Patient safety culture in forensic psychiatric hospital care : Health care staff perceptions'

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DISSERTATIONS | ANSSI KUOSMANEN | PATIENT SAFETY CULTURE IN FORENSIC PSYCHIATRIC HOSPITAL CARE | No 648

ANSSI KUOSMANEN

Patient safety culture in forensic psychiatric hospital

care

Dissertations in Health Sciences

PUBLICATIONS OF

THE UNIVERSITY OF EASTERN FINLAND

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PATIENT SAFETY CULTURE IN FORENSIC PSYCHIATRIC HOSPITAL CARE

HEALTH CARE STAFF PERCEPTIONS´

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Anssi Kuosmanen

PATIENT SAFETY CULTURE IN FORENSIC PSYCHIATRIC HOSPITAL CARE

HEALTH CARE STAFF PERCEPTIONS´

To be presented by permission of the Faculty of Health Sciences, University of Eastern Finland for public examination in Vanha Juhlasali, Niuvanniemi Hospital, Kuopio on November 26^th, 2021, at 12 o’clock noon

Publications of the University of Eastern Finland Dissertations in Health Sciences

No 648

Department of Nursing Science, and Department of Forensic Psychiatry, Faculty of Health Sciences, University of Eastern Finland, Kuopio

2021

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Series Editors

Professor Tomi Laitinen, M.D., Ph.D.

Institute of Clinical Medicine, Clinical Physiology and Nuclear Medicine Faculty of Health Sciences

Lecturer Tarja Välimäki, Ph.D.

Department of Nursing Science Faculty of Health Sciences

Professor Ville Leinonen, M.D., Ph.D.

Institute of Clinical Medicine, Neurosurgery Faculty of Health Sciences

Professor Tarja Malm, Ph.D.

A.I. Virtanen Institute for Molecular Sciences Faculty of Health Sciences

Lecturer Veli-Pekka Ranta, Ph.D.

School of Pharmacy Faculty of Health Sciences

Distributor:

University of Eastern Finland Kuopio Campus Library

P.O.Box 1627 FI-70211 Kuopio, Finland

www.uef.fi/kirjasto

PunaMusta Oy Joensuu 2021

ISBN: 978-952-61-4320-0 (print/nid.) ISBN: 978-952-61-4321-7 (PDF)

ISSNL: 1798-5706 ISSN: 1798-5714 ISSN: 1798-5706 (PDF)

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Author’s address: Department of Nursing Science University of Eastern Finland KUOPIO

FINLAND

Doctoral programme: Doctoral Programme in Health Sciences

Supervisors: Professor Hannele Turunen, Ph.D., RN Department of Nursing Science University of Eastern Finland Kuopio University Hospital KUOPIO

FINLAND

Professor Jari Tiihonen, M.D., Ph.D Department of Forensic Psychiatry University of Eastern Finland KUOPIO

FINLAND

Department of Clinical Neuroscience Karolinska Institutet

STOCKHOLM SWEDEN

Reviewers: Professor Maritta Välimäki, Ph.D., RN Department of Nursing Science University of Turku

TURKU FINLAND

Docent Teemu Reiman, Ph.D.

Department of Industrial Engineering and Management Aalto University

ESPOO FINLAND

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Opponent: Docent Minna Anttila, Ph.D.

Department of Nursing Science University of Turku

TURKU FINLAND

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Kuosmanen, Anssi

Patient safety culture in forensic psychiatric care - health care staff perceptions´

Kuopio: University of Eastern Finland

Publications of the University of Eastern Finland Dissertations in Health Sciences 648. 2021, 89 p.

ISBN: 978-952-61-4320-0 (print) ISSNL: 1798-5706

ISSN: 1798-5714

ISBN: 978-952-61-4321-7 (PDF) ISSN: 1798-5706 (PDF)

ABSTRACT

This dissertation aims to describe health care staff perceptions of patient safety culture (PSC) in Finnish state forensic psychiatric hospitals, analyze PSC changes after an intervention, and detail the most typical patient safety incidents.

The research presented in this dissertation covers three sub-studies. The first sub-study was an electronic survey in 2010 (n=283) and 2013 (n=161) for social- and health-care professionals. In these surveys, PSC and its development over time were evaluated using the HSOPSC measure. In the second sub-study, nursing staff perceptions (n=72) of PSC were assessed in 2010 through an electronic, open- ended questionnaire on patient safety, incidents and their reporting. In the third sub-study, register data on incidents (f=2521) from 2012–2018 were analyzed to clarify the type and frequency of safety incidents at the study hospital.

Statistical methods were applied in sub-studies I and III, while the qualitative data collected for sub-study II were analyzed by inductive content analysis.

The results showed that teamwork within and across the units was assessed as a strength, while the PSC dimension related to responses to errors received the most critical scores. PSC differed between subcultures (e.g. manager status, occupational and hospital groups). Access to supplementary education was associated with higher overall PSC scores. Furthermore, the results revealed that patient safety interventions positively impacted an organization’s PSC. The research presented in this dissertation identified six main PSC themes: 1) systematic, open and trusting communication culture; 2) visible and close

interaction between management and staff; 3) non-punitive responses to errors, learning from mistakes and development; 4) balance between staff and patient safety perspectives; 5) practical safety-related guidelines; and 6) adequate human resources to ensure safety. According to voluntary incident reports, the patient did

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not experience any harm in more than half (51%) of the reported cases. The most common type of incident was violence (38%), which most frequently occurred in department corridors (32%). To drive development, it was most often mentioned (77%) that the event would be discussed in the unit.

