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International Journal for Quality in Health Care 2006; Volume 18, Number 4: pp. 281–286 10.1093/intqhc/mzl020Advance Access Publication: 19 July 2006
International Journal for Quality in Health Care vol. 18 no. 4© The Author 2006. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved 281
Nurses’ and nursing assistants’ perceptions of patient safety culture in nursing homesCARMEL M. HUGHES1 AND KATE L. LAPANE2
1School of Pharmacy, Queen’s University Belfast, Belfast, Antrim, UK, and 2Community Health, Brown University, Providence, RI, USA
Abstract
Objectives. To evaluate whether perceptions of patient safety in nursing homes vary by length of employment, type ofemployee, and shift worked.
Design. Cross-sectional study.
Setting. Twenty-six nursing homes in Ohio participating in a randomized trial to test the effectiveness of a clinical informaticstool to improve patient safety during the medication monitoring.
Participants. Nurses (n = 367) and nursing assistants (n = 636) employed at the time of the survey in the summer and fall of2003.
Main outcome measurements. Resident safety questions included 34 items on different aspects of resident safety (overallsafety perception, teamwork within and between departments, communication openness, feedback and communication abouterror, non-punitive response to error, organizational learning, management expectations, and actions promoting safety, staff-ing, and management support for patient safety).
Results. Overall perceptions of resident safety by employees were acceptable, with clear management communication of safetygoals. Approximately 40% of nursing staff found it difficult to make changes to improve things most or all of the time; similarproportions indicated that management seriously considered staff suggestions to improve resident safety; only half reportedmanagement discussions with staff to prevent recurrence of mistakes. Regardless of staff type, one in five reported feeling pun-ished and two in five reported that reporting of errors was seen as a ‘personal attack’.
Conclusions. Interventions to change the safety culture in nursing homes are warranted. Nursing homes need guidance onhow to use information to implement safety improvement projects in the context of a strict regulatory environment which mayprohibit innovative system change.
Keywords: nursing assistants, nursing homes, nursing, patient safety, safety culture
Over 1.8 million people reside in approximately 17 000 USnursing homes [1]. Despite sweeping reform which occurredwith the Nursing Home Reform Act embedded in the Omni-bus Budgetary Reconciliation Act (OBRA) of 1987 [2], con-cerns regarding patient safety remain [3]. Untoward eventsoccurring in this health care setting include pressure ulcers,adverse drug events, and falls.
OBRA legislation has sought to improve the quality ofnursing home care through an adversarial regulatory andinspection approach. The Centers for Medicare and MedicaidServices (CMS; the main administrative agency for health inthe United States) developed a set of regulations, outlining allaspects of nursing home operation [4]; this has also extendedto the use of quality measures that are posted on a publiclyaccessible Website [5]. If a nursing facility is deemed not to beattaining the required standard, then a number of sanctionsare available including termination of provider agreement,
transfer of residents with closure of facility, and a directedplan of correction. Such negative incentives may prevent thereporting and disclosing of errors.
Assuring the safety of nursing home residents is com-pounded by restrictive reimbursement systems, increasinglyfrail residents, and poor staffing levels. An astounding 92% ofnursing homes do not have sufficient staff to provide levelsof care to meet the federal regulations and practice guidelines[5,6]. The average one-year turnover rate is high for nursingassistants and licensed practical nurses (85.8%) and registerednurses (55.4%) in US nursing homes [7]. The instability of thenursing staff has been correlated with decreases in quality ofcare [7,8]. We sought to document the perceptions of patientsafety among nurses and nursing assistants in nursing homesand to evaluate the extent to which perceptions of patientsafety in nursing homes varies by length of employment, typeof employee, and shift worked.
Address reprint requests to Carmel M. Hughes, School of Pharmacy, Queen’s University Belfast, 97 Lisburn Road, BelfastBT9 7BL, Northern Ireland. E-mail: [email protected]
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Methods
The study protocol was approved by the Brown MedicalSchool Institutional Review Board. Twenty-six nursing faci-lities included in this study were participating in a large rand-omized clinical trial funded by the Agency for HealthcareResearch and Quality, testing the effects of a unique clinicalinformatics tool on patient safety outcomes in nursing homes.Nursing homes provided the research team with an enumera-tion of nurses (registered and licensed practical nurses, n =721) and nursing assistants (n = 1233) as well as a preferencefor distribution method (either directly to staff members attheir home address or mailed to the nursing facility for distri-bution at work). We performed four mailings spaced 2 weeksapart in the following sequence: an initial mailing of the sur-vey packet, a reminder postcard, a re-mail of the surveypacket to non-respondents to the initial survey, and a finalreminder postcard. The survey packets consisted of a coverletter explaining the survey and including the elements ofinformed consent, as well as the procedures necessary toreceive the incentive for survey completion, the survey withthe unique identifier included on the survey (but not therespondent’s name), and a postage paid return envelope.Return envelopes were addressed to the research team atBrown Medical School. The respondents were asked not tocomplete the survey at work. Mailings began in August 2003and continued throughout the fall of 2003, before the initia-tion of the randomized trial. After we mailed $15 incentivechecks to respondents, data were de-identified.
