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Abstract
Background Achieving a culture of safety is believed to be an important mechanism for improving patient safety. The Safety Attitudes Questionnaire (SAQ) measures provider perceptions of patient safety culture across six domains; higher scores denote more positive perceptions. Although professional differences on the SAQ have been explored, sex differences have not.
Methods The SAQ was administered to operating room (OR) care givers at nine Department of Veterans Affairs hospitals. We determined the mean domain scores by care giver profession and sex, used analysis of variance to compare mean scores across professions, used t tests to compare mean scores between sexes and created regression models of the six patient safety domains.
Results The SAQ was completed by 187 OR care givers. Older care givers were significantly more likely to report favourable perceptions of teamwork climate; surgeons were significantly more likely to report favourable perceptions of working conditions; anaesthesia providers were significantly more likely to report favourable perceptions of stress recognition but also less favourable perceptions of safety climate. Women were significantly more likely to report less favourable perceptions of job satisfaction and working conditions.
Conclusion This pilot study confirms previously reported profession differences in OR care giver patient safety attitudes. We also found previously unreported sex differences. Educational efforts designed to enhance patient safety should be designed so that they address such differences.
- Patient safety
- interprofessional education
- sex
- communication
- safety culture
- teams
- crew resource management
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- Patient safety
- interprofessional education
- sex
- communication
- safety culture
- teams
- crew resource management
To reduce adverse events, many organisations, including the Department of Veterans Affairs (VA), have committed to developing a culture of safety.1 Higher scores on measures of patient safety attitudes among clinicians have been associated with improved patient outcomes including shorter lengths of stay, fewer medication errors, lower ventilator-associated pneumonia rates, lower bloodstream infection rates and lower risk-adjusted mortality rates.2 3
Differences in perceptions of patient safety on the Safety Attitudes Questionnaire (SAQ) are associated with care giver profession.4–7 In intensive care units, nurses were shown to have lower perceptions of working conditions and management when compared to physicians.4 In the operating room (OR), profession differences have been found in perceptions of teamwork and safety.6 7 No studies have examined the relationship between care giver perceptions of patient safety and care giver sex.
We were interested in exploring the relationships between profession, sex and patient safety for two reasons. First, because most nurses are women, we reasoned that sex might be a confounder that could explain differences in patient safety perception seen when comparing nurses to other professions.4 5 Second, we wondered whether female providers might perceive patient safety differently than males. If so, we thought that education programmes designed to improve the performance of teams composed of both men and women might need to explicitly address such differences.
The purposes of this study, therefore, were to confirm previously reported profession differences in care giver perceptions of patient safety and to determine if sex impacts care giver perceptions of patient safety. These findings can be used to guide future implementation of medical team training (MTT) in the VA.
Methods
In 2003, the VA initiated an MTT programme that is based on the principles of crew resource management and is designed to improve communication among OR care givers.8 The programme consists of a 1-day learning session that is delivered at the facility and provides educational content about teamwork and methods to enhance communication and collaboration. Before each learning session, participants are asked to complete the SAQ—a 59-item validated questionnaire that explores attitudes towards patient safety; 30 of these items are used to generate six domain scores.9 These domains are Teamwork Climate (the perceived quality of collaboration between personnel), Safety Climate (perceptions of a strong and proactive organisational commitment to safety), Job Satisfaction (positivity about the work experience), Stress Recognition (acknowledgement of how performance is influenced by stressors), Perceptions of Management (approval of managerial action) and Working Conditions (the perceived quality of the work environment and logistical support). Items by domain are listed in Appendix 1. The questionnaire takes approximately 15 min to complete. Each of items is answered using a five-point Likert scale (1= disagree strongly, 2=disagree slightly, 3=neutral, 4=agree slightly, 5=agree strongly). Standardised algorithms are used to aggregate individual items to a 0 to 100 scale for each domain. Low scores represent less favourable perceptions on that domain and high scores represent more favourable perceptions.
Respondents to the questionnaire provided individual demographic data that included profession, sex, age, years in profession and years in VA. Between August and December of 2006, the SAQ (OR version) was administered to 187 care givers at nine VA medical centres. We aggregated responses into surgeons, anaesthesia providers (anaesthesiologists and certified registered nurse anaesthetists) and nurses (OR nurses and surgical technicians).