PSC, along with the relevant influencing factors, should be given more attention and evaluated regularly. This may be pivotal to developing a more positive PSC through training, by learning from incidents, and sharing safety-related

development measures. Patient safety related development measures should focus more from individual patient-specific factors to systemic factors and then finding ways to integrate them into management strategy to ensure that provided safety improvements are evidence-based. An instrument to measure of patient safety culture in forensic psychiarty should be developed to take better account of the patient perspective, safety guidelines and the phenomenon of violence.

Keywords: Patient Safety; Forensic Psychiatry; Hospitals, Psychiatric; Safety Culture; Safety Management; Organizational Culture

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Kuosmanen, Anssi

Potilasturvallisuuskulttuuri oikeuspsykiatrisessa sairaalahoidossa - henkilöstön näkökulma

Kuopio: Itä-Suomen yliopisto

Publications of the University of Eastern Finland Dissertations in Health Sciences 648. 2021, 89 s.

ISBN: 978-952-61-4320-0 (nid.) ISSNL: 1798-5706

ISSN: 1798-5714

ISBN: 978-952-61-4321-7 (PDF) ISSN: 1798-5706 (PDF)

TIIVISTELMÄ

Tämän tutkimuksen tarkoituksena oli kuvata potilasturvallisuuskulttuuria henkilöstön näkökulmasta valtion oikeuspsykiatrisissa sairaaloissa Suomessa, analysoida intervention vaikutusta potilasturvallisuuskulttuuriin ja selvittää tyypillisimpiä potilaisiin kohdistuvia vaaratapahtumia.

Tutkimus sisälsi kolme osatutkimusta, joista ensimmäisessä osatutkimuksessa aineistonkeruumenetelmänä käytettiin sähköistä kyselyä vuosina 2010 (n=283) ja 2013 (n=161) sosiaali- ja terveydenhuollon ammattihenkilöille. Näissä kyselyissä potilasturvallisuuskulttuuria ja sen muutosta arvioitiin HSOPSC-mittarin avulla.

Toisessa osatutkimuksessa hoitajien näkökulmia (n=72)

potilasturvallisuuskulttuurista kerättiin vuonna 2010 sähköisesti avoimella kysymyksellä potilasturvallisuudesta, vaaratapahtumista ja niiden raportoinnista.

Kolmannessa osatutkimuksessa rekisteritutkimuksen aineisto vaaratapahtumista (f=2521) vuosilta 2012–2018 koottiin sairaalan vaaratapahtumien

raportointijärjestelmästä.

Osatutkimuksissa I ja III hyödynnettiin tilastollisia menetelmiä ja osatutkimuksessa II laadullinen aineisto analysoitiin induktiivisella sisällönanalyysillä.

Tutkimus osoitti, että potilasturvallisuuskulttuurissa oli eroja ammattiryhmien ja sairaaloiden välillä. Yhteistyö yksikön sisällä ja muiden yksiköiden välillä arvioitiin hyväksi. Potilasturvallisuuskulttuurin kannalta kaikkein kriittisimmin arvioitiin syyllistämätöntä virheiden käsittelytapaa. Hyvät koulutusmahdollisuudet olivat yhteydessä parempaan potilasturvallisuuskulttuuriin. Lisäksi tulokset osoittivat, että potilasturvallisuuskulttuuria voidaan kehittää koulutuksen ja oppimisen kautta.

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Tutkimuksessa tunnistettiin kuusi potilasturvallisuuskulttuurin pääteemaa: 1) systemaattinen, luotettava ja avoin viestintä, 2) läpinäkyvä ja välitön vuorovaikutus johdon ja henkilöstön välillä, 3) syyllistämättömyys, virheistä oppiminen ja

kehittäminen, 4) henkilökunnan ja potilaiden turvallisuuden tasapaino, 5)

turvallisuuteen liittyvät käytännönläheiset ohjeet ja 6) riittävät henkilöstöresurssit.

Potilasturvallisuuteen liittyvällä interventiolla saatiin positiivisia vaikutuksia organisaation potilasturvallisuuskulttuuriin. Vapaaehtoisten

vaaratapahtumailmoitusten mukaan yli puolessa (51 %) tapauksista potilaalle ei sattunut lainkaan haittaa. Yleisin vaaratapahtumatyyppi oli väkivalta (38 %), jota esiintyi eniten osaston käytävillä (32 %). Kehittämisehdotuksiksi mainittiin usein (77 %), että tapahtumasta keskustellaan yksikössä.

Potilasturvallisuuskulttuuriin ja siihen vaikuttaviin tekijöihin tulisi kiinnittää aiempaa enemmän huomiota ja arvioida sitä säännöllisesti.

Potilasturvallisuuskulttuuria voidaan kehittää myönteiseen suuntaan muun muuassa koulutuksen avulla, oppimalla vaaratapahtumista sekä jakamalla turvallisuuteen liittyviä kehittämistoimenpiteitä. Potilasturvallisuuteen liittyvissä kehitystoimenpiteissä tulisi huomioida yksittäisen potilasnäkökulman lisäksi systeemitekijöiden vaikutus. Tällaiset kehitystoimenpiteet tulisi integroida

toimintatavaksi tutkimusnäyttöön perustuvaan potilasturvallisuuden johtamiseen.

Potilasturvallisuuskulttuuria arvioivaa mittaria tulisi kehittää oikeuspsykiatrisen hoidon näkökulmasta siten, että se huomioisi paremmin potilaan näkökulman, turvallisuuteen liittyvät ohjeistukset sekä väkivaltaan liittyvät vaaratapahtumat.