The nurse questionnaire and nursing assistant questionnairecontained questions that were adapted from a safety cultureassessment tool [9,10] modified by Emory and MorehouseUniversities (Joseph Ouslander, personal communication).Resident safety questions included 34 items on different
aspects of resident safety. Domains included overall safetyperception, teamwork within and between departments, com-munication openness, feedback and communication abouterror, non-punitive response to error, organizational learning,management expectations, and actions promoting safety,staffing, and management support for patient safety.
Descriptive analyses were performed by nursing staff type(nurses and nursing assistants), length of employment (≤1year, 1+ years), and shift worked (first, second, third, or rotat-ing across shifts as needed). Typically, first shift is 7 a.m.–3p.m., second is 3 p.m.–11 p.m., and third is 11 p.m.–7 a.m.We hypothesized that those in longer employment wouldhave had a clear understanding of safety issues within thenursing home, whereas those who worked later shifts (partic-ularly the third shift) may have been more professionally iso-lated and less exposed to communication and discussion onresident safety. We compared the distributions of categoricalvariables using chi-square tests and Fisher’s exact test whenthe cell sizes were less than five.
Results
We received 367 completed nurse surveys and yielding a 56%response rate and 636 nursing assistant surveys yielding a60% response rate. Over 90% of nurses and nursing assist-ants were women, with nurses reporting higher education lev-els than nursing assistants (Table 1). Nursing assistants weremore likely to report being of a racial/ethnic minority (32%)than nurses (12%).
In terms of overall resident safety ratings given by staff,excellent grades were given by 11% of nurses (n = 40) and13% of nursing assistants (n = 83), whereas a poor/failinggrade was given by approximately 5% of both nursing types.
Table 1 Sociodemographic characteristics of nurses and nursing assistants employed at 26 nursing homes participating inOhio
Characteristics Nurses (n = 367) Nursing assistants (n = 636).........................................................................................................................................................................................................................
Women (%) 95 94Racial/ethnicity minority (%) 12 32Education (%)
Less than high school 1 15High school or general equivalency diploma 1 38Vocational/trade school 22 12
Some college 38 29Associate degree 27 4Bachelors degree 10 2
Postgraduate degree 2 0.3Shift worked (%)
First 52 43Second 13 25Third 16 18Varies 18 14
Years worked for nursing home [mean (SD)] 6.7 (6.6) 5.4 (6.3)Years worked in present position [mean (SD)] 6.9 (7.3) 6.7 (7.2)
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Length of employment (less or more than 1 year) had littleimpact on safety ratings. Third shift employees were the leastlikely to give their departments an overall very good oracceptable grade. Approximately 10% of nursing staffreported most/or all of the time resident safety problemsoccur on their unit, with ∼15% reporting that they feel mostor all of the time that it is pure luck that more serious mis-takes did not happen in their department. These estimates didnot vary appreciably by nursing grade, length of employment,and shift worked.
Table 2 summarizes the resident safety items stratified bynurse grade (nurse or assistant) and duration of employment.In terms of nurse grade, nurses were more likely to report thatwhen a lot of work needed to be done quickly, staff workedtogether as a team to get the work done most or all of thetime compared with nursing assistants. However, more nurs-ing assistants (30%) compared with nurses (23%) reportedthat staff worked on their own and did not want to help oth-ers most or all of the time (P = 0.02). High proportions ofboth staff categories had reported a safety problem in the lastmonth to someone at least once (81% nurses and 62% assist-ants; P < 0.0001), with more nurses than assistants havingwritten at least one incident report in the last month (68%versus 19%; P < 0.0001). Nursing assistants (25%) were morelikely to report that when a safety incident was beingreported, the person was being written up rather than theproblem, but nurses rather than assistants were more likely toindicate that the reporting of errors of another staff memberwas seen as a personal attack against them.
