Patient Safety Culture in Healthcare: A Literature Review

Introduction to Patient Safety Culture

Bonner (2008) asserted in his study that the most significant feature for creating high reliability in hospitals is patient safety culture (PSC). Nevertheless, some researchers have shown the relationship between PSC and actual clinical outcomes. In his study, Bonner highlights that nursing home studies have newly appeared in the current literature available in the medical domain. Nursing homes and hospitals are very different from each other because in nursing homes certified nursing assistants (CNAs) provide specialized care. As a result, nursing home PSC differs from PSC in acute care institutions (Bonner, 2008).

Bonner (2008) focused on the use of secondary data analysis to examine whether CNAs' perceptions of PSC were linked with clinical outcomes in a random sample of 74 nursing homes selected from five states. The study reveals that in the first half of 2005, the selected nursing homes and states achieved synchronization between the certified nursing assistants' PSC analysis data — using the Hospital Survey on Patient Safety Culture (HSOPSC) — with the Minimum Data Set (MDS), Area Resource File (ARF), and Online Survey Certification and Reporting (OSCAR). Studies showed that out of 2,872 nurses, only 1,579 were nurse aides, and when the survey was completed the response rate was 55% (Bonner, 2008).

Carroll and Quijada (2010) emphasized that experts in numerous healthcare sectors and organizations who inquire about the enhancement of patient safety culture in the highly competitive and demanding medical environment often recognize culture as an obstruction to positive and necessary change. The focus of the patient safety culture concept centers on individual sovereignty — a value that appears to work in conflict with already established standards of teamwork, problem solving, and the processes of knowledge and learning. Through cultural analysis, professional values can be redirected to uphold change efforts, as culture is one of the important factors enabling lasting transformation. Examples from various organizations illustrate the cultural strength that creates new working methods and produces a gradual shift in culture (Carroll and Quijada, 2010).

Organizational Culture and Quality of Healthcare

Davies and colleagues (2000) explained that health policy in the industrialized and developed countries of the world is dedicated to analyzing and enhancing the overall delivery of healthcare. In the USA, specific concern has been identified over quality issues, and a high number of medical errors have been reported over the years, as indicated in a report by the Institute of Medicine (as cited in Davies et al., 2000). Quality improvement has become one of the most important areas of medical discussion as quality scandals came to the fore in the UK. The central question raised is: how is quality enhancement to be fashioned within such an intricate system as healthcare?

Another dilemma when assessing the quality of safety and service in healthcare is the impact of potential changes in organizational structure; many practitioners refer to this as "the key to quality improvement." In considering how such evolving organizational structures can influence patient safety culture, one researcher suggested that cultural change needs to be created alongside structural reorganization and system restructuring. This in turn will result in the formation of a culture that complements change and adaptation to methods that improve the level of quality. A continuous evaluation of change in the UK over the past two decades was also discussed thoroughly by Davies and colleagues (2000), who concluded that cultural change had come in various forms — it was in fact the only constant, and was neither new nor unpredictable. On the other hand, discussion of "culture" and "cultural change" raises complex questions regarding the fundamental structures within which adaptation or change programs are applied in hospital settings (Davies et al., 2000).

Schein (1992) took a distinct approach to the literature on safety culture and safety climate, focusing on social-psychological and organizational-psychological traditions. He asserts that even though both safety culture and safety climate are recognized as important concepts, little consensus has been reached on their origins, contexts, or outcomes over the past several decades. Moreover, there are limited models focused primarily on illustrating the relationship between safety, risk management in hospital settings, and an analysis of patient safety and care procedures.

Safety Culture and Safety Climate Frameworks

According to Schein, the difference between safety culture and safety climate can be understood through the universal organizational cultural structure he established (1992). This universal structure identified three levels that can be used to evaluate organizational culture in any setting:

Basic assumptions form the deepest level of organizational culture. Espoused values are the attitudes associated directly with the phenomenon of patient safety climate. Artifacts are the visible, surface-level expressions of culture. The core of patient safety culture is shaped by basic assumptions. It has been debated whether basic assumptions are necessarily considered when addressing patient safety specifically; many researchers believe that if they were taken into account, the impact on patient safety culture structures could be significantly positive. We might therefore consider the factors shaping organizational culture as potential indicators of safety performance, though research should focus more rigorously on their scientific validity. Guldenmund (2000) supports this view by asserting that the assessment of an organization's basic assumptions is important because those assumptions are the underlying explanations for the attitudes that exist when dealing with patient safety culture (Guldenmund, 2000).

Flin (2007) observed that safety measurement techniques used in high-risk industries have been adopted by Western healthcare organizations in response to growing concern about patient safety. In his study, Flin examined the perceptions and attitudes of the workforce toward both worker and patient safety using a safety climate questionnaire technique. He concluded that earlier safety climate procedures did not meet adequate psychological standards, and he designed a model using prior research as a basis to explain the hypothetical relationship between the perception of patient safety climate and worker behavior (Flin, 2007). His model highlighted new psychological and practical examples of the relationship between the two aspects, including employee satisfaction, employee–patient communication, and lateral as well as top-down and bottom-up understanding of responsibilities.

Conclusion

Research indicates that US hospitals are becoming more accountable in the matter of reducing medical errors and improving patient safety. According to the published report of the Institute of Medicine, patient safety has become the main motive behind numerous changes in organizational structures currently adopted within US hospitals (Institute of Medicine, 2000, 2001).