Nurse-reported patient safety climate in Swiss hospitals: a descriptive-explorative substudy of the Swiss RN4CAST study.

QUESTIONS UNDER STUDY: Measuring the patient safety climate in the organisation of healthcare can help to identify problematic issues with a view to improving patient safety. We aimed (1) to describe the nurse-reported engagement in safety behaviours, (2) to describe the prevailing nurse-reported patient safety climate of general medical, surgical and mixed medical-surgical units in Swiss acute-care hospitals and (3) to explore differences between hospital type, unit type and language regions. METHODS: This substudy utilised data from the nurse survey (N = 1,633) of the multicentre-cross sectional RN4CAST study. Patient safety climate was measured with the 9-item Safety Organizing Scale (SOS) which captured registered nurses' engagement in safety behaviours and practices at the unit level. RESULTS: A total of 35 Swiss hospitals participated in the study. Of the 120 eligible units included in the analysis, only on 33 units (27.5%) did at least 60% of the nurses report a positive patient safety climate. A majority of nurses (51.2-63.4%, n = 1,564) reported that they were "consistently engaged" in only three of the nine measured patient safety behaviours. Our multilevel regression analyses revealed both significant between-unit and between-hospital variability. From our three variables of interest (hospital type, unit type and language regions) only language regions was consistently related to nurse-reported patient safety climate. Nurses in the German-speaking region reported a more positive patient safety climate than nurses in the French- and Italian-speaking language regions. CONCLUSIONS: The findings of this study suggest a need to improve the patient safety climate on many units in Swiss hospitals. Leaders in hospitals should strengthen the patient safety climate at unit level by implementing methods, such as root cause analysis or patient safety leadership walk rounds, to improve individual and team skills and redesign work processes. The impact of these efforts should be measured by periodically assessing the patient safety climate with the SOS.

Republished paper: Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.

AIM: The goal of this project was to improve unit-based safety culture through implementation of a multidisciplinary (pharmacy, nursing, medicine) teamwork and communication intervention. METHOD: The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture was used to determine the impact of the training with a before-after design. RESULTS: Surveys were returned from 454 healthcare staff before the training and 368 staff 1 year later. Five of eleven safety culture subscales showed significant improvement. Nurses perceived a stronger safety culture than physicians or pharmacists. CONCLUSION: While it is difficult to isolate the effects of the team training intervention from other events occurring during the year between training and postevaluation, overall the intervention seems to have improved the safety culture on these medical units.

Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.

AIM: The goal of this project was to improve unit-based safety culture through implementation of a multidisciplinary (pharmacy, nursing, medicine) teamwork and communication intervention. METHOD: The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture was used to determine the impact of the training with a before-after design. RESULTS: Surveys were returned from 454 healthcare staff before the training and 368 staff 1 year later. Five of eleven safety culture subscales showed significant improvement. Nurses perceived a stronger safety culture than physicians or pharmacists. CONCLUSION: While it is difficult to isolate the effects of the team training intervention from other events occurring during the year between training and postevaluation, overall the intervention seems to have improved the safety culture on these medical units.

The influence of age on thermosensitivity during cold water immersion.

OBJECTIVE: This investigation evaluated the influence of older age (OLD) vs younger age (YNG) on thermosensitivity and metabolic heat production (HP) during cold water immersion (20 degrees C) in 15 YNG (22.7 +/- 2.7 years) vs 7 OLD (41.7 +/- 2.7 years) individuals. METHODS: After a 20-minute baseline (BASE) period, subjects were immersed in 20 degrees C water until esophageal temperature (Tes) reached 36.5 degrees C, or for a maximum preocclusion (pre-OCC) time of 40 minutes. Arm and thigh cuffs were then inflated to 180 and 220 mm Hg, respectively, for 10 minutes (termed "occlusion" [OCC]). After release of the inflated cuffs (postocclusion [post-OCC]), the slope (beta) of the relationship between the decrease in Tes and the increase in HP was used to quantify thermosensitivity. RESULTS: Analysis of variance showed no significant difference in thermosensitivity between OLD and YNG (OLD = 2.25 +/- 1.72 W x kg(-1) x degrees C(-1) vs YNG = 3.56 +/- 1.53 W x kg(-1) x degrees C(-1)). No significant differences (P > .05) were found for mean skin temperature (Tsk; OLD = 23.8 degrees C +/- 0.31 degrees C vs YNG = 24.2 degrees C +/- 0.19 degrees C), HP (P > .05; OLD = 3.10 +/- 0.38 W x kg(-1) vs YNG = 2.50 +/- 0.22 W x kg(-1)), or Tes (OLD = 36.61 degrees C +/- 0.11 degrees C vs YNG = 36.74 degrees C +/- 0.06 degrees C). CONCLUSIONS: Therefore, these data demonstrate that when faced with a cold challenge, there is a similar response in beta, HP, Tes, and Tsk between OLD and YNG individuals.

