Original Research Article
Health care professionals' skills regarding patient safety
Indrė Brasaitė
a,b,* , Marja Kaunonen
a,c, Arvydas Martinkėnas
b, Vida Mockienė
b, Tarja Suominen
aaSchoolofHealthSciences,UniversityofTampere,Tampere,Finland
bFacultyofHealthSciences,KlaipėdaUniversity,Klaipėda,Lithuania
cPirkanmaaHospitalDistrict,Tampere,Finland
article info
Articlehistory:
Received5October2015 Receivedinrevisedform 17March2016
Accepted26May2016 Availableonline30June2016
Keywords:
Patientsafety
Healthcareprofessionals Skills
abstract
Backgroundandobjective: Theimportanceofpatientsafetyisgrowingworldwide,andevery day,healthcareprofessionalsfacevariouschallengesinhowtoprovidesafecarefortheir patients.Patientsafetyskillsareoneofthemaintoolstoensuresafepractice.Thisstudy lookstodescribehealthcareprofessionals'skillsregardingpatientsafety.
Materialsandmethods:DatawerecollectedusingtheskillscaleofthePatientSafetyAtti- tudes,SkillsandKnowledge(PS-ASK)instrumentfromdifferenthealthcareprofessionals (n=1082:physicians,headnurses,nursesandnurseassistants)workinginhospitalsfor adultpatientsinthreeregionalmulti-profilehospitalsinthewesternpartofLithuania.
Results:Overall,theresultsofthisstudyshowthatbasedontheirownevaluations,health careprofessionalswerecompetentregarding theirsafetyskills.Inparticular,theywere competentinthesub-scaleareasoferroranalysis(mean=3.09)andinavoidingthreatsto patient safety (mean=3.31), but only somewhatcompetent in using decision support technology(mean=2.00).Demographicandotherworkrelatedbackgroundfactorswere onlyslightlyassociatedwiththesepatientsafetyskillsareas.Especially,itwasnotedthat nurseassistantsmayneedmoresupportfrommanagersandcolleaguesindevelopingtheir patientsafetyskillscompetence.
Conclusions: Thisstudyhasservedtoinvestigatethegeneralskillsofhealthcareprofes- sionalsinregardtopatientsafety.Itprovidesnewknowledgeaboutthetopicinthecontext oftheBaltic countries andcanthusbeused inthefuturedevelopment ofhealth care services.
#2016TheLithuanianUniversityofHealthSciences.ProductionandhostingbyElsevier Sp.zo.o.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creative- commons.org/licenses/by-nc-nd/4.0/).
PeerreviewundertheresponsibilityoftheLithuanianUniversityofHealthSciences.
*Correspondingauthorat:DepartmentofNursing,FacultyofHealthSciences,KlaipėdaUniversity,HerkausManto84,92294Klaipėda, Lithuania.
E-mailaddress:Brasaite.Indre.X@student.uta.fi(I.Brasaitė).
Availableonlineatwww.sciencedirect.com
ScienceDirect
journalhomepage:http://www.elsevier.com/locate/medici
http://dx.doi.org/10.1016/j.medici.2016.05.004
1010-660X/#2016TheLithuanianUniversityofHealthSciences.ProductionandhostingbyElsevierSp.zo.o.Thisisanopenaccess articleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Most recently, the concept of safety skills (i.e. skills and behaviorsthatenhancethesafedeliveryofcare)hasemerged in healthcare literature [1–3]. Safety skills include non- technicalskills suchasleadership, teamwork,communica- tion,co-operation,situationawarenessanddecisionmaking, and also go beyond these to include other behaviors and attributessuchasconscientiousness,vigilanceandhumility.
Importantly,theseskillshavebeenrecognizedasbothcrucial topatientsafetyandalsoashighlytrainable[1].Non-technical skillssupporttechnicalskillssuchassystematicassessment, fluid management during simulation, urethral catheteriza- tion, central venous catheter insertion performed during resuscitation,orcarryingoutsurgery[3].
Researchersinvestigatinghealthcareprofessionals'knowl- edge, attitudes and skills regarding patient safety have remarkedthatalessinvestigatedfieldisthatofsafetyskills [4]. In the varied and complex health care systems seen worldwide, risks frequently occur that impact upon safe patientcare.Healthcareprofessionalshavetomanagethese risksusingtheirknowledgeandskillsincomplexsystems,and alsowhilstmaintainingasafelevelofpatientcare[5].
