidence-based knowledge of the critical success factors facilitating and impeding collaboration could help managers make collaboration more effective.

Diagnosis, prognosis and awareness of dying in nursing homes: towards the Gold Standard?

BACKGROUND: In Western society and increasingly elsewhere, death has become medicalised and 'hospitalised' even when people are enduring deteriorating terminal conditions such as dementia and heart failure. In an attempt to rationalise and dignify the place and manner of death, evidence is emerging that the adoption of end-of-life care pathways and models can improve the experience of the end-of-life care across a range of care settings. Each of these demands skills and knowledge in the assessment and prediction of the dying trajectory. AIM: In this study, we report complexities facing relatives, residents and nursing home staff in the awareness, diagnosis and prediction of the dying trajectory. METHODS: Data were collected and analysed within a broadly qualitative methodology. The contexts were two nursing homes in the Greater Manchester area, each at different stages of implementing 'Gold Standards Framework' approaches to planning end-of-life care with residents and their relatives. From 2008 to 2011 and with appropriate consent, data were collected by a mixture of interviews and participant observation with residents, relatives and staff. Appropriate ethics approvals were sought and given. RESULTS: Key emerging themes were diagnosis and awareness of dying in which there is no substitute for experience. Significant resource is needed to engage staff, residents and relatives/carers with the idea of advance care planning. CONCLUSIONS: Talking to residents and relatives about their feelings and wishes for care at the end of life remains especially difficult, but education and training in key skills and knowledge can engender confidence. Challenges include diagnosing and predicting dying trajectories. IMPLICATIONS FOR PRACTICE: Advance care planning can reduce the distress from and number of inappropriate hospital admissions, but requires determination and consistent application of the approach. This can be very challenging in the face of staff rotation and the unpredictability both of the dying trajectory and the decision-making of some out of hours medical staff.

A review of nursing workforce policies in five European countries: Denmark, Finland, Ireland, Portugal and United Kingdom*/England.

AIM: Review nursing workforce policies in five European countries: Denmark, Finland, Ireland, Portugal and the United Kingdom*. BACKGROUND: Imbalances in registered nurse (RN) supply and demand is a global, significant and recurring issue that impacts on healthcare systems, organizations, staff and patients. METHOD: Policy Review using resources located by a systematic search of relevant healthcare databases and policies in Danish, English, Finnish and Portuguese over the time period 2003-2007. Content analysis was used to identify themes and compare policies. RESULTS: Common nursing workforce policy themes were identified across the five countries: (1) improving retention through effective human resource management, improving the practice environment and nurses' working lives and (2) improving recruitment through attracting more new recruits and RNs back to practice, and international recruitment. The present study also identified methodological issues relating to data quality and quantity. Lack of an agreed definition and standardized measures of nursing need and shortage makes comparison and evaluation of policy effectiveness and impact difficult. IMPLICATIONS FOR NURSING MANAGEMENT: Healthcare systems and organizations need to identify and implement effective policies that promote the retention of RNs in the workforce, or risk threats to healthcare system sustainability, as well as patient care quality and safety.

Understanding eating behaviours in Spanish women enrolled in a weight-loss treatment.

AIM: To identify the beliefs and attitudes of a sample of obese and overweight Spanish women undertaking a weight-loss treatment. BACKGROUND: Obesity is a global epidemic. Weight-loss treatments focus on changing eating behaviours; however, many patients fail to adhere to the diet. This suggests that more effective behaviour-change interventions are required to help people change their eating behaviours. According to the theory of planned behaviour (TPB) human behaviour is influenced by beliefs. Identification of people's beliefs is an essential step in the design of behaviour-change interventions. DESIGN: A qualitative approach was employed using semi-structured interviews to interview participants. Seventeen obese and overweight Spanish women enrolled in a weight-loss treatment were recruited using a criterion sample strategy. FINDINGS: Participants' reported beliefs referring to the benefits of losing weight and the emotions related to dieting. The more positive these beliefs were the more positive their attitude towards the diet seemed to be. Findings highlight the importance of follow-ups in creating a subjective norm to maintain a diet. Perceived behavioural control to diet seemed to be related to beliefs about social support; whereas beliefs about lack of willpower to overcome temptations seemed to decrease perceived control over eating behaviours. CONCLUSIONS: Participants reported several beliefs and attitudes that offer plausible explanations of their eating behaviours. Data from this study seemed to fit the propositions of the TPB and could be used in further research to develop effective eating behaviour-change interventions. RELEVANCE TO CLINICAL PRACTICE: Nurses could use the TPB to assess individuals' attitudes, beliefs and expectations when following a diet. That assessment would provide insight into what aspects are relevant for individual patients when dieting, which could lead to more effective diet behaviour-change interventions being designed.

