Literature search

A literature search for earlier peer-reviewed publications was used to synthesize the current knowledge on PSC in forensic psychiatry care. Systematic searches of the Cinahl, PsycINFO, PubMed and Scopus databases were conducted in January 2021. The search terms culture of safety, organizational culture, safety culture and patient safety were used in various combinations (Figure 2). The literature search was limited to empirical research covering forensic psychiatry or adopting a psychiatric perspective that had been published between 2010–2020. The search was limited to peer-reviewed publications in the English language. The systematic searches were performed by an information specialist at the University of Eastern Finland.

The database search yielded 245 original publications, after which duplicates (147) were removed. Titles and abstracts were then reviewed to determine whether the research was relevant to PSC in the context of forensic psychiatry care. A total of 31 full articles were evaluated for relevance, with nine article included in the final analysis. The reference lists of these articles were also searched manually to ensure that no relevant research was missed. This yielded three more relevant articles. Furthermore, the websites of various organizations, e.g., WHO (2009), European Union (2021), AHRQ (2020), were consulted for further

relevant knowledge concerning PSC in forensic psychiatry care. The selection process (Figure 3) yielded a total of 12 articles, and is described in detail in Appendix 1.

Figure 3. The process followed during the literature search of patient safety culture in forensic psychiatry.

The literature review demonstrated that PSC in forensic psychiatry has only received limited research attention. Of the 12 identified articles, none focused specifically on forensic psychiatric care settings. Only one study (Schwappach &

Niederhauser, 2019) partially covered forensic psychiatric care. More specifically, Schwappach & Niederhauser (2019) studied professional groups (n=817) in six psychiatric hospitals where forensic psychiatric services were mentioned along other psychiatric specializations (e.g. adult, geriatric, child). The research did not specifically discuss forensic psychiatry background variables.

The 12 identified studies were conducted in nine different countries; seven were conducted in Europe. Over a half of the studies (7) used a commonly available survey instrument (HSOPSC, SAQ, MaPSAF) to measure PSC, with three studies using HSOPSC (Vlayen et al., 2011; Vlayen et al., 2015; Hamaideh, 2017).

SAQ was used in three studies (Kristensen et al., 2016; Oliveira et al., 2018; Dickens et al., 2019), while MaPSAF was used in one study (Öhrn, 2011). In four studies, PSC was measured through various distinct instruments (Mahoney et al., 2012;

Heckemann et al., 2019; Schwappach & Niederhauser, 2019). One of the studies was a systematic review which identified ten patient safety categories, including safety culture, for inpatient psychiatric care (Thibaut et al., 2019).

Teamwork was the PSC dimension that received the highest scores (Hamaideh, 2017; Oliveira et al., 2018), while working conditions (Oliveira et al., 2018), along with non-punitive response to error, communication openness, staffing and frequency of events reported (Hamaideh, 2017), received the lowest scores, and thus, indicate a need for development in mental health hospitals. The literature review revealed that long-term and psychiatric hospitals demonstrate higher scores across PSC dimensions than acute hospitals, with the exception of emergency care (Vlayen, 2012; Danielsson et al., 2019). However, prior research suggests that psychiatric departments are slower to improve adverse event reporting, have lover PSC scores and act to improve various aspects of PSC than other subareas of health care (Öhrn, 2011).

According to Vlayen (2012), health care professionals with more work

experience showed higher PSC scores, whereas Dickens et al. (2019) found total work experience to be negatively associated with safety attitudes. Furthermore, employees at organizations with a more market-oriented culture showed inferior safety-related attitudes relative to employees from organizations with a clan-type culture. The researchers also found that significant predictors of an employee’s decision to raise a safety issue included hierarchical level and perceived risk of harm to a patient (Schwappach & Niederhauser, 2019).

The identified studies discussed three different strategies for promoting PSC in psychiatric care. First, Patient Safety Dialogue was a regional intervention in Sweden that aimed to improve PSC in hospitals and primary health care by building trust and understanding, encouraging leadership commitment, and fostering learning about patient safety issues (Öhrn et al., 2011). Second, Kristensen et al. (2016) described a multicomponent programme for clinical leaders featuring academic input, exercises, reflection and discussion, networking, and action learning that was designed to broaden their knowledge and strengthen leadership skills. Third, TeamSTEPPS was implemented in one psychiatric hospital to address the need for team training (Mahoney et al., 2012).

The results of these studies revealed that strengthening leadership can significantly improve the proportion of staff with positive attitudes and build a more positive culture. Notably, the proportion of frontline staff with positive attitudes towards safety improved across five of the seven PSC dimensions, while a positive change was witnessed for six PSC dimensions (Kristensen et al., 2016).

Öhrn et al. (2011) reported that most of the studied departments evaluated the intervention (Patient Safety Dialogue) as effective in improving PSC. TeamSTEPPS was also successfully implemented, leading to positive changes across in the team attributes in five of seven subscales (Mahoney et al., 2012).

Concerning perceptions about PS, respondents felt that a different approach is needed when implementing interventions aiming to improve PSC (Vlayen, 2012).

Furthermore, perceptions of safety culture must be generalized between, or even within, different types of health care settings with caution, as each subarea has a highly context-specific nature (Vlayen, 2015).

Two studies highlighted a specific PS feature related to violence in psychiatry.

Heckemann et al. (2019) reported that a positive PSC might lead teams to be more effective in managing patient and visitor aggression. In 2019, Thibaut et al.,

indentified a violence theme in a systematic review of approximately three out of ten categories (interpersonal violence, self-harm, safety of the physical

environment) that serve as threats to PS.