Physiciansplayanimportantroleintheirworkplacerelated topatientsafety.Assuch,theyneedsafetyskillsintheirdaily activities.Theyshouldalsobeabletorecognizepatientsafety incidents, conduct patient safety incident analysis using protocols,workinateam,learnfromerrors,andbeableto identify actions and recommendations on how to prevent patient safety incidents [6,7]. Nurses have a tradition of enhancing the quality of health care and patient safety, particularlythroughtheuseofproblem-solvingandpractice developmentskills[8].Forexample,nursesmustexercisetheir professionaljudgmentwhenadministeringanymedication, andapplytheirskillsinanygivensituationsoastoactinthe bestinterestsofthepatient[9].
Previousresearchhaslackedanyinvestigationofhowwell healthcareprofessionalsperforminerroranalysis,although errors themselves have been given more coverage. For example,itwasfoundthatmorethan90%ofmedicalerrors intheUnitedStateswerepreventable, andthattoimprove patientsafetyanderrorprevention,itisessentialtoutilize errorreportingmechanisms[10].Improvementsinsurgeons' skillshavebeenreportedasimprovingfollowingtheanalysis of patient safety issues, and a greater understanding and recognitionofpatientsafetyissueswasseenfollowingasafety skillstrainingcourse[1].Also,anotherstudy[11]foundthat safetyimprovementprogramcourses improvedhealthcare professionals'understandingandallowedthemtoconducta root-causeanalysis,andmostagreedthatthisimprovedtheir skillstoleadorbeinvolvedinroot-causeanalysis.Inthesame study,mostofthehealthcareprofessionalsinvolvedgained moreskillsregardingerrorreportingpractices.
Thereareseveralwaystoavoidthreatstopatientsafetyin clinical practice, such as using pressure relieving bedding materialstopreventpressure ulcers,orusingantimicrobial handwashing substancestoreduce infection. Handwashing hasbeen investigatedinseveralhealthcarestudies, and a compliance withhand hygieneprotocols isseen asagood
qualityindicatorofpatientsafety[12].Basedonearlierstudies, apoorcompliancewithhandhygienehasbeenseen.Inone study,only66%ofpersonnelperformedhandhygienebefore or upon entryinto apatient'sroom, and 58%upon exiting the patient's room [13], although a systematic review of handwashingpracticesworldwidehasshowedthatapproxi- mately19%oftheworld'spopulationwashestheirhandswith soapaftercontactwithexcreta[14].
Onewaytoaddsupporttopatientsafetyistoconsiderhow wemayusetechnologytoassistourdecisionmaking,related topatientsafetyissues.Thedegreetowhichtechnologyhas succeeded in supporting health careprofessionals in their decision making has not been investigated in any depth.
Overall however, while studies have shown a general improvementinpatientsafetyskills,theyhavenotreported anydirectpatientbenefits[15].
The healthcare management body hasa central role in helpingstafftodevelopgoodpatientsafetyskills.Withinthis, atransformationalleadershipstylehasbeenshowntohavea biginfluenceincreatingapositivesafetyclimate,contrarytoa morelaisser-fairestyleofleadershipwhichtendstofocusona cultureofblame[16].
Thisstudylookstodescribethekindsofpatientsafetyskills thathealthcareprofessionalshaveandtheassociationsthat relatedindividualbackgroundsfactorshaveonthem.
2. Materials and methods
2.1. DatacollectionThe data were collected in three regional multi-profile hospitals in the western part of Lithuania. The study participantswerehealthcareprofessionals(physicians,head nurses,nursesandnurseassistants)workinginhospitalsfor adult patients.Permissiontoconductthe studyandcollect datawasgrantedbytheethicalcommitteesofthehospitals whichparticipatedinboththepilotphaseandthemaindata collection.Theethicalconsiderationsrelatedtodatacollection focusedontheethicalprinciplesforresearch,namelythoseof confidentiality,privacy,andthevoluntarynatureofparticipa- tioninthestudy[17].Permissiontousetheinstrumentusedin the study was obtained from the copyright holder of the instrumentbythefirstauthor.
The questionnaire consisted of two parts: background questions,andtheinstrumentwhichmeasuredtherespon- dent's skills regardingpatient safety. Nineteenbackground questionsgathereddataonbasicdemographiccharacteristics (e.g.workposition,age,gender,education,yearsatwork,usual shift,etc.),andfurtherquestionsgatheredinformationabout theirexperiencesofpatientsafety.
