Deborah Tregunno

‘Not another safety culture survey’: using the Canadian patient safety climate survey (Can-PSCS) to measure provider perceptions of PSC across health settings

Background The importance of a strong safety culture for enhancing patient safety has been stated for over a decade in healthcare. However, this complex construct continues to face definitional and measurement challenges. Continuing improvements in the measurement of this construct are necessary for enhancing the utility of patient safety climate surveys (PSCS) in research and in practice. This study examines the revised Canadian PSCS (Can-PSCS) for use across a range of care settings. Methods Confirmatory factor analytical approaches are used to extensively test the Can-PSCS. Initial and cross-validation samples include 13u2005126 and 6324 direct care providers from 119 and 35 health settings across Canada, respectively. Results Results support a parsimonious model of direct care provider perceptions of patient safety climate (PSC) with 19 items in six dimensions: (1) organisational leadership support for safety; (2) incident follow-up; (3) supervisory leadership for safety; (4) unit learning culture; (5) enabling open communication I: judgement-free environment; (6) enabling open communication II: job repercussions of error. Results also support the validity of the Can-PSCS across a range of care settings. Conclusions The Can-PSCS has several advantages: (1) it is a theory-based instrument with a small number of actionable dimensions central to the construct of PSC; (2) it has robust psychometric properties; (3) it is validated for use across a range of care settings, therefore suitable for use in regionalised health delivery systems and can help to raise expectations about acceptable levels of PSC across the system; (4) it has been tested in a publicly funded universal health insurance system and may be suitable for similar international systems.

Integrating patient safety into health professionals’ curricula: a qualitative study of medical, nursing and pharmacy faculty perspectives

Background As efforts to integrate patient safety into health professional curricula increase, there is growing recognition that the rate of curricular change is very slow, and there is a shortage of research that addresses critical perspectives of faculty who are on the ‘front-lines’ of curricular innovation. This study reports on medical, nursing and pharmacy teaching faculty perspectives about factors that influence curricular integration and the preparation of safe practitioners. Methods Qualitative methods were used to collect data from 20 faculty members (n=6 medical from three universities; n=6 pharmacy from two universities; n=8 nursing from four universities) engaged in medical, nursing and pharmacy education. Thematic analysis generated a comprehensive account of faculty perspectives. Results Faculty perspectives on key challenges to safe practice vary across the three disciplines, and these different perspectives lead to different priorities for curricular innovation. Additionally, accreditation and regulatory requirements are driving curricular change in medicine and pharmacy. Key challenges exist for health professional students in clinical teaching environments where the culture of patient safety may thwart the preparation of safe practitioners. Conclusions Patient safety curricular innovation depends on the interests of individual faculty members and the leveraging of accreditation and regulatory requirements. Building on existing curricular frameworks, opportunities now need to be created for faculty members to act as champions of curricular change, and patient safety educational opportunities need to be harmonises across all health professional training programmes. Faculty champions and practice setting leaders can collaborate to improve the culture of patient safety in clinical teaching and learning settings.

Development and testing of an objective structured clinical exam (OSCE) to assess socio-cultural dimensions of patient safety competency

Background Patient safety (PS) receives limited attention in health professional curricula. We developed and pilot tested four Objective Structured Clinical Examination (OSCE) stations intended to reflect socio-cultural dimensions in the Canadian Patient Safety Institutes Safety Competency Framework. Setting and participants 18 third year undergraduate medical and nursing students at a Canadian University. Methods OSCE cases were developed by faculty with clinical and PS expertise with assistance from expert facilitators from the Medical Council of Canada. Stations reflect domains in the Safety Competency Framework (ie, managing safety risks, culture of safety, communication). Stations were assessed by two clinical faculty members. Inter-rater reliability was examined using weighted κ values. Additional aspects of reliability and OSCE performance are reported. Results Assessors exhibited excellent agreement (weighted κ scores ranged from 0.74 to 0.82 for the four OSCE stations). Learners’ scores varied across the four stations. Nursing students scored significantly lower (p<0.05) than medical students on three stations (nursing student mean scores=1.9, 1.9 and 2.7; medical student mean scores=2.8, 2.9 and 3.5 for stations 1, 2 and 3, respectively where 1=borderline unsatisfactory, 2=borderline satisfactory and 3=competence demonstrated). 7/18 students (39%) scored below ‘borderline satisfactory’ on one or more stations. Conclusions Results show (1) four OSCE stations evaluating socio-cultural dimensions of PS achieved variation in scores and (2) performance on this OSCE can be evaluated with high reliability, suggesting a single assessor per station would be sufficient. Differences between nursing and medical student performance are interesting; however, it is unclear what factors explain these differences.

