Patient safety attitudes of paediatric trainee physicians
- 1Department of Medicine, Children’s Hospital Boston, Boston, Massachusetts, USA
- 2National Institute of Mental Health, NIH, Bethesda, Maryland, USA
- 3Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
- Correspondence to Gareth Parry,
- Accepted 10 October 2008
Objectives: To measure the patient safety attitudes of trainee physicians at an academic paediatric hospital.
Design: Cross-sectional survey.
Setting: An academic paediatric hospital.
Participants: 209 trainee physicians based at the academic paediatric hospital in January 2004.
Main outcome measures: Patient safety attitudes of trainee physicians measured using the Safety Attitudes Questionnaire (Inpatient Version) and a specific trainee survey.
Results: In the Safety Attitudes Questionnaire, responses were most positive in areas associated with independent care: job satisfaction (mean factor score = 77.5) safety climate (76.1), working conditions (75.6), perception of management (70.4) and less positively in areas associated with interdependent care: teamwork climate (64.6) and stress recognition (59.1). In the trainee survey, following a principal component analysis to identify summary factors, responses were most positive in the independent areas of clinical supervision and support (75.0), communication with their immediate senior physician (65.5) and orientation of new personnel (63.9), and less positive in the interdependent areas of handoffs and multiple services, (58.1), role identification during codes (51.0) and support following an adverse event (42.8). The combined independent factor scores were higher than the interdependent (difference = 17.9, 95% CI 16.1 to 19.7, p<0.001). Fellows reported higher independent factor scores than residents (5.5, 95% CI 2.2 to 8.9, p = 0.001), but not for the interdependent scores (−0.5, 95% CI −3.6 to 2.7, p = 0.767).
Conclusions: Trainees appear comfortable with caring independently for patients but less so caring interdependently. With experience, trainee physicians may experience improvement in their ability to act independently but not interdependently. Recently developed patient safety culture instruments may enable additional understanding of what could be implemented to make improvements.
The next generation of trainee physicians will have a major impact on whether the future healthcare system will provide safer and higher quality care than is currently available. This group of physicians will apply their training in a variety of settings and may take with them not only the medical skills they acquired but also the attitudes and beliefs to patient safety they developed within the training programme. Current theory states that improvements in the patient safety climate of a healthcare institution are likely to lead to improvements in overall patient safety.1 2 3 4 In order to improve the healthcare systems in which trainee physicians work, an important starting point is to understand the current safety attitudes of trainee physicians.
Previous studies have reported variation in the perception of safety attitudes among various types of hospital staff, with few focusing on trainee physicians.5 6 There is some evidence that on measures assessing patient safety attitudes, trainee physicians differ from more experienced clinicians in their responses. For example, trainee physicians in the USA report teamwork within their hospital setting more positively than the senior physicians in their own discipline, but less so than senior physicians in other settings.3 Another study in the UK found that more junior physicians rate leadership and communication in an operating room setting less positively than more senior physicians.7
The results of most previous studies are based on the application of a variety of patient safety climate and related surveys.3 5 6 7 There is a growing number of such tools and little consensus to guide researchers in choosing the most appropriate.8 As part of an evaluation of the implementation of Patient Safety Executive WalkRounds at an academic paediatric hospital in Massachusetts, USA, clinical staff were surveyed using the Safety Attitudes Questionnaire (SAQ) designed by Sexton and colleagues 9 The SAQ has been used internationally in more than 200 hospitals.3 10 In light of the limited literature on trainee physicians noted above, our goal was to supplement the SAQ with a survey specifically designed for physician trainees (trainee survey). The trainee survey was created to include specific questions designed to probe communication within and across disciplines, continuity of care, supervision and support following an adverse event. We undertook this survey in order to describe trainee physicians’ attitudes towards patient safety, explore if type of training experience impacted their responses and to identify, from the training perspective, where problems in the patient safety climate might exist in a paediatric hospital.
The study was conducted in a 325-bed tertiary care urban paediatric teaching hospital in Massachusetts, USA, with a broad range of medical and surgical specialties, solid organ and stem cell transplantation units, and cardiac, medical/surgical and neonatal intensive care units. The hospital also provides primary care and hospital services for a large, diverse patient population in its adjacent geographical area.
