ORIGINAL ARTICLE
Patient Involvement in Patient Safety: A Qualitative Study of Nursing Staff and Patient Perceptions Andrea C. Bishop, PhD* and Marilyn Macdonald, RN, PhD† Objectives: The risk associated with receiving health care has called for an increased focus on the role of patients in helping to improve safety. Recent research has highlighted that patient involvement in patient safety practices may be influenced by patient perceptions of patient safety practices and the perceptions of their health care providers. The objective of this research was to describe patient involvement in patient safety practices by exploring patient and nursing staff perceptions of safety. Methods: Qualitative focus groups were conducted with a convenience sample of nursing staff and patients who had previously completed a patient safety survey in 2 tertiary hospital sites in Eastern Canada. Six focus groups (June 2011 to January 2012) were conducted and analyzed using inductive thematic analysis. Findings: Four themes were identified: (1) wanting control, (2) feeling connected, (3) encountering roadblocks, and (4) sharing responsibility for safety. Both patient and nursing staff participants highlighted the importance of building a personal connection as a precursor to ensuring that patients are involved in their care and safety. However, perceptions of provider stress and nursing staff workload often reduced the ability of the nursing staff and patient participants to connect with one another and promote involvement. Conclusions: Current strategies aimed at increasing patient awareness of patient safety may not be enough. The findings suggest that providing the context for interaction to occur between nursing staff and patients as well as targeted interventions aimed at increasing patient control may be needed to ensure patient involvement in patient safety. Key Words: patient involvement, patient safety, perceptions, focus groups, thematic analysis (J Patient Saf 2014;00: 00–00)
atients face significant risks when receiving health care.1–4 On the basis of this knowledge, the role of the patient within the patient safety continuum has begun to be explored. Patient involvement in patient safety is paramount to achieving patient safety targets set out by both domestic and international bodies.5–8 Whereas provider-oriented strategies are important in ensuring the long-term safety of patients while hospitalized, patient involvement provides an opportunity to address gaps in information and continuity of care, diagnostic accuracy, appropriateness of treatment options, disease management techniques, and monitoring of adverse events.7 Ensuring that patients have the information and knowledge needed to act as an advocate for themselves may help to decrease patient safety incidents associated with health care provider handoffs and long-term management of chronic diseases.9,10 The nurse-patient encounter provides an ideal opportunity for patient education related to patient safety practices. Explaining
to patients the importance of asking questions, and creating a sense of comfort surrounding asking challenging questions, may be a key step in involving more patients in error-prevention strategies. Vincent and Coulter7 propose a collaborative approach to bringing patients into the patient safety movement. They acknowledge that although some clinical encounters may present specific challenges to involving patients, such as in times of urgent and emerging health care crises, many nurse-patient encounters provide an opportunity for patient involvement in the diagnosis, treatment, and monitoring of health conditions. The identification of patient involvement as a priority in improving patient safety has been an important catalyst for research in this area. In recent years, there have been a number of studies aimed at better understanding patient involvement in selected patient safety practices. A U.S. study conducted by Waterman et al11 indicated that although 91% of respondents agreed that patients could help prevent errors, patient comfort levels with patient safety practices varied greatly, with patients very comfortable asking the purpose of a medication but very uncomfortable asking providers if they had washed their hands. Research has also demonstrated that the discipline of the health care professional (e.g., physician or nurse) does play a major role in patient involvement, with patients more willing to ask confrontational questions of nursing staff.12 The objective of this research was to describe patient involvement in patient safety practices by exploring patient and nursing staff perceptions of safety, to describe how provider behavior can influence patient willingness to become involved, and to identify strategies to improve patient involvement in patient safety.
METHODS
P
Design and Setting
From the *Department of Psychology, Saint Mary’s University; and †School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada. Correspondence: Andrea C. Bishop, Department of Psychology, Saint Mary’s University, 923 Robie St, Halifax, Nova Scotia, Canada B3H 3C3 (e‐mail: andrea [email protected]). The authors disclose no conflict of interest. Supported by Eli Lilly Canada, Ltd. The first author’s stipend during this research was provided through a Canadian Institutes for Health Research (CIHR) Doctoral Research Award. Copyright © 2014 by Lippincott Williams & Wilkins
This study took place in 2 tertiary care hospital sites located in 1 district health authority in Eastern Canada. Four units across the 2 sites were selected to participate in this study, including 2 surgical units and 2 medical units. Patient inclusion criteria included being 18 years or older, being competent to answer questions about health care experiences, having had a minimum length of stay of 1 night within a participating unit, and having been discharged directly to the community. Inclusion criteria for nursing staff included being a licensed registered nurse (RN) or a licensed practical nurse (LPN) employed in a participating unit, working full time, having worked in the unit for at least 6 months before the research start date, and providing direct frontline care to patients. Focus groups were conducted as part of a larger mixed methods study that included surveying both providers and patients with regard to their perceptions of patient safety. Results from the survey phase of this research have been reported previously.13 Focus group data were collected after survey analysis to help explain and follow up on significant results. Significant results from the quantitative phase included patients being more willing to engage in factual versus challenging patient safety practices, the importance of self-efficacy for patients in the performance of patient safety practices, as well as the link between provider perceptions
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of patient safety and the encouragement of patients to become involved. Results from the survey revealed that provider perceptions of threat and barriers versus benefits ultimately influenced whether they encouraged patients to become involved or to ask questions, which in turn influences patient willingness to become involved in patient safety practices. Moderator guides were prepared ahead of the patient and nursing staff focus groups. Focus group questions were developed and informed by the results from the patient and provider surveys
and were aimed at eliciting further information as to how patients view their involvement, how provider perceptions and behavior influence their invol vement, and how best to get patients further involved in patient safety and their care (Tables 1, 2). Focus groups for patients were conducted within the community setting at an independent research facility, whereas the nursing staff focus groups were held at both hospital sites during staff education days. The first author was present for all focus group sessions.