A Multi-Method Study of the Geriatric Learning Needs of Acute Care Hospital Nurses in Ontario, Canada.

Older people are at risk of experiencing functional decline and related complications during hospitalization. In countries with projected increases in age demographics, preventing these adverse consequences is a priority. Because most Canadian nurses have received little geriatrics content in their basic education, understanding their learning needs is fundamental to preparing them to respond to this priority. This two-phased multi-method study identified the geriatrics learning needs and strategies to address the learning needs of acute care registered nurses (RNs) and registered practical nurses (RPNs) in the province of Ontario, Canada. In Phase I, a survey that included a geriatric nursing knowledge scale was completed by a random sample of 2005 Ontario RNs and RPNs. Average scores on the geriatric nursing knowledge scale were in the neither good nor bad range, with RNs demonstrating slightly higher scores than RPNs. In Phase II, 33 RN and 24 RPN survey respondents participated in 13 focus group interviews to help confirm and expand survey findings. In thematic analysis, three major themes were identified that were the same in RNs and RPNs: (a) geriatric nursing is generally regarded as simple and custodial, (b) older peoples care is more complex than is generally appreciated, and (c) in the current context, older peoples care is best learned experientially and in brief on-site educational sessions. Healthcare providers, policy-makers, and educators can use the findings to develop educational initiatives to prepare RNs and RPNs to respond to the needs of an aging hospital population.

Patient, Treatment, and Health Care Utilization Variables Associated with Adherence to Metabolic Monitoring Practices in Children and Adolescents Taking Second-Generation Antipsychotics

Objective: Children and adolescents with a range of psychiatric disorders are increasingly being prescribed atypical or second-generation antipsychotics (SGAs). While SGAs are effective at treating conduct and behavioural symptoms, they infer significant cardiometabolic risk. This study aims to explore what patient, treatment, and health care utilization variables are associated with adherence to Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA) metabolic monitoring guidelines. Method: A retrospective chart review of 294 children and adolescents accessing a large outpatient psychiatry setting within a 2-year study period (2014-2016) was conducted. Baseline and follow-up metabolic monitoring, demographic, treatment, and health care utilization variables were then assessed over a 1-year period of interest. Results: Metabolic monitoring practices did not adhere to CAMESA guidelines and were very poor over the 1-year observation period. There were significant differences between children (ages 4-12 years, n = 99) and adolescents (ages 13-18 years, n = 195). In adolescents, factors associated with any baseline metabolic monitoring were a higher number of psychiatry visits (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.10 to 1.41), longer duration of contact (OR, 14; 95% CI, 2.31 to 82.4), and use of other non-SGA medications (OR, 3.2; 95% CI, 1.17 to 8.94). Among children, having an emergency room visit (OR, 3.4; 95% CI, 1.01 to 11.71) and taking aripiprazole (OR, 7.4; 95% CI, 2.02 to 27.45) increased the odds of receiving baseline metabolic monitoring. Conclusion: Findings from this study highlight the need for better metabolic monitoring for children and adolescents taking SGAs. Enhanced focus on opportunities for multidisciplinary collaboration is needed to improve the quality of care offered to this population.

Patient safety in practical nurses' education: A cross-sectional survey of newly registered practical nurses in Canada

BACKGROUNDnPractical nurses have experienced an increasing scope of practice, including an expectation to care for complex patients and function on interdisciplinary teams. Little is known about the degree to which patient safety principles are addressed in practical nursing education.nnnPURPOSEnTo examine self-reported patient safety competencies of practical nurses.nnnDESIGNnA cross-sectional online survey (July 2014) and face-to-face interviews (June 2015).nnnSETTINGnOntario, Canada.nnnPARTICIPANTSnSurvey participants were practical nurses newly registered with the College of Nurses of Ontario between January 2012 and December 2013. Interview participants were faculty and students in a practical nursing program in Ontario.nnnMETHODSnSurvey respondents completed the Health Professional Education in Patient Safety Survey online. Self-reported competencies in various patient safety domains were compared between classroom and clinical settings. Faculty members were interviewed about educational preparation of practical nurses and students were interviewed to provide insight into interpretation of survey questions.nnnRESULTSnThe survey response rate was 28.4% (n=1104/3883). Mean domain scores indicated a high level of confidence in patient safety competence (<4.0/5.0). Confidence was highest in respondents registered with the College of Nurses of Ontario >2years and in those who obtained their education outside of Canada. Faculty believed their approach to teaching and learning instilled a deep understanding of the limits to practical nurse autonomous practice.nnnCONCLUSIONSnPractical nurses were confident in what they learned about patient safety in their educational programs. The high degree of patient safety competence may be a true reflection of practical nurses understanding of, and comfort with, the limits of their knowledge and, ultimately, the limits of their individual autonomous practice. Further exploration as to whether the questionnaire requires additional modification for use with practical nurse populations is warranted. However, this study provides the first examination of practical nurses perspectives and perceptions about patient safety education.