In the USA, the term “trainee physician” can apply to both “resident” physicians and or physicians doing a fellowship, called “fellows”. Having previously completed a medical degree, resident physicians enter a postgraduate medical training programme (residency) leading to eligibility for board certification in either a principal or subspecialty. The programme typically takes 3 years to complete and involves care of inpatient or ambulatory patients, with direct supervision by senior physicians. Fellows have completed their full residency programme and are undertaking further clinical training in a highly specialised area, for example in paediatric anaesthesiology. Fellowship programmes typically run for 2 or 3 years (including time for research in addition to clinical activities), but can be longer for some surgical specialities.
All 295 registered (120 residents, 175 fellows) medical and surgical trainees at the study hospital in January 2004 were eligible for the study.
The SAQ (Inpatient Version) contains 54 questions (items) with closed-ended responses asking the respondents to indicate their level of agreement with each item on a 5-point scale ranging from “1” (strongly disagree) to “5” (strongly agree). Responses to the SAQ can be summarised into six factors: perceptions of management, safety climate, teamwork climate, working conditions, stress recognition and job satisfaction.
The Trainee Survey (Box 1) supplemented the SAQ by including the more trainee-relevant areas of communication (items 1, 2, 3, 19, 20, 21, 22) handoffs/continuity of care (5, 6, 7, 9) and supervision (10, 11, 12, 13, 15, 16, 17, 18), as well as additional items related to institutional support following an adverse event (4, 8, 23). The items in the Trainee Survey were taken from the unpublished work of Samandari and colleagues, who developed a larger survey examining patient safety in the same paediatric hospital. For the Trainee Survey, respondents were asked to indicate their level of agreement with each item on a 4-point scale ranging from “1” (strongly disagree) to “4” (strongly agree), with an added option of “I don’t know” scored as a missing value.
Surveys were distributed and collected by administrative assistants in 26 of 38 hospital departments and divisions with training programmes.
SAQ data items were aggregated into the six factors: perceptions of management, safety climate, teamwork climate, working conditions, stress recognition and job satisfaction.4
For the Trainee Survey, a factor analysis was carried out to explore the latent structure of the response variables and to identify practical summary factors. The principal components analysis was conducted on the responses using a varimax rotation to maximise the loadings on each factor. Using standard methodology, an eigenvalue (an indication of the overall variation in the response variables explained) greater than 1 was used as a criterion for identifying factors. Responses coded as “I don’t know” or missing were coded as the mean of that item for the purposes of the factor analysis.
For ease of interpretation, both the SAQ and Trainee Survey summary factors were each converted into factor scores on a 0- to 100-point scale.4 For example, a Teamwork factor score of 0 indicated a person had responded “disagree strongly” in all items relating to that factor and a score of 100 indicated they had responded “agree strongly” in all items.
For both the SAQ and the Trainee Survey, the reliability of each factor (or amount which the items comprising the factor are correlated with each other) was assessed by calculating the Cronbach α value.11
Pearson correlation coefficients were calculated to examine the extent to which all the factors across both the SAQ and Trainee Survey are associated.
A comparison of the mean summary factor scores (using a t test) by whether the responder was a trainee or a more experienced fellow and between responders reporting to be within their first 2 years or later stages of their current programme was performed.
The study was considered to be an initiative of the hospital’s quality improvement programme, so formal institutional review board approval was not required. However, we did follow institutional review board guidelines in adding a cover letter to the surveys stating that the surveys were anonymous, aggregate results from the survey might be published, response was voluntary and that individuals who did not want their responses included in published aggregate data should submit blank surveys.
The survey was administered to 295 trainee physicians and returned by 209 (71%). Residents and fellows accounted for 61 (29.2%) and 148 (70.8%) of responses respectively. Seven (2.3%) surveys were returned blank and 3 (1.4%) were incomplete. For residents, 25 (39%) were in the first or second year of training, and for fellows, 94 (64%) were in the first or second year.
Identification of trainee survey factors
Factor analysis of the trainee survey (Box 1) resulted in identification of six summary factors (each associated with an eigenvalue >1), explaining a total of 64% of the total variation in the responses. Details of the factor loading and the percentage of variance in the principal component analysis explained by each factor are given in Appendix A. The summary factor (itemised in Appendix A) scores were converted to factor scores on a scale of 0 to 100. The factors were described as: clinical supervision and support, communication with senior clinical staff, handoffs and multiple services, orientation of new personnel, role identification during codes and support following an adverse event.