Organizational culture, continuous quality improvement, and medication administration error reporting.

This study explores the relationships among measures of nurses' perceptions of organizational culture, continuous quality improvement (CQI) implementation, and medication administration error (MAE) reporting. Hospital-based nurses were surveyed using measures of organizational culture and CQI implementation. These data were combined with previously collected data on perceptions of MAE reporting. A group-oriented culture had a significant positive correlation with CQI implementation, whereas hierarchical and rational culture types were negatively correlated with CQI implementation. Higher barriers to reporting MAE were associated with lower perceived reporting rates. A group-oriented culture and a greater extent of CQI implementation were positively (but not significantly) associated with the estimated overall percentage of MAEs reported. We conclude that health care organizations have implemented CQI programs, yet barriers remain relative to MAE reporting. There is a need to assess the reliability, validity, and completeness of key quality assessment and risk management data.

The influence of ethnicity on thermosensitivity during cold water immersion.

PURPOSE: This investigation evaluated the influence of ethnicity, Caucasian (CAU) vs. African American (AA), on thermosensitivity and metabolic heat production (HP) during cold water immersion (20 degrees C) in 15 CAU (22.7 +/- 2.7 yr) vs. 7 AA (21.7 +/- 2.7 yr) males. METHODS: Following a 20-min baseline period (BASE), subjects were immersed in 20 degrees C water until esophageal temperature (Tes) reached 36.5 degrees C or for a maximum pre-occlusion (Pre-OCC) time of 40 min. Arm and thigh cuffs were then inflated to 180 and 220 mm Hg, respectively, for 10 min (OCC). Following release of the inflated cuffs (Post-OCC), the slope of the relationship between the decrease in Tes and the increase in HP was used to define thermosensitivity (beta). RESULTS: ANOVA revealed no significant difference in thermosensitivity between CAU and AA (CAU = 3.56 +/- 1.54 vs. AA = 2.43 +/- 1.58 W.kg(-1). degrees C(-1)). No significant differences (p > 0.05) were found for Tsk (CAU = 24.2 +/- 1.1 vs. AA = 25.1 +/- 1.1 degrees C) or HP (p > 0.05; CAU = 2.5 +/- 0.8 vs. AA = 36.5 +/- 1.8 W.kg(-1)). However, a significant (p < 0.05) main effect for ethnicity for Tes was observed (CAU = 36.7 +/- 1.8 vs. AA = 36.5 +/- 1.8 degrees C). CONCLUSION: These data suggest, despite a differential response in Tes between AA and CAU groups, the beta of HP during cold water immersion is similar between CAU and AA. Therefore, these data demonstrate that when faced with a cold challenge, there is a similar response in HP between CAU and AA that is accompanied by a differential response in Tes.

Nurse experience and education: effect on quality of care.

OBJECTIVE: To describe the relationships between the quality of patient care and the education and experience of the nurses providing that care. BACKGROUND: There is a call for more nurses with baccalaureate degrees and more experienced nurses to work in hospitals. Previous research studies have examined the characteristics, abilities, and work assignments of nurses with and without baccalaureate degrees but have not examined the quality of the patient care delivered. It is generally believed that more experienced nurses provide higher-quality care, but again few studies have actually examined this issue. METHODS: A secondary analysis of data, collected in two previous studies of the relationship between nurse staffing (hours of care, staff mix) and the quality of patient care, was used to determine the relationship between nurses' education and experience and the quality of care provided. The data were collected at the patient care unit level (42 units in study 1 and 39 units in study 2). Quality of care was indicated by lower unit rates of medication errors and patient falls. RESULTS: Controlling for patient acuity, hours of nursing care, and staff mix, units with more experienced nurses had lower medication errors and lower patient fall rates. These adverse occurrence rates on units with more baccalaureate-prepared nurses were not significantly better.

Influence of gender and menstrual cycle on a cold air tolerance test and its relationship to thermosensitivity.