Data Analysis TABLE 1. Patient Focus Group Questions 1. To start, I’m wondering to what extent you felt involved in your health care? 2. Were you involved in decisions about your care? a. Would you say your level of involvement differed over the years? (i.e., different recently compared to in the past) b. Has your level of involvement differed in different situations? (i.e., with different health care workers) 3. Did you ask questions at any time during your stay? At what point? 4. If yes: Did you feel they were adequately answered? 5. Were there any times when you had unanswered questions? If so, when? What could have been done so that you had your questions answered? 6. In your opinion, how important is it to you to be involved in your health care while in hospital? a. Are there times when you feel involvement is more important/ less important? b. How do you feel patient involvement in health care could improve care overall? 7. Describe how your relationship(s) with your health care providers helped you to be involved in your health care. a. Did health care providers make you feel comfortable/at ease? If so, how? 8. And now describe how your relationship(s) with your health care providers could have been improved to help you become more in volved in your care. 9. Describe behaviors exhibited by your health care providers that helped you to ask questions about your health care. a. Did behaviors of 1 particular health care provider group stand out as being especially positive/negative? If so, what? 10. And now describe any behaviors that did not help you to ask questions about your health care. a. What could be improved? b. Did behaviors of 1 particular health care provider group stand out as being especially negative? If so, what? 11. How could health care providers help patients to be more comfortable in being involved in their health care? a. Is it useful to have health care providers indicate that they would like you to ask questions? When/at what stage? b. How (i.e., by what methodology) could they best answer those questions? 12. How could health care workers help patients feel more comfortable being involved in their health care? a. Many survey respondents indicated that they had not heard the term patient safety before, why do you think that is? b. What does the term patient safety mean to you? 13. Do you think strategies of the health care system to improve patient safety are working? If so, how? If not, what could be improved? 14. Describe how you would have liked to have been involved in patient safety during your hospital stay. a. What role do you see the patient fulfilling in a safe health care environment?
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A thematic analysis approach was used to conduct the analysis of the focus group data. Thematic analysis involves the coding of qualitative data to produce themes. A theme is a pattern found in the information that, at a minimum, describes and organizes the possible observations as well as, at a maximum, interprets aspects of the phenomenon.14 Braun and Clarke15 have identified 6 phases that constitute thematic analysis and that were ultimately used to conduct the analysis: (1) immersion/familiarization, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, as well as (6) producing the report. Both patient and provider transcripts were compiled as 1 complete data set to provide a holistic interpretation of the phenomenon of patient involvement during the patient-nurse encounter. To ensure credibility throughout this process, a reflexive and methodological journal was kept to make explicit the assumptions that may have impacted the development of codes and themes. This study was given full approval by the health authority research ethics board.
Rigor In their seminal work, Lincoln and Guba16 suggest the use of 4 criteria to explore the trustworthiness of a qualitative inquiry: (1) transferability, (2) dependability, (3) confirmability, and (4) credibility. Transferability was achieved through rich and thick description of the study setting, participants, and narratives, which have been used to better contextualize the phenomenon and allow readers to assess potential transferability of the findings to other settings.16 Dependability and confirmability of the results were enhanced through detailed documentation of the data collection and analysis methods, through verification of participant narratives with audio-recording and verbatim transcripts, and through the collection of data for a period of time. Credibility in this study was strengthened through rich description of the phenomenon itself and through validation of the phenomenon with existing theory.17 Finally, trustworthiness was enhanced in this study through the triangulation of data sources through an overarching mixed methods approach.
FINDINGS The study participants included 10 patients and 27 nursing staff (23 RNs and 4 LPNs). Focus groups were conducted during the period from June 2011 to January 2012. A summary of the number, composition, and duration of the patient and nursing staff focus groups can be found in Table 3. Four main themes were identified in the data: (1) wanting control, (2) feeling connected, (3) encountering roadblocks, and (4) sharing responsibility for safety.
Theme 1: Wanting Control Patients Part of being in control is being in the know. The patient participants in this study explained that they did not know enough about their health care while hospitalized. Not knowing meant feeling as if they did not know anything about their care and were merely objects of treatment. The patients reported that not knowing © 2014 Lippincott Williams & Wilkins
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TABLE 2. Provider Focus Group Questions 1. To start, in what ways do patients become involved in their health care while hospitalized on your unit? a. Are they invited to become involved? b. Do patients ask questions about their health care treatment? At what point? 2. Describe how you might feel if a patient asked you safety questions that were factual versus challenging/confrontational. 3. There seems to be a particular hesitation with patients wanting to ask health care providers if they have washed their hands. Why do you think that is? 4. What does the term patient safety mean to you? 5. Describe the types of behavior that you exhibit that helps to relax patients/put them at ease. a. Is this behavior easy to perform? b. How can providers help patients to be more comfortable? 6. Describe how your relationship with your patients helps/does not help them to be involved in their care. a. Does workload interfere? b. How can providers help patients to be more involved? 7. Do you believe that greater patient involvement in their health care helps you to perform your job more safely? a. Many survey respondents answered positively. Why do you think that is? b. Are there times when patients should not be involved? c. Do you think patients understand/know about patient safety incidents? 8. Is patient safety a priority on your unit? a. Describe how you would know if patient safety were a priority. b. Is patient safety a priority in the hospital as a whole? 9. Describe how your unit promotes patient safety. a. Are staff involved in setting strategies? b. Describe the kind of feedback you get regarding patient safety incidents. 10. Describe how you would like to see patients involved in patient safety strategies.
ranged from being fearful during their hospitalization to being left without direction. For some patients, not knowing information stemmed from health care providers not sharing important information with them, and sometimes, it was due to the inability to pinpoint a clinical diagnosis. One patient described his/her fear as not feeling informed.
“I think for me, the fear factor was not being able to get certain answers. You know, like for my heart attack, I’ve often said I wish that I would have had blockages and they could have put in some stents and that would have been the end. But it was the constant testing to find out why I had that heart attack because I didn’t have any blockages at all.”
For other patients, there was a feeling that they could not do anything about their situation while in the hospital or that they were “overwhelmed” with their situation. For these individuals, © 2014 Lippincott Williams & Wilkins
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their treatment was something that was happening to them and not something that they felt they could take responsibility for.
“I don’t know whether I’ve been there 5 minutes or 2 hours. And I don’t know if anybody knows I’m even there because the last person I saw just disappeared. That was it. And so that feeling of I could be here 24 hours and nobody even know I was here, you know, or where I am.”