Skillswereinvestigatedusingtheskillsscale(13items)of the PatientSafety Attitudes,Skillsand Knowledge(PS-ASK) instrumentdevelopedbySchnall[18]measuringhealthcare professionals'generalskillsrelatedtopatientsafety.Thescale hasthreesubscales:erroranalysis(6items),threatstopatient safety(4items)anddecisionsupporttechnology(3items).The items measuring health care professionals' error analysis relatedtopatientsafetyincludeditemssuchas‘‘participating as a team member of a Failure Mode & Effect analysis,’’
‘‘interpretingaggregateerrorreportdata,’’‘‘participatingasa teammemberofaroot-causeanalysis,’’‘‘accuratelyentering an error report,’’ ‘‘participating in morbidity and mortality conferences,’’and‘‘supportingandadvisingapeerwhomust decidehowtorespondtoanerror.’’Thesubscaleconcerned withavoidingthreatstopatientsafetyincludeditemssuchas
‘‘using antimicrobial hand washing substances,’’ ‘‘using
pressure relieving bedding materials to prevent pressure ulcers,’’‘‘askingpatientstorecallandrestatewhattheyhave beentoldduringtheinformedconsentprocess,’’and‘‘disclos- inganerrortoapatientand/orfamilymember.’’Theuseof decisionsupporttechnologywasinvestigatedbyitemssuchas
‘‘usingcomputer-based provider order entry,’’ ‘‘using com-
puter-based falls risk assessment,’’ and ‘‘using barcode medicationadministrationsystem.’’Allitemswereratedon aLikert scale(1,notcompetent;2,somewhatcompetent;3, competent;4,proficient;5,expert;and6,notapplicable).
TheinstrumentusedwasoriginallydevelopedintheUS, and wastranslatedfrom English into Lithuanianusingthe back-translation technique [19]. For an evaluation of the instrument'svalidityanditsuseintheLithuaniancontext,a pilotstudywasconductedinoneregionalhospitalinWestern Lithuania. The hospital was selected, based on the multi- profile services it provided for adult patients. Data were collectedfromallofthehealthcareprofessionalsinvolvedin thepilottest(n=90),whichtookplaceinFebruary2014.Based onthepilot,theinstrumentdevelopedbySchnallwasshown to have good psychometric properties in the Lithuanian context, so no changes were made. The scale's reliability wasassessedwithatotalCronbach'salphaof0.91,corrected byinter-itemcorrelation from 0.13to 0.84.TheCronbach's alphavaluesweregoodforthewholescaleinboththepilot andmainstudy,andalsoforthesub-scalesoferroranalysis (0.82and 0.90),threatstopatientsafety(0.53and 0.66),and decisionsupporttechnology(0.91and0.92)(Table1).
Themaindatawerecollectedinthreeregionalhospitalsin May2014.Eachhospitalgavetheirpermissiontoconductthe study, and to have one contact person who circulated questionnaires withenvelopestoall of the staff (N=1687).
Aftertwoweeks,theresearchercollectedthequestionnaires insealedenvelopesfromeachunit.Inordertoincreasethe responserate, anadditional two weeks responsetimewas given.Afterthat,theresearcherreturnedtotheunitstocollect theremainingquestionnaires.Thetotalresponserateforthis studywas64%(n=1082).
2.2. Statisticalanalysis
Descriptivestatisticswereusedtodescribethecharacteristics ofrespondents,thesafetyskillssub-scaleitems,andthescale- level results of the three hospitals. Differences in sample characteristics between hospitals and professional groups
were tested using the Kruskal–Wallis test. Differences in samplecharacteristicsbetweenspecifichospitalsweretested usingtheMann–WhitneyUtest.Datawerepresentedusing mean (SD) or median (IQR) expressions. Any negatively worded items of the instruments were reversed prior to analysis.Theinternalconsistencyofthesafetyskillsinstru- mentsandthesub-scalesoferroranalysisrelatedtopatient safety,avoidingthreatstopatientsafety,anddecisionsupport technologywasmeasuredbycalculatingtheCronbach'salpha for each sub-scale and total field. Associations between respondents' background factors and their patient safety skillswerecalculatedbywayofSpearmancorrelations.Allof thedatawereanalyzedusingSPSS(v.22.0;SPSSInc.,Chicago, IL,USA).APvalueof<0.05wasconsideredtobestatistically significant.
3. Results
3.1. ParticipantsAltogether,1082healthcareprofessionalsparticipatedinthe study. Thebiggest employment groupof participants were nurses(n=756,70%),withsmallergroupsofnurseassistants (n=180, 17%)and physicians (n=146, 14%).Thenumber of returnsfromthethreeregionalhospitalswas:301(28%)from hospital 1; 411 (38%) from hospital 2; and 370 (34%) from hospital 3.Themean ageof participants was46.7 (SD=11) years.Theyhadmanyyearsofworkexperience(mean=24), andworkedanaverageof40hperweekintheirunit.Theunits inwhichrespondentsworkedwereinternalmedicine(n=276, 26%),acute(n=161,15%),psychiatric(n=134,12%),surgical (n=131,12%),andothers(n=380,35%).Giventhatthebiggest groupofparticipantswerenurses,themostcommoneduca- tioninstitutionofthestudyparticipantswasmedicalschool 493 (46%), and the main base-qualifications were a non- university bachelor 130 (12%) and a university bachelor program118(11%).Themajorityofhealthcareprofessionals (n=659,61%)workedvariableshifts,inunitswithanaverage of30.7(SD=17.27)bedsperunit,24.1staffmembersperunit (SD=10.33), and they had an average of 18 patients per workingshift(SD=12.03).Morethanhalfoftheparticipants (n=673,62%)ofthisstudyhadreceivednoinformationabout patientsafetyduringtheirvocationaleducation,butabouthalf (n=589,54%)hadreceivedinformationduringtheircontinu- ing education. Four-fifths (n=866, 80%)of respondentshad reportednopatientsafetyincidentsduringthelastyear.
