René Schwendimann

Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States

Objective To determine whether hospitals with a good organisation of care (such as improved nurse staffing and work environments) can affect patient care and nurse workforce stability in European countries. Design Cross sectional surveys of patients and nurses. Setting Nurses were surveyed in general acute care hospitals (488 in 12 European countries; 617 in the United States); patients were surveyed in 210 European hospitals and 430 US hospitals. Participants 33 659 nurses and 11 318 patients in Europe; 27 509 nurses and more than 120 000 patients in the US. Main outcome measures Nurse outcomes (hospital staffing, work environments, burnout, dissatisfaction, intention to leave job in the next year, patient safety, quality of care), patient outcomes (satisfaction overall and with nursing care, willingness to recommend hospitals). Results The percentage of nurses reporting poor or fair quality of patient care varied substantially by country (from 11% (Ireland) to 47% (Greece)), as did rates for nurses who gave their hospital a poor or failing safety grade (4% (Switzerland) to 18% (Poland)). We found high rates of nurse burnout (10% (Netherlands) to 78% (Greece)), job dissatisfaction (11% (Netherlands) to 56% (Greece)), and intention to leave (14% (US) to 49% (Finland, Greece)). Patients’ high ratings of their hospitals also varied considerably (35% (Spain) to 61% (Finland, Ireland)), as did rates of patients willing to recommend their hospital (53% (Greece) to 78% (Switzerland)). Improved work environments and reduced ratios of patients to nurses were associated with increased care quality and patient satisfaction. In European hospitals, after adjusting for hospital and nurse characteristics, nurses with better work environments were half as likely to report poor or fair care quality (adjusted odds ratio 0.56, 95% confidence interval 0.51 to 0.61) and give their hospitals poor or failing grades on patient safety (0.50, 0.44 to 0.56). Each additional patient per nurse increased the odds of nurses reporting poor or fair quality care (1.11, 1.07 to 1.15) and poor or failing safety grades (1.10, 1.05 to 1.16). Patients in hospitals with better work environments were more likely to rate their hospital highly (1.16, 1.03 to 1.32) and recommend their hospitals (1.20, 1.05 to 1.37), whereas those with higher ratios of patients to nurses were less likely to rate them highly (0.94, 0.91 to 0.97) or recommend them (0.95, 0.91 to 0.98). Results were similar in the US. Nurses and patients agreed on which hospitals provided good care and could be recommended. Conclusions Deficits in hospital care quality were common in all countries. Improvement of hospital work environments might be a relatively low cost strategy to improve safety and quality in hospital care and to increase patient satisfaction.

Interventions for preventing falls in acute and chronic care hospitals: a systematic review and meta-analysis.

OBJECTIVES: To determine the characteristics and the effectiveness of hospital fall prevention programs.

Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study

Background Little is known of the extent to which nursing-care tasks are left undone as an international phenomenon. Aim The aim of this study is to describe the prevalence and patterns of nursing care left undone across European hospitals and explore its associations with nurse-related organisational factors. Methods Data were collected from 33 659 nurses in 488 hospitals across 12 European countries for a large multicountry cross-sectional study. Results Across European hospitals, the most frequent nursing care activities left undone included ‘Comfort/talk with patients’ (53%), ‘Developing or updating nursing care plans/care pathways’ (42%) and ‘Educating patients and families’ (41%). In hospitals with more favourable work environments (B=−2.19; p<0.0001), lower patient to nurse ratios (B=0.09; p<0.0001), and lower proportions of nurses carrying out non-nursing tasks frequently (B=2.18; p<0.0001), fewer nurses reported leaving nursing care undone. Conclusions Nursing care left undone was prevalent across all European countries and was associated with nurse-related organisational factors. We discovered similar patterns of nursing care left undone across a cross-section of European hospitals, suggesting that nurses develop informal task hierarchies to facilitate important patient-care decisions. Further research on the impact of nursing care left undone for patient outcomes and nurse well-being is required.

