Perceptions of Staff Nurses about Patient Safety Culture at Minia General Hospital

Introduction

Millions of patients suffer from illnesses, accidents, or death each year due to unsafe medical practices (Al- Lawati et al., 2019). Worldwide, it is estimated that 4 in 10 patients are harmed in primary and outpatient health care. In the developed countries, the number of patients harmed during hospitalization is estimated to be one in ten patients. Also, in low and middle-income countries (LMICs), each year, 134 million adverse events occur in hospitals due to unsafe care, resulting in 2.6 million deaths (World Health Organization, 2020).

A positive safety culture will improve a hospital's patient safety performance, which could help the organization strengthen its safety outcomes. A high level of safety control benefits physical and psychological health directly and positively. Furthermore, if the perception of safety control is high, negative consequences or reprisals for reporting safety issues will be reduced (El-Jardali et al., 2014).

Patient safety is defined as avoiding preventable harm to a patient during the health care process and reducing to an appropriate minimum risk of unintended harm that associated with health care (Al- Lawati et al., 2019). Also Patient safety is defined as the avoidance and prevention of patient injuries or adverse events resulting from the processes of health care delivery (Abdelrahman & Mohamed, 2017). To prevent such harm, it is recommended from health care setting and health care providers to maintain and enhance the patient safety culture (Ammouri et al., 2015).

Attaining a safety culture requires an understanding of the values, attitudes, beliefs, and norms important to health care organizations and what attitudes and behaviors are appropriate and expected for patient safety (Ulrich & Kear, 2014). Positive and robust patient safety cultures have significantly reduced the number of adverse events reported in a healthcare organization (DiCuccio, 2015).

Patient safety has become a major healthcare challenge since concerns about not harming patients have received increased attention in recent years. Numerous studies revealed that high chances exist of adverse events occurring in general healthcare environments (Graban & Toussaint, 2018). The event is defined as any type of error, mistake, incident, accident, or deviation, regardless of whether or not it results in patient harm (Abdelrahman, Mohamed, 2017).

These unintended adverse events can lead to hospital admissions, a prolongation of hospital stays, increased medical expenditures, and the occurrence of serious permanent injury or death. Evidence from several studies suggested that these adverse events are often preventable, and are therefore manageable and avoidable (Cheng et al., 2019).

Therefore, establishment of a supportive patient safety culture in healthcare organizations is widely accepted and needed to be among the highest priorities for reducing adverse events and improving patient safety as well as quality of care. The safety climate generally refers to measurable components of safety culture. Assessment of the patient safety climate for healthcare workers is considered essential as a primary strategy to promote patient safety in organizations (Pousette et al., 2017).

Many factors can be associated with patient safety culture. Organizational culture that encourages reporting and avoids blame and improved communication are reported as important factors to improve patient safety culture. Elmontsri et al., (2017) showed that blame culture and poor communication were common factors associated with a low patient safety culture in Arab countries. Another review related to Almutairi et al., (2015) showed a communication issue between healthcare providers and patients, leading to preventable errors and low-quality care. This communication deficit was linked to language barriers, workforce diversity, and cultural differences.

Other studies showed that patient safety culture can be influenced by respondent and hospital characteristics, work area, position, extent of participation in a patient safety program, communication, and patient safety management and resources. Inappropriate funding and unavailability of critical support systems including strategies, guidelines, tools and patient safety standards remain major worries in Africa. Furthermore, understanding of the problems associated with patient safety culture is hampered by inadequate data (Wami et al., 2016).

Significance of the study

Nurses are considered the backbone of the health care and an important part of the health care team. A growing body of evidence indicated that the rate of medical errors and adverse events are associated with the perception of healthcare professionals towards safety (Salmond & Echevarria,  2017).

During the work at Minia General Hospital, the researcher observed that nurses' staff had various problems related to patients' safety culture such as, poor infection control, improper waste management, and medication errors. Highly technologically advanced environment add to the complexity of care, together with communication barriers, and carrying out a great many activities per patient and per day, considered to be a great challenge for health care providers. So the researcher decides to assess perceptions of staff nurses about patient safety culture.

Because nurses are the frontline risk managers caring for patients 24 hours a day, investigating and analyzing their patient safety culture, perception of safety control, and patient safety management activities are necessary to prevent medical errors and improve patient safety (Jang et al., 2017).