Nursing Staff The nursing staff described lack of control as symptomatic of patients being hesitant to ask questions about their care because they viewed providers as too busy or feared offending them. This was acknowledged as a possible source of hesitation in all 4 of the nursing staff focus groups, “Yes. Because they say that, “Oh, no, you’re running all over the place, never mind.” The nursing staff seemed to understand that patients are very much aware of their “busyness” and that this can often lead to patients refraining from asking certain questions or interacting with providers because they do not want to “hold them up.” Although this was understood, there was also a sense that the participants did not feel that this was something that could be changed but that perhaps other behaviors could help to compensate for it, such as inviting patients to ask questions or sitting down with the patient while conversing.
Theme 2: Feeling Connected Patients Feeling connected describes how patients and providers connect on a personal level. For some patient participants, this was seen as being friendly with one another, whereas others saw it as showing respect for the patient as a person. Connections ranged from spending time with one another, to building rapport, to sharing information, and showing respect. The patient and nursing staff participants saw the act of building a connection as an important step in ensuring patient involvement in their care. For many patient participants, connections with their health care providers were built when they viewed providers as taking the time to listen to them, “they’ve come in and they’ve sat down with me,” or “they didn’t seem rushed or hurried or whatever.” One patient illustrated the importance of taking the time to make a patient feel comfortable when he/she said:
TABLE 3. Summary of Focus Group Participants
FG Session
Date of FG
No. FG Participants
Length of FG
FG 1 Patient FG 2 Patient FG 1 Nurse FG 2 Nurse FG 3 Nurse FG 4 Nurse
June 2011 January 2012 November 2011 November 2011 January 2012 January 2012
Patient: 4 Patient: 6 LPN: 2, RN: 4 LPN: 1, RN: 5 LPN: 1, RN: 8 RN: 6
95 min 109 min 33 min 33 min 36 min 36 min
FG, focus group.
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“I think that’s really, really important. If you want to feel like you’re a part of a whole thing, your whole illness then the professional people could take their time to make you feel that they’ve got all the time in the world for you.”
their workload gave testimony to how stretched to the limit they felt in their ability to interact with patients and to perform their tasks safely. The nursing participants reported wanting to spend more time with patients, “but it’s always on your mind, there’s a hundred things on your mind that you know you have to do but….” The nursing participants also explained that their time is often “limited” because of the complexity of patient cases they deal with on their unit. When prompted to further describe this, 1 participant responded:
Nursing Staff The nursing staff participants also noted the importance of connecting with patients to facilitate awareness and involvement. The participants tried to help patients become involved through providing that “human connection.” For 1 nursing participant, it was “just even when they get that bad diagnosis and they’re in a 4-bed ward, it can be just a hug or it can be just taking them down to the family room. Just having that quiet moment away from being in the ward.” Another nursing participant noted that it was really making sure that the patient was made to feel like a person and “sometimes reaffirming that our reaction would be similar to theirs if it were happening to us.” This was echoed by the nursing participants who also noted that having that connection with patients meant showing respect and reassurance for them and for their concerns, as 1 participant stated:
“I think it’s how we handle their initial questions when they do ask something, that we don’t treat something that is every day to us as silly or that we encourage them to ask more. But it’s how we treat them when they do ask.”
“It’s huge. You have a limited amount of time. Our patients, they have a lot going on. And you’d love to stay a little longer with them but you’re thinking in the back of your mind, you’ve got 10 other things you’ve got to get done right now. And you have to cut the conversation off.”
Theme 4: Sharing Responsibility for Safety Patients For the patient participants, sharing responsibility highlighted the behaviors or actions they took while hospitalized to ensure that they felt safe. Behaviors and actions ranged from asking questions of their health care providers regarding their care, to being engaged when given information, to making sure that they had an advocate available to ensure their well-being. Self-protection for some patient participants meant asking questions to make sure that they were informed about their treatment, “Well, I asked. Like they would tell me you’re taking this and you’re taking this, and then I’d ask what’s it for? So I asked a few more questions so I knew what I was taking and why.” Another patient related how he ensured that he knew what medication he was supposed to be taking:
Theme 3: Encountering Roadblocks Patients Every patient participant indicated feeling that his/her health care providers were often too busy to answer questions or talk, especially nurses, “I just had the feeling that the nurses were so pushed, they just didn’t seem to have a whole lot of time other than to rush in and rush out.” This perception of nurses being in a rush ultimately led the patient participants to avoid involving themselves in their care as they might have wanted to, including not wanting to bother them, with 1 patient participant remarking, “I thought I might annoy them.” The patient participants described this stress as a systems problem and not necessarily one under the control of nursing staff themselves. There was the sense that the patient participants did not want to complain about their level of interaction but rather to explain it in terms of “how the system works.” The perception of some patient participants was that of quality care being delivered despite the “burden” that is placed on nursing staff to provide care, “that’s the point I’m making. In the midst of all that, the nurses do a hell of a good job.”
Nursing Staff For the nursing staff participants, roadblocks represented what was going on in their day-to-day world of work that prevented them from getting to know their patients to the level and extent they believed necessary to provide safe patient care. Not only did the patients report how stretched to the limit they observed the nursing staff to be, but nursing participant reports of
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“I asked a lot of questions. In fact, this clip … I always had a clipboard with me. And whenever they’d give me a medication, I’d write down the time and what it was they gave me, and what it was I was supposed to be on. So I was trying to make sense of the whole thing as we went.”
When the patients were not able to fully participate in their care because of sedation or competence, they suggested having an “advocate” or “minder” present with them throughout their hospitalization. One participant reported, “My wife told me to go by myself to my appointment. She should be right here to know exactly what’s happening.” Another participant related:
“I agree with [name] and [name], that in that situation, you need somebody with you. Somebody who will speak for you if you’re not getting through yourself as a patient because of either pain or medication or intimidated by this very educated, intelligent person, and to have somebody with you.”
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Nursing Staff Improving patient safety within the entire care team was a concept brought forth in all 4 of the nursing staff focus groups. For the nursing staff, creating a team meant ensuring that the patient is always the focus of health care and providing support to one another to achieve this goal. Discussions ranged from improving communication between units and during patient transfers to being cognizant of the demands placed on colleagues. Teamwork was also seen as a strategy to improve stress levels. The nursing participants noted several circumstances from their own experiences in which patient safety was not the focus of the entire care team, with patients often being transferred during shift change or a lack of communication during handoffs. One participant shared the following example:
“We had a patient arrive on the unit at 7:00. So change of shift. No report given from Emerg. The patient just showed up. And then at 7:30, they called to send the patient to the OR. And it’s like okay, first of all, we didn’t get a report from Emerg so that's not safe. And we haven’t even had time to do our complete assessment. And now you want them for the OR. Right? And if this patient is going to surgery, there’s obviously something up. So they should have something to go by. Right?”