3.2. Safetyskills
Overall, the results of this study showed that based on their own evaluations, health care professionals perceived
Table1–Safetyskillssub-scalesandpsychometricproperties.
Safetyskillssub-scales Items Cronbach'salphafrompilotstudy Cronbach'salphafrommainstudy
Erroranalysis 6 0.82 0.90
Threatstopatientsafety 4 0.53 0.66
Decisionsupporttechnology 3 0.91 0.92
themselvesascompetentregardingtheirsafetyskills.They werecompetentinerroranalysis(mean=3.09)andskillsto avoid threats to patient safety (mean=3.31), but only somewhatcompetent inusingdecisionsupport technology (mean=2.00).Inerroranalysis, therespondentsweremost skilledinsupportingandadvisingapeerwhomustdecidehow torespondto anerror. Respondents wereseen tobe least skilledininterpretingaggregateerrorreportdata.Inlookingat theareaofhowskilledstaffwasinavoidingthreatstopatient safety, the highest evaluated skill was seento bein using antimicrobial handwashing substances. Lesser evaluated skillsincludeddisclosinganerrortoapatientand/orfamily member.Aconsiderableamountofvariationwasseeninthe areaofusingdecisionsupporttechnology(Table2).
Basedontheirprofessionandtheareaofhospitalhealth carethatprofessionalsworkedin,somestatisticallysignifi- cantfindingswerefound.Physiciansandnursesweremore skilled than nurse assistants in error analysis (P<0.001).
Nursesweremoreskilledregardingtheavoidanceofthreatsto patientsafetythannurseassistants(P<0.001),andalsomore skilled in using decision support technology than nurse assistants (P<0.01). Differences between safety skills sub- scalesregardingusingdecisionsupporttechnologywerealso seen by hospital, and health care professionals were less skilled in hospitals 1 and 2 than in hospital 3 (P<0.001) (Table3).
Manyof theparticipants demographicand work related backgroundfactorswereslightlyassociatedwithseveralareas of patient safety skills. Especially, the professionals' back- ground factors seem to correlate with their safety skills involvingerroranalysisandtheavoidanceofthreatstopatient safety(Table4).Healthcareprofessionalswithauniversityor collegeeducationwereseentobelessskilledregardingerror analysis( 0.062,P<0.05),inavoidingthreatstopatientsafety ( 0.158,P<0.01),andinusing decisionsupporttechnology ( 0.065,P<0.05),than those who had receivedtheirnurse educationinmedicalschool(vocational).
Healthcareprofessionals withmoreexperience in their primary specialty were seen to be more skilled in error analysis (0.098,P<0.01), avoiding threats to patientsafety
(0.061,P<0.05),andusingdecisionsupporttechnology(0.089, P<0.01).Thosewho receivednoinformation aboutpatient safetyintheircontinuingeducationhadlessskillsinregardto erroranalysis( 0.082,P<0.01)andavoidingthreatstopatient safety( 0.079,P<0.01).
Professionals with more beds per unit evaluated them- selvestobelessskilledinareasrelatedtoavoidingthreatsto patientsafety( 0.090,P<0.01),butmoreskilledwithusing decision support technology (0.072, P<0.05). When more nursesworkedonanightshift,healthcareprofessionalswere seentohavebetterskillsinerroranalysis(0.086,P<0.05)and in avoiding threats to patient safety (0.097, P<0.01). The higherthenumberofpatientsthathealthcareprofessionals usuallyhadper workingshift,the lessskilled theywerein avoiding threatstopatientsafety( 0.077,P<0.05),but the moreskilledtheyseemedtobewithusingdecisionsupport technology(0.067,P<0.05).