Developing countries have been encouraged by the joint global initiative of the WHO and the World Alliance for Patient Safety (WAPS) to launch a concerted effort which will help in the assessment of the magnitude of the problem. One of the studies that evaluated patient safety in Arab countries has used the Patient Safety Friendly Hospital Initiative (PSFHI) standards. Ministries of health in seven developing countries have been assessed using the PSFHI which included Egypt, Jordan, Morocco, Pakistan, Sudan, Tunisia and Yemen. One hospital in each country was assessed against the PSFHI standards (Shu et al., 2015) so, the assessment of staff nurses perceptions about patient safety culture is important.

Aim of the study:

The aim of the current study is to assess perceptions of staff nurses about patient safety culture at Minia General Hospital

Research questions

1. What is perception of staff nurses about patient safety culture at General Hospital?
2. What are the levels of patient safety culture among the nurses?
3. Is there a relation between perceptions of staff nurses about patient safety culture at General Hospital and their personal data?

Subjects and Methods

Research Design

Descriptive cross sectional research design was used to achieve the aim of the current study.

Setting

The study was conducted at Minia General Hospital, at Minia city, Egypt. Minia General Hospital composed from three building; first building consisted of three floors (the administration in the ground floor, second and third floor contain different departments such as (Medical, Surgical, Obstetric, Gynecological, Burn and Delivery Room). The second building consist of three floors (Emergency Department in the ground floor; CCU is in the second floor; and Neonatal Intensive Care Unit (NICU) and pediatric department are in the third floor). The third building contains dialysis units. This hospital is generalized in caring for all specialties; it provides free and economic services through different departments and units.

Subjects

Study subjects were included all available staff nurses during data collection at Minia General Hospital. The study subjects were consisted from all units of hospital (no.=280) and divided as follows:

Data Collection Tool

Data was collected by using one tool that comprised of two parts as follows:

Part I: personal data sheet

It was used to collect data about the staff nurses data. It included items related to age, gender, marital status, qualification, years of experience in the nursing field, department, and shift of working.

Part II: Patient Safety Culture

The tool developed by the Agency for Healthcare Research and Quality (AHRQ) (2016) in the USA to measure patient safety culture. It consisted of 42 items grouped into 12 dimensions as follows: teamwork within units (4 items) ,supervisor/management& actions promoting patient safety (4 items), organizational learning (3 items), management support for patient safety (3 items), overall perception of patient safety (4 items), feedback& communication about error (3 items), communication openness (3 items), frequency of events reported (3 items), teamwork across units (4 items), staffing (4 items) handoffs & transitions (4 items) and non-punitive response to errors (3 items). Each item will be measure using five point Likert scale ranged as "strongly disagree = 1 to strongly agree = 5".

Validity of the tool:

Tool was tested for the content validity by a jury of (5) experts in the field of Nursing Administration and necessary modifications were done. The jury composed of one Professor and one Assistant Professor from Faculty of Nursing, Minia University; and three professors from Faculty of Nursing Assuit University. Each of the expert panel was asked to assess the instruments for content coverage, clarity, wording, length, format, and overall appearance. No necessary modification was done from jury panel.

Reliability of the tool:

Reliability of the tool was performed to confirm its consistency. The internal consistency measured to identify the extent to which the items of the tool measured the same concept and correlate with each other by Cronbach’s alpha test that revealed good internal reliability for the tool; and it was (0.88) for the tool.

Pilot Study

A pilot study was conducted on 10% of participants (28 nurses' staff) to ascertain the clarity, comprehensiveness, and applicability of the tool as well as to estimate the appropriate time required to fill the questionnaire. Based on pilot study there was no modification done, and it was added to final results.

Data Collection Procedure

• An official letter was granted from the Nursing Faculty Dean at Minia University, Ethical committee Nursing Faculty at Minia University, and Ministry of Health – Egypt,
• Written approvals were obtained from the Director of Minia General Hospital, and director of nursing in Minia General Hospital, Minia city after explaining the purpose of the study.
• The questionnaire was distributed to all the participants after explaining the purpose of the study and data collection. Tool was administered directly and supervised by the researcher with the assistance of head nurse for each unit.
• The researcher had a group interview with study participants through morning, evening, and night shift during the working days. 
• Participants were given from 20 minute to 30 minutes to answer the tool. They were allowed to discuss with researcher any item that needs more clarification. 
• The data collection was performed from staff nurses of Minia General Hospital, at Minia City during the period of 3 months from the beginning of March 2021 to the end of May 2021. 