DISCUSSION Feeling connected captured patient participant perceptions concerning wanting to be involved and respected. However, it is important to note that these perceptions were not necessarily centered on involvement in decision making or the sharing of medical information but rather describe the need to feel respected and welcome. Similar results were found by Levinson et al,18 in their survey of preferences for involvement, with 96% of respondents indicating that they wanted to be given options by their physicians and 52% preferring to leave final decisions to their physicians. The results of this study suggest that patients may not view sharing the responsibility for safety as shared decision making but rather as treating patients with respect and providing the opportunity for patients to become involved when they choose to do so. Policy makers can help to achieve this by framing the issue as a standard of care. Many professional standards of care and practice guidelines for health care providers do contain language regarding patient collaboration. However, there is a need for regulatory bodies to ensure that patient collaboration and involvement are a required and supported action.19,20 Ongoing evaluation consisting of both practitioner and patient satisfaction surveys will be helpful to understanding the barriers and benefits to further patient involvement in care and patient safety. The focus group results also revealed that both workload and communication may be critical factors in why some patient involvement strategies are not widely adopted by nursing staff. Under the theme of encountering roadblocks, the nursing staff discussed how workload interferes with them performing tasks or actions that could improve patient safety. Time constraints and the complexity of patient caseloads were cited as deterrents to increased patient interaction and involvement. The nursing participants often felt rushed and sometimes unable to incorporate patient safety behaviors into their workload. A qualitative study conducted with nurses in 2002 found similar results, with nurses indicating that physical environments, equipment, and workload © 2014 Lippincott Williams & Wilkins
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all contributed to greater risk for untoward incidents occurring.21 To overcome this barrier, it is suggested that organizations start by conducting a workflow analysis of hospital units. Often, inefficiencies in workflow result in overworked and stressed employees. Identifying areas of workflow that are inefficient or counterproductive to greater patient involvement will help organizations to better allocate time to patient–nursing staff interaction. Interdisciplinary teams should be assembled to complete the analysis, with steps including diagramming current workflow processes, identifying current patient safety strategies, identifying potential waste within the process, as well as redesigning the workflow and the environment to assist providers in involving patients.22
Limitations The results of this study represent the experiences of a selfidentified convenience sample of patients and nursing staff in 2 tertiary hospitals in Eastern Canada. As such, the representativeness of patient and nursing staff experiences may diminish the transferability of the results to other jurisdictions. In addition, the nursing staff focus groups were mainly conducted during previously scheduled staff education days, limiting focus group length to 30 minutes. Although the entire focus group guide was incorporated within this time frame, the length of time might have lessened the ability to have greater in-depth narratives on the subject matter. To lessen the impact of this, a greater number of nursing staff focus groups were conducted than patient focus groups. Finally, focus group moderator guides were developed based on findings from a previously administered perception survey, thus influencing the questions explored in the qualitative phase presented in this article.
CONCLUSIONS Patient safety has been demonstrated as an area of importance because of the number of preventable incidents associated with health care treatment in Canada and worldwide. The findings revealed that patient comfort level with nursing staff and control over their health care are an important aspect of patient involvement in patient safety practices. Ensuring that nursing staff and patients have the necessary time to interact with one another, and in an environment that is conducive to openness, is a critical component in promoting greater patient involvement in both their health care and patient safety. This has implications for how hospitals and health centers currently address patient involvement in patient safety; rather than just increasing patient awareness of safety issues while hospitalized, hospitals must also ensure that workflow and patient-provider encounters are designed to improve a feeling of connectedness and trust. As such, aligning patient safety strategies within existing care mechanisms (e.g., involvement opportunities during intake and discharge procedures), rather than through increased awareness through posters and signs, may help to provide the context for greater involvement to occur. REFERENCES 1. Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170:1678–1686. 2. Brennan TA, Leape LL, Laird LM. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. NEJM. 1991;324:370–377. 3. Wilson RM, Runciman WB, Gibberd RW, et al. The quality in Australian health care study. Med J Aust. 1995;163:458–476. 4. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001;322:517.
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5. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: Academy Press; 1991.
14. Boyatzis RE. Transforming Qualitative Information: Thematic Analysis and Code Development. Thousand Oaks, CA: Sage Publications; 1998.
6. Koutantji M, Davis R, Vincent CA, et al. The patient’s role in patient safety: engaging patients, their representatives, and health professionals. Clin Risk. 2005;11:99–105.
15. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.
7. Vincent CA, Coulter A. Patient safety: what about the patient? BMJ Qual Saf. 2002;11:76–80. 8. World Health Organization. Patients for patient safety. 2012. Available at: http://www.who.int/patientsafety/patients_for_patient/en/. Accessed January 14, 2014. 9. Bergeson SC, Dean JD. A systems approach to patient-centered care. JAMA. 2006;296:2848–2851. 10. Holman H, Lorig K. Patient self-management: a key to effectiveness and efficiency in the care of chronic disease. Public Health Rep. 2004;119:239–243. 11. Waterman AD, Gallagher TH, Garbutt J, et al. Hospitalized patients’ attitudes about and participation in error prevention. J Gen Intern Med. 2006;21:367–370. 12. McGuckin M, Waterman R, Storr J, et al. Evaluation of a patient-empowering hand hygiene programme in the UK. J Hosp Infect. 2001;48:222–227. 13. Bishop AC, Boyle TA. The role of safety culture in influencing provider perceptions of patient safety. J Patient Saf. 2014; Mar 10. (Epub ahead of print).