In relation to opinion on resident safety according tolength of employment, employees working for the facilitygreater than 1 year were more likely to report that staffworked as a team when a lot of work needed to be donequickly and that there was a good deal of cooperation amongdepartments relative to newly hired nursing staff. Newlyemployed nursing staff were less likely to report that trainingwas provided most or all of the time relative to thoseemployed greater than a year (P = 0.0006).
Although comparisons of resident safety items by shift ofemployee revealed few differences in perceptions of residentsafety items by shift, third shift employees gave their depart-ments less favorable ‘overall grades’ on resident safety. Whenanalyses were further stratified by staff type (data not shown),second and third shift nursing assistants were much less likelyto report adequate training had been provided (P = 0.0165).
Discussion
To our knowledge, this is the first article that has examinedsafety issues in nursing homes from the perspective of thenursing staff. Although this has been done in hospitals, e.g.[11], the results are not likely generalizable to the nursinghome setting for several reasons. A nursing home is supposedto be a home environment with medicalization of the environ-ment kept to a minimum. Resident autonomy, dignity, andparticipation in decision-making have been reported to be themost important quality of life attributes for nursing home
residents [12]. Ironically, these attributes may be difficult toimplement if safety is considered the number one priority.Kapp [3] has noted that safety does not represent all the resi-dents’ expectations and preferences concerning the quality ofcare and quality of life. Despite the complex milieu in whichnursing home care is provided, a consideration of how safetycan be maximized in this environment should not be pre-cluded. These data provide the perspective of the health pro-fessionals on the front line in nursing homes—nursing staff.
Leadership in safety issues has been shown to be influentialin creating a positive safety culture [13–15] and has also beenshown to be critical in high quality care [16]. In this study,∼60% of nursing staff reported that management showed res-ident safety was a top priority and safety goals were clearly artic-ulated most or all of the time. Despite such clarity, indicators ofineffective leadership are provided. Approximately 40% ofnursing staff found it difficult to make changes to improvethings most or all of the time; similar proportions indicated thatmanagement seriously considered staff suggestions to improveresident safety; only half reported management discussionswith staff to prevent recurrence of mistakes. Our findings areconsistent with a report from the Office of the Inspector Gen-eral in the United States, which found that ‘while quality assur-ance committees have an array of information to help thempinpoint problems in nursing homes, knowledge of how to usethis information to execute projects remains a key barrier’ [17].Typically, nursing homes use the traditional quality assurancemodels, which retrospectively monitor aspects of care, address-ing problems on an individual basis rather than on a systemslevel, and minimizing staff input. Nursing homes have neitherthe staff nor the expertise in monitoring systems of care andwork environments [18] and are challenged by strict regulatoryenvironment that may prohibit innovative system change [19].Individual State Quality Improvement Organizations adminis-tered by the CMS are uniquely positioned to provide directguidance sorely needed in this setting [18].
Organizations with a positive safety culture set the tone foracknowledgement of error (e.g. communications founded onmutual trust), which in turn permits learning from experienceand mitigating further errors [20]. Unfortunately, data fromthis study suggest that a ‘blame and shame’ culture predomi-nates in the nursing home setting. Regardless of staff type,one in five reported feeling punished and two in five reportedthat reporting of errors was seen as a ‘personal attack’. Thenegative patient safety culture that exists in nursing homesmay be a function of the adversarial and punitive nature of USnursing home regulation [3,21,22]. Nursing homes are underconstant scrutiny and subject to detailed inspections (or sur-veys) and those which do not meet the regulations may besubject to a number of penalties, the most severe being clo-sure of the facility. Staff may feel reluctant to report safetyissues that may draw attention to individuals and to the nurs-ing home. It would be interesting to carry out a similar studyin nursing homes in a different regulatory setting outside theUnited States. Despite the consequences, we found that atleast 60% of nursing assistants and 80% of nurses reported asafety problem at least once in the past month, with nursesbeing primarily involved in writing incident reports. The
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Tab
le 2
Opi
nion
s of
res
iden
t saf
ety
acco
rdin
g to
sta
ffin
g ca
tego
ry a
nd le
ngth
of e
mpl
oym
ent
% w
ho a
nsw
ered
‘mos
t or
all o
f the
tim
e’N
urse
s (n
= 3
67)
Nur
sing
ass
ista
nts
(n =
636
)P
val
ueE
mpl
oyed
≤1
year
(n =
259
)E
mpl
oyed
>1
year
(n =
744
)P
val
ue
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
.....