We determined the mean domain scores by care giver profession and sex, used analysis of variance to compare mean score across professions, used t tests to compare mean scores between sexes and created regression models of the six patient safety domains. For each domain score, we simultaneously entered all five demographic variables into the model to determine which variables accounted for variation in the mean domain scores.
Because categorical predictor variables cannot be entered directly into a regression model and be meaningfully interpreted, the variable must be split into separate variables. In general, a categorical variable with k levels will be transformed into k−1 variables each with two levels. For example, if a categorical variable had three levels, then two dichotomous variables could be constructed that would contain the same information as the single categorical variable. Dichotomous variables have the advantage that they can be directly entered into the regression model. The process of creating dichotomous variables from categorical variables is called dummy coding.
All analyses were performed using SPSS V.13.0. Statistical significance was defined as p <0.05. The Veterans Healthcare Administration Medical Team Training programme was reviewed by the Dartmouth College Institutional Review Board and determined to be exempt.
Results
The study group consisted of 66 surgeons, 35 anaesthesia providers and 86 nurses. There were 104 men and 83 women. Most surgeons were men and most nurses were women. Care giver demographics are provided in table 1. The average age and years in profession of OR nursing was less than surgeons and anaesthesia providers. Surgeons had the least number of years in VA. Fifteen per cent of surgeons were women; thirty-seven per cent of anaesthesia providers were women; 70% of OR nursing were women.
Demographic variables by profession
Differences in mean domain scores are provided in table 2. Perceptions of stress recognition and working conditions differed by care giver profession. Anaesthesia providers had more favourable perceptions of stress recognition (82) than both OR nursing (69) and surgeons (65). OR nursing had less favourable perceptions of working conditions (57) than surgeons (75). Perceptions of teamwork, job satisfaction, management and working conditions differed by care giver sex. Women had less favourable perceptions of teamwork (69, vs 76 for men), job satisfaction (74, vs 80 for men), management (60, vs 69 for men) and working conditions (57, vs 72 for men).
Mean domain scores by care giver profession and sex
We used regression analysis to determine the association of mean domain scores with care giver profession, age, years in profession, years in VA and sex (table 3). All regression models were statistically significant except the one for perceptions of management. The regression model for teamwork climate accounted for 10% of the variance; older care givers were more likely to have favourable perceptions of teamwork climate. The regression model for safety climate accounted for 7% of the variance; anaesthesia providers were more likely to have less favourable perceptions of safety climate. The regression model for job satisfaction accounted for 8% of the variance; men were significantly more likely to have favourable perceptions of job satisfaction. The regression model for stress recognition accounted for 9% of the variance; anaesthesia providers were significantly more likely to have favourable perceptions of stress recognition. The regression model for working conditions accounted for 17% of the variance; surgeons and men were significantly more likely to have favourable perceptions of working conditions.
Unstandardised coefficients and R2 for six regression models
Discussion
We explored professional and sex differences in patient safety attitudes among OR care givers at nine VA medical centres. Of the six patient safety domains, Stress Recognition and Working Conditions showed significant differences by univariate analysis of profession. Of the six patient safety domains, four showed significant differences by univariate analysis of sex (Teamwork Climate, Job Satisfaction, Perceptions of Management and Working Conditions). Regression analysis reveals that sex differences are present above and beyond those accounted by profession for Job Satisfaction and Working Conditions.
Our results confirmed previously published studies. Similar to the intensive care units, our surgeons had more favourable perceptions of working conditions than nurses.4 Similar to the outpatient clinic, our surgeons had less favourable perceptions of stress recognition than nurses.5 Surgeons in our study did differ from the previous outpatient study in that the surgeons in our study had more favourable perceptions of management than (OR) nurses, whereas the (outpatient) nurses in the previous study were more satisfied with management than the (outpatient) physicians.
Sexton et al reported a statistically significant difference in OR care giver perceptions of teamwork climate; surgeons scored higher (78) than OR nurses (66).6 Our surgeons had more favourable perceptions of teamwork climate (76) than did OR nurses (71), but this was not statistically significant.
Makary et al7 noted a difference in OR care giver perceptions of safety climate that was not statistically significant; surgeons scored higher (74) than OR nurses (70). The safety climate perceptions of our surgeons (74) were essentially the same as those of OR nurses (73).