Administrative design

A written initial approval was obtained from the Research Ethics Committee of the Faculty of Nursing, Minia University. An official letter was granted from Faculty Dean, Ministry Of Health and director of Minia General Hospital, at Minia City.

Ethical Consideration

The participants were informed that the participation in the study was voluntary and they will not have any harm if they do not participate in the study. Oral consent was obtained from staff nurses after explaining the nature and benefits of the study. The participants' name was not appearing on the sheets for the purpose of anonymity and confidentiality.

Data statistical analysis

Data entry was done using compatible personal computer. Statistical analysis done by using statistical package of social science (SPSS, IBM) version 25 and excel for figures. The content of tool was analyzed, categorized, and then coded. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables and; means and standard deviations for quantitative variables.  Statistical significance used at P value

Results

Table (1): Distribution of the staff nurses' personal data (no. =280)                                                                

Table (1) shows the personal data of the staff nurses, in relation to age there are (68.2%) have (22-23) years old with mean age score (31.77+87.25). Regarding marital status there are (71.4%) married; and for educational qualification there are (39.3%) of staff nurses have diploma degree. For years of experiences, there are (67.1%) have (1- 10) years of experiences.

Figure (1): Distribution of the staff nurses' regarding their gender (no.=280)

Figure (2): Distribution of the staff nurses' regarding their departments (no=280)

Figure (1) shows that there are (73.9%) of staff nurses are female. Regarding departments, figure (2) shows that there are (14.3%, 13.9%, and 13.2%) of staff nurses work in surgical units, emergency and intensive care unit respectively

Figure (3): Distribution of the staff nurses' regarding their shift at (no=280)

Speaking about shift, figure (3) shows that there are (50%) of staff nurses work in the morning shift.

Table (2) Levels of nurses staff perceptions regarding patient safety culture dimensions (no=280)

Table (2) displays that the staff nurses have high total scores regarding patient safety culture for the dimensions (feedback and communication about error (53.3%) followed by frequency of event reporting (48.2%), then teamwork within units (46.1%) and then organizational learning  continuous improvement (45.4%). While; the staff nurses have moderate response for the rest of patient safety culture dimensions.

Also, this table shows that have low score in "high response" from staff nurses perception are supervisor \ manager expectations and actions promoting patient safety (25%), overall perceptions of patient safety (26.5%), staffing (27.9%) and teamwork across hospital units (29.6%)

Figure (4) Percentage distribution of staff nurses total scores regarding patient safety culture (no=280)

Figure (4) displays that the (71.4%) of staff nurses have moderate total scores regarding patient safety culture, as well there are (16.8%) of them have high responses, and only (11.8%) have low perception regarding patient safety culture.

Figure (5) Relation between staff nurses' age and total score of patient safety culture (no=280)

Figure (5) displays that there are highly statistical significant relations between staff nurses age and their total score regarding the patient safety culture in favor to the staff nurses with age (22-32 years) there are (81.20%) of them have moderate score; and there are (25%) of staff nurses with age (>55 years) have high score to patient safety culture with p-value (=0.0001).

Figure (6) Relation between staff nurses' gender and total score of patient safety culture (no=280)

Figure (6) displays that there is no statistical significant relation between staff nurses gender and their total score regarding the patient safety culture with p-value (=0.071)

Figure (7) Relation between staff nurses' marital statues and total score of patient safety culture (no.=280)

Figure (7) displays that there are highly statistical significant relations between staff nurses marital status and their total score regarding the patient safety culture in favor to the staff nurses who are single as (84.2%) of them have moderate score; and there are (40%) of widow have high score with p-value (=0.0001).

Figure (8) Relation between staff nurses' educational qualification and total score of patient safety culture (no=280)

Figure (8) shows that there are statistical significant relations between staff nurses educational qualifications and their total score regarding the patient safety culture in favor to the staff nurses who have bachelor degree in which there are (82.4%) of them have moderate score and (10.8%) of them have high total score; as well as there are (22.9%) of staff nurses who had technical degree have high total score with p-value (=0.041)

Figure (9) Relation between staff nurse's years of experience and total patient safety culture (no=280)

Figure (9) shows that there are statistical significant relations between staff nurses years of experiences and their total score regarding the patient safety culture in favor to the staff nurses who have (1 to 10) years of experiences as (76.6%) of them have high moderate score and there are (33.4%) of staff nurses who have (>31 years) have high score with p-value (=0.010)