....
....
....
.....
....
....
....
....
....
....
....
....
.....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
.....
....
....
....
.
Tea
m w
ork
with
in a
nd b
etw
een
depa
rtm
ents
Whe
n a
lot o
f wor
k ne
eds
to b
e do
ne q
uick
ly, h
ow o
ften
do
staf
f wor
k to
geth
er a
s a
team
to g
et th
e w
ork
done
?73
58<
0.00
158
660.
02
Whe
n on
e pe
rson
get
s re
ally
bus
y, h
ow o
ften
do
othe
rs n
ot w
ant t
o pi
tch
in?
2934
0.09
3232
0.98
How
oft
en d
o st
aff w
ork
on th
eir
own
and
do n
ot w
ant t
o he
lp o
ther
s m
uch?
2330
0.02
2927
0.47
How
oft
en d
o de
part
men
ts w
ork
toge
ther
to g
ive
the
best
car
e fo
r re
side
nts?
6555
0.00
263
570.
09H
ow o
ften
do
depa
rtm
ents
fail
to c
oord
inat
e w
ell w
ith e
ach
othe
r?17
210.
1520
200.
77H
ow o
ften
is th
ere
good
coo
pera
tion
amon
g de
part
men
ts th
at n
eed
to w
ork
toge
ther
?52
520.
8546
540.
03
How
oft
en is
it u
nple
asan
t to
have
to w
ork
with
sta
ff fr
om o
ther
dep
artm
ents
?9
120.
2211
110.
84C
omm
unic
atio
nW
hen
staf
f see
a c
owor
ker
not f
ollo
win
g st
anda
rd p
ract
ices
, how
oft
en d
o th
ey
poin
t it o
ut to
him
/her
? (O
)50
500.
9249
500.
93
How
oft
en d
o st
aff c
heck
the
wor
k of
oth
ers
whe
n th
ey a
re s
uppo
sed
to?
(O)
5648
0.01
5250
0.68
Whe
n a
mis
take
hap
pens
, how
oft
en d
o st
aff a
void
rep
ortin
g it?
(O)
89
0.61
108
0.56
How
oft
en d
o su
perv
isor
s/m
anag
ers
and
staf
f dis
cuss
mis
take
s to
kee
p th
em
from
hap
peni
ng a
gain
? (F
)53
550.
5351
560.
25
How
oft
en d
o yo
u ta
lk o
penl
y ab
out r
esid
ent s
afet
y pr
oble
ms
that
exi
st in
you
r de
part
men
t? (F
)59
46<
0.00
0148
520.
35
How
oft
en a
re s
taff
told
abo
ut w
hat h
appe
ns a
s a
resu
lt of
an
inci
dent
rep
ort?
(F)
4243
0.68
4042
0.54
How
oft
en d
o st
aff f
eel l
ike
they
are
bei
ng p
unis
hed
whe
n an
inci
dent
rep
ort i
s w
ritt
en u
p on
a m
ista
ke th
ey h
ave
mad
e? (N
)27
220.
059
2623
0.25
Whe
n a
safe
ty in
cide
nt is
rep
orte
d, h
ow o
ften
doe
s it
feel
like
the
pers
on is
bei
ng
wri
tten
up,
not
the
prob
lem
? (N
)18
250.
009
2122
0.62
How
oft
en is
rep
ortin
g th
e er
rors
of a
noth
er s
taff
mem
ber
seen
as
a pe
rson
al
atta
ck a
gain
st th
em?
(N)
4236
0.04
3639
0.47
Man
agem
ent p
riorit
ies
and
expe
ctat
ions
and
act
ions
How
oft
en d
oes
the
beha
vior
of m
anag
emen
t sho
w th
at r
esid
ent s
afet
y is
a to
p pr
iorit
y? (P
)60
610.
8355
580.
49
How
oft
en d
oes
man
agem
ent c
lear
ly te
ll st
aff w
hat t
he r
esid
ent s
afet
y go
als
are?
(P)
5658
5761
0.20
0.48
How
oft
en d
oes
your
sup
ervi
sor/
man
ager
say
a g
ood
wor
d w
hen
he/s
he s
ees
a jo
b do
ne b
y th
e ri
ght p
roce
dure
s an
d ru
les?
(E)
2729
0.58
2928
0.81
How
oft
en d
oes
your
sup
ervi
sor/
man
ager
serio
usly
con
side
r sta
ff su
gges
tions
for
impr
ovin
g re
side
nt s
afet
y? (E
)42
380.
