Article Text

Patient safety culture assessment in the nursing home
1. S M Handler1,2,
2. N G Castle3,
3. S A Studenski1,4,
4. S Perera1,5,
5. D B Fridsma2,
6. D A Nace1,
7. J T Hanlon1,6,7
1. 1Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
2. 2Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
3. 3Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
4. 4GRECC, VA Pittsburgh, Pittsburgh, Pennsylvania, USA
5. 5Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
6. 6Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
7. 7Center for Health Equity Research, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
1. Correspondence to:  Dr S M Handler  Division of Geriatric Medicine, University of Pittsburgh, 3471 Fifth Avenue, Suite 500, Pittsburgh, PA 15213, USA; handlersm{at}upmc.edu

## Abstract

Objective: To assess patient safety culture (PSC) in the nursing home setting, to determine whether nursing home professionals differ in their PSC ratings, and to compare PSC scores of nursing homes with those of hospitals.

Methods: The Hospital Survey on Patient Safety Culture was modified for use in nursing homes (PSC-NH) and distributed to 151 professionals in four non-profit nursing homes. Mean scores on each PSC-NH dimension were compared across professions (doctors, pharmacists, advanced practitioners and nurses) and with published benchmark scores from 21 hospitals.

Results: Response rates were 68.9% overall and 52–100% for different professions. Most respondents (76%) were women and had worked in nursing homes for an average of 9.8 years, and at their current facility for 5.4 years. Professions agreed on 11 of 12 dimensions of the survey and differed significantly (p<0.05) only in ratings for one PSC dimension (attitudes about staffing issues), where nurses and pharmacists believed that they had enough employees to handle the workload. Nursing homes scored significantly lower (ie, worse) than hospitals (p<0.05) in five PSC dimensions (non-punitive response to error, teamwork within units, communication openness, feedback and communication about error, and organisational learning).

Conclusions: Professionals in nursing homes generally agree about safety characteristics of their facilities, and the PSC in nursing homes is significantly lower than that in hospitals. PSC assessment may be helpful in fostering comparisons across nursing home settings and professions, and identifying targets for interventions to improve patient safety.

• HSOPSC, Hospital Survey on Patient Safety Culture
• PSC, patient safety culture
• PSC-NH, patient safety culture in nursing homes

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### Data analysis

To calculate response rates, the number of respondents per nursing home or profession was divided by the total number of potential respondents per nursing home or profession. Descriptive statistics were computed for all respondents and also stratified by profession, accounting for the effect of clustering due to facility on standard errors (SE) of the means. To compare our results for the whole group with the published benchmarks, a one-sample hypothesis test was performed for each domain, using a z statistic constructed with the SE corrected for clustering and its asymptotic normality. To compare PSC domain scores across professions, a linear mixed model was fit to each domain score, with profession as the main fixed effect of interest and facility as a random effect to account for clustering.20,21 To compare proportions of positive responses to each individual survey question across professions, a generalised estimating equations model was fit to each individual survey question with profession as the main fixed effect of interest, and a within-facility exchangeable correlation structure to account for facility level clustering, in further exploratory analyses (data not shown).21 All statistical analyses were conducted using SAS V.8.2.

## RESULTS

### Response rates and demographics

Of 151 surveys distributed, 104 (68.9%) were returned. Facility response rates ranged from 55.8% to 92.9%. Pharmacists had the highest response rate and doctors the lowest (100% v 52%). In all, <1% of surveys had missing information. There was no identifiable pattern of missing responses across items or nursing homes. Most respondents were women and were full-time employees (table 1). Respondents had worked in nursing homes for a mean of 9.8 years and in their current position and current facility for a mean of 7.1 and 5.4 years, respectively. Of the 104 respondents, 82 (78.8%; 78 nurses and 4 doctors) were employees of a participating facility.

Table 1

Characteristics of respondents, stratified by profession*

### PSC across professions in the nursing home

Mean scores for each PSC-NH dimension varied by profession (table 2). Only attitudes about staffing issues (eg, having enough employees to handle the workload) differed significantly across professions (p<0.03); nurses and pharmacists had higher mean scores than advanced practitioners and doctors. The composite scores for 7 of the 12 dimensions were lower (ie, worse) for advanced practitioners than the other professions, whereas pharmacists rated 6 of the 12 dimensions higher than the other professions.

Table 2

Mean patient safety culture composite scores across professions*†

### PSC-NH compared with hospital benchmarking data

For 5 of the 12 dimensions, nursing home composite scores were significantly lower than hospital composite scores (table 3). The largest differences were in non-punitive response to error (10.6 for nursing homes v 43.0 for hospitals; p<0.01) and teamwork within units (45.6 v 74.0; p<0.01). Significant differences (p<0.05) were also found in communication openness; feedback and communication about error; and organisational learning and continuous improvement. In only one dimension—that is, management support for patient safety—were scores higher for nursing homes than hospitals, but the difference was not significant (66.2 v 60.0; p = 0.34).

Table 3

Comparison of mean patient safety culture composite scores of nursing homes and hospitals

Survey respondents from nursing homes reported a higher number of adverse events during a 12-month period (fig 122) and a lower overall patient safety grade (fig 222) than hospitals.