Sex is associated with differences in attitudes.10 Within healthcare, female students have been shown to have different attitudes and opinions concerning collaborative learning and working than their male counterparts.11–13 Previous studies have shown that women place more value on “connected” learning, whereas men prefer “separate” learning and that women are particularly likely to describe adversarial learning environments as inhibiting their confidence and voice.14 Our study confirms that sex differences exist and should be taken into consideration to optimise overall system and team performance. These attitudinal differences may require different learning interventions. Future educational efforts that are designed to improve communication among team members should explicitly address both profession-based and sex-based differences in perceptions of patient safety.
Our study contributes to the understanding of safety culture. Our report adds to the reported clinical experience with the SAQ.4–7 9 15–18 The need to determine the effect of sex on SAQ factor differences had previously been noted but not yet reported.9 19 Our results suggest that differences in patient safety attitudes are likely to exist within surgical teams and that sex may be an important contributor to those differences. The finding that female providers in the OR had less favourable perceptions of job satisfaction and working conditions may be attributable to general differences between sexes. The differences in safety attitudes may be relevant to how MTT programmes are designed and implemented. As part of the MTT programme evaluation follow-up, questionnaires are administered to explore post-training reactions. The results will determine changes to the programme including specific target audiences.
Our study has several limitations. First, we examined only providers in VA hospitals. Findings may not be generalisable to non-VA settings. Second, the study was cross-sectional and examined data collected before the MTT intervention. Longitudinal studies are required to determine whether MTT efforts are associated with changes in safety attitudes perceptions among professionals, whether male or female. In addition, other factors such as management style and policies or sex-related pay differential could contribute to the differences that we found. Finally, our analysis was limited to questionnaire responses. Other qualitative methods should be used to further explore the sex differences that we found.
Despite these limitations, this pilot study identifies OR care giver differences in perceptions of patient safety. We confirmed previously reported profession differences: surgeons were significantly more likely to report favourable perceptions of working conditions; anaesthesia providers were significantly more likely to report favourable perceptions of stress recognition. We also found sex differences not previously reported—women were significantly more likely to report less favourable perceptions of job satisfaction and working conditions. These differences provide challenges and opportunities for MTT.
Appendix
Questionnaire items by domain
Teamwork climate
Nurse input about patient care is well received in the OR.
In the OR, it is difficult to speak up if I perceive a problem with patient care.
Disagreements in this clinical area are resolved appropriately (ie, not who is right, but what is best for the patient).
I have the support I need from personnel to care for patients.
It is easy for personnel here to ask questions when there is something that they do not understand.
The physicians and nurses here work together as a well-coordinated team.
Safety climate
I would feel safe being treated here as a patient.
Medical errors are handled appropriately in this hospital.
I know the proper channels to direct questions regarding patient safety in the ORs here.
I receive appropriate feedback about my performance.
In the OR, it is difficult to discuss errors.
I am encouraged by my colleagues to report any patient safety concerns I may have.
The culture in the ORs here makes it easy to learn from the errors of others.
Job satisfaction
I like my job.
Working in this hospital is like being part of a large family.
This hospital is a good place to work.
I am proud to work at this hospital.
Morale is high in the ORs here.
Stress recognition
When my workload becomes excessive, my performance is impaired.
I am less effective at work when fatigued.
I am more likely to make errors in tense or hostile situations.
Fatigue impairs my performance during emergency situations.
Perceptions of management
Hospital administration supports my daily efforts.
Hospital administration does not knowingly compromise the safety of patients.
I am provided with adequate, timely information about events in the hospital that might affect my work.
The levels of staffing in our ORs are sufficient to handle the number of patients.
Working conditions
This hospital does a good job of training new personnel.
All the necessary information is available before the start of a procedure.
Trainees in my discipline are adequately supervised.
This hospital deals constructively with problem physicians and employees.
Footnotes
Funding This work is supported by the Department of Veterans Affairs (VA), Veterans Health Administration. All authors work for the Veterans Health Administration. BTC, PDM and WBW are located in White River Junction, Vermont. JPB is located in Ann Arbor, Michigan. PDM is the Director of the Field Office for the VA National Center for Patient Safety and Adjunct Associate Professor of Psychiatry at Dartmouth Medical School. JPB the Chief Patient Safety Officer for Veterans Affairs, Director of the VA National Center for Patient Safety, Clinical Associate Professor of Preventive Medicine and Community Health at the University of Texas Medical Branch and Adjunct Assistant Professor of Military and Emergency Medicine—Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine.
Competing interests None
Ethics approval This study was conducted with the approval of the Dartmouth Committee for Protection of Human Subjects.
Provenance and peer review Not commissioned; externally peer reviewed.
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