Characteristics of Hospital Inpatient Falls across Clinical Departments

Background: Hospital inpatient falls are common and may lead to injuries and prolonged hospitalization. Although hospital studies have reported overall fall rates and injuries associated with falls, few have addressed population characteristics and circumstances of falls across clinical departments within a hospital setting. Objective: To determine inpatient fall rates in an urban public hospital and to explore associated characteristics across clinical departments. Methods: The study was conducted in a 300-bed urban public hospital in Switzerland from 1999 to 2003. Patient data and data from the hospital’s standardized fall reporting system on hospital inpatients’ first falls, along with associated characteristics, across the departments of internal medicine, geriatrics and surgery, were analyzed. Descriptive statistics and statistical tests: χ2 and ANOVA tests with multiple comparisons tests (post-hoc analysis) were used. Results: Over this 5-year period, 34,972 patients were hospitalized (female 53.6%; mean age 67.3 ± 19.3 years; mean length of stay 11.9 ± 13.2 days) including 2,512 patients (7.5%) who experienced at least one fall during their hospitalization (geriatrics 24.8%; internal medicine 8.8%; surgery 1.9%). The fall rates per 1,000 patient (adjusted for age) days differed significantly between all of the departments (geriatrics 10.7; internal medicine 9.6; surgery: 3.2) (p < 0.001). Overall, 30.1% of the patients who fell experienced minor injuries and 5.1% major injuries. In geriatrics, fall-related circumstances such as transferring were more common (40.4%) than in medicine (33%) or surgery (30.4%) (p < 0.001), whereas falling out of bed was rarer (16.4%) (surgery 27.1%; internal medicine 20.5%) (p < 0.001). In addition, the prevalence of risk factors among patients who fell varied significantly among clinical departments, except for impaired cognition and narcotic use. Conclusion: In the hospital studied, inpatient falls are significantly more common in departments of geriatrics and internal medicine than in surgical departments. Fall rates, related injuries and circumstances of inpatient falls varied significantly among clinical departments, probably due to differences in patient characteristics. When monitoring falls, hospitals should therefore consider differences in characteristics associated with patient falls across clinical departments. High priorities should be allocated in view of identifying patients at risk of falling and implementing fall prevention strategies and interventions.

Fall Prediction in Inpatients by Bedside Nurses Using the St. Thomas's Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) Instrument: A Multicenter Study

OBJECTIVES: To assess the predictive value of the St. Thomass Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) instrument, a simple fall‐risk assessment tool, when administered at a patients hospital bedside by nurses.

Variation in safety culture dimensions within and between US and Swiss Hospital Units: an exploratory study

Background The purpose of this study was to explore the variability in safety culture dimensions within and between Swiss and US clinical areas. Methods Cross-sectional design. The 30-item Safety Attitudes Questionnaire (SAQ) was distributed in 2009 to clinicians involved in direct patient care in medical and surgical units of two Swiss and 10 US hospitals. At the unit level, results were calculated as the percentage of respondents within a unit who reported positive perceptions. MANOVA and ANOVA were used to test for differences between and within US and Swiss hospital units. Results In total, 1370 clinicians from 54 hospital units responded (response rate 84%), including 1273 nurses and 97 physicians. In Swiss hospital units, three SAQ dimensions were lower (safety climate, p=0.024; stress recognition, p<0.001; and perceptions of management, p<0.001) compared with US hospital units. There was significant variability in four out of six SAQ dimensions (teamwork climate, safety climate, job satisfaction and perceptions of unit management) (p<0.001). Moreover, intraclass correlations indicate that these four dimensions vary more at the unit level than hospital level, whereas stress recognition and working conditions vary more at the hospital level. Conclusions The authors found differences in SAQ dimensions at the country, hospital and unit levels. The general emphases placed on teamwork and safety climate in quality and safety efforts appear to be highlighting dimensions that vary more at the unit than hospital level. They suggest that patient safety improvement interventions target unit level changes, and they support the emphasis being placed on teamwork and safety climate, as these vary significantly at the unit level across countries.

Assessing the safety attitudes questionnaire (SAQ), German language version in Swiss university hospitals - a validation study

BackgroundImproving patient safety has become a major focus of clinical care and research over the past two decades. An institution’s patient safety climate represents an essential component of ensuring a safe environment and thereby can be vital to the prevention of adverse events. Covering six patient safety related factors, the Safety Attitudes Questionnaire (SAQ) is a validated and widely used instrument to measure the patient safety climate in clinical areas. The objective of this study was to assess the psychometric properties of the German language version of the SAQ.MethodsA survey was carried out in two University Hospitals in Switzerland in autumn 2009 where the SAQ was distributed to a sample of 406 nurses and physicians in medical and surgical wards. Following the American Educational Research Association guidelines, we tested the questionnaire validity by levels of evidence: content validity, internal structure and relations to other variables. Confirmatory factor analysis was used to examine factor structure. Cronbach’s alphas and inter-item correlations were calculated to examine internal consistency reliability.ResultsA total of 319 questionnaires were completed representing an overall response rate of 78.6%. For three items, the item content validity index was <0.75. Confirmatory factor analysis showed acceptable model fit (RMSEA = 0.045; CFI = 0.944) for the six-factor model. Additional exploratory factor analysis could not identify a better factor model. SAQ factor scores showed positive correlations with the Safety Organizing Scale (r = .56 - .72). The SAQ German version showed moderate to strong internal consistency reliability indices (Cronbach alpha = .65 - .83).ConclusionsThe German language version of the SAQ demonstrated acceptable to good psychometric properties and therefore shows promise to be a sound instrument to measure patient safety climate in Swiss hospital wards. However, the low item content validity and large number of missing responses for several items suggest that improvements and adaptations in translation are required for select items, especially within the perception of management scale. Following these revisions, psychometric properties should reassessed in a randomly selected sample and hospitals and departments prior to use in Swiss hospital settings.

