Copyright © eContent Management Pty Ltd. Contemporary Nurse (2014) 47(1–2): 27–35.
Measuring hospital falls prevention safety climate
Paul N Bennett, Cherene Ockerby, Judy Stinson*, Karlene Willcocks* and Cheyne Chalmers* Centre for Nursing Research, Deakin University and Monash Health Partnership, Melbourne, VIC, Australia; *Monash Health, Melbourne, VIC, Australia
Abstract: The prevention of falls is a key safety priority for hospitals. There are no tools that examine the safety climate from a falls prevention perspective. The aim of this study was to measure the falls prevention safety climate at an Australian metropolitan hospital. The Victorian Safety Climate Survey (SCS) was used to examine the general safety climate, with four items replicated and modified to examine the falls prevention climate. Data (N = 458) for the six SCS domains compared favourably with statewide data. The falls prevention items were correlated with the original items from which they were derived but responses regarding falls prevention tended to be less positive than patient safety more broadly. Priorities for improvement identified using a falls SCS can inform the development of falls prevention strategies and form the basis of a more comprehensive tool to explore the falls prevention safety climate.
Keywords: falls prevention, safety climate, acute care
A
s health care organisations continually strive to improve the service they provide to patients, there is growing recognition of the need to establish an organisational culture where safety is paramount (Chaboyer et al., 2013; Sorra & Nieva, 2004; Thomas et al., 2012). Consequently, there is increasing emphasis on quantifying organisational safety culture or safety climate (Flin, Burns, Mearns, Yule, & Robertson, 2006; Morello et al., 2013). The prevention of falls and harm from falls has recently been identified as a key safety priority for Australian health services with the introduction of a falls-specific accreditation standard (Australian Commission on Safety and Quality in Health Care, 2011). There is, however, a paucity of tools available to measure staff perceptions of safety climate in relation to falls prevention. In this study an existing safety culture measure was modified to include additional items to address this gap. This paper reports findings from the overall safety climate survey (SCS), with a focus on falls prevention, and suggests a gap between staff perceptions of the falls prevention safety culture compared with patient safety more broadly.
Background literature The terms safety culture and safety climate are often used interchangeably but this fails to acknowledge the difference between these concepts and the relationship between them. Although definitions
vary, Wiegmann, Zhang, von Thaden, Sharma, and Mitchell (2002) describe safety culture as ‘the enduring value and priority placed on safety by everyone in every group at every level of an organization. It refers to the extent to which individuals and groups will commit to personal responsibility for safety, act to preserve, enhance and communicate safety concerns, strive to actively learn, adapt and modify … behaviour based on lessons learned from mistakes’ (p. 8). In this way, safety culture can be viewed as one aspect of the broader organisational culture (Morello et al., 2013; Singer, Lin, Falwell, Gaba, & Baker, 2009; Wiegmann et al., 2002). Safety culture, however, can be difficult to quantify (Singer et al., 2009; Wiegmann et al., 2002) and therefore the more easily measurable safety climate is often used to examine an organisation’s safety culture. Safety climate differs from safety culture in that it is ‘the temporal state measure of safety culture, subject to commonalities among individual perceptions of the organization. It is therefore situationally based, refers to the perceived state of safety at a particular place at a particular time, is relatively unstable, and subject to change depending on the features of the current environment or prevailing conditions’ (Wiegmann et al., 2002, p. 10). It appears therefore, that most questionnaires that purport to measure safety culture are, in fact, measuring safety climate. Thus safety climate is the term used throughout this paper.
Volume 47, Issue 1–2, April/June 2014
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27
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Paul N Bennett et al.