Assessment of trainee survey and SAQ factors
Having identified summary factors for both the Trainee Survey and using established methodology to calculate summary factors for the SAQ, their distribution, reliability and between-factor correlation were examined. The average values (on a scale of 0 to 100) of the six summary factors of the SAQ and Trainee Survey are shown in table 1 together with the Cronbach α values resulting from the reliability analysis. All Cronbach α values were greater than 0.6, indicating satisfactory reliability. Appendix B provides details of the correlation coefficients between all factors across both the SAQ and Trainee Survey. Within the SAQ factors, the SAQ safety climate factor correlated most highly with working conditions (r = 0.69), teamwork (0.62) and job satisfaction (0.61). Within the Trainee Survey factors, the SAQ safety climate factor correlated highest with orientation of new personnel (0.48) and handoffs and multiple services (0.44).
Description of trainee survey and SAQ factors
From table 1, summary SAQ factor scores were highest (mean = 77.5, SD (19.4)) for both residents and fellows in job satisfaction, followed by safety climate (65.5 (76.1)), working conditions (75.6 (15.6)), perception of management (70.4 (20.4)), teamwork climate (64.6 (12.5)) and stress recognition (59.1, 17.1). In the Trainee Survey, the highest scores were for clinical supervision and support, (75.0 (18.2)), followed by communication with their immediate senior physician, (65.5 (17.5)), orientation of new personnel, (63.9 (21.5)), handoffs and multiple services, (58.1 (16.0)), role identification during codes (51.0 (22.3)) and support following an adverse event (42.8 (28.0)).
The factor scores suggest that trainee physicians report higher in areas characterised by independent (where the associated items that make up these factors relate to situations where the respondent is acting alone or is responding to the feedback they receive from one other person) delivery of care (job satisfaction, safety climate, working conditions, clinical supervision and support and communication with their immediate senior physician) and less highly in areas of interdependent (where the items that make up these factors are based on situations where respondents interact with another group of providers) delivery of care (teamwork climate, handoffs and multiple services, role identification during codes, support following an adverse event). Using a post-hoc repeated measures analysis, the combined factor scores for the independent factors were found to be significantly higher than the interdependent factors (difference = 17.9, 95% CI 16.1 to 19.7, p<0.001), indicating that such differences are consistent within individual trainee physicians.
Comparison of trainee survey and SAQ factors by respondent experience
Fellows reported more positive attitudes than residents in all the SAQ factors (p<0.05), other than stress recognition (Table 1 and figure 1A). Within the Trainee Survey, although fellows reported more positively than residents to orientation of new personnel, communication with senior clinical staff and support following an adverse event, these differences were not statistically significant (figure 2A).
Using a post-hoc repeated measures analysis, the combined factor scores for the independent factor scores were found to be significantly higher in fellows than in residents (5.5, 95% CI 2.2 to 8.9, p = 0.001), but no difference was found in the interdependent scores between residents and fellows (−0.5, 95% CI −3.6 to 2.7, p = 0.767).
Compared to fellows in years 1 and 2 of their training, those in years 3 and 4 reported more positive responses to the SAQ job satisfaction, working conditions, teamwork and stress factors and in the Trainee Survey to orientation of new personnel, handoffs and multiple services, role identification during codes and support following an adverse event. However, these are not statistically significant differences (table 1).
The post-hoc repeated measures analysis found no difference in the independent (1.2, 95% CI −4.0 to 6.4, p = 0.655) and interdependent (1.1, 95% CI −2.8 to 5.1, p = 0.574) factor scores for fellows in years 1 and 2 of their training compared to those in years 3 and 4.
The small number of respondents reporting their “years of training” prevented a similar meaningful analysis within the resident group.
Trainee physicians rated most positively job satisfaction, safety climate, working conditions, clinical supervision and support and communication with their immediate senior physician. Overall, they rated less positively teamwork climate, stress recognition, handoffs and multiple services, role identification during codes, support following an adverse event. These data may suggest that trainee physicians are comfortable with their ability to care independently for patients and to ask for help from their immediate supervisor. However, results also indicate that trainee physicians are not fully comfortable with their ability to act interdependently. The survey results provide some evidence that trainee physicians become more comfortable with their ability to act independently as their experience grows, but their comfort at acting interdependently remains unchanged.
