Patient Safety Culture in Rural Hospitals: A Systematic Review

Contact for the review: Name: Julie Langlois Telephone: (613)254-8873 Email: [email protected] Review question/objective How is patient safety culture measured/monitored/described in a rural hospital setting? Background One of the major transitions in healthcare in the last decade has been an emphasis on patient safety. Since the landmark book, To Err is Human was released, health care professionals in hospitals have had patient safety on their healthcare agenda.1 Researchers and policy makers in governments, healthcare accreditation bodies and newly formed agencies started researching and developing strategies and guidelines to facilitate this new initiative called patient safety. Some of the literature has focused on different aspect of Patient safety. This systematic review protocol will be to review patient safety culture in rural hospitals Rural Hospitals Rural hospitals have unique characteristics including their location and size. For the purposes of this protocol rural will be described as a “community living outside the commuting zone of a larger urban centre and has less than 10,000 people” 2 Rural hospitals are generally smaller as the population is less than in urban areas and typically range between 25 to 100 acute care beds.3 Vartak and colleagues3 suggest that there are even differences between rural hospitals that have fewer than 50 beds and those with over 50 beds. This includes the clients they serve and the services they provide. The leadership and organizational structure may vary in a rural setting. Bushy4 suggests that limited financial and human resources may necessitate a different structure. The hospital is often the largest employer in the rural community. The administrators in a rural hospital will usually have several portfolios instead of just one. Health care professionals may have difficulty articulating their roles in patient safety culture when they have several roles within the rural hospital that may include director of nursing and patient safety officer. Collaboration and autonomy is often part practice in a rural setting. Nurses may work alone in the hospital with physicians fifteen or twenty minutes away.5-6 Nurses and physicians must work together as they may be the only practitioners. They need to be multi-specialists.5-6 Since they work together they may feel closer and more valued than in an anonymous urban centre. This may also blur the roles of health care professionals in a patient safety culture. Wholey and colleagues7 suggested that health care professional may not feel comfortable speaking out about safety issues especially when it means changing practice. Implementing patient safety culture initiatives or quality improvement initiatives would appear easier with less staff. Klinger and colleague8 reveals that rural hospitals face issues around funding of projects, communication processes, and less access to technology. Funding in rural hospitals may not be used for patient safety initiatives especially if there is a belief that the current system is working well. Health care professionals may find it difficult even to receive funding to attend education sessions on patient safety. The communication surrounding the reporting of errors may be difficult without an anonymous system of reporting. Health care professionals in small communities may be afraid to report errors because it may damage their reputation within the community. Rural hospitals are unique in their services and characteristics. Research is needed to reflect their unique characteristic and to understand how to implement appropriate practices in this setting. Patient Safety Patient safety is defined as “the reduction and mitigation of unsafe acts within the health-care system, as well as through the use of best practices shown to lead to optimal patient outcomes”.9(p11) Patient safety has many elements that involve individual factors and organizational factors and approaches. Researchers in businesses and industries, including the aviation industry, have helped those working in health care understand complex work environments. Reason10 describes the person approach and the system approach involved in errors surrounding patient safety. The person approach entails an individual making and being responsible for the mistake. The system approach implies that the both organization and individual are responsible. The organization recognizes that humans make errors and that systems should be in place to decrease the chance of error. Reason explains two kinds of errors: 1) Active errors occur where people ignore or skip important safety steps that have been developed; and 2) atent errors occur when there are systematic issues such as chronic understaffing or faulty equipment. Reason10 expresses that if organizations take only the individual approach, staff will avoid reporting errors and organizations will miss important systems issues. The organizations need to make staff feel safe to report any error to be able to build systems that will decrease errors. This will help build a patient safety culture. Vincent11 explains that patient safety culture encompasses building both systems approaches and individual's capacity. Patient safety is not created by a single act of reporting errors. It encompasses many facets or layers in the healthcare system. Vincent11 highlights communication, education, teamwork, protocols and safe work environment as some of the approaches needed for patient safety. These approaches are part of the building blocks of a patient safety culture. A safety culture has staff in an organization constantly committed to patient safety.12 This commitment is integrated throughout the healthcare system. Pizzi and colleagues12 go on to describe four elements of patient safety culture; recognition of a high risk environment, a blame free reporting system, collaborative work environment and a commitment of resources to change unsafe situations. In the Canadian Patient Safety Institute (CPSI) patient safety competencies, a culture of patient safety is described as having two “interdependent factors”.13 The first factor is the organizational structure that supports patient safety and the second factor is the people working to create and maintain patient safety. Both of these elements are needed to work symbiotically in order to sustain a culture of safety. The structures include work environment, protocols and support systems for staff to work safely. The people need the proper expertise and knowledge about patient safety. They must engage in learning and application of patient safety initiatives. The concept of a ‘safety culture’ has been described in many different ways, but common elements run through each description. These common elements often converge on the systems approach and person approach first described by Reason10. Measuring Patient Safety Culture Health care professionals can draw on guidelines and research to guide their work in creating and sustaining a culture of safety. Government and accrediting bodies have created guidelines and programs based on the research to facilitate integration of patient safety initiatives in healthcare organizations. These initiatives include adverse event reporting systems and incorporating patient safety as a strategic goal for the organization.14 Patient safety culture surveys were developed by researchers using research generated by the aviation and business industries. Nieva and Sorra15 suggest that health care professionals choose the most appropriate instrument for the information they would like to capture. There are instruments focused on leadership and others are focused on frontline staff perspectives. Some accrediting bodies have made it mandatory to use a patient safety culture survey on a regular basis.14 Patient Safety and Rural hospitals Although