Avainsanat: potilasturvallisuus; oikeuspsykiatria; psykiatriset sairaalat;

turvallisuuskulttuuri; turvallisuusjohtaminen

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To my family with love

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ACKNOWLEDGEMENTS

This stydy was carried out at the Department of Nursing Science, Faculty of Health Sciences, in collaboration with the Department of Forensic Psychiatry, University of Eastern Finland. I wish to express my gratitude to the Niuvanniemi and Vanha Vaasa hospital staffs for making this project possible.

The process and journey has been very long, over ten years. I have been surrounded with encouragement on this journey and now it is time to express my sincere gratitude to all the wonderful people, who have supported me during my doctoral studies and made this study possible.

My deepest and humble gratitude goes to my principal supervisor, Professor Hannele Turunen. Your guidance, support and encouragement have been endless during this process. I am very grateful to you for challenging me to think in a scientific style, and thus supported me widening my perspective. I also owe my sincere thanks to my second supervisor Professor Jari Tiihonen for his accurate expert guidance during all phases of this thesis. You have guided me whenever I needed it.

I warmly thank my co-author, Adjunct Professor Eila Repo-Tiihonen, the former Medical Director of Niuvanniemi hospital, for her constructive comments and support during the study process. I am also thankful to co-author, Adjunct Professor Markku Eronen for his valuable help and MSc, Biostatistician Tuomas Selander, for providing his expertise in statistics. With all my heart, I want to thank Tarja Koskela and Aija Räsänen for their valuable help during the entire process.

I would like to thank my official reviewers Professor Maritta Välimäki and Adjunct Professor Teemu Reiman. They gave me constructive and helpful

comments. Their efforts on this thesis were essential, and helped me to improve it.

I sincerely thank Adjunct Professor Minna Anttila for promising to act as my opponent.

I would like to thank the instances that provided me financial support during this project: Taja ry and the Finnish Nursing Accociation. The Finnish Ministry of Health and Social Affairs financially supported this work through the development fund for Niuvanniemi Hospital, Kuopio, Finland.

I owe my sincere thanks to Kari Ojala, who is the leader of Niuvanniemi hospital, for your support and conversations. Director of nursing Satu Tuovinen, I would like to thank you for helping me in my scientific reflections.

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During this process, my nearest friends have supported me in many ways. Matti and Ville, I am grateful for our friendship that has lasted since the beginning of our nursing careers. I have experienced many unforgettable moments with you. Many thanks! My childhood friend Arto, thanks for travelling with me during these years.

I am grateful for our discussions about science and life in general.

I have been fortunate to be able to collaborate with many safety professionals during these years and have had the grateful opportunity to share this experience and knowledge with you in an incredibly productive atmosphere. I especially want to thank you Jarkko Wallenius and Arto Helovuo for offering your different

perspectives and thank you for the all-joyful and relaxing company.

The warmest thanks to my football family and coach Timo. With you, I could always take a break away from my study and work mode.

Most of all, I would like express my deepest gratitude and love to my family - Venla, Eeli and Topi (and the animals), I have no words for what you mean to me.

Thank you for reminding me constantly what is the most important thing in life after all. Finally, my beloved wife Mari. I owe you the deepest and most sincere thanks for your endless love and support. Thank you for all the times we have shared - it is grateful for having you beside me! I love you more than I can say.

In Käpälämäki, 6th October 2021

Anssi Kuosmanen

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LIST OF ORIGINAL PUBLICATIONS

This dissertation is based on the following original publications:

I Kuosmanen A, Tiihonen J, Repo-Tiihonen E, Eronen M and Turunen H. Patient safety culture in two finnish state-run forensic psychiatric hospitals. Journal of Forensic Nursing 9: 207–216, 2013.

II Kuosmanen A, Tiihonen J, Repo-Tiihonen E, Eronen M and Turunen H.

Changes in patient safety culture: A patient safety intervention for finnish forensic psychiatric hospital staff. Journal of Nursing Managament 27: 848–

857, 2019.

III Kuosmanen A, Tiihonen J, Repo-Tiihonen E, Eronen M and Turunen H. Nurses’

views highlight a need for the systematic development of patient safety culture in forensic psychiatry nursing. Journal of Patient Safety 17: e228–e233, 2021.

IV Kuosmanen A, Tiihonen J, Repo-Tiihonen E and Turunen H. Voluntary patient safety incidents reporting in forensic psychiatry - What do the reports tell us?

Journal of Psychiatric and Mental Health Nursing 00: 1–12, 2021.

The publications were adapted with the permission of the copyright owners.

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ABBREVIATIONS

AHRQ Agency for Healthcare Research and Quality

ANOVA Analysis of Variance

CINAL Cumulative Index to Nursing and Allied Health Literature

COREQ Consolidated Criteria for Reporting Qualitative Research

CRM Crew Resource Management

FTE Full-time equivalent

GDPR General Data Protection Regulation

HaiPro Finnish safety incident reporting database

HSOPSC Hospital Survey on Patient Safety Culture (nowdays as SOPS® = Surveys on Patient Safety Culture™, also referred to as HSOPS, HSPSC)

IOM Institute of Medicine (nowdays as NASEM = National Academies of Sciences, Engineering, and Medicine)

MaPSaF The Manchester Patient Safety Framework

MD Medical Doctor

NPSA National Patient Safety Agency

PMN Practical Mental Nurse

PS Patient Safety

PSC Patient Safety Culture

PSiRS Patient Safety Incident

PsyCINFO Database of abstracts of literature in the field of psychology

PUBMED United States National Library of Medicine

RCA Root Cause Analysis

RN Registered Nurse

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SAQ The Safety Attitudes Questionnaire SD Standard Deviation