Comparingthe safety skillsbetween healthcareprofes- sionals by working unit, some significant differences were found.Thoseworkinginacute andother unitshad signifi- cantly more safety skills regardingerror analysis (P<0.05) comparedtohealthcareprofessionalswhoworkedininternal medicine,surgical,andpsychiatricunits.Healthcareprofes- sionalsworkinginacuteunitshadsignificantlymoresafety skills relating tothe avoidance of threatstopatient safety (P<0.05),thanthoseworkingininternalmedicine,surgical, and psychiatricunits.Nosignificantdifferenceswerefound betweenhealthcareprofessionalsbyworkingunitregarding theirskillsinusingdecisionsupporttechnology.
Amongstrespondentswhohadreportedasafetyincident duringthelastyear,physiciansandnurseshadsignificantly higher safety skills related toerror analysis (P<0.01) than nurseassistants.Alsowithinthesamegroup,skillsrelatingto the avoidance of threats to patient safety (P<0.01) were significantlyhigherfornursesthan nurseassistants.Inthe healthcareprofessionalgroupwhohadnotreportedasafety incident during the last year, physicians and nurses had significantlyhighersafetyskillsrelatedtoerroranalysisthan nurseassistants(P<0.001).Physicianswhohadnotreported safetyincidentsduringthelastyearhadmoreskillsregarding
Table2–Patientsafetyskillsbyparticipants.
Safetyskillssub-scales Mean SD
Erroranalysis
Supportingandadvisingapeerwhomustdecidehowtorespondtoanerror 3.19 0.840
Participatingasateammemberofaroot-causeanalysis 3.18 0.816
ParticipatingasateammemberofaFailureMode&Effectanalysis 3.16 0.834
Accuratelyenteringanerrorreport 3.09 0.792
Participatinginmorbidityandmortalityconferences 3.06 0.925
Interpretingaggregateerrorreportdata 2.93 0.871
Avoidancethethreatstopatientsafety
Usingantimicrobialhandwashingsubstances 3.78 0.734
Usingpressurerelievingbeddingmaterialstopreventpressureulcers 3.12 0.955
Askingpatientstorecallandrestatewhattheyhavebeentoldduringtheinformedconsentprocess 3.08 0.840
Disclosinganerrortoapatientand/orfamilymember 2.75 0.883
Usingdecisionsupporttechnology
Usingcomputer-basedproviderorderentry 1.93 1.210
Usingbarcodemedicationadministrationsystem 1.92 1.193
Usingcomputer-basedfallsriskassessment 1.72 1.090
Table3–Patientsafetyskillsbyparticipantgroupsandhospitals.
Safetyskillssub-scales Mean(SD) Median(IQR) Chi-square Pvalue
Erroranalysis 67.22 <0.001
Physicians 3.25(0.59) 3.33(0.7)***
Nurses 3.16(0.59) 3.0(0.7)###
Nurseassistants 2.64(0.84) 2.83(1.2)***,###
Total 3.09(0.67) 3.0(0.7)
Avoidancethethreatstopatientsafety 40.41 <0.001
Physicians 3.27(0.58) 3.25(0.7)**
Nurses 3.39(0.59) 3.33(0.8)**,###
Nurseassistants 3.01(0.76) 3.0(1.0)**,###
Total 3.31(0.63) 3.25(0.75)
Useofdecisionsupporttechnology 8.61 0.014
Physicians 1.96(1.13) 1.67(2.0)
Nurses 2.08(1.19) 1.67(2.0)##
Nurseassistants 1.69(0.99) 1.0(1.3)##
Total 2.00(1.16) 1.67(2.0)
Themeandifferencebetweenparticipantsbychi-square(Kruskal–Wallistest).
Themeandifferencebetweenconcreteparticipants(Mann–Whitneytest):
**P<0.01betweenphysiciansandnurses,nurseassistants.
***P<0.001betweenphysiciansandnurseassistants.
##P<0.01betweennursesandnurseassistants.
###P<0.001betweennursesandnurseassistants.
Erroranalysis 3.26 0.196
Hospital1 3.10(0.60) 3.0(0.6)
Hospital2 3.04(0.71) 3.0(0.7)
Hospital3 3.13(0.68) 3.0(0.7)
Total 3.09(0.67) 3.0(0.7)
Avoidancethethreatstopatientsafety 0.97 0.617
Hospital1 3.35(0.64) 3.25(0.8)
Hospital2 3.27(0.60) 3.25(0.7)
Hospital3 3.32(0.66) 3.25(0.8)
Total 3.31(0.63) 3.25(0.75)
Useofdecisionsupporttechnology 26.84 <0.001
Hospital1 1.73(0.97) 1.0(1.3)***
Hospital2 1.70(1.09) 1.0(1.7)###
Hospital3 2.33(1.26) 2.0(2.3)***,###
Total 2.00(1.16) 1.67(2)
Themeandifferencebetweenthreehospitalsbychi-square(Kruskal–Wallistest).