1939
400.
82
cont
inue
d
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Patient safety in nursing homes
285
E, e
xpec
tatio
ns a
nd a
ctio
ns; F
, fee
dbac
k ab
out e
rror
; N, n
on-p
uniti
ve r
espo
nse
to e
rror
; O, o
penn
ess;
P, m
anag
emen
t prio
ritie
s.
Tab
le 2
cont
inue
d
% w
ho a
nsw
ered
‘mos
t or
all o
f the
tim
e’N
urse
s (n
= 3
67)
Nur
sing
ass
ista
nts
(n =
636
)P
val
ueE
mpl
oyed
≤1
year
(n =
259
)E
mpl
oyed
>1
year
(n =
744
)P
val
ue
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
.....
....
....
....
.....
....
....
....
....
....
....
....
....
.....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
.....
....
....
....
.
How
oft
en d
oes
your
sup
ervi
sor/
man
ager
ove
rlook
resi
dent
saf
ety
prob
lem
s th
at
happ
en o
ver
and
over
? (E
)7
100.
119
90.
89
How
oft
en d
oes
your
sup
ervi
sor/
man
ager
neg
lect
to p
ay e
noug
h at
tent
ion
to
resi
dent
saf
ety
prob
lem
s? (E
)5
70.
098
60.
19
Whe
neve
r pre
ssur
e bu
ilds u
p, h
ow o
ften
doe
s yo
ur s
uper
viso
r/m
anag
er w
ant y
ou
to w
ork
fast
er e
ven
if it
mea
ns ta
king
sho
rtcu
ts?
(E)
1816
0.43
1517
0.30
How
oft
en d
oes
man
agem
ent h
elp
you
feel
goo
d ab
out g
ivin
g re
side
nts
safe
car
e? (E
)40
340.
0536
360.
94
Org
aniz
atio
nal l
earn
ing
How
oft
en is
it d
iffic
ult t
o m
ake
chan
ges
to im
prov
e th
ings
in y
our
depa
rtm
ent?
4230
0.00
0332
350.
49H
ow o
ften
do
staf
f not
see
m to
lear
n fr
om m
ista
kes?
1115
0.12
1214
0.44
How
oft
en d
o st
aff r
ecei
ve e
noug
h tr
aini
ng to
pro
vide
saf
e ca
re to
res
iden
ts?
6970
0.95
6172
0.00
06W
hen
the
sam
e m
ista
ke k
eeps
hap
peni
ng, h
ow o
ften
do
staf
f loo
k at
pro
cedu
res
to s
ee if
they
nee
d to
mak
e ch
ange
s?65
590.
0757
620.
15
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usefulness of the reporting systems may be limited as onlytwo in five staffs reported that they were told what happensas a result of incident reports most or all of the time.
Training is clearly an important aspect of safety improve-ment [20]. The logistic challenges of provision of trainingequally across shifts and continuously (given the poor reten-tion of staff) is non-trivial. Training programs have beennoted to help facilities achieve the ‘three R’s of retention: rela-tionships, respect, and recognition’ [23]. Online resources areavailable for ideas on how to ‘build and maintain a stable,high-quality workforce’ [24]. Innovative computer-basedcomprehensive curriculum of individual, self-paced educationthrough interactive documentaries may provide solutions tothe practical training challenges of the nursing home environ-ment [25]. Widespread dissemination of effective trainingmodalities is hampered by the lack of computer equipment.
We interpret these data with caution. Although the originaltool has good psychometric properties [10], it was notdesigned for use in nursing homes. Despite our inclusion of asurvey incentive and multiple mailings, our response rate wasnot optimal. Our data are cross-sectional and thus provide asnapshot of the perceptions of nursing staff. The results mayalso not be generalizable to all nursing homes in the UnitedStates. All participating homes were in one state (Ohio)although not owned by the same proprietor. The homes hadat least 50 residents each and had stable contracts with onepharmacy services provider.
To date, the nursing home has largely been invisible in thesafety debate. Yet, the older and frail residents in nursinghome settings may be at greater risk for adverse safety eventsthan individuals in other health care settings. A greater focuson these residents should be more clearly articulated by policymakers, managers, and practitioners.
Acknowledgement
This study was supported by a grant from the Agency forHealth Care Research and Quality.
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Accepted for publication 25 May 2006
at Universidad PolitÃ
©cnica de M
adrid on April 28, 2014
http://intqhc.oxfordjournals.org/D
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