Figure 1

Respondent estimates of events reported by nursing homes and hospitals in a 12-month period. Hospital benchmarking data derived from Agency for Healthcare Research and Quality.22

Figure 2

Respondent report of overall patient safety grade in nursing homes and hospitals. Hospital benchmarking data derived from Agency for Healthcare Research and Quality.22

### Internal consistency

The internal consistency of the individual PSC-NH dimensions was generally similar to that of the HSOPSC. Cronbach’s α values ranged from 0.50 for staffing to 0.84 for teamwork across units.

## DISCUSSION

### Key findings

This study provides the most complete information available to date on patient safety culture in nursing homes and disclosed two important findings. Firstly, the various types of professionals working in nursing homes were in general agreement on 11 of the 12 PSC dimensions measured in the survey. Secondly, on five dimensions, the composite scores for nursing homes were significantly lower than those for hospitals.

Staffing was the only PSC dimension in which nursing home professions differed. Adequate nurse staffing levels are important to ensure quality and reduce risks of healthcare problems.23–26 When compared with doctors and advanced practitioners, nurses were more likely to perceive that there was enough staff to handle the workload, the staff were not working for more hours than is best for patient care, and the staff was not trying to do too much too quickly. This finding is in contrast with recent studies documenting insufficient nursing staff and difficulties in recruiting and retaining qualified staff.27–29

Nursing homes differed from hospitals especially in perceived response to error, which was reported as more punitive in the nursing home. This finding was not unexpected, because error-reporting policies and processes are believed to perpetuate a punitive environment in nursing homes.30 Regulation, the predominant form of overseeing nursing homes, is believed to invoke a more punitive culture, as opposed to accreditation, the predominant form in other healthcare settings.9 In fact, only a fraction of nursing homes are accredited by the Joint Commission on Accreditation of Healthcare Organizations, despite evidence suggesting that accredited nursing homes have fewer complaints and instances of deficiencies filed against them.31

Previous studies have described nursing homes as rigidly hierarchical and particularly difficult environments for quality-improvement initiatives.32,33 This environmental characteristic may underlie the significantly lower scores in nursing homes compared with hospitals on teamwork within units, communication openness, feedback and communication about error, and organisational learning. Only in management support for patient safety was the composite score greater for nursing homes than hospitals.

One key to quality improvement is the introduction of organisational changes that focus on PSC.34–37 Fundamental cultural change is necessary to ensure that innovations introduced to improve patient safety, such as computerised provider-order entry and computerised decision-support systems, are realised.16 Therefore, before patient safety initiatives are implemented in nursing homes, an important step is to measure the PSC.38

### Strengths and limitations

This study has a substantial number of strengths. It is the first systematic assessment of PSC in the nursing home setting. The instrument to measure PSC is based on the same items and dimensions as the hospital instrument developed by the Agency for Health Care Research and Quality.19 The response rate was good and comparable with previous studies in the hospital setting.22,38

There are also limitations. Although only modest modifications were made for use in the nursing home setting, the instrument’s psychometric properties were altered slightly. Although the study included nursing home professionals in four categories, nurses’ responses dominate the aggregate results. The smaller numbers of other types of health professionals may have limited the statistical power to detect significant differences across professions. Nevertheless, nurses represent the most prevalent professional staff in most healthcare settings and the distribution of professions among study respondents was similar to other PSC studies.22,38 Excluding certified nursing assistants is a limitation, as they provide a considerable amount of direct patient care, and their responses would have provided an important perspective on PSC. Only a small number of facilities in the same metropolitan area were surveyed and all were non-profit institutions, potentially limiting the generalisability of our results.

### Implications and further research

PSC should be assessed in more nursing homes with varied institutional characteristics and in a broader range of personnel including certified nursing assistants and nursing home administrators. To better understand the relationship between PSC and institutional characteristics, studies should examine relationships with bed size, type of ownership, staffing levels, staff turnover rate, and number and type of deficiencies. Data on PSC can help establish a baseline for future benchmarking, identify opportunities for quality improvement, serve as a basis for policy changes and long-term reform strategies, and provide consumers with information helpful in selecting a nursing home.16,39

Additional studies in the nursing home relating patient and staff outcomes to PSC should be conducted. In the hospital setting, PSC interventions have been shown to help reduce lengths of stay, decrease drug-reconciliation errors and improve nursing staff retention.40 A strong safety culture has also been linked to compliance with safety work practices among nurses.41 Longitudinal studies and clinical trials can assess the effect of safety culture interventions on important patient and staff outcomes.

## CONCLUSIONS

Professionals in nursing homes generally agree about safety characteristics of their facilities, and PSC is significantly lower in nursing homes than in hospitals. The new assessment survey could foster comparisons across nursing homes and professions and help identify targets for interventions to improve patient safety (see Appendix available online).

## Acknowledgments

We thank the staff of Asbury Health Center, Baptist Homes of Western Pennsylvania, RxPartners-LTC, UPMC Senior Living Seneca Place, and UPMC Senior Living Heritage Shadyside for their assistance throughout the study.

## Supplementary materials

• Files in this Data Supplement:

## Footnotes

• Funding: This study was supported in part by NIH grants 8K12 RR 023267 (Roadmap Multidisciplinary Clinical Research Career Development Award Grant), 5T32AG021885, P30-AG024827, The American Medical Directors Association Foundation/Pfizer Quality Improvement Award and by the Merck/AFAR Junior Investigator Award in Geriatric Clinical Pharmacology.

• Competing interests: None declared.