SPSS Statistical Package for the Social Sciences

TeamSTEPPS

Team Strategies and Tools to Enhance Performance and Patient Safety

TUKU Nordic patient safety culture questionnaire

WHO World Health Organization

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1 INTRODUCTION

Patient safety (PS) continues to be a problem in hospitals (Lachman, 2019); for this reason, improving PS has emerged as a primary health care challenge (McFadden et al., 2015). The groundbreaking report ‘To Err Is Human: Building a Safer Health System’ published by the Institute of Medicine in 1999 (Kohn et al., 2000; AHRQ, 2016; Pronovost et al., 2016) prompted the introduction of several initiatives to develop PS. It has been estimated that up to one in ten hospitalized patients are affected by at least one adverse event (AE), half of which are preventable (de Vries et al., 2008; Schwendimann et al., 2018). A positive safety culture has been

associated with the quality of care as well as reductions in adverse events (Sorra et al., 2012; Woodward et al, 2014; Braithwaite et al., 2017; Hessels et al., 2019), and was recently linked to patient outcomes (Dicuccio, 2015; Braithwaite et al., 2017).

The importance of safety culture in health care has been highlighted by several authors (IOM, 2001; Halligan & Zecevic, 2011; Vlayen et al., 2015). Notably, the Institute of Medicine (IOM) already recommended that hospitals should create a safety culture as an explicit organizational goal and a top priority nearly two decades ago. The report also emphasized strong and visible leadership and learning from errors, as well as changes in collective professional norms and expectations (Kohn et al., 2000). In addition, Finland’s updated National Patient Safety Strategy (Ministry of Social Affairs and Health, 2017) was published in 2017 to help develop a common security culture in Finnish social welfare and health care and now, as a result, days measurements of patient safety culture (PSC) is understooded to be one a leading indicator of patient safety (PS) (de Bienassis et al., 2020).

According to Leonard & Frankel (2012), PSC involves considering the incidents to be systemic errors, while also making it clear that engaging in unsafe behavior or destructive acts is unacceptable. The key components of PSC are leadership’s responsibility for safety, learning, recognition and proactive actions towards safety errors, and the presence of a nonpunitive system for reporting and analyzing adverse events (Helmreich & Merritt, 2001; Sammer et al., 2010; Halligan &

Zecevic, 2011). Teamwork, communication (Sammer et al., 2010; Halligan &

Zecevic, 2011), a patient-centered approach (Sammer et al., 2010), and shared beliefs are important parts of PSC (Halligan & Zecevic, 2011). Additional research has shown that PSC influences staff attitudes towards incident reporting

(Kusumawati et al., 2019), while a patient safety learning system should be

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designed to identify the cultural barriers and facilitators of successful adoption and implementation (Health Quality Ontario, 2017).

However, it is often difficult to determine whether a health care organization has fostered a culture of safety (Pronovost et al., 2006); for this reason, measures relevant to PSC must be tied to strategies that aim to develop safety at the

organizational level (Reis et al., 2018). This means that PSC assessments are a part of organizational learning and continuous improvement processes. This is

important because culture was identified as a key patient safety factor in psychiatric care (Kanerva et al., 2016; True et al., 2017; Vandewalle et al., 2018).

Recent research has clarified which strategies can be used to strengthen patient safety culture (PSC) in general health care (Morello et al., 2013; Weaver et al., 2013;

Mc Kenzie et al., 2019), yet only a handful of studies have assessed PSC in

psychiatric care and provided solutions for its development. Despite these positive developments, PS is still under researched in the psychiatric context when

compared to other health care settings (Thibaut et al., 2019) in which PSC and its development has not specially been studied, such as forensic psychiatry care.

The research presented in this thesis aimed to assess and develop the PSC in Finnish state forensic psychiatric hospitals. As such, one of the primary objectives of the research presented in this thesis was to improve the current knowledge base concerning the culture surrounding patient safety incidents in Finnish forensic psychiatry care to ultimately improve PSC in this context. The results highlight that to develop the PS in forensic psychiatric care, it is firstly important to evaluate PSC and analyze patient safety incident reports.

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2 THEORETICAL BACKROUND

2.1 FORENSIC PSYCHIATRIC CARE

Forensic psychiatric treatment focuses on specific types of care, including the risk and management of violence, along with impulse control (Nedopil, 2009). Previous studies have shown that the risk of committing crimes is influenced by both static factors, such as prior offenses or job history, and dynamic factors like antisocial attitudes, substance abuse and antisocial associations (Penney et al., 2016; Ward &

Fortune, 2016). Nurses are at a frontline position for ensuring that patients receive safe treatment (Barnao & Ward, 2015), but it is possible that a patient’s rights may be restricted on the basis of the Mental Health Act (Hörberg & Dahlberg, 2015).

Forensic nurses work with the most vulnerable and challenging psychiatric patients (Durey et al., 2014; Sampson et al., 2016) and demonstrate a safety culture based on how they interact with these patients. Vulnerable patient behaviors within psychiatric care require specialized management strategies (Dewa et al., 2018), which may entail rather powerful coercive measures to avoid violent incidents and ensure safe care in comparison to other fields of health care (Kanerva et al., 2013).

In addition, Finnish forensic psychiatric care occurs at the intersection between mental health care and the law. The Health Care Act (2010/1326), Mental Health Act (1990/1116), Criminal Law (1889/39) and Law on State Mental Hospitals (1987/1293) regulate forensic psychiatric activities in Finland (Seppänen et al., 2020). Regulations concerning the actions of hospitals are outlined in the Health Care Act, with the Mental Health Act describing principles that are specific to psychiatric health services and involuntary hospital care, while the principles of criminal responsibility are included in Finnish Criminal Law.

