Health care delivery systems suffer from a variety of quality problems such as underuse, overuse, and misuse of health services. There are a variety of causes of these quality problems including rapid advancements in medical technologies, aging populations with comorbid chronic illnesses, complex care processes etc. These interrelated factors also contribute to complexity and tight coupling among system components that can eventually lead to medical errors. Empirical evidence from a number of international studies suggests that an adverse event occurs in up to 10% of hospitalizations and that half of these events are preventable (1,2,3). Moreover, medical errors are costly; for example, preventable adverse events in Canadian acute care systems result in $397 million in extra health care costs annually (4). Over the last decade, implementation of standardized clinical interventions such as hand hygiene guidelines and surgical checklists have reduced preventable medication, diagnostic and surgical errors (5). However, a growing body of evidence suggests that contextual factors (e.g., teamwork and culture) positively influences perceptions of patient safety (6) and can increase the likelihood of successfully implementing these safety improvement interventions (7,8).
The objectives of this mixed-methods study are to examine the relationships (i.e., direct and moderated) between nurses’ perceptions of senior leadership, supervisory leadership, teamwork, turnover intention and a self-reported patient safety measure. Further evidence of the relationship between contextual factors, such as leadership support for safety and teamwork, and outcomes such as patient safety can contribute to a growing body of empirical work on the role of context in improving quality and safety practices.
Relational factors affecting perceptions of patient safety
Empirical evidence in healthcare settings suggest that safety climate perceptions of employees can be significantly improved by leaders’ safety related behaviours such as frontline safety forums (9), senior leadership walkrounds (10), adopt-a-work unit (11) establishing unit norms of openness (12), and adopting situation specific leadership style (13). The positive impact of leadership support for safety on patient outcomes (e.g., decreased falls, lower rates of medication errors, and less likelihood of hospital-acquired infections) is also starting to emerge in healthcare research (14,15). However, only a handful of empirical studies have examined the interactive effect of senior and supervisory leadership on safety outcomes (6). There is a need for further empirical research to better understand the impact of different levels of leadership on patient safety.
In the past, highly specialized professionals operating in silos were often sufficient to provide appropriate treatment to patients. However, changing disease patterns and growing complexity of care delivery now require healthcare teams to engage in teamwork behaviours (e.g., communication, coordination, cooperation) to reduce preventable errors and improve safety outcomes (17). Indeed, emerging empirical evidence suggests that positive staff perceptions of teamwork are associated with better patient safety outcomes – e.g., reduced odds of poor surgical outcomes (18), reduced incidence of in-hospital adverse events (14) and reduced hospital readmission rates (19).
Some employee turnover is to be expected, however, safe functioning of healthcare organizations is threatened when workforce turnover is high (20). There are direct (e.g., hiring, advertisement, and recruitment costs) and indirect (e.g., lower morale, reduced productivity, increased workload) negative consequences of high employee turnover rate on organizational functioning and performance (21). High turnover can trap an organization in a vicious cycle where remaining employees are more likely to leave due to increased workload and low morale (22,20). In healthcare organizations, the well-being of patients is at risk when employee turnover is high. For example, healthcare-acquired infections, hospitalizations, and medical errors are more likely in the presence of high nursing turnover (23,24). On the other hand, occurrence of medication errors, patient falls, and adverse events are less likely when nursing turnover is low (25). Turnover intention is the strongest most immediate predictor of turnover and hence a valid proxy for employee leaving behaviours (26,21). Turnover intention is also likely to be associated with many of the same indirect costs as turnover (e.g. low morale, reduced workforce productivity). However, to our knowledge, none of the previous empirical studies have examined the relationship between healthcare staff turnover intention and their perceptions of patient safety outcomes. There is a need to empirically examine this pertinent relationship due to conceptual (e.g., supporting turnover intention as a valid proxy of turnover) and practical (e.g., encouraging healthcare organizations to proactively implement staff retention strategies) implications.
The research community has made important inroads in understanding the impact of context-related predictors on patient safety. However, there are several gaps in the literature on patient safety that still need to be addressed. First, much of the empirical research on contextual factors has employed quantitative time-series, before-and-after, or cross-sectional research designs (27). However, context-related factors such as teamwork and turnover intention are inherently socially constructed phenomenon and greater use of qualitative or mixed methods designs can provide valuable insights that may be missed by over-reliance on quantitative research (28). Second, past empirical research has focused primarily on certain patient safety predictors – e.g., teamwork – while the impact of other pertinent patient safety predictors – e.g., turnover intention – have largely been underexplored. Third, empirical research in healthcare settings has been limited to an examination of main effects of constructs on outcomes with little attention to potentially important interactive effects (28,6) – there is a need to examine mediating and moderating influences of predictors on safety outcomes.
The current mixed-methods study seeks to address the above noted gaps in the patient safety literature by examining how nurses’ perceptions of senior leaders, immediate supervisors, teamwork and turnover intention impact their perceptions of patient safety. More specifically, it is hypothesized that:
Hypothesis 1
Perceptions of senior leadership support for safety, supervisory leadership support for safety, and teamwork will be positively associated with overall patient safety grade. On the other hand, perceptions of turnover intention will be negatively associated with overall patient safety grade. All of these associations are predicted to be significant.
Hypothesis 2
The leadership and teamwork predictor variables will moderate the negative impact of turnover intention on perceptions of overall patient safety grade.