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16. Lincoln YS, Guba EG. Naturalistic Inquiry. Thousand Oaks, CA: Sage Publications; 1985. 17. Lee TW. Using Qualitative Methods in Organizational Research. Thousand Oaks, CA: Sage Publications; 1999. 18. Levinson W, Kao A, Kuby A, et al. Not all patients want to be involved in decision making. J Gen Intern Med. 2005;20:531–535. 19. Baker GR, Denis JL, Pomey MP, et al. Effective Governance for Quality and Patient Safety in Canadian Health Care Organizations. Ottawa, Canada: Canadian Health Services Research Foundation; 2010. 20. Rowell PA. The professional nursing association’s role in patient safety. Online J Issues Nurs. 2003;8:3. 21. Nicklin W, McVeety JE. Canadian nurses’ perceptions of patient safety in hospitals. Can J Nurs Leadersh. 2002;15:11–21. 22. Lighter DE. Process orientation in health care quality. In: Lighter DE, Fair DC, eds. Principles and Methods of Quality Management in Health Care. Gaithersburg, MD: Aspen Publishers Inc; 2000:37–85.
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Patient Involvement in Patient Safety: A Qualitative Study of Nursing Staff and Patient Perceptions Andrea C. Bishop, PhD* and Marilyn Macdonald, RN, PhD† Objectives: The risk associated with receiving health care has called for an increased focus on the role of patients in helping to improve safety. Recent research has highlighted that patient involvement in patient safety practices may be influenced by patient perceptions of patient safety practices and the perceptions of their health care providers. The objective of this research was to describe patient involvement in patient safety practices by exploring patient and nursing staff perceptions of safety. Methods: Qualitative focus groups were conducted with a convenience sample of nursing staff and patients who had previously completed a patient safety survey in 2 tertiary hospital sites in Eastern Canada. Six focus groups (June 2011 to January 2012) were conducted and analyzed using inductive thematic analysis. Findings: Four themes were identified: (1) wanting control, (2) feeling connected, (3) encountering roadblocks, and (4) sharing responsibility for safety. Both patient and nursing staff participants highlighted the importance of building a personal connection as a precursor to ensuring that patients are involved in their care and safety. However, perceptions of provider stress and nursing staff workload often reduced the ability of the nursing staff and patient participants to connect with one another and promote involvement. Conclusions: Current strategies aimed at increasing patient awareness of patient safety may not be enough. The findings suggest that providing the context for interaction to occur between nursing staff and patients as well as targeted interventions aimed at increasing patient control may be needed to ensure patient involvement in patient safety. Key Words: patient involvement, patient safety, perceptions, focus groups, thematic analysis (J Patient Saf 2014;00: 00–00)
atients face significant risks when receiving health care.1–4 On the basis of this knowledge, the role of the patient within the patient safety continuum has begun to be explored. Patient involvement in patient safety is paramount to achieving patient safety targets set out by both domestic and international bodies.5–8 Whereas provider-oriented strategies are important in ensuring the long-term safety of patients while hospitalized, patient involvement provides an opportunity to address gaps in information and continuity of care, diagnostic accuracy, appropriateness of treatment options, disease management techniques, and monitoring of adverse events.7 Ensuring that patients have the information and knowledge needed to act as an advocate for themselves may help to decrease patient safety incidents associated with health care provider handoffs and long-term management of chronic diseases.9,10 The nurse-patient encounter provides an ideal opportunity for patient education related to patient safety practices. Explaining
to patients the importance of asking questions, and creating a sense of comfort surrounding asking challenging questions, may be a key step in involving more patients in error-prevention strategies. Vincent and Coulter7 propose a collaborative approach to bringing patients into the patient safety movement. They acknowledge that although some clinical encounters may present specific challenges to involving patients, such as in times of urgent and emerging health care crises, many nurse-patient encounters provide an opportunity for patient involvement in the diagnosis, treatment, and monitoring of health conditions. The identification of patient involvement as a priority in improving patient safety has been an important catalyst for research in this area. In recent years, there have been a number of studies aimed at better understanding patient involvement in selected patient safety practices. A U.S. study conducted by Waterman et al11 indicated that although 91% of respondents agreed that patients could help prevent errors, patient comfort levels with patient safety practices varied greatly, with patients very comfortable asking the purpose of a medication but very uncomfortable asking providers if they had washed their hands. Research has also demonstrated that the discipline of the health care professional (e.g., physician or nurse) does play a major role in patient involvement, with patients more willing to ask confrontational questions of nursing staff.12 The objective of this research was to describe patient involvement in patient safety practices by exploring patient and nursing staff perceptions of safety, to describe how provider behavior can influence patient willingness to become involved, and to identify strategies to improve patient involvement in patient safety.
METHODS
P
Design and Setting
From the *Department of Psychology, Saint Mary’s University; and †School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada. Correspondence: Andrea C. Bishop, Department of Psychology, Saint Mary’s University, 923 Robie St, Halifax, Nova Scotia, Canada B3H 3C3 (e‐mail: andrea [email protected]). The authors disclose no conflict of interest. Supported by Eli Lilly Canada, Ltd. The first author’s stipend during this research was provided through a Canadian Institutes for Health Research (CIHR) Doctoral Research Award. Copyright © 2014 by Lippincott Williams & Wilkins
This study took place in 2 tertiary care hospital sites located in 1 district health authority in Eastern Canada. Four units across the 2 sites were selected to participate in this study, including 2 surgical units and 2 medical units. Patient inclusion criteria included being 18 years or older, being competent to answer questions about health care experiences, having had a minimum length of stay of 1 night within a participating unit, and having been discharged directly to the community. Inclusion criteria for nursing staff included being a licensed registered nurse (RN) or a licensed practical nurse (LPN) employed in a participating unit, working full time, having worked in the unit for at least 6 months before the research start date, and providing direct frontline care to patients. Focus groups were conducted as part of a larger mixed methods study that included surveying both providers and patients with regard to their perceptions of patient safety. Results from the survey phase of this research have been reported previously.13 Focus group data were collected after survey analysis to help explain and follow up on significant results. Significant results from the quantitative phase included patients being more willing to engage in factual versus challenging patient safety practices, the importance of self-efficacy for patients in the performance of patient safety practices, as well as the link between provider perceptions
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of patient safety and the encouragement of patients to become involved. Results from the survey revealed that provider perceptions of threat and barriers versus benefits ultimately influenced whether they encouraged patients to become involved or to ask questions, which in turn influences patient willingness to become involved in patient safety practices. Moderator guides were prepared ahead of the patient and nursing staff focus groups. Focus group questions were developed and informed by the results from the patient and provider surveys
and were aimed at eliciting further information as to how patients view their involvement, how provider perceptions and behavior influence their invol vement, and how best to get patients further involved in patient safety and their care (Tables 1, 2). Focus groups for patients were conducted within the community setting at an independent research facility, whereas the nursing staff focus groups were held at both hospital sites during staff education days. The first author was present for all focus group sessions.