Measuring competence in healthcare learners and healthcare professionals by comparing self-assessment with objective structured clinical examinations (OSCEs): a systematic review protocol

Review question/objective The objective of this systematic review is to compare the use of self‐assessment instruments versus an objective structured clinical examination (OSCE) to measure the competence of healthcare learners and healthcare professionals. The specific question that will guide this review is: When measuring the competence of healthcare learners and healthcare professionals is the evaluation obtained by self‐assessment instruments comparable to performance on an OSCE? Background Establishing the effectiveness of the health professional education process is complex and requires a multifaceted approach to assess the outcomes.1 Typically, outcomes are assessed in terms of the competence of the professional, level of confidence, performance and/or skills. Throughout the literature on this topic, these terms are used interchangeably, but there is overlap and some terms may encompass others. It is important to begin by providing descriptions/definitions of these terms. Competence In their paper that discusses the definition and assessment of professional competence, Epstein and Hundert define professional competence as: the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and community being served.2(p226) Confidence Hollands concept analysis of professional confidence describes four components, namely affect (feelings associated with action), reflection (thoughtfully examine ones actions and intentions), higher cognitive functioning (which includes aspects such as learning and integration of concepts, decision making, attention, motivation and memory) and action.3 (p219) Performance The on‐line Merriam‐Webster dictionary defines performance as the execution of an action or something accomplished ‐ a deed or feat.4 Skill Skill is defined as proficiency, facility, or dexterity that is acquired or developed through training or experience.5 Self‐efficacy Self‐efficacy is defined as peoples beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives.6 Knowledge Knowledge is defined as (1) the fact or condition of knowing something with familiarity gained through experience or association; (2) acquaintance with or understanding of a science, art, or technique.7 Empathy Empathy is defined as the ability to understand and share the feelings of another.8 Looking at the above definitions of competence, confidence and performance it is clear that there is considerable overlap. The term competence was found to be the most inclusive. However, because there are nuances involved in each term, in this review the following concepts will be referred to: that of competence (including knowledge and performance) and confidence (including self‐efficacy). There are a variety of ways to measure health professionals’ competence and self‐assessment is a cost effective source of information. Self‐assessment has been defined as: the evaluation or judgment of ‘the worth’ of ones performance and the identification of ones strengths and weaknesses with a view to improving ones learning outcomes.9 (p146) For example, self‐reported patient safety competence may provide data about learners’ insights into and likely safety of, their own practice,10 and about their perceived strengths or limitations.11,12 The value of using more objective methods to assess competence is unclear. Recent studies examining self versus expert assessment of technical and non‐technical skills have produced mixed results. Surgeons seem to be able to accurately assess their own technical skills but not their non‐technical skills;13 however, an earlier study of junior medical officers found no correlation between their self‐assessments of confidence and their measured competencies on routine procedural skills.14 In a systematic review published in 2006, Davis and colleagues describe how accurately health professionals, primarily physicians, subjectively evaluate their own competence compared with external observations of their competence.15 They concluded that physicians have a limited ability to accurately self‐assess and this may be particularly true among those rated as the least skilled and those who were also the most confident. These results were found to be consistent with other professions.16 The objective structured clinical examination (OSCE) is another method that has shown to be a useful means to assess the competence of a learner. Typically an OSCE consists of a specific scenario established by the examiners that requires the learner to demonstrate their proficiency in that area. The evaluator can control the environment and standardize the patient and in this manner use the OSCE to objectively assess competencies (i.e. knowledge, attitudes and behaviors). There is growing recognition that OSCEs are appropriate for evaluating the interpersonal skills associated with breaking bad news or cross‐cultural interviewing.17 The use of the OSCE to assess physician communication skills is also becoming more common (e.g. Huntley, Salmon, Fisher, Fletcher, & Young;18 Iramaneerat, Myford, Yudkowsky, & Lowenstein;19 Ponton‐Carss, Hutchison, & Violato;20 Van Nuland, Van den Noortgate, van der Vleuten, & Jo.21) In the realm of patient safety there is a small but emerging body of literature encouraging the use of OSCEs to assess aspects of patient safety competence among medical trainees.22‐28 In this area most OSCEs assess the technical aspects of patient safety or quality improvement competence,25,27‐29 or clinical aspects of patient safety such as hand hygiene compliance and medication labeling.25 Few studies describe the use of OSCEs to assess socio‐cultural aspects of patient safety,24,26 and those that do tend to focus on communicating or disclosing an error and are discipline‐specific in nature.30,31 In nursing, a recent integrative review by Walsh and colleagues located 41 papers and identified major gaps regarding the psychometrics of nursing OSCEs.32 In concluding their review, the researchers highlighted the need for additional research on using the OSCE as an evaluative tool in nursing. The OSCE is thought to be a more objective measure than self‐assessment. However, while limited, examinations of the extent to which OSCE performance predicts outcomes on other performance metrics are somewhat equivocal. Some studies have failed to detect a significant positive relationship between OSCE performance and other forms of summative evaluations of health professionals and learners.23 A study by Tamblyn found that scores achieved in a patient‐physician communication and clinical decision‐making OSCE, that was part of a national licensing examination, predicted complaints to medical regulatory authorities up to 10 years later.33 In an environment where providing optimal student learning and quality patient care is a goal, there is a need to explore whether a link exists between self‐assessment scores and OSCEs in light of providing the best learning for the most affordable means. It has been noted that some studies comparing self and external assessments of competence (such as the OSCE) have had several methodological problems. Davis and colleagues report that fewer than half of the studies they included in their systematic review (1) used pretested or validated OSCEs or standardized patients or assessment instruments, or (2) described objective criteria for performance assessment.15 Others have noted there is insufficient methodological detail in most published research involving standardized patients (SP), in particular details pertaining to SP characteristics and their training. An examination of the Cochrane Library of Systematic Reviews, the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports and the PROSPERO database indicates that no systematic reviews have been completed (or proposed) on this topic since the Davis review in 2006. Building on the Davis review, this systematic review will explore research that examines the relationship between self‐assessed competence and objective assessments of competence using the OSCE. The proposed synthesis is part of a broader program of research which builds on recommendations from numerous international bodies regarding the need to restructure health professional education to ensure it equips learners with the knowledge, skills and attitudes they need to function safely.1,34‐37 Notably, there is also recognition that what is evaluated drives what is taught and learnt.38,39 Accordingly, development of an OSCE for adoption by various health professional education programs may be crucial for truly integrating patient safety into health professional education. Just as written examinations and OSCEs assess different things,40,41 so do subjective and objective assessments; however, both are understood to yield important data.10