Framework for Evaluating the Impact of Advanced Practice Nursing Roles

PURPOSE To address the gap in evidence-based information required to support the development of advanced practice nursing (APN) roles in Switzerland, stakeholders identified the need for guidance to generate strategic evaluation data. This article describes an evaluation framework developed to inform decisions about the effective utilization of APN roles across the country. APPROACH A participatory approach was used by an international group of stakeholders. Published literature and an evidenced-based framework for introducing APN roles were analyzed and applied to define the purpose, target audiences, and essential elements of the evaluation framework. Through subsequent meetings and review by an expert panel, the framework was developed and refined. FINDINGS A framework to evaluate different types of APN roles as they evolve to meet dynamic population health, practice setting, and health system needs was created. It includes a matrix of key concepts to guide evaluations across three stages of APN role development: introduction, implementation, and long-term sustainability. For each stage, evaluation objectives and questions examining APN role structures, processes, and outcomes from different perspectives (e.g., patients, providers, managers, policy-makers) were identified. CONCLUSIONS A practical, robust framework based on well-established evaluation concepts and current understanding of APN roles can be used to conduct systematic evaluations. CLINICAL RELEVANCE The evaluation framework is sufficiently generic to allow application in developed countries globally, both for evaluation as well as research purposes.

Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout

Background Leadership WalkRounds (WR) are widely used in healthcare organisations to improve patient safety. The relationship between WR and caregiver assessments of patient safety culture, and healthcare worker burnout is unknown. Methods This cross-sectional survey study evaluated the association between receiving feedback about actions taken as a result of WR and healthcare worker assessments of patient safety culture and burnout across 44 neonatal intensive care units (NICUs) actively participating in a structured delivery room management quality improvement initiative. Results Of 3294 administered surveys, 2073 were returned for an overall response rate of 62.9%. More WR feedback was associated with better safety culture results and lower burnout rates in the NICUs. Participation in WR and receiving feedback about WR were less common in NICUs than in a benchmarking comparison of adult clinical areas. Conclusions WR are linked to patient safety and burnout. In NICUs, where they occurred more often, the workplace appears to be a better place to deliver and to receive care.

Content validity and internal consistency of the Dutch translation of the Safety Attitudes Questionnaire: An observational study

BACKGROUND Patient safety is fundamental to healthcare quality. Attention has recently focused on the patient safety culture of an organisation and its impact on patient outcomes. A strong safety climate appears to be an essential condition for safe patient care in the hospital. A number of instruments are used to measure this patient safety climate or culture. The Safety Attitudes Questionnaire is a validated, widely used instrument to investigate multiple dimensions of safety climate at the clinical level in a variety of inpatient and outpatient settings. OBJECTIVES The purpose of this study is to explore the face- and content validity and the internal consistency of the Safety Attitudes Questionnaire in a large Belgian academic medical center. METHOD The translation into Dutch was done by three researchers. A panel of fifteen Dutch speaking experts evaluated the translation and its content validity. Content validity was quantified by the content validity index (CVI) and a modified kappa index. Face validity was evaluated by two nurses and two physicians who assessed the Dutch version of the SAQ. A cross-sectional design was used to test internal consistency of the SAQ items by calculating Cronbachs alpha and corrected item-total correlations. RESULTS Twenty-three of the 33 SAQ items showed excellent and seven items showed good content validity. One item had a fair kappa value (item 20) and two items had a low content validity index (items 15 and 16). The average CVI of the total scale was 0.83 and ranged from 0.55 to 0.97 for the six subscales. The face-validity was good with no fundamental remarks given. The SAQs overall Cronbachs alpha was 0.9 and changed minimally when removing items. The item-total correlations ranged from 0.10 to 0.63, no single items were strongly correlated with the sum of the other items. CONCLUSION We conclude that in this study the Dutch version of the Safety Attitudes Questionnaire showed acceptable to good psychometric properties. In line with previous evidence, this instrument seems to be an acceptable to adequate tool to evaluate the safety climate.