Research has emerged in recent years to indicate a link between safety climate and safety performance in acute hospital settings. For example, safety climate has been associated with incident severity (Kline, Willness, & Ghali, 2008), mortality and length of stay (Huang et al., 2010), and readmission for patients with acute myocardial infarction and heart failure (Hansen, Williams, & Singer, 2011). Of particular interest in this study, safety climate has also been linked with rates of patient falls, both in acute settings (Vogus & Sutcliffe, 2007) and nursing homes (Thomas et al., 2012). Falls are the most frequently reported adverse event in the acute inpatient setting (Currie, 2008). The Victorian Quality Council report a rate of between 2 and 7 falls per 1000 bed days for hospital patients, resulting in injury in 30–40% of cases (Victorian Quality Council, 2009). Falls during hospital admissions can lead to increased complications, additional diagnostic testing, and an increase in length of stay of 4–11 days (Victorian Quality Council, 2009). Falls prevention has been included as a National Patient Safety Goal in the USA since 2005 (Eldridge, 2005). The importance of falls prevention in Australia is reinforced by the inclusion of preventing falls and harm from falls in the recent Australian National accreditation standards (Australian Commission on Safety and Quality in Health Care, 2011). As part of a wider strategy to prevent patient falls, one Australian hospital sought to measure staff perceptions of the safety climate in relation to falls prevention. Various tools have been developed to examine safety climate but none contain items specific to falls prevention. The Safety Attitudes Questionnaire (SAQ; Sexton et al., 2006) was recently adapted for use in Victorian hospitals (Victorian Managed Insurance Authority & Victorian Quality Council, 2011) and this SCS was deemed the most suitable tool to measure general safety climate in this study. A further four items were added to the tool to specifically measure the falls-related safety climate, supplemented by a qualitative item asking staff for suggestions to prevent patient falls. 28
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The aims of this study were to: • collect baseline data about the current safety climate at the hospital and benchmark against external data, • compare responses to the four falls-specific items with the four original items from which they were derived, and • identify strengths and opportunities for improvement in patient safety, with a specific focus on falls prevention. Method Setting and participants The study was conducted at a tertiary hospital in metropolitan Melbourne, Australia, that provides services across the care continuum from emergency and critical care to rehabilitation and subacute care. Surveys were distributed to multidisciplinary staff involved in direct patient care as well as staff providing patient support (e.g., managers, administrative staff, and support staff). A total of 1100 surveys were distributed which targetted approximately 40% of eligible staff at this site. Of these, 458 surveys were completed representing a 42% response rate and 16% of the overall staff population. Measures The SCS was based on the SAQ (Sexton et al., 2006) and was modified for the Victorian hospital context by the Victorian Managed Insurance Authority and Victorian Quality Council (2011). The SCS comprises 74-items including 42 items that form six factor analysis-derived domains in the original SAQ and a further 32 items that do not contribute to domains but were retained because they still provided important information. The SCS was developed and tested with a sample of 1626 staff from six Victorian healthcare services (Victorian Managed Insurance Authority, Victorian Quality Council, & UltraFeedback Pty Ltd, 2011) and was recommended for use in Victorian healthcare organisations. The data from the statewide pilot provided data against which to benchmark our own findings. To further examine the specific safety culture around falls prevention, four items that asked about patient safety broadly were replicated and the words ‘patient safety’ were replaced with ‘falls
Volume 47, Issue 1–2, April/June 2014
© eContent Management Pty Ltd
Falls prevention safety climate prevention’ or similar. Thus the four additional items were: This health service provides adequate falls prevention education and training; All personnel in my work area take responsibility for falls prevention; We are actively doing things to prevent falls in my work area; and Falls prevention is constantly reinforced as a priority in my work area. An open-ended question was also modified to ask respondents for their suggestions about ways to prevent patient falls. The SCS also contained a set of demographic items that were adapted for the Australian context. Procedure The study was approved by the human research ethics committee (#12357Q) at the hospital. Hard copy surveys were distributed to managers of all relevant wards and departments to distribute to staff. Staff were able to return completed surveys either via a sealed box in their respective unit/ department or send it directly to the research team via the internal hospital mail service. Consent was implied by completing and returning the survey. Surveys were distributed in the first week of December 2012 with a closing date 3 weeks later. Data analysis Quantitative data were analysed using IBM SPSS Statistics version 21 (IBM Corp, Armonk, NY) including descriptive and inferential statistics. A mean score was calculated for each of the six domains and was compared with data reported for the statewide pilot sample (Victorian Managed Insurance Authority et al., 2011) using single sample t-tests with Cohen’s d used as a measure of effect size. A ‘Priority to Improve’ (PTI) score is calculated for each survey item, based on the Pearson’s correlation (r) between each survey item and the key item I would feel safe being treated here as a patient, and the difference (Gap) between the mean score of the survey item and the mean score of the key item (PTI = r × Gap). Items with the highest PTI score are most strongly related to the key item but are being performed the least well (Victorian Managed Insurance Authority et al., 2011). Pearson’s correlations were used to examine the association between the four Falls Prevention items with the original patient safety items from
© eContent Management Pty Ltd
CN
which they were derived. The coefficient of determination (r2) was also calculated for correlations to determine the shared variance between items. Additional analyses were conducted to compare the responses of staff to the four falls prevention items based on their demographic characteristics. An independent samples t-test was used to compare the responses of full time and part time staff, and analysis of variance (ANOVA) was used to compare the responses of staff on other demographic variables including job level, current role, health service area, and number of years working in this health service. Demographic categories with
Measuring hospital falls prevention safety climate
Paul N Bennett, Cherene Ockerby, Judy Stinson*, Karlene Willcocks* and Cheyne Chalmers* Centre for Nursing Research, Deakin University and Monash Health Partnership, Melbourne, VIC, Australia; *Monash Health, Melbourne, VIC, Australia
Abstract: The prevention of falls is a key safety priority for hospitals. There are no tools that examine the safety climate from a falls prevention perspective. The aim of this study was to measure the falls prevention safety climate at an Australian metropolitan hospital. The Victorian Safety Climate Survey (SCS) was used to examine the general safety climate, with four items replicated and modified to examine the falls prevention climate. Data (N = 458) for the six SCS domains compared favourably with statewide data. The falls prevention items were correlated with the original items from which they were derived but responses regarding falls prevention tended to be less positive than patient safety more broadly. Priorities for improvement identified using a falls SCS can inform the development of falls prevention strategies and form the basis of a more comprehensive tool to explore the falls prevention safety climate.
