6.2 Validity, strengths and limitations
6.2.3 Statistical analyses
Several statistical analyses were conducted in sub-studies I, and III. The employed statistical methods were chosen based on the quality and size of the data.
Parametric and non-parametric tests were used to examine associations between variables in sub-study I, while the data collected for study III were only described as percentages and frequencies. The response rates associated with web-based surveys are usually lower than those for surveys conducted in other ways, which may lead to non-response bias and even reduce validity (Alderman & Salem, 2010).
The small sample size in sub-study I (pre-intervention 43%, post-intervention 77%)
affected the choice of analyses and the potential for generalizing the results obtained.
Moreover, the trends observed in this work may not apply to all organizations and times, especially since the participants were anonymous and not randomly chosen. This could have negatively affected the validity. This is a drawback of quasi-experimental research, as a design without randomization can lead to selection and regression biases (Jordan et al., 2013). Therefore, the results - which detail the elopementent of PSC within forensic psychiatry care over time - should be generalized with caution.
7 CONCLUSIONS
This dissertation aimed to draw upon hospital-level data to clarify how both PSC and patient safety have developed at two Finnish forensic psychiatric hospitals. In addition, some of the appended studies represent the first examples of research into PSC within the context forensic psychiatry. The presented research applied the HSOPS survey to describe the effects of a three-year patient safety
intervention, more specifically, the implementation of a patient safety incident reporting system (PSiRS), on PSC.
The findings covered in this thesis showed that certain elements of a blame culture still persist in Finnish forensic psychiatry (articles I and III). Overall, there are positive indications about how PSC is developing, as many of the PSC
dimensions have moved away from a secretive or blame culture (article II), and the reporting of incidents was shown to positively affect organizational learning and the establishment of a safety culture (articles II and IV).
However, the findings suggest that Finnish forensic psychiatry care has not yet fully evolved to a just culture. Hence, patient safety is not truly at the core of the organization, and staff views about safety factors are not always fully taken into account. Thus, the implementation of evidence-based practices relevant for positive PSC is still underway.
In general, the HSOPS instrument is suitable for measuring forensic psychiatric PSC. However, some new cultural dimensions could be considered for addition to the instrument to measure the contextual factors specific for forensic care. For instance, in article III, respondents highlighted operational guidelines, and staff and patient perspectives. Futhermore, in article IV, the violence theme emerged.
None of these three perspectives are clearly consider in the original HSPOSC instrument.
The following conclusions can be made based on the research covered in this dissertation:
• PSC in psychiatry, especially forensic psychiatry care, has only been
marginally studied up to this point. It seems that the importance of patient safety in forensic psychiatry is recognized, but PSC has not yet been fully developed.
• Both the implementation of PSiRS and appropriate education can positively influence PSC, and represent robust approaches for improving patient safety. These factors should be considered regarding the
management strategies.
• Establishing a positive PSC and embedding it across all organizational levels is vital; this requires the adoption of a systems-level approach for examining patient safety incidents that encourages open reporting and communication. Patient safety surveys are effective instruments for gauging shared values, beliefs, and attitudes towards patient safety among staff members. Staff should be engaged in discussions about their
perceptions of safety to raise awareness of patient safety.
• There is a clear gap in how managers and the other health care staff perceive patient safety. Managers should discuss patient safety issues with all health care staff to increase common understanding and support patient safety initiatives to serve as an example for the organization.
• Nursing staff views on patient safety factors and the existing safety culture should be considered when planning strategies to strengthen patient safety in an organization. According to health care staff suggestions, patient safety could improve through an open culture and protocols.
Furthermore, nurses - based on their continuous interaction with patients - serve the important role of coordinators in patient safety work.
• The presented research may drive further patient safety initiatives based on the provided empirical evidence for how many adverse events are preventable. It will be important for organizations to first determine what type of patient safety incidents they are experiencing and which factors influence their occurrence and find systemic factors that may lead to incidents. Therefore, organizations should actively collect data as well as regularly present statistics and share good practices with staff members – an example of transformative learning.
The presented studies suggest the following avenues for future research:
• Further research is required to determine how effective various learning and teaching methods are at developing PSC. For example, future research should be targeted toward individual units and focused on patient
outcomes and quality of care, e.g., prevention of harm, patient satisfaction and general comfort.
• There is a clear need to study patient safety from the patient’s point of view. This is because patients can identify risk factors that health care staff may not discern.
• Forensic psychiatric staff perceptions of PSC should be further studied through various research methods (e.g. qualitative approach) provide comprehensive knowledge about this phenomenon. In addition,
comparisons of patient and health care staff perceptions of PSC could be valuable, along with descriptions of how newly employed health care staff or students perceive PSC.
• The measurement of PSC in forensic psychiatry could be developed, considering operational safety quidelines and patient perspective to culture dimensions, as well as the specificities of forensic psychiatry related to violence.
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