Data Analysis TABLE 1. Patient Focus Group Questions 1. To start, I’m wondering to what extent you felt involved in your health care? 2. Were you involved in decisions about your care? a. Would you say your level of involvement differed over the years? (i.e., different recently compared to in the past) b. Has your level of involvement differed in different situations? (i.e., with different health care workers) 3. Did you ask questions at any time during your stay? At what point? 4. If yes: Did you feel they were adequately answered? 5. Were there any times when you had unanswered questions? If so, when? What could have been done so that you had your questions answered? 6. In your opinion, how important is it to you to be involved in your health care while in hospital? a. Are there times when you feel involvement is more important/ less important? b. How do you feel patient involvement in health care could improve care overall? 7. Describe how your relationship(s) with your health care providers helped you to be involved in your health care. a. Did health care providers make you feel comfortable/at ease? If so, how? 8. And now describe how your relationship(s) with your health care providers could have been improved to help you become more in volved in your care. 9. Describe behaviors exhibited by your health care providers that helped you to ask questions about your health care. a. Did behaviors of 1 particular health care provider group stand out as being especially positive/negative? If so, what? 10. And now describe any behaviors that did not help you to ask questions about your health care. a. What could be improved? b. Did behaviors of 1 particular health care provider group stand out as being especially negative? If so, what? 11. How could health care providers help patients to be more comfortable in being involved in their health care? a. Is it useful to have health care providers indicate that they would like you to ask questions? When/at what stage? b. How (i.e., by what methodology) could they best answer those questions? 12. How could health care workers help patients feel more comfortable being involved in their health care? a. Many survey respondents indicated that they had not heard the term patient safety before, why do you think that is? b. What does the term patient safety mean to you? 13. Do you think strategies of the health care system to improve patient safety are working? If so, how? If not, what could be improved? 14. Describe how you would have liked to have been involved in patient safety during your hospital stay. a. What role do you see the patient fulfilling in a safe health care environment?
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A thematic analysis approach was used to conduct the analysis of the focus group data. Thematic analysis involves the coding of qualitative data to produce themes. A theme is a pattern found in the information that, at a minimum, describes and organizes the possible observations as well as, at a maximum, interprets aspects of the phenomenon.14 Braun and Clarke15 have identified 6 phases that constitute thematic analysis and that were ultimately used to conduct the analysis: (1) immersion/familiarization, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, as well as (6) producing the report. Both patient and provider transcripts were compiled as 1 complete data set to provide a holistic interpretation of the phenomenon of patient involvement during the patient-nurse encounter. To ensure credibility throughout this process, a reflexive and methodological journal was kept to make explicit the assumptions that may have impacted the development of codes and themes. This study was given full approval by the health authority research ethics board.
Rigor In their seminal work, Lincoln and Guba16 suggest the use of 4 criteria to explore the trustworthiness of a qualitative inquiry: (1) transferability, (2) dependability, (3) confirmability, and (4) credibility. Transferability was achieved through rich and thick description of the study setting, participants, and narratives, which have been used to better contextualize the phenomenon and allow readers to assess potential transferability of the findings to other settings.16 Dependability and confirmability of the results were enhanced through detailed documentation of the data collection and analysis methods, through verification of participant narratives with audio-recording and verbatim transcripts, and through the collection of data for a period of time. Credibility in this study was strengthened through rich description of the phenomenon itself and through validation of the phenomenon with existing theory.17 Finally, trustworthiness was enhanced in this study through the triangulation of data sources through an overarching mixed methods approach.
FINDINGS The study participants included 10 patients and 27 nursing staff (23 RNs and 4 LPNs). Focus groups were conducted during the period from June 2011 to January 2012. A summary of the number, composition, and duration of the patient and nursing staff focus groups can be found in Table 3. Four main themes were identified in the data: (1) wanting control, (2) feeling connected, (3) encountering roadblocks, and (4) sharing responsibility for safety.
Theme 1: Wanting Control Patients Part of being in control is being in the know. The patient participants in this study explained that they did not know enough about their health care while hospitalized. Not knowing meant feeling as if they did not know anything about their care and were merely objects of treatment. The patients reported that not knowing © 2014 Lippincott Williams & Wilkins
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TABLE 2. Provider Focus Group Questions 1. To start, in what ways do patients become involved in their health care while hospitalized on your unit? a. Are they invited to become involved? b. Do patients ask questions about their health care treatment? At what point? 2. Describe how you might feel if a patient asked you safety questions that were factual versus challenging/confrontational. 3. There seems to be a particular hesitation with patients wanting to ask health care providers if they have washed their hands. Why do you think that is? 4. What does the term patient safety mean to you? 5. Describe the types of behavior that you exhibit that helps to relax patients/put them at ease. a. Is this behavior easy to perform? b. How can providers help patients to be more comfortable? 6. Describe how your relationship with your patients helps/does not help them to be involved in their care. a. Does workload interfere? b. How can providers help patients to be more involved? 7. Do you believe that greater patient involvement in their health care helps you to perform your job more safely? a. Many survey respondents answered positively. Why do you think that is? b. Are there times when patients should not be involved? c. Do you think patients understand/know about patient safety incidents? 8. Is patient safety a priority on your unit? a. Describe how you would know if patient safety were a priority. b. Is patient safety a priority in the hospital as a whole? 9. Describe how your unit promotes patient safety. a. Are staff involved in setting strategies? b. Describe the kind of feedback you get regarding patient safety incidents. 10. Describe how you would like to see patients involved in patient safety strategies.
ranged from being fearful during their hospitalization to being left without direction. For some patients, not knowing information stemmed from health care providers not sharing important information with them, and sometimes, it was due to the inability to pinpoint a clinical diagnosis. One patient described his/her fear as not feeling informed.
“I think for me, the fear factor was not being able to get certain answers. You know, like for my heart attack, I’ve often said I wish that I would have had blockages and they could have put in some stents and that would have been the end. But it was the constant testing to find out why I had that heart attack because I didn’t have any blockages at all.”