patient safety surveys have been developed and implemented internationally, there are few patient safety measures specific to rural hospitals.16 Thornlow17 reviewed nursing patient safety research limiting her review to practice orientated studies related to nursing care in rural home care. The researcher did not include research outside of nursing, policy papers or standards designed for rural hospitals. The twenty articles reviewed were mainly about reporting errors, medications, care given, and client safety review. Thornlow17 suggests that further research and reviews are needed on patient safety culture. Some of the article she found could not be included since they were not nurse researchers. Vartak and colleagues3 compared small urban hospitals to rural hospitals. They found that small rural hospitals had less adverse events and better patient outcomes than small urban hospitals when the data was not adjusted for patient characteristics and profiles. The researchers suggested that the small urban hospitals tended to have more invasive procedures and more acute patients than the rural counterpart. The range of acuity and patient interventions performed in each organization complicates the ability to compare the research in these settings. Rationale for Systematic Review This systematic review will integrate the literature about patient safety in rural hospitals in order to identify areas for future patient safety research in this setting. The literature contains a vast amount of research on patient safety but much of the literature has focused on other settings. For example, patient safety in large urban hospitals dominates the research but findings from this research may not be translatable to rural settings. This systematic review will describe patient safety culture as it applies to rural hospitals and focus on the measurement and monitoring of this culture. Definitions The definition of Rural used in this review will be a “community living outside the commuting zone of a larger urban centre and has less than 10,000 people”.2 ‘Rural hospitals’ will refer to hospitals that are in a rural community with less that than 100 acute care beds.3 Patient safety is defined as “the reduction and mitigation of unsafe acts within the health-care system, as well as through the use of best practices shown to lead to optimal patient outcomes”.9(p11) Patient safety culture encompasses two “interdependent factors”.13 The first factor is the organizational structure that supports patient safety and the second factor is the people working to create and maintain patient safety. Inclusion criteria Types of participants This review will include as participants any healthcare worker including but not limited to nurses, physicians, physiotherapists, pharmacists, diagnostic technicians and/or occupational therapists respirologists, social workers, psychologists, that are part of the patient safety culture in a rural hospital. Types of intervention(s)/phenomena of interest The review will consider studies that measure, monitor and describe patient safety culture in rural hospitals. Types of outcomes This systematic review will consider outcomes that include measurement, monitoring and description of patient safety culture in rural hospitals. The specific outcomes may include but not limited to monitoring strategies, descriptions, current standards and expectation of patient safety culture in rural hospitals. Types of studies This systematic review will be a mixed methods review. Limiting the review to quantitative data especially related to culture may not appropriate. Schein18 suggests that surveys give superficial information about a culture. The issue that needs to be explored may not be included in the survey instrument. Qualitative research and textual document review may be more suitable to provide a comprehensive understanding of patient safety culture. By using a mix methods approach, this systematic review will examine and describe not only the current understanding but also the expectations of patient safety culture in rural hospitals. The criteria selection for considering studies for this review will be guided by the context of patient safety culture, rural and the rural hospital. Since there are variation in definitions for patient safety culture and rural hospitals, the studies will be reviewed on a case-to-case basis to ensure the fit is congruent. The authors will substantiate their choice if there is a variation. Quantitative This review will consider any quantitative studies that examine patient safety culture in rural hospitals. This will include research designs based on the hierarchy of quantitative study design.19 Examples include experimental studies (e.g. RCT with concealed allocation),quasi-experimental studies (e.g. experimental study without randomization),controlled observational studies, observational studies without control groups and expert opinion based on bench research or consensus.19 Qualitative This review will consider studies using qualitative methodologies including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research, and case study. Other text such as opinion papers, reports, governmental and nongovernmental reports will also be reviewed. Search strategy The search seeks to find both published and unpublished studies in the English language from January 2000 to May 2011 inclusive and using a three-step search strategy. The start date of 2000 was selected because research on patient safety did not start until after the landmark book, To Err is Human was released in 2000.1 The research before this time tended to be focused more on quality than safety.17 An initial limited search of MEDLINE and CINAHL databases will be conducted to identify keywords contained in the title or abstract. A second extensive search will be undertaken using the identified key words and index terms. The third step will be to search the reference lists and bibliographies of all relevant articles. Initial search terms will be: Rural, patient safety, culture, outpost, patient safety culture. small hospitals The databases to be searched include: CINAHL Health Source: Nursing/Academic Edition Elsevier Science Direct EMBASE ISI Web of Science MEDLINE PSYCINFO AMED (allied health) The search for unpublished studies will include: Dissertations Conference Proceedings Index to Theses AHRQ (Agency for Healthcare Research and Quality) Theses Canada Portal CHSRF GoogleScholar.com Canadian Patient safety Institute Canadian Nursing Association Governmental agencies (Health Canada, CIHI) Accreditation Standards National Patient Safety Agency Institute for Health & Social Care Research (IHSCR) National Library of Health (NLH) The Open University World Health Organization Library (WHOLIT) Assessment of methodological quality Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-QARI (Appendix II). Textual data will be extracted from papers included in the review using the standardised data extraction tool from JBI-NOTARI (Appendix II). Data synthesis Quantitative papers will, where possible be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different quantitative study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Qualitative research findings will, where possible be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorising these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Textual papers will, where possible be pooled using JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorising these conclusions on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the conclusions will be presented in narrative form. Conflicts of interest None Acknowledgements This systematic review is part of a PhD thesis. The authors would also like to acknowledge the assistance from the staff of the Queen's Joanna Brigg's Collaboration.

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