Patient safety in an English pre-registration nursing curriculum.

This study explored patient safety in an English pre-registration nursing curriculum. The need to improve patient safety has been recognised as a key priority, both nationally and internationally. Education has a crucial role in developing the knowledge, skills and attitudes that promote patient safety. However, evidence about how patient safety is addressed in healthcare professional curricula and how organisations develop safe practitioners is limited. An organisational case study identified factors affecting patient safety educational provision. Content analysis revealed what aspects of patient safety featured in the formal pre-registration nursing curriculum. Interviews were conducted with students, lecturers and key education stakeholders from various levels of the educational organisation, to explore their perceptions of patient safety and its location in the curriculum and practice. Patient safety was not explicit in the formal curriculum, but was included in teaching. Students reported gaining most knowledge and experience from clinical practice. The organisational culture of both education and practice was characterised as defensive and closed, and as having an individual versus a systems approach. Findings suggest the need for clarification of the concept of patient safety, as well as revision of curricula and teaching, learning and assessment strategies in order to address patient safety explicitly.

The expectations and experiences of blended learning approaches to patient safety education.

E-learning facilitates access to educational programmes via electronic asynchronous or real time communication without the constraints of time or place. However, not all skills can be acquired via e-learning, thus blended approaches have emerged, where traditional academic processes have been combined with e-learning systems. This paper presents qualitative findings from a study evaluating a blended approach to patient safety education. The 3-day face-to-face training in Root Cause Analysis supported by e-learning resources was designed by the National Patient Safety Agency. The study evaluated the efficacy of the blended learning approach, and explored how operational practices in NHS organisations supported staffs' skill in using electronic resources. Data collection techniques included pre and post-course Confidence Logs, Individual Interviews, Focus Groups and Evaluation Questionnaires. Students' views on blended learning varied. Some were positive, while others felt e-learning did not suit their preferred learning style, or the subject matter. Many students did not engage with the e-learning resources. Lack of awareness regarding the e-learning component, combined with inconsistent access to computing facilities may have contributed to this. For this reason a series of recommendations are outlined to guide those wishing to adopt blended learning approaches in the future.

Factors influencing nurses' decisions to raise concerns about care quality.

AIM: To explore factors that influence nurses' decisions to raise concerns about standards of practice. BACKGROUND: Health care practitioners have a key role in monitoring care quality. Nurses are required by their professional body to raise concerns about standards; however, under-reporting is the norm. METHOD: Grounded theory was used to collect and analyse data from semi-structured interviews with 142 practising nurses, theoretically sampled from three Acute NHS Trusts in England. FINDINGS: Fear of repercussions, retribution, labelling and blame for raising concerns, about which they predicted nothing would be done, were identified as disincentives to raising concerns. Reporting was perceived as a high-risk:low-benefit action. Nurses lacked confidence in reporting systems. CONCLUSIONS: Disincentives to reporting need to be addressed if an open culture, which promotes quality, safety and learning, is to be developed. Findings give cause for concern and indicate a need to review organizational and professional guidelines, and organizational reporting systems.

Evaluating healthcare education: issues and methods.