In Finland, forensic psychiatry is an established, independent medical speciality (Seppänen et al., 2020). The Finnish forensic psychiatric care system is responsible for three specific tasks: 1) conducting forensic mental examinations; 2) treating forensic psychiatric patients who have committed a criminal offense but were not found not guilty for the reason of insanity and prescribed involuntary treatment;

and 3) treat patients who are dangerous and/or difficult-to-treat in municipal mental hospitals (Eronen et al., 2000; Kuivalainen et al., 2014).

The Finnish forensic psychiatric services are provided at two state-run hospitals and single wards at regional psychiatric hospitals (Tuovinen, 2017; Seppänen et al.,

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2020). These hospitals provide specialist high-quality forensic psychiatric services and mental examinations across Finland and are also responsible for training and developing healthcare personnel. These hospitals perform tasks such as forensic mental examinations, forensic psychiatric treatment for patients found not guilty by reason of insanity, along with the care of patients deemed too dangerous and difficult to treat in municipal hospitals (Tuovinen et al., 2017; Seppänen et al., 2020).

Treatment at forensic psychiatric hospitals differs from conventional psychiatric treatment in many ways. The treatment periods are typically long, several years or more, and all of the patients are under involuntary care. In addition, nearly all of the patients have schizophrenia, which most often manifests in the paranoid form (Paavola & Tiihonen, 2010). A majority of the patients have specific problems with substance abuse, poor insight into their illness, and a diminished ability to control violent behavior and aggressiveness (Tiihonen, 2020). Male patients with psychotic disorders have a significantly higher risk of criminal behavior, more specifically, committing violent offences (Tiihonen et al., 1997), while Kuivalainen et al. (2014) found that nearly 18% of the patients (n=502) in Finnish forensic psychiatric hospitals exhibit violent behavior. Forensic psychiatric patients also often have criminal responsibility issues and long-term post-sentencing mental illness that leads to an elevated risk of inter- or intra-personal violence (Seppänen et al., 2018).

2.2 PATIENT SAFETY

The Institute of Medicine (IOM) has long recognized patient safety to be an integral part of health care quality (IOM, 2001). Patient safety is commonly explained as freedom from accidental injury (Kohn et al., 2000), the absence of preventable harm to patients, and reducing the risk of unnecessary harm associated with health care to an acceptable minimum (WHO, 2009). In the field of patient safety, the term “adverse event” is typically used to describe injuries caused by medical conduct that result in prolonged hospitalization and/or disability at the time of discharge (Brennan et al., 1991; Kohn et al., 2000). Another commonly used term is

“near miss”, which is defined as “an act of commission or omission that could have harmed the patient but did not cause harm as a result of chance, prevention, or mitigation” by the IOM (Aspden, 2004).

The health care organization has been identified as a complex adaptive system in which patient safety can be ensured, or at least maximized, via effective

interactions within the health care system such as safety evaluations based on reactive and proactive indicators (Reason, 2000, 2009; Reiman & Pietikäinen, 2012).

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Indicators based on events that have already occurred (for example, incident types and frequency rates) are considered reactive, whereas proactive safety indicators are based on the identification of entities known to influence an organization’s state of safety, e.g., cooperation, communication, guidelines and documentation (Reason, 2009; Reiman & Pietikäinen, 2012).

Patient safety is difficult to define in the context of psychiatric care. Dewa et al.

(2018, p. 1) have defined it as “the avoidance of unintended, unsafe or iatrogenic harm associated with mental health care (either an error in inappropriate treatment or an omission to detect unsafe behavior)”. Patient safety - and the resulting interventions - are usually based on event reporting systems and the subsequent RCA (Shojania et al., 2002). This is also the case in the field or psychiatry, where incident reporting systems and the review of medical records are used to describe the level of patient safety (Marcus et al., 2017; Reilly et al., 2019). However, patient safety in psychiatric care remains an under-researched topic (Daumit & McGinty 2018; Shields et al., 2018; Thibaut et al., 2019).

Patient safety requires leaders who can control and steer an organization, as well as be mindful of the social processes and psychological phenomena that influence the functioning of the organization (Reiman et al., 2010; Vlayen et al., 2015). Since the IOM recommended hospitals to develop a culture driven by leadership based on the report 'To err is human: building a safer health system’

(2001), numerous studies have covered this topic (Kohn et al., 2000; DiCuccio, 2015; National Patient Safety Foundation, 2015; Mc Kenzie et al., 2019).

Transformational leadership has been shown to positively influence safety culture (Merril, 2015). In this leadership style, managers work to broaden the interests of their employees, generate awareness and acceptance of the organizational mission, and motivate staff to look beyond their own self-interests for the good of the group (Bass, 1991). Although managers have been shown to be essential to changes in organizational culture, it has been suggested that they do not always recognize the connection between organizational culture and patient safety (Levine et al., 2020).

Measures for assessing the capacity to deliver safe care are essential for effective health care systems, but it is also important to assess systemic and organizational factors that are linked to risk reduction. Furthermore, these

systems need to integrate learning-based approaches and take human factors into account to foster a culture of patient safety (Mc Kenzie et al., 2019; de Bianassis, 2020). In the context of psychiatric care, safety culture and the clinical

environment have been identified as research priorities for patient safety (Kontio et al., 2014; Dewa et al., 2018).

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2.3 SAFETY CULTURE

The term safety culture came into prominence as a result of the Chernobyl nuclear accident in 1986 (International Nuclear Safety Advisory Group, 1986). From then on, the term safety culture has been applied to various high risk industries, including aviation and the oil and gas industry (Hudson, 2004; Waterson, 2014).

Recently, safety culture has become an increasingly recognized area of interest in health care (Vincent, 2016).