For other patients, there was a feeling that they could not do anything about their situation while in the hospital or that they were “overwhelmed” with their situation. For these individuals, © 2014 Lippincott Williams & Wilkins
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their treatment was something that was happening to them and not something that they felt they could take responsibility for.
“I don’t know whether I’ve been there 5 minutes or 2 hours. And I don’t know if anybody knows I’m even there because the last person I saw just disappeared. That was it. And so that feeling of I could be here 24 hours and nobody even know I was here, you know, or where I am.”
Nursing Staff The nursing staff described lack of control as symptomatic of patients being hesitant to ask questions about their care because they viewed providers as too busy or feared offending them. This was acknowledged as a possible source of hesitation in all 4 of the nursing staff focus groups, “Yes. Because they say that, “Oh, no, you’re running all over the place, never mind.” The nursing staff seemed to understand that patients are very much aware of their “busyness” and that this can often lead to patients refraining from asking certain questions or interacting with providers because they do not want to “hold them up.” Although this was understood, there was also a sense that the participants did not feel that this was something that could be changed but that perhaps other behaviors could help to compensate for it, such as inviting patients to ask questions or sitting down with the patient while conversing.
Theme 2: Feeling Connected Patients Feeling connected describes how patients and providers connect on a personal level. For some patient participants, this was seen as being friendly with one another, whereas others saw it as showing respect for the patient as a person. Connections ranged from spending time with one another, to building rapport, to sharing information, and showing respect. The patient and nursing staff participants saw the act of building a connection as an important step in ensuring patient involvement in their care. For many patient participants, connections with their health care providers were built when they viewed providers as taking the time to listen to them, “they’ve come in and they’ve sat down with me,” or “they didn’t seem rushed or hurried or whatever.” One patient illustrated the importance of taking the time to make a patient feel comfortable when he/she said:
TABLE 3. Summary of Focus Group Participants
FG Session
Date of FG
No. FG Participants
Length of FG
FG 1 Patient FG 2 Patient FG 1 Nurse FG 2 Nurse FG 3 Nurse FG 4 Nurse
June 2011 January 2012 November 2011 November 2011 January 2012 January 2012
Patient: 4 Patient: 6 LPN: 2, RN: 4 LPN: 1, RN: 5 LPN: 1, RN: 8 RN: 6
95 min 109 min 33 min 33 min 36 min 36 min
FG, focus group.
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“I think that’s really, really important. If you want to feel like you’re a part of a whole thing, your whole illness then the professional people could take their time to make you feel that they’ve got all the time in the world for you.”
their workload gave testimony to how stretched to the limit they felt in their ability to interact with patients and to perform their tasks safely. The nursing participants reported wanting to spend more time with patients, “but it’s always on your mind, there’s a hundred things on your mind that you know you have to do but….” The nursing participants also explained that their time is often “limited” because of the complexity of patient cases they deal with on their unit. When prompted to further describe this, 1 participant responded:
Nursing Staff The nursing staff participants also noted the importance of connecting with patients to facilitate awareness and involvement. The participants tried to help patients become involved through providing that “human connection.” For 1 nursing participant, it was “just even when they get that bad diagnosis and they’re in a 4-bed ward, it can be just a hug or it can be just taking them down to the family room. Just having that quiet moment away from being in the ward.” Another nursing participant noted that it was really making sure that the patient was made to feel like a person and “sometimes reaffirming that our reaction would be similar to theirs if it were happening to us.” This was echoed by the nursing participants who also noted that having that connection with patients meant showing respect and reassurance for them and for their concerns, as 1 participant stated:
“I think it’s how we handle their initial questions when they do ask something, that we don’t treat something that is every day to us as silly or that we encourage them to ask more. But it’s how we treat them when they do ask.”
“It’s huge. You have a limited amount of time. Our patients, they have a lot going on. And you’d love to stay a little longer with them but you’re thinking in the back of your mind, you’ve got 10 other things you’ve got to get done right now. And you have to cut the conversation off.”
Theme 4: Sharing Responsibility for Safety Patients For the patient participants, sharing responsibility highlighted the behaviors or actions they took while hospitalized to ensure that they felt safe. Behaviors and actions ranged from asking questions of their health care providers regarding their care, to being engaged when given information, to making sure that they had an advocate available to ensure their well-being. Self-protection for some patient participants meant asking questions to make sure that they were informed about their treatment, “Well, I asked. Like they would tell me you’re taking this and you’re taking this, and then I’d ask what’s it for? So I asked a few more questions so I knew what I was taking and why.” Another patient related how he ensured that he knew what medication he was supposed to be taking:
Theme 3: Encountering Roadblocks Patients Every patient participant indicated feeling that his/her health care providers were often too busy to answer questions or talk, especially nurses, “I just had the feeling that the nurses were so pushed, they just didn’t seem to have a whole lot of time other than to rush in and rush out.” This perception of nurses being in a rush ultimately led the patient participants to avoid involving themselves in their care as they might have wanted to, including not wanting to bother them, with 1 patient participant remarking, “I thought I might annoy them.” The patient participants described this stress as a systems problem and not necessarily one under the control of nursing staff themselves. There was the sense that the patient participants did not want to complain about their level of interaction but rather to explain it in terms of “how the system works.” The perception of some patient participants was that of quality care being delivered despite the “burden” that is placed on nursing staff to provide care, “that’s the point I’m making. In the midst of all that, the nurses do a hell of a good job.”
Nursing Staff For the nursing staff participants, roadblocks represented what was going on in their day-to-day world of work that prevented them from getting to know their patients to the level and extent they believed necessary to provide safe patient care. Not only did the patients report how stretched to the limit they observed the nursing staff to be, but nursing participant reports of
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“I asked a lot of questions. In fact, this clip … I always had a clipboard with me. And whenever they’d give me a medication, I’d write down the time and what it was they gave me, and what it was I was supposed to be on. So I was trying to make sense of the whole thing as we went.”
When the patients were not able to fully participate in their care because of sedation or competence, they suggested having an “advocate” or “minder” present with them throughout their hospitalization. One participant reported, “My wife told me to go by myself to my appointment. She should be right here to know exactly what’s happening.” Another participant related:
“I agree with [name] and [name], that in that situation, you need somebody with you. Somebody who will speak for you if you’re not getting through yourself as a patient because of either pain or medication or intimidated by this very educated, intelligent person, and to have somebody with you.”