This investigation evaluated the influence of gender and phase of menstrual cycle [follicular (FOL): Days 2-6) and luteal (LUT: Days 19-24)] on a cold air tolerance test (CATT: 90-min of exposure to 5 degrees C air) in 8 females (22.7 +/- 3.0 yr) and 15 males (22.3 +/- 2.9 yr). In addition, central thermosensitivity (beta; W x kg(-1) x degrees C(-1) [i.e., the slope of the relationship between the decrease in esophageal temperature (Tes) and the increase in heat production (HP)], gathered during a separate water trial in 20 degrees C water, was correlated to the change (delta) in Tes and HP across the 90 min of resting exposure during the CATT. Analysis of variance revealed no significant differences between phase of menstrual cycle or gender for HP, mean skin temperature (Tsk), and insulation; however, a main effect for time for these parameters was demonstrated. Despite these similarities, Tes differed (P < 0.05) between males and females. Additionally, no relationship was found between beta and deltaHP and deltaTes in the males and females. Also, there was no relationship between beta and thermoregulation during the CATT in these subjects. These data suggest that menstrual cycle phase did not cause a differential response in Tes, Tsk, and HP during a CATT. Furthermore, women maintained a higher Tes than men during the CATT despite similarities in HP and Tsk.

The influence of gender and menstrual phase on thermosensitivity during cold water immersion.

BACKGROUND: This investigation evaluated the influence of gender and phase of menstrual cycle [follicular (FOL: days 2-6) and luteal (LUT: days 19-24) phases] on thermosensitivity and metabolic heat production (HP) during cold water immersion (20 degrees C) in 10 females (22.4 +/- 2.8 yr) and 16 males (22.4 +/- 2.9 yr). METHODS: Following a 20-min baseline period (BASE), subjects were immersed until esophageal temperature (Tes) reached 36.5 degrees C or for a maximum pre-occlusion (Pre-OCC) time of 40 min. An arm and thigh cuff were then inflated to 180 and 220 mmHg, respectively, for 10 min (OCC). Following release of the inflated cuffs (Post-OCC), the slope (beta) of the relationship between the decrease in Tes and the increase in HP was used to quantify thermosensitivity. RESULTS: ANOVA revealed no significant difference in thermosensitivity between phases of the menstrual cycle or between men and women (FOL = -2.76, LUT = -3.05, Males = -3.24 W x kg(-1) x degrees C(-1)). A significant (p < 0.05) main effect for gender for HP, and a significant (p < 0.05) main effect for menstrual phase for mean skin temperature (Tsk) were observed. CONCLUSIONS: These data suggest, despite gender differences in HP, that the thermosensitivity of HP during cold water immersion is similar between males and females and is not influenced by menstrual cycle phase. Therefore, these data indicate that when faced with a cold challenge, women respond similarly to men in both phases of their menstrual cycle.

The effects of gender and menstrual phase on carbohydrate utilization during acute cold exposure.

OBJECTIVE: The purpose of this study was to evaluate the effects of gender and menstrual cycle on the percent of carbohydrate (CHO) utilized during cold water immersion (20 degrees C). Previous research has suggested that males and females utilize CHO differently during submaximal exercise. This study examined whether this differential response is replicated during a submaximal elevation in metabolism, as demonstrated during thermogenesis (i.e., shivering during acute cold exposure). METHODS: Male and female subjects between the ages of 18 and 30 years were recruited for this study. Female subjects underwent the experimental trial once during the follicular phase and once during the luteal phase of their menstrual cycle. Subjects were immersed to the first thoracic vertebra until esophageal temperature reached 36.5 degrees C or for a maximum preocclusion period of 40 minutes. Peripheral temperature homeostasis via cuff occlusion (right arm and left leg) took place for 10 minutes, after which the pressure cuffs were released (postocclusion) and the subjects remained in the water for an additional 10 minutes. The following variables were measured: respiratory exchange ratio, percent of CHO utilization, and oxygen consumption (Vo2). RESULTS: Analysis of variance demonstrated no significant difference between genders or phases of the menstrual cycle in respiratory exchange ratio, percent CHO utilization, or Vo2 during cold water immersion. A significant difference was observed between men and women for absolute Vo2. CONCLUSIONS: These data suggest that although men and women differ with respect to absolute aerobic metabolism, this distinction does not cause a differential response with respect to substrate utilization during acute cold exposure.

Understanding and comparing differences in reported medication administration error rates.