Know Your Client and Know Your Team: A Complexity Inspired Approach to Understanding Safe Transitions in Care

Background. Transitions in care are one of the most important and challenging client safety issues in healthcare. This project was undertaken to gain insight into the practice setting realities for nurses and other health care providers as they manage increasingly complex care transitions across multiple settings. Methods. The Appreciative Inquiry approach was used to guide interviews with sixty-six healthcare providers from a variety of practice settings. Data was collected on participants experience of exceptional care transitions and opportunities for improving care transitions. Results. Nurses and other healthcare providers need to know three things to ensure safe care transitions: (1) know your client; (2) know your team on both sides of the transfer; and (3) know the resources your client needs and how to get them. Three themes describe successful care transitions, including flexible structures; independence and teamwork; and client and provider focus. Conclusion. Nurses often operate at the margins of acceptable performance, and flexibility with regulation and standards is often required in complex sociotechnical work like care transitions. Priority needs to be given to creating conditions where nurses and other healthcare providers are free to creatively engage and respond in ways that will optimize safe care transitions.

Enhancing metabolic monitoring for children and adolescents using second-generation antipsychotics

The prevalence of children and adolescents using second-generation antipsychotics (SGAs) has increased significantly in recent years. In this population, SGAs are used to treat mood and behavioural disorders although considered off-label or not approved for these indications. Metabolic monitoring is the systematic physical health assessment of antipsychotic users utilized to detect cardiovascular and endocrine side effects and prevent adverse events such as weight gain, hyperglycaemia, hyperlipidemia, and arrhythmias. This practice ensures safe and efficacious SGA use among children and adolescents. Despite widely available, evidence-based metabolic monitoring guidelines, rates of monitoring continue to be suboptimal; this exposes children to the unnecessary risk of developing poor cardiovascular health and long-term disease. In this discursive paper, existing approaches to metabolic monitoring as well as challenges to implementing monitoring guidelines in practice are explored. The strengths and weaknesses of providing metabolic monitoring across outpatient psychiatry, primary care, and collaborative community settings are discussed. We suggest that there is no one-size-fits-all solution to improving metabolic monitoring care for children and adolescents using SGA in all settings. However, we advocate for a pragmatic global approach to enhance safety of children and adolescents taking SGAs through collaboration among healthcare disciplines with a focus on integrating nurses as champions of metabolic monitoring.