Themeandifferencebetweenspecifichospitals(Mann–Whitneytest):
***P<0.001betweenhospital1andhospital3.
###P<0.001betweenhospital2andhospital3.
Table4–Correlationsbetweenrespondents'backgroundfactorsandtheirpatientsafetyskills.
Demographicandworkrelatedcharacteristics Error analysis
Avoidanceofthreats topatientsafety
Useofdecision supporttechnology
Age 0.060* 0.035 0.021
Education(e.g.medicalschool,college,bachelor,etc.) 0.062* 0.158** 0.065*
Yearsofexperienceinprimaryspecialty 0.098** 0.061* 0.089**
Yearsofworkexperienceingeneral 0.091** 0.027 0.057
Informationaboutpatientsafetyincontinuingeducation 0.082** 0.079** 0.011
Usualshift 0.063* 0.052 0.033
Extrajob 0.054 0.012 0.063*
Receivedhoursregardingextrajob 0.071 0.077 0.207*
Numberofbedsperunit 0.061 0.090** 0.072*
Numberofphysiciansworkinginunitondayshifts 0.035 0.080* 0.007
Numberofnursesworkinginunitondayshifts 0.058 0.116** 0.001
Numberofnursesworkinginunitoneveningshifts 0.101** 0.071 0.055
Numberofnursesworkinginunitonnightshifts 0.086* 0.097** 0.026
Numberofpatientshealthcareprofessionalsusuallyhave perworkingshift
0.041 0.077* 0.067*
* P<0.05.
** P<0.01.
theavoidanceofthreatstopatientsafetythannurses(P<0.05) andnurseassistants(P<0.01).Nursesinthesamegroupwere significantlymoreskilledthannurseassistants(P<0.001),and had significantly higher safety skills related to decision support technology (P<0.01) than nurse assistants in the samegroup.
4. Discussion
Overall,healthcareprofessionalswerecompetentregarding patientsafetyskills,basedontheirownevaluations.Inmore detail, health careprofessionals werecompetent regarding erroranalysisandtheavoidanceofthreatstopatientsafety, butonlysomewhatcompetentregardingtheiruseofdecision supporttechnologies.Regardingthreatstopatientsafety,they weremost competent in using antimicrobial handwashing substancesandusingpressurerelievingbeddingmaterialsto preventpressureulcers,andoverall,themeanofhandwash- ingskillswasseentobethehighest.Healthcareprofessionals werealsoseentobecompetentinsupportingandadvisinga peerwhomustdecideonhowtorespondtoanerror,andin participatingasateammemberofaroot-causeerroranalysis.
Health care professionals showed the lowest level of competenceregardingtheuseofdecisionsupporttechnology (mean=2.00).Decisionsupporttechnologiesarequitenewin Lithuaniaandnotoftenused.Therefore,inthissetting,hospital managersmayneedtopaymoreattentiontocomputer-based learningwhenplanninghealthcareprofessionals'continuing education in this field. National-level support may also be neededwiththeintegrationofcomputer-basedtechnologies intohealthcareprofessionals'dailypractices,soastopromote patient safety and good quality patient care. This is an especiallyimportantissue,asatthetimeofdatacollection, thehospitalsincludedinthisstudywereatdifferentstagesin using decision support technologies in the area of patient safety.However, theresources, technologyandrelated staff educationshouldbeatsamelevelatsimilartypesofhospitals toensuretheprovisionofequalcareineachpubliclyfunded hospital, therefore we asked how much they used the technologyandnotwhetheritwasavailable.
Based on this study, the central issues related to the respondent'spatientsafetyskillsarewhethertheyweremore experienced and educated, and whether there were more nursesworkingduringnightshifts.Asurprisingresultisthat healthcareprofessionalswithalowerlevelofeducation(such as that received in a medical school for nurses) evaluated themselves as more skilled than those who received their professional education at bachelor level at a university.
However,giventhattheymayalsobedifferentlytrained,have lessresponsibilityetc.,thismayinfluencehowtheyevaluate their skillscomparedtothosewho havedifferentrolesand responsibilities.IntheLithuaniancontext,nursingscienceis veryyoungandbachelorstudieswereonlyestablishedin1990 (initially only available in the city of Kaunas). Most of participantsinthisstudywerenurses,andoneofthemain reasonsfor thiseducationalobservationisthatnurseswho studiedatmedicalschooltendedtogainmorepracticalskills whichtheycouldusemoreeasilyinclinicalpractice.Theresults ofthisstudyalsoconfirmthathealthcareprofessionalstendto
gaintheirsafetyskillsthroughmanyyears'ofexperience,and so their education levelis not the only contributoryfactor.