A recent study by Sexton et al4 reported SAQ factor scores from all hospital staff from the USA, UK and New Zealand. Compared to the current study, factor scores were lower in the Sexton study for Safety Climate, Perceptions of Management, Job Satisfaction and Working Conditions; similar for Teamwork and higher for Stress Recognition. All though of some contextual interest, comparison between these studies is hampered by the different characteristics of the respondents sampled.
Senior role models in the medical field will be critically instrumental in convincing trainees that quality improvement and patient safety are as high a priority as learning more traditional medical skills.12 13 14 Moreover, institutions will need to provide time and incentives for trainees to acquire these skills and to participate in improvement initiatives. Furthermore, fostering interdependence may be maximised if hospital systems are designed to encourage and support interdependent work. These processes are more likely to succeed if trainees participate in their design; nevertheless, this requires skills which most residents do not acquire either in their medical schools or hospital training programmes.
It is concerning that results indicate that trainee physicians tend not to recognise that they are experiencing stress and fatigue that might contribute to error. This is particularly relevant in light of the debate over mandates reducing the hours resident physicians spend in the hospital.15 16
Another important finding suggested that trainee physicians report they are not fully aware of hospital systems for reporting errors and adverse events, follow-up procedures or confidential emotional support. If the factors that lead to errors are to be understood and addressed, clinical staff must know how to report incidents and what will happen subsequently.17 18 19 The hospital has expanded clinician support services, including an ombudsman that provides confidential counsel. Currently, all trainees in the study hospital are provided with information about this service during orientation and through web-based resources.
An alternative interpretation of the survey results is that they reflect behaviour inherent to trainee physicians, in that they may not be expected to be comfortable acting in an interdependent way when they are embarking on a period of training. There is often a friction between the need to allow residents and fellows to develop their newly acquired skills and the need to provide consistently safe care. These results cannot inform this debate directly, however the results do suggest that the patient safety attitudes of trainee physicians may alter positively over time. To fully explore this area, it may be important to re-administer the surveys in the future.
The survey results should be interpreted with the following limitations. More recent tools (eg, the Hospital Survey on Patient Safety Culture and Manchester Patient Safety Assessment Framework) include additional areas that may inform an overall safety culture.20 21 This implies there is no universally accepted or definitive model of patient safety culture. Furthermore all of these tools, including the SAQ may not feature the full range of components that make up safety culture. While quantitative surveys may be useful in highlighting problem areas, they do not provide a deep understanding of the underlying culture. Such survey tools do not allow for recognition that people act not only on their own opinions but also on the shared values or beliefs of the environment within which they work. Thus, a person may behave quite differently depending on the social expectations and other factors influencing group behaviour in various settings. Of note, little published evidence exists establishing a link between safety culture or climate and indicators of patient safety.5 22 23 This makes it difficult to know which of the factors (if any) should be prioritised for targeting improvements.24 Lastly, there is little understanding of what results should be expected from such surveys and all though more data is being accrued and reported, the ability to directly benchmark results is currently limited.25
There has been encouraging progress in the USA to improve the education of physician trainees in quality improvement and patient safety. In 1999, the Accreditation Council for Graduate Medical Education endorsed general clinical competencies for resident physicians.26 In meeting these expectations it is reasonable to ask, who will train the trainees? Most junior and senior faculty in academic institutions may not have these skills themselves, and therefore will require the necessary education in order to serve as effective role models and teachers.27 28 29 30
In conclusion, we found that physician trainees may perceive gaps in interdependent patient care. Moreover, they may not yet fully understand how to access systems specifically designed for individuals involved in errors and adverse events. The relative importance or clinical impact of these gaps is unclear. There is some evidence to suggest that with experience, trainee physicians do experience some improvement in their ability to act independently but not interdependently.
Ongoing monitoring of patient safety climate or culture within the hospital may lead to a deeper understanding of this complex area and greater insights into where improvements may or may not need to be focused.
▸ Additional appendices and a sample survey form are published online only at http://qshc.bmj.com/content/vol18/issue6
Funding GP was supported in writing this paper by the Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health and social issues. The views presented here are those of the authors and not necessarily those of Commonwealth Fund, its director, officers or staff.
Competing interests None.