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Nursing Staff Improving patient safety within the entire care team was a concept brought forth in all 4 of the nursing staff focus groups. For the nursing staff, creating a team meant ensuring that the patient is always the focus of health care and providing support to one another to achieve this goal. Discussions ranged from improving communication between units and during patient transfers to being cognizant of the demands placed on colleagues. Teamwork was also seen as a strategy to improve stress levels. The nursing participants noted several circumstances from their own experiences in which patient safety was not the focus of the entire care team, with patients often being transferred during shift change or a lack of communication during handoffs. One participant shared the following example:
“We had a patient arrive on the unit at 7:00. So change of shift. No report given from Emerg. The patient just showed up. And then at 7:30, they called to send the patient to the OR. And it’s like okay, first of all, we didn’t get a report from Emerg so that's not safe. And we haven’t even had time to do our complete assessment. And now you want them for the OR. Right? And if this patient is going to surgery, there’s obviously something up. So they should have something to go by. Right?”
DISCUSSION Feeling connected captured patient participant perceptions concerning wanting to be involved and respected. However, it is important to note that these perceptions were not necessarily centered on involvement in decision making or the sharing of medical information but rather describe the need to feel respected and welcome. Similar results were found by Levinson et al,18 in their survey of preferences for involvement, with 96% of respondents indicating that they wanted to be given options by their physicians and 52% preferring to leave final decisions to their physicians. The results of this study suggest that patients may not view sharing the responsibility for safety as shared decision making but rather as treating patients with respect and providing the opportunity for patients to become involved when they choose to do so. Policy makers can help to achieve this by framing the issue as a standard of care. Many professional standards of care and practice guidelines for health care providers do contain language regarding patient collaboration. However, there is a need for regulatory bodies to ensure that patient collaboration and involvement are a required and supported action.19,20 Ongoing evaluation consisting of both practitioner and patient satisfaction surveys will be helpful to understanding the barriers and benefits to further patient involvement in care and patient safety. The focus group results also revealed that both workload and communication may be critical factors in why some patient involvement strategies are not widely adopted by nursing staff. Under the theme of encountering roadblocks, the nursing staff discussed how workload interferes with them performing tasks or actions that could improve patient safety. Time constraints and the complexity of patient caseloads were cited as deterrents to increased patient interaction and involvement. The nursing participants often felt rushed and sometimes unable to incorporate patient safety behaviors into their workload. A qualitative study conducted with nurses in 2002 found similar results, with nurses indicating that physical environments, equipment, and workload © 2014 Lippincott Williams & Wilkins
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all contributed to greater risk for untoward incidents occurring.21 To overcome this barrier, it is suggested that organizations start by conducting a workflow analysis of hospital units. Often, inefficiencies in workflow result in overworked and stressed employees. Identifying areas of workflow that are inefficient or counterproductive to greater patient involvement will help organizations to better allocate time to patient–nursing staff interaction. Interdisciplinary teams should be assembled to complete the analysis, with steps including diagramming current workflow processes, identifying current patient safety strategies, identifying potential waste within the process, as well as redesigning the workflow and the environment to assist providers in involving patients.22
Limitations The results of this study represent the experiences of a selfidentified convenience sample of patients and nursing staff in 2 tertiary hospitals in Eastern Canada. As such, the representativeness of patient and nursing staff experiences may diminish the transferability of the results to other jurisdictions. In addition, the nursing staff focus groups were mainly conducted during previously scheduled staff education days, limiting focus group length to 30 minutes. Although the entire focus group guide was incorporated within this time frame, the length of time might have lessened the ability to have greater in-depth narratives on the subject matter. To lessen the impact of this, a greater number of nursing staff focus groups were conducted than patient focus groups. Finally, focus group moderator guides were developed based on findings from a previously administered perception survey, thus influencing the questions explored in the qualitative phase presented in this article.
CONCLUSIONS Patient safety has been demonstrated as an area of importance because of the number of preventable incidents associated with health care treatment in Canada and worldwide. The findings revealed that patient comfort level with nursing staff and control over their health care are an important aspect of patient involvement in patient safety practices. Ensuring that nursing staff and patients have the necessary time to interact with one another, and in an environment that is conducive to openness, is a critical component in promoting greater patient involvement in both their health care and patient safety. This has implications for how hospitals and health centers currently address patient involvement in patient safety; rather than just increasing patient awareness of safety issues while hospitalized, hospitals must also ensure that workflow and patient-provider encounters are designed to improve a feeling of connectedness and trust. As such, aligning patient safety strategies within existing care mechanisms (e.g., involvement opportunities during intake and discharge procedures), rather than through increased awareness through posters and signs, may help to provide the context for greater involvement to occur. REFERENCES 1. Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170:1678–1686. 2. Brennan TA, Leape LL, Laird LM. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. NEJM. 1991;324:370–377. 3. Wilson RM, Runciman WB, Gibberd RW, et al. The quality in Australian health care study. Med J Aust. 1995;163:458–476. 4. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001;322:517.
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16. Lincoln YS, Guba EG. Naturalistic Inquiry. Thousand Oaks, CA: Sage Publications; 1985. 17. Lee TW. Using Qualitative Methods in Organizational Research. Thousand Oaks, CA: Sage Publications; 1999. 18. Levinson W, Kao A, Kuby A, et al. Not all patients want to be involved in decision making. J Gen Intern Med. 2005;20:531–535. 19. Baker GR, Denis JL, Pomey MP, et al. Effective Governance for Quality and Patient Safety in Canadian Health Care Organizations. Ottawa, Canada: Canadian Health Services Research Foundation; 2010. 20. Rowell PA. The professional nursing association’s role in patient safety. Online J Issues Nurs. 2003;8:3. 21. Nicklin W, McVeety JE. Canadian nurses’ perceptions of patient safety in hospitals. Can J Nurs Leadersh. 2002;15:11–21. 22. Lighter DE. Process orientation in health care quality. In: Lighter DE, Fair DC, eds. Principles and Methods of Quality Management in Health Care. Gaithersburg, MD: Aspen Publishers Inc; 2000:37–85.
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