As safety culture is a complex phenomenon, a wide array of definitions for safety culture have been presented in the literature (Glendon & McKenna, 1995;

Hale, 2000; Pronovost et al., 2009). Additionally, Patankar & Sabin developed a conceptual model to describe safety culture across multiple layers (Patankar &

Sabin, 2010). Figure 1 illustrates the safety culture pyramid developed by Patankar and Sabin.

Figure 1. The safety culture pyramid, as presented by Patankar & Sabin (2010).

A common definition characterizes safety culture as “the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an

organization's health and safety management” (Health and Safety Commission, 1993). Moreover, the European Society for Quality in Healthcare define patient safety culture as “a pattern of individual and organizational behavior, based upon

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shared beliefs and values that continuously seeks to minimize patient harm, which may result from the process of care delivery” (EUNetPaS, 2010, p. 4).

Fleming & Wentzell (2008) described different stages of safety culture maturity in an organization (Table 1), ranging from pathological to generative.

Table 1. Levels of patient safety culture maturity (Fleming & Wenzell, 2008, page 12).

Maturity level Approach to improving patient safety culture Pathological No systems in place to promote a positive safety culture

Reactive Systems are piecemeal, developed only in response to occurences and/or regulatory or accreditation requirements

Calculative Systematic approach to patient safety exists, but implementation is patchy and inquiry into events is limited to circumstances surrounding a specific event

Proactive Comprehensive approach to promoting positive safety culture, evidence-based interventions implemented across the organization Generative Creation and maintenance of a positive safety culture are central to the

organization’s mission, learning from failure and success and then taking meaningful action to improve the system

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In contrast, Patankar et al. (2012) presented a model (Figure 2) that is more focused on learning.

footnote: G=GOAL; T= TACTICS

Figure 2. The four safety culture stages model (Patankar et al., 2012, page 114).

Both of these models emphasize the development of culture, along with an understanding of which characteristics define safety culture and how this culture can influence the performance of health care organizations. According to these models, health care leaders must balance between the extremes of punishment and blamelessness to create an environment in which employees understand that they are accountable for engaging in unsafe behavior and know that gross

negligence, willful violations and destructive acts will not be accepted (Dekker, 2008; Leonard & Frankel, 2012).

2.4 PATIENT SAFETY CULTURE

2.4.1 Definition and meaning

Safety culture has considered a complex with multi-dimensions and in health care has emphasized term patient safety culture (PSC). Researchers usually use the term patient safety culture (PSC) whenever safety culture has a defined impact on patient welfare (Reiman et al., 2010; Sammer et al., 2010; Reis at al., 2018). PSC is generally regaded as a subcategory of organizational culture because numerous

SECRETIVE (Failure to learn)

G: Hide/ignore the problem T: Cover up

BLAME (Isolated learning) G: Solve the spesific problem T: Terminate the employee who was closest to the problem

REPORTING (Continuous learning) G: Solve the cluster of problems T: Address systemic issues that led to the problem

JUST

(Transformative learning)

G: Build a system of addressing latent factors that may lead to problems

T: Build a "system of systems" to continuously scan for signs of deteriotion in safety

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aspects of organizational culture have a palpable impact on patient safety (Antonsen, 2009). Sammer et al. (2010) identified seven PS subcultures in their literature review: (a) leadership; (b) teamwork; (c) evidence‐based; (d)

communication; (e) learning; (f) just; and (g) patient-centered. Furthermore, according to the Canadian Institute for Patient Safety (CPSI), health care organizations with positive safety culture share the following characteristics: 1) informed culture; 2) reporting culture; 3) learning culture; 4) just culture; and 5) flexible culture (CPSI, 2020).

In Finland, the second National Patient Safety Strategy (2017–2021) and the Patient and Client Safety Strategy Implementation plan were developed to

promote the development of a common safety culture in Finnish social and health care, and to harmonize the implementation of the programs required for this purpose (Ministry of Social Affairs and Health, 2017, 2020). The establishment of a PSC is included under the management pillar alongside a blame-free environment and high transparency and is indicator of PS (Ministry of Social Affairs and Health, 2017; de Bianassis, 2020).

Organizational culture has been shown to enhance patient safety in health care facilities (Department of Health, 2000; Kohn et al., 2000; Halligan & Zecevic, 2011), whereas poor PSC was identified as a contributing factor to adverse events (Francis, 2013). In their systematic review, Braithwaite et al. (2017) found that positive organizational and workplace cultures were frequently associated with changes in various patient outcomes, namely, reduced mortality rates, falls, and hospital acquired infections, along with increased patient satisfaction. In health care, PSC has evolved to be a concept that is based on structured methods to understand phenomena linked to safety (Nordin et al., 2013). When focusing specifically on psychiatric care, three systematic reviews (Brickell et al., 2009;

Kanerva et al., 2013; Thibaut et al., 2019) have described factors that influenced PS. These include the complexity of PS, establishing a culture of PS (including the adoption of a system-level procedure for examining patient safety incidents), promoting open reporting and communication, along with the elimination of stigma (Brickel et al., 2011).

The importance of PSC has already been emphasized for decades, with several studies detailing how health care organizations have developed a safety culture (Morello et al., 2013; Basson et al., 2018). Reviews have showed that unit-based programs, leadership rounds, teamwork, and communication have a positive effect on PSC (Morello et al., 2013; Weaver et al., 2013). Various patient safety strategies and actions for developing PSC have also been described, including leaders discussing patient safety topics during hospital rounds (Basson et al., 2018;

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Singer & Tucker, 2014), teamwork (Jones et al., 2013), electronic medical record system implementation (McGuire et al., 2013), risk management workshops and system thinking education program (Tetuan et al., 2017), as well as the

implementation of crew resource management (Hefner et al., 2016).