The prevention of medication administration errors (MAEs) represents a central focus of hospitals' quality improvement and risk management initiatives. Because the identification and reporting of MAEs is a nonautomated and voluntary process, it is essential to understand the extent to which errors may not be reported. This study reports the results of 2 multihospital surveys in which over 1300 staff nurses in each survey estimated the extent to which various types of nonintravenous (non-i.v.) and intravenous (i.v.)-related MAEs are actually being reported on their nursing units. Overall, respondents estimated that about 60% of MAEs are actually being reported. Considerable differences in estimated rates of MAE reporting were found between staff and supervisors working on the same patient care units. A simulation based on actual and perceived rates of MAE reporting is presented to estimate the range of errors not being reported. Implications regarding the reliability, validity, and completeness of MAEs actually being reported are discussed.

Understanding why medication administration errors may not be reported.

Because the identification and reporting of medication administration errors (MAE) is a nonautomated and voluntary process, it is important to understand potential barriers to MAE reporting. This paper describes and analyzes a survey instrument designed to assist in evaluating the relative importance of 15 different potential MAE-reporting barriers. Based on the responses of over 1300 nurses and a confirmatory LISREL analysis, the 15 potential barriers are combined into 4 subscales: Disagreement Over Error, Reporting Effort, Fear, and Administrative Response. The psychometric properties of this instrument and descriptive profiles are presented. Specific suggestions for enhancing MAE reporting are discussed.

Residential status and birth outcomes: is the rural/urban distinction adequate?

In studies comparing the birth outcomes of rural and urban women, residency status is frequently defined dichotomously as either rural or urban. Since residency status appears to be a continuum, however, the usefulness of other categorization systems needs to be explored. The purpose of this study was to compare birth outcomes using a three-level variable for residency status (rural, rural adjacent to urban, and urban). The study population was comprised of women who delivered by cesarean section over an 18-month period (N = 263) at a tertiary care hospital. Data were collected from patient charts, interviews, and the hospital information system. Residency status was determined by county of residence. Birth outcomes examined included gestational age, birthweight, Apgar scores, maternal complications, length of hospital stay, and costs of hospital care. Rural women had worse birth outcomes overall and traveled the greatest distance for delivery. Rural-adjacent women had the best birth outcomes of the three groups, yet were the youngest, least educated, least likely to be married, and the least likely to be privately insured. By using a nondichotomous three-level variable for residency status, two distinct groups of rural women were identified whose maternal health care needs may differ from each other.

A multisite study of nurse staffing and patient occurrences.

Restructuring of nursing care models has led to more "non-professional" caregivers, sometimes called unlicensed assistive personnel (UAPs) who provide more of the basic delegable direct patient care activities in collaboration with RNs. The purpose of this study, wherein data were collected from 39 units in 11 hospitals, was to determine the relationship between different levels of nurse staffing and patient outcomes (adverse occurrences). Using and tracking the same indicators of patient quality outcomes over a significant time period in different institutions with similar patient groups would greatly enhance the usefulness of such data. Among the more surprising findings in this study was the "non-linear" relationship between the proportion of RNs in the staff mix and MAEs. As the proportion of RNs on a unit increased from 50% to 85% "the rate of MAEs declined, but as the RN proportion increased from 85% to 100% the rate of MAEs increased." Further investigations are needed to explain this finding.

Adverse patient occurrences as a measure of nursing care quality.

OBJECTIVE: The purpose of this study was to describe relationships among adverse patient occurrences aggregated at the unit level of measurement. Relationships between adverse occurrences and a patient acuity measure were also described. BACKGROUND: Adverse patient occurrence data have been traditionally a major indicator of quality care in hospitals; however, few studies have examined relationships among these indicators or the usefulness of these indicators for assessing the quality of nursing care. METHODS: A correlational design was used to examine and describe patterns of relationships among in-patient units in a tertiary care hospital. The results demonstrated positive correlations between medication error rates and patient falls; these adverse occurrences correlated negatively with pressure ulcers, infections, patient complaints, and death. Pressure ulcers, infections, patient complaints and death intercorrelated positively and also related positively to patient acuity levels. RESULTS: An examination of these same rates for a subset of units with similar patient acuity levels revealed that most of the interrelationships among the entire set of adverse occurrence indicators were positive. When patient acuity was taken into account, these adverse outcomes appeared to indicate some common underlying characteristic of the units, such as quality of nursing care. CONCLUSIONS: This study suggests a relationship between the adverse occurrences that were correlated (pressure ulcers, patient complaints, infection, and death) and the severity of patient illness. Medication error rates and patient fall rates were not correlated with patient acuity and are more likely to indicate quality of nursing care across all types of units.