This paper analyses the methodological issues inherent in evaluating healthcare education and considers approaches for addressing these. Recent policies have exhorted practitioners to base their practice on evidence; however in healthcare education the evidence base is not extensive. Whilst educational evaluation has advanced in the last decades, standardised designs and toolkits are not available. Each evaluation has different aims and occurs in specific contexts, thus the design has to fit the circumstances, yet meet the challenge of scientific credibility. Indicators of educational processes and outcomes are not scientifically verified; no toolkit of standardised 'off-the-shelf' valid, reliable and sensitive measures exists. The evidence base of educational practice is largely derived from small-scale, single case studies; the majority of measures are self-devised, unvalidated tools of unproven reliability, thus meta-synthesis is not appropriate and results are not generalisable. Healthcare educational evaluators need valid and reliable assessments of both knowledge acquisition and its application to practice. The need to establish and explain attribution, i.e. the relationship between educational inputs and outcomes is complex and requires experimental/quasi-experimental design. In addition, educational evaluators face the pragmatic challenge of practice in healthcare contexts, where confounding variables are hard to control and resources are scarce.

Evaluating healthcare education: Issues and methods.

This paper analyses the methodological issues inherent in evaluating healthcare education and considers approaches for addressing these. Recent policies have exhorted practitioners to base their practice on evidence; however in healthcare education the evidence base is not extensive. Whilst educational evaluation has advanced in the last decades, standardised designs and toolkits are not available. Each evaluation has different aims and occurs in specific contexts, thus the design has to fit the circumstances, yet meet the challenge of scientific credibility. Indicators of educational processes and outcomes are not scientifically verified; no toolkit of standardised 'off-the-shelf' valid, reliable and sensitive measures exists. The evidence base of educational practice is largely derived from small-scale, single case studies; the majority of measures are self-devised, unvalidated tools of unproven reliability, thus meta-synthesis is not appropriate and results are not generalisable. Healthcare educational evaluators need valid and reliable assessments of both knowledge acquisition and its application to practice. The need to establish and explain attribution, i.e. the relationship between educational inputs and outcomes is complex and requires experimental/quasi-experimental design. In addition, educational evaluators face the pragmatic challenge of practice in healthcare contexts, where confounding variables are hard to control and resources are scarce.

Nursing agency and governance: registered nurses' perceptions.

AIM: To explore registered nurses' perceptions of standards of nursing practice and factors that affect nursing practice standards. BACKGROUND: Nursing governance affects nurses' ability to manage nursing practice standards. Lack of nursing professional autonomy has been associated with occupational dissatisfaction, stress, turnover and low morale, which impact upon care quality. METHOD: Grounded theory was used. Data, gathered by semistructured interviews with 142 nurses, theoretically sampled from three National Health Service hospitals were analysed using constant comparative analysis. FINDINGS: Nurses were dissatisfied with their governance over factors that they believed had most influence on nursing practice standards. Perceived lack of control over factors that affect practice standards generated dissatisfaction, frustration and demoralization. CONCLUSIONS: Nurses' perceived lack of governance over their practice requires investigation and attention if occupational dissatisfaction, stress, turnover and low morale, which impact on quality care, are to be reduced. Dissatisfaction with nursing governance indicates a need to review nurses' professional involvement in clinical governance.

Patient safety: do nursing and medical curricula address this theme?

In this literature review, we examine to what extent patient safety is addressed within medical and nursing curricula. Patient safety is the foundation of healthcare practice and education both in the UK and internationally. Recent research and policy initiatives have highlighted this issue. The paper highlights the significance of this topic as an aspect of study in its own right by examining not only the fiscal but also the human costs such events invite. In the United Kingdom patient safety issues feature prominently in the (Department of Health, 2000a. An organisation with a memory. The report of an expert group on learning from adverse events. The Stationery Office, London, Department of Health, 2000b. Handling complaints: monitoring the NHS complaints procedures (England, Financial year 1998-99). The Stationery Office, London.) policy documentation but this is not reflected within the formal curricula guidelines issued by the NMC and GMC. Yet if healthcare educational curricula were to recognise the value of learning from errors, such events could become part of a wider educational resource enabling both students and facilitators to prevent threats to patient safety. For this reason, the paper attempts to articulate why patient safety should be afforded greater prominence within medical and nursing curricula. We argue that learning how to manage errors effectively would enable trainee practitioners to improve patient care, reduce the burden on an overstretched health care system and engage in dynamic as opposed to defensive practice.