Keywords: falls prevention, safety climate, acute care
A
s health care organisations continually strive to improve the service they provide to patients, there is growing recognition of the need to establish an organisational culture where safety is paramount (Chaboyer et al., 2013; Sorra & Nieva, 2004; Thomas et al., 2012). Consequently, there is increasing emphasis on quantifying organisational safety culture or safety climate (Flin, Burns, Mearns, Yule, & Robertson, 2006; Morello et al., 2013). The prevention of falls and harm from falls has recently been identified as a key safety priority for Australian health services with the introduction of a falls-specific accreditation standard (Australian Commission on Safety and Quality in Health Care, 2011). There is, however, a paucity of tools available to measure staff perceptions of safety climate in relation to falls prevention. In this study an existing safety culture measure was modified to include additional items to address this gap. This paper reports findings from the overall safety climate survey (SCS), with a focus on falls prevention, and suggests a gap between staff perceptions of the falls prevention safety culture compared with patient safety more broadly.
Background literature The terms safety culture and safety climate are often used interchangeably but this fails to acknowledge the difference between these concepts and the relationship between them. Although definitions
vary, Wiegmann, Zhang, von Thaden, Sharma, and Mitchell (2002) describe safety culture as ‘the enduring value and priority placed on safety by everyone in every group at every level of an organization. It refers to the extent to which individuals and groups will commit to personal responsibility for safety, act to preserve, enhance and communicate safety concerns, strive to actively learn, adapt and modify … behaviour based on lessons learned from mistakes’ (p. 8). In this way, safety culture can be viewed as one aspect of the broader organisational culture (Morello et al., 2013; Singer, Lin, Falwell, Gaba, & Baker, 2009; Wiegmann et al., 2002). Safety culture, however, can be difficult to quantify (Singer et al., 2009; Wiegmann et al., 2002) and therefore the more easily measurable safety climate is often used to examine an organisation’s safety culture. Safety climate differs from safety culture in that it is ‘the temporal state measure of safety culture, subject to commonalities among individual perceptions of the organization. It is therefore situationally based, refers to the perceived state of safety at a particular place at a particular time, is relatively unstable, and subject to change depending on the features of the current environment or prevailing conditions’ (Wiegmann et al., 2002, p. 10). It appears therefore, that most questionnaires that purport to measure safety culture are, in fact, measuring safety climate. Thus safety climate is the term used throughout this paper.
Volume 47, Issue 1–2, April/June 2014
CN
27
CN
Paul N Bennett et al.