Nurses' perceptions of why medication administration errors occur.

Nurses play a key role in medication administration in hospital settings. Five categories of reasons for medication errors were identified in a survey of 1,384 nurses. These categories include physician, systems, pharmacy, individual, and knowledge-related factors. In this article, issues surrounding the occurrence and prevention of medication errors are discussed.

Nurse staffing and patient outcomes.

BACKGROUND: Nursing studies have shown that nursing care delivery changes affect staff and organizational outcomes, but the effects on client outcomes have not been studied sufficiently. OBJECTIVE: To describe, at the level of the nursing care unit, the relationships among total hours of nursing care, registered nurse (RN) skill mix, and adverse patient outcomes. METHODS: The adverse outcomes included unit rates of medication errors, patient falls, skin breakdown, patient and family complaints, infections, and deaths. The correlations among staffing variables and outcome variables were determined, and multivariate analyses, controlling for patient acuity, were completed. RESULTS: Units with higher average patient acuity had lower rates of medication errors and patient falls but higher rates of the other adverse outcomes. With average patient acuity on the unit controlled, the proportion of hours of care delivered by RNs was inversely related to the unit rates of medication errors, decubiti, and patient complaints. Total hours of care from all nursing personnel were associated directly with the rates of decubiti, complaints, and mortality. An unexpected finding was that the relationship between RN proportion of care was curvilinear; as the RN proportion increased, rates of adverse outcomes decreased up to 87.5%. Above that level, as RN proportion increased, the adverse outcome rates also increased. CONCLUSIONS: The higher the RN skill mix, the lower the incidence of adverse occurrences on inpatient care units.

Implications of nursing taxonomies for middle-range theory development.

Given the broad acceptance for the need to develop middle-range theory to support nursing practice, nursing scientists must consider how to proceed with dispatch to develop these theories. This article suggests using the concepts in the newly developing taxonomies of nursing knowledge as the building blocks for these theories. Taxonomies of nursing diagnoses (NANDA), nursing interventions (NIC), and nursing outcomes (NOC) can speed the construction of the theories needed for nursing practice.

Perceived barriers in reporting medication administration errors.

BACKGROUND: Assuring that medication administration error (MAE) reports are reliable and valid is of great significance for the patient, the hospital, and the nurse. In most hospitals, MAE reporting relies on the nurse who discovers an error to initiate an error report, whether the error was committed by that nurse or someone else. Because of the potential for negative consequences, there may be significant disincentives for the nurse to report the error. This, the first of two articles, describes the results of a large-scale survey designed to assess nurses' perceptions of the reasons why MAE may not be reported. The companion article compares nurses' estimates of the extent to which MAEs are reported with the actual reported medication error rates. METHODS: Nurses in 24 acute-care hospitals were surveyed to determine perceptions of reasons why medication errors may not be reported. RESULTS: The factor analysis reveals four factors explaining why staff nurses may not report medication errors: fear, disagreement over whether an error occurred, administrative responses to medication errors, and effort required to report MAEs. CONCLUSIONS: There are potential changes in both systems and management responses to MAEs that could improve current practice. These changes need to take into account the influences of organizational, professional, and work group culture.

Outcomes of hospital-based managed care: a multivariate analysis of cost and quality.

OBJECTIVE: To determine the effects a hospital-based managed care intervention has on the cost and quality of care. METHODS: The intervention consisted of a CareMap and a nurse case manager. The CareMap contained both a critical path and a set of expected patient outcomes. The study population comprised all women who delivered by cesarean during the 18 months of the study and who were cared for in the maternity unit at a tertiary-level university hospital. The effects of the intervention were determined by comparing the after group with the before group in regard to length of stay and costs of care post-cesarean delivery, patient ratings of quality of care, and the physical recovery of the patients by discharge and 1 month later. RESULTS: After the implementation of hospital-based managed care, the average length of stay decreased 13.5% (0.7 days) and the average costs decreased 13.1% ($518). These decreases were statistically significant and remained so after controlling for co-morbid and complicating conditions. Patients perception of the quality of care increased from 4.26 to 4.41 on a 1-5 scale, a statistically significant increase. In particular, patients believed that they had an increased level of participation in their care. The physical recovery scores obtained at discharge did not change. CONCLUSION: Hospital-based managed care can reduce resource use, length of stay, and cost associated with hospital care while maintaining or improving the quality of care. Whether these effects are reproducible and generalizable to other conditions should be addressed in future studies; the duration of these effects should also be examined.