Safetycompetencewasseentobecloselyassociatedwiththe presenceofmorenursesworkingonnight shifts,andthisis quiteanaturalfindingashavingmorestafftodoclinicalworkis likely tomake for a safer nursing environment. Especially, having a higher staffing ratio is important in managing situationsthatentailahighnumberofpatients.Whenmore nursingpersonnelarepresent,itmayalsobethathealthcare professionalsfeeltheyhaveasupportiveworkingatmosphere andarebetterabletoconsultwithcolleagueswhenfacedwith challengingworkingsituations.
However,itseemedthatmorebedsandahighernumberof patients inthe unit poseda threattopatient safety skills.
According to the Lithuanian Ministerof Health Order [20], nursesshouldhaveamaximumof11patientspernursewhen theyareworkingwithpsychiatricpatientsandadescending ratio with patients of other profiles. It seems that a high patient-to-nurseratioforcesnursestoworkquicklybecause they do not have enough time for each patient, and this presentsachallengefornursestomaintainahighqualityof nursingcare,andtotakesafecareoftheirpatients.Previous literaturehasfoundthatsafetyincidentshavebeenespecially associatedwithnurseovertimeandpatient–nurseratios[21], anditisthereforeimportantfornursestohaveenoughstaffing andresourcestodeliveragoodqualityofnursingcare[22].
Strengths and limitations of this study have to be mentioned.Thestrengthofthisstudyisthatthesamplesize (n=1082)waslargeandtheresponserate(64%)wasgood.It also comprised several health care professional groups, including physicians, nurses, and nurse assistants. Given the lack of previous studies concerning patient safety conductedintheBalticarea,thisstudycanbeconsideredas apioneeringwork.Furthermore,thisstudyisthefirstofits kindtoinvestigatethegeneralpatientsafetyskillsofhealth careprofessionalsinLithuania.
However,alimitationexistsrelatedtotheinstrumentused inthisstudy.Theissuesconcerningpatientsafetyskillswere investigatedatgenerallevel,forthepurposeofinvestigatinga representative spectrum of health professionals such as physicians, nurses and nurse assistants. To expand this general view, further research isneeded toinvestigate the specific skill areas in different professions, and also in differentclinicalsettings.Thedatawerepurposefullycollect- edinoneregion,butitisoneofthebiggestregionsinLithuania and maybeseen asrepresentativeof thenationalcontext.
Also,thosewhodropped-out(36%)mighthaveadifferentlevel ofpatientsafetyskillsthanmajorityrespondentsofthisstudy.
Furthermore thecorrelationsfound werevery weak, sowe needtomoderatewhichkindofconclusionswemakebased ontheresults.
Regardlessofthesepoints,however,theinstrumentsused inthestudywerevalidatedandpilotedinthefeaturedresearch context,andreturnedagoodpsychometricperformance.
5. Conclusions
Thisstudyhasservedtoinvestigatethegeneralskillsofhealth careprofessionalsinregardtopatientsafety.Itprovidesnew
knowledgeaboutthetopicinBalticcountries,andcanthusbe used in the development of health care services. Overall, healthcareprofessionalsinthissettinghadgoodskillsinerror analysisandskillslinkedtotheavoidanceofthreatstopatient safety, but were less skilled in using decision support technology.Healthcareprofessionalswhoweremoreexperi- encedandwithamedicalschooleducationhadbettersafety skills, asdid those who worked on nightshifts withmore nursingpersonnel.However,itwasshownthatcomparedto the other groups in this study, nurse assistants wereless skilledregardingpatientsafety. Therefore,moresupportby managersandcolleaguesis neededtoensuretheir compe- tence. Further research is also needed to investigate the patientsafetyskillsofdifferent healthcareprofessions,and morespecifically,todeterminetheirsafetyskillsneeds.
Conflict of interest
Nonedeclared.
Authors' contribution
Study conception/design: I.B., M.K., T.S.; data collection/
analysis:I.B.,A.M.;draftingandwritingthemanuscript:I.B., M.K.,A.M.,V.M.,T.S.;approvalofthefinaltext:I.B.,M.K.,A.M., V.M.,T.S.
Funding
The study was partly funded by the Competitive State Research Financing of the Expert Responsibility Area of TampereUniversityHospital:GrantNumber9S065.
Ethical approval
Ethicalapprovalwasreceivedfromtheethicalcommitteeof Klaipeda University, Faculty of Health Sciences and study permissionwasobtainedfromthehospitalswhoparticipated inthisstudy.
references
[1] AroraS,SevdalisN,AhmedM,WongH,MoorthyK,Vincent C.Safetyskillstrainingforsurgeons:ahalf-day
interventionimprovesknowledge,attitudesandawareness ofpatientsafety.Surgery2012;152(1):26–31.