It has been earlier reported that the first stage of improving PSC is controlling and steering an organization towards the right values and being mindful of the social processes and psychological phenomena which influence PS (Reiman et al., 2010; Diya et al., 2012; Vlayen et al., 2015). Furthermore, group values, perceptions and behaviors have been suggested to play a larger role in changing PSC than the actions of an individual caretaker (Lee et al., 2019); however, for this to happen the management must understand why PSC is important.

2.4.2 Measuring

Methods for measuring PSC have improved over recent years. Several instruments have been specifically designed for this purpose. In the field of health care, safety culture is typically evaluated by quantitative surveys based on individual items organized across various dimensions (Flin, 2007; Waterson, 2014; Churruca, 2021) . As such, quantitative studies focusing on safety culture usually employ safety questionnaires (Guldenmund, 2000), which can be used to increase staff

awareness of PS, identify areas that need improvement, and/or assess current PSC status and trends (Cooper, 2000; Danielsson et al., 2019). It is recommended that a safety culture questionnaire should be appropriately validated before being applied to a specific health care context (Vlayen, 2015).

Several instruments have also been designed - and used - to measure health care staff perceptions of safety culture (Colla et al., 2005; Singla et al., 2006; Flin et al., 2007; Halligan & Zecevic, 2011; Waterson, 2014; van Nunen et al., 2018; de Bienassis, 2020). In 2010, The European Network for Patient Safety Project identified 19 different survey instruments and methodologies used to measure safety culture in various European Union (EU) member states (Kristensen &

Bartels, 2010).

Although various instruments to measure PSC exist, this concept is usually described through dimensions such as management/supervision, leadership, risk, commitment to safety, safety systems, rules, staff competence/adequacy,

communication, teamwork and nonpunitive response to errors (Singla et al., 2006;

Waterson, 2014). For this reason, several studies have suggested that a standard measurement instrument for patient safety should be developed and applied in the health care field (Lee & Quinn, 2020).

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The Manchester Safety Framework (MaPSaF), the Safety Attitudes Questionnaire (SAQ), and Hospital Survey on Patient Safety Culture

(HSOPSC/HSPSC), all of which have been rigorously tested, are the most commonly used instruments in health care, both worldwide as well as in the EU member states (Kristensen & Bartels, 2010; Simsekler 2020). The Nordic Patient Safety Culture Questionnaire (TUKU) and HSOPSC (Kristensen & Bartels, 2010) are the most commonly used instruments in Finland. In 2019, HSOPSC was updated by removing 21 items, renaming 25, and adding 10 new ones. The resulting instrument is known as SOPS® (Sorra et al., 2019a, 2019b).

Among these instruments, HSOPSC is the instrument most commonly used in research concerning safety culture (Reis et al., 2018). HSOPSC was also used in the research presented in this dissertation. The evaluation of safety culture needs to be linked to strategies that aim to develop safety culture on an organizational level (Reis et al., 2018). At present, several valid survey instruments can be used to assess health care staff perceptions of safety culture (Colla et al., 2005; Flin et al., 2006; Singla et al., 2006; van Nunen et al., 2018), but the PSC of forensic psychiatry care has only received limited research attention.

2.4.3 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

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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.

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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).

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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.

2.5 SUMMARY OF THEORETICAL BACKROUND

Patient safety has been studied less extensively in psychiatric care than in other inpatient settings (Daumit & McGinty, 2018; Shields et al., 2018; Thibaut et al., 2019), and there is a clear lack of knowledge concerning PS and PSC in forensic psychiatry care.

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Methods for improving patient safety in psychiatry are relevant because previous research has shown that improvements to adverse event reporting and actions to improve PSC are slowly implemented in psychiatric care (Öhrn et al., 2011) and professionals’ safety culture result was below the recommended (Oliveira et al., 2018). This may be due to the fact that PS definitions remain unclear in mental health care (Brickell et al., 2011). Moreover, psychiatry and speficially forensic psychiatry may have some specific features, such as the threat of violence, that should be considered. Enhancing PSC involves creating a culture of safety and integrating it across organizational levels. This requires the adoption of a systems level approach to analyzing patient safety incidents, encouraging open communication, and considering the patient’s perspective (Brickell et al., 2011).

Leadership and management can provide the stimulus needed for PSC improvements, with middle management having been shown to be particularly influential in terms of organizational change, especially positive modifications in PSC (Gutberg & Berta, 2017). Leaders must be encouraged to commit to improving PSC. Next, the organization must be steered towards a certain culture through specific interventions (Patankar & Sabin, 2010; Vlayen et al., 2015).

Various strategies have been used to improve PSC, e.g., hospital rounds, risk management workshops and the implementation of crew resource management (Öhrn et al., 2011; Mahoney et al., 2021; Hefner et al., 2016; Kristensen et al., 2016;

Tetuan et al., 2017; Basson et al., 2018). In this research, implementation of patient safety incident system and appropriate education were used to improve PSC in forensic psychiatric care.

The development of PSC requires the active identification of opportunities for improvement and establishing the willingness of the organization to implement change (Vlayen et al., 2012, 2015; Kristensen et al., 2016). Both of these issues can be assessed by PSC surveys, the most common of which are HSOPSC and SAQ (Vlayen et al., 2012, 2015; Hamaideh, 2017; Kristensen et al., 2016; Oliveira et al., 2018; Dickens et al., 2019).

PSC is also affected by how employees, leaders and an organization handle patient safety incidents, while information on the prevalence, severity, and

preventability of these events is valuable to the creation of future safety initiatives (Kohn et al., 2000; Brickel et al., 2011; Francis, 2013; Braithwaite et al., 2017;

Thibaut et al., 2019).