Research has emerged in recent years to indicate a link between safety climate and safety performance in acute hospital settings. For example, safety climate has been associated with incident severity (Kline, Willness, & Ghali, 2008), mortality and length of stay (Huang et al., 2010), and readmission for patients with acute myocardial infarction and heart failure (Hansen, Williams, & Singer, 2011). Of particular interest in this study, safety climate has also been linked with rates of patient falls, both in acute settings (Vogus & Sutcliffe, 2007) and nursing homes (Thomas et al., 2012). Falls are the most frequently reported adverse event in the acute inpatient setting (Currie, 2008). The Victorian Quality Council report a rate of between 2 and 7 falls per 1000 bed days for hospital patients, resulting in injury in 30–40% of cases (Victorian Quality Council, 2009). Falls during hospital admissions can lead to increased complications, additional diagnostic testing, and an increase in length of stay of 4–11 days (Victorian Quality Council, 2009). Falls prevention has been included as a National Patient Safety Goal in the USA since 2005 (Eldridge, 2005). The importance of falls prevention in Australia is reinforced by the inclusion of preventing falls and harm from falls in the recent Australian National accreditation standards (Australian Commission on Safety and Quality in Health Care, 2011). As part of a wider strategy to prevent patient falls, one Australian hospital sought to measure staff perceptions of the safety climate in relation to falls prevention. Various tools have been developed to examine safety climate but none contain items specific to falls prevention. The Safety Attitudes Questionnaire (SAQ; Sexton et al., 2006) was recently adapted for use in Victorian hospitals (Victorian Managed Insurance Authority & Victorian Quality Council, 2011) and this SCS was deemed the most suitable tool to measure general safety climate in this study. A further four items were added to the tool to specifically measure the falls-related safety climate, supplemented by a qualitative item asking staff for suggestions to prevent patient falls. 28
CN
The aims of this study were to: • collect baseline data about the current safety climate at the hospital and benchmark against external data, • compare responses to the four falls-specific items with the four original items from which they were derived, and • identify strengths and opportunities for improvement in patient safety, with a specific focus on falls prevention. Method Setting and participants The study was conducted at a tertiary hospital in metropolitan Melbourne, Australia, that provides services across the care continuum from emergency and critical care to rehabilitation and subacute care. Surveys were distributed to multidisciplinary staff involved in direct patient care as well as staff providing patient support (e.g., managers, administrative staff, and support staff). A total of 1100 surveys were distributed which targetted approximately 40% of eligible staff at this site. Of these, 458 surveys were completed representing a 42% response rate and 16% of the overall staff population. Measures The SCS was based on the SAQ (Sexton et al., 2006) and was modified for the Victorian hospital context by the Victorian Managed Insurance Authority and Victorian Quality Council (2011). The SCS comprises 74-items including 42 items that form six factor analysis-derived domains in the original SAQ and a further 32 items that do not contribute to domains but were retained because they still provided important information. The SCS was developed and tested with a sample of 1626 staff from six Victorian healthcare services (Victorian Managed Insurance Authority, Victorian Quality Council, & UltraFeedback Pty Ltd, 2011) and was recommended for use in Victorian healthcare organisations. The data from the statewide pilot provided data against which to benchmark our own findings. To further examine the specific safety culture around falls prevention, four items that asked about patient safety broadly were replicated and the words ‘patient safety’ were replaced with ‘falls
Volume 47, Issue 1–2, April/June 2014
© eContent Management Pty Ltd
Falls prevention safety climate prevention’ or similar. Thus the four additional items were: This health service provides adequate falls prevention education and training; All personnel in my work area take responsibility for falls prevention; We are actively doing things to prevent falls in my work area; and Falls prevention is constantly reinforced as a priority in my work area. An open-ended question was also modified to ask respondents for their suggestions about ways to prevent patient falls. The SCS also contained a set of demographic items that were adapted for the Australian context. Procedure The study was approved by the human research ethics committee (#12357Q) at the hospital. Hard copy surveys were distributed to managers of all relevant wards and departments to distribute to staff. Staff were able to return completed surveys either via a sealed box in their respective unit/ department or send it directly to the research team via the internal hospital mail service. Consent was implied by completing and returning the survey. Surveys were distributed in the first week of December 2012 with a closing date 3 weeks later. Data analysis Quantitative data were analysed using IBM SPSS Statistics version 21 (IBM Corp, Armonk, NY) including descriptive and inferential statistics. A mean score was calculated for each of the six domains and was compared with data reported for the statewide pilot sample (Victorian Managed Insurance Authority et al., 2011) using single sample t-tests with Cohen’s d used as a measure of effect size. A ‘Priority to Improve’ (PTI) score is calculated for each survey item, based on the Pearson’s correlation (r) between each survey item and the key item I would feel safe being treated here as a patient, and the difference (Gap) between the mean score of the survey item and the mean score of the key item (PTI = r × Gap). Items with the highest PTI score are most strongly related to the key item but are being performed the least well (Victorian Managed Insurance Authority et al., 2011). Pearson’s correlations were used to examine the association between the four Falls Prevention items with the original patient safety items from
© eContent Management Pty Ltd
CN
which they were derived. The coefficient of determination (r2) was also calculated for correlations to determine the shared variance between items. Additional analyses were conducted to compare the responses of staff to the four falls prevention items based on their demographic characteristics. An independent samples t-test was used to compare the responses of full time and part time staff, and analysis of variance (ANOVA) was used to compare the responses of staff on other demographic variables including job level, current role, health service area, and number of years working in this health service. Demographic categories with