[2] GordonM,DarbyshireD,BakerP.Non-technicalskills trainingtoenhancepatientsafety:asystematicreview.
MedEduc2012;46:1042–54.
[3] WhiteN.Understandingtheroleofnon-technicalskillsin patientsafety.NursStand2012;26(26):43–8.
[4] BrasaiteI,KaunonenM,SuominenT.Healthcare professionals'knowledge,attitudesandskillsregarding patientsafety:asystematicliteraturereview.ScandJ CaringSci2015;29:30–50.
[5] LeapeL,BerwickD,ClancyC,ConwayJ,GluckP,GuestJ, etal.Transforminghealthcare:asafetyimperative.Qual SafHealthCare2009;18(6):424–8.
[6] AhmedM,AroraS,BakerP,HaydenJ,VincentC,SevdalisN.
Buildingcapacityandcapabilityforpatientsafety education:atrain-the-trainersprogrammeforsenior doctors.BMJQualSaf2013;22(August(8)):618–25.
[7] AhmedM,AroraS,TiewS,HaydenJ,SevdalisN,VincentC, etal.Buildingasaferfoundation:theLessonsLearntpatient safetytrainingprogramme.BMJQualSaf2014;23:78–86.
[8] MilliganF,DennisS.Buildingasafetyculture.NursStand 2005;20(11):48–52.
[9] NdosiMwidimiE,NewellR.Nurses'knowledgeof pharmacologybehinddrugstheycommonlyadminister.J ClinNurs2009;18:570–80.
[10] HughesRG,editor.Patientsafetyandquality:anevidence- basedhandbookfornurses.AHRQPublicationNo.08-0043.
Rockville,MD:AgencyforHealthcareResearchandQuality;
2008,March[chapter35].
[11] BraithwaiteJ,WestbrookMT,MallockNA,TravagliaJF, IedemaRA.Experiencesofhealthprofessionalswho conductedrootcauseanalysesafterundergoingasafety improvementprogramme.QualSafHealthCare 2006;15:393–9.
[12] MarraAR,EdmondMB.Newtechnologiestomonitor healthcareworkerhandhygiene.ClinMicrobiolInfect 2014;20(1):29–33.
[13] ComunaleME,SandovalM,BroussardT.Anassessmentof basicpatientsafetyskillsinresidentsenteringthefirstyear ofclinicaltraining.JPatientSaf2015.http://dx.doi.org/
10.1097/PTS.0000000000000179
[14] FreemanMC,StocksME,CummingO,JeandronA,Higgins JP,WolfJ,etal.Hygieneandhealth:systematicreviewof handwashingpracticesworldwideandupdateofhealth effects.TropMedIntHealth2014;19(8):906–16.
[15] KirkmanMK,SevdalisN,AroraS,BakerP,VincentC, AhmedM.Theoutcomesofrecentpatientsafetyeducation interventionsfortraineephysiciansandmedicalstudents:
asystematicreview.BMJOpen2015;5:e007705.http://dx.
doi.org/10.1136/bmjopen-2015-007705
[16] MerrillKC.Leadershipstyleandpatientsafety:implications fornursemanagers.JNursAdm2015;45(6):319–24.
[17] DeclarationofHelsinki.WMADeclarationofHelsinki– EthicalPrinciplesforMedicalResearchInvolvingHuman Subjects;2013,http://www.wma.net/en/30publications/
10policies/b3[accessed22.01.15].
[18] SchnallR,StoneP,CurrieL,DesjardinsK,JohnRM,Bakken S.Developmentofaself-reportinstrumenttomeasure patientsafetyattitudes,skills,andknowledge.JNurs Scholarsh2008;40:391–4.
[19] BurnsN,GroveSK.Thepracticeofnursingresearch:
appraisal,synthesis,andgenerationofevidence.St.Louis, MO:SaundersElsevier;2009.
[20] LietuvosRespublikossveikatosapsaugosministro įsakymasNr.V-400.DėlSlaugytojųdarbokrūvionustatymo tvarkosaprašopatvirtinimo(Žin.,2012,Nr.55-2751) [LithuanianMinisterofHealthOrderNo.V-400.Procedural approvalforestablishingnursesworkload(OfficialGazette.
2012,No.55-2751)].
[21] LiuLF,LeeS,ChiaPF,ChiSC,YinYC.Exploringthe associationbetweennurseworkloadandnurse-sensitive patientsafetyoutcomeindicators.JNursRes2012;20 (4):300–9.
[22] SmedsAleniusL,TishelmanC,RunesdotterS,LindqvistR.
StaffingandresourceadequacystronglyrelatedtoRNs' assessmentofpatientsafety:anationalstudyofRNs workinginacute-carehospitalsinSweden.BMJQualSaf 2014;23(3):242–9.