The performed literature review demonstrated that PSC in psychiatry has intensified in recent years, yet no studies have specifically focused on forensic psychiatry care. PSC changes should be assessed whenever health care managers

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make modifications to safety protocols, e.g., how adverse events are handled, or introduce processes that will transform the organizational culture. However, it should be noted that health care staff are the professionals who are in direct contact with patients, which means that it could be beneficial to consider their suggestions for how PS can be developed. The research presented in this dissertation describes PSC in Finnish forensic psychiatry based on the HSOPSC instrument and descriptive qualitative data, as well as uses voluntary incident reports from staff to detail PS in forensic psychiatry care.

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3 AIMS OF THE STUDY

The main aim of the research presented in this dissertation was to examine patient safety culture (PSC) in Finnish forensic psychiatric care from the perspective of health care staff.

The additional aims of the presented research are as follows:

1. to describe PSC from the staff member´s perspective with the objective of identifying both areas of strength and improvement needs and comparing them to background variables:

a) hospital b) manager

c) opportunity for supplementary education d) professional status (sub-study I, article I),

2. to examine how a safety intervention influences PSC in forensic psychiatric hospitals (sub-study I, article II),

3. to describe forensic psychiatric nurses´ views about patient safety, PSC and errors (sub-study II, article III),

4. to characterize patient safety incident types, including frequencies and typical recommendations for how to handle these events (sub-study III, article IV).

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4 MATERIAL AND METHODS

4.1 STUDY DESIGN

The qualitative and quantitative data used in the research underlying this dissertation were collected and analysed independently, and are further synthesized and presented in the discussion section (Figure 4).

Figure 4. Study design.

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PSC was studied in two state-run mental hospitals in Finland. Both hospitals provide the same professional forensic psychiatric services and treat similar groups of patients (Seppänen et al., 2020), with the exception that one has an adolescent ward and the other does not. These two state hospitals admit three groups of patients: patients who have committed a crime but were found not guilty by reasons of insanity; patients who are considered too dangerous or difficult to treat in municipal hospitals; and patients undergoing a forensic mental examination. These hospitals can accommodate over 450 patients, which

represents a majority of the total beds available in Finnish forensic psychiatric hospitals. These two state hospitals employ approximately 660 social- and healthcare staff, with roughly 85% of them nurses (RN/PMN).

This study consists of three sub-studies (article I–IV), which included different samples, time frames, settings, designs, as well as data collection and analysis methods (Table 2). The first sub-study (articles I and II) was a cross-sectional study which described PSC in two forensic hospitals in Finland and examined whether PSC changed following a safety stepvise intervention (Table 3). The second sub- study (article III) concentrated on nurses´ subjective views of PSC in their hospitals (same hospitals as article I). The third sub-study (article IV) investigated voluntary patient safety incident reports from one forensic psychiatric hospital.

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Table 2. Descriptions of the original studies underlying this dissertation. Original study / articlesDesignSample and size Data collection and instrumentData analysis I Patient Safety Culture in Two Finnish State-Run Forensic Psychiatric Hospitals Quantitative; Cross-sectional study Social- and health-care staff (n=283) working in two forensic hospitals in Finland Anonymous electronic web- based survey using the HSOPSC questionnaire, April-May 2010

Cronbach’s alpha, Descriptive statistics, Post-hoc Bonferroni test, T-Test, Mann-Whitney U-test, ANOVA, Kruskall-Wallis test II Changes in Patient Safety Culture: A Patient Safety Intervention for Finnish Forensic Psychiatric Hospital Staff

Quantitative; correlational, nonequivalent comparison group study One study and one control hospital; study hospital (baseline n=199, follow-up n=207); control hospital (baseline n=84, follow-up n=77) Anonymous electronic web- based survey using the HSOPSC questionnaire, April-May 2010 (baseline) and April–May 2013 (follow- up)

Cronbach’s alpha, Descriptive statistics, Pearson’s chi- squared test, Z-score test, T-test III Nurses’ Views Highlight a Need for the Systematic Development of Patient Safety Culture in Forensic Psychiatry Nursing

Qualitative; descriptive survey study Nurses (n=77) working in two forensic hospitals in Finland

Anonymous electronic web- based open-ended survey, April–May 2010

Inductive qualitative content analysis IV Voluntary Patient Safety Incidents Reporting in Forensic Psychiatry - What they tell to us?

Quantitative; retrospective, register study Voluntary patient safety incident reports (n=2521) from a forensic psychiatric hospital Patient safety incident reporting system, March 2012–February 2018

Descriptive statistics

Patient safety culture in forensic psychiatric hospital care : Health care staff perceptions'

ANSSI KUOSMANEN

Patient safety culture in forensic psychiatric hospital

care

Dissertations in Health Sciences

PATIENT SAFETY CULTURE IN FORENSIC PSYCHIATRIC HOSPITAL CARE

Anssi Kuosmanen

PATIENT SAFETY CULTURE IN FORENSIC PSYCHIATRIC HOSPITAL CARE

ABSTRACT

TIIVISTELMÄ

To my family with love

ACKNOWLEDGEMENTS

Anssi Kuosmanen

LIST OF ORIGINAL PUBLICATIONS

CONTENTS

ABBREVIATIONS

1 INTRODUCTION

2 THEORETICAL BACKROUND

2.1 FORENSIC PSYCHIATRIC CARE

2.2 PATIENT SAFETY

2.3 SAFETY CULTURE

2.4 PATIENT SAFETY CULTURE

2.5 SUMMARY OF THEORETICAL BACKROUND

3 AIMS OF THE STUDY

4 MATERIAL AND METHODS

4.1 STUDY DESIGN