First, we describe how managers saw their role in developing and sustaining a culture for patient safety and the role of patient safety culture surveys in guiding patient safety work. Second, we present the results from the deductive analysis that yielded five themes describing strategies that managers used to promote patient safety and patient safety culture within their units: Valuing and developing healthcare professionals´ expertise, Organizing for resilience, Being present and setting a good example in daily work, Encouraging individual and organizational learning from incidence reporting and Balancing adherence to and questioning of standardized operative procedures.
A. Developing and sustaining a culture for patient safety
In general, the first line managers were convinced that they personally had a great impact on patient safety and patient safety culture within the unit as was phrased by one of them in the following way:
” I believe I play a tremendous role in promoting patient safety” (IP2)
The managers also expressed a deep commitment to patient safety issues and viewed these missions as their main duties as exemplified by this quotation:
” Looking at my job in a wider perspective I think it is all about strengthening patient safety” (IP5)
The managers strongly believed they played an important role in the development of a positive patient safety culture which also was looked upon as a never-ending mission. The importance of their personal attitudes in situations where they, themselves, might have put patients at risk or even worse, made them experience harm, was described as essential for building a supportive safety culture. One of the managers formulated this as follows:
” Yes, I do think it is very important that you dare to speak up about your own mistakes. Because I think that´s what it´s all about. To have psychological safety – yes, dare to show your own mistakes.” (IP6)
” If they do not feel comfortable and like it here then there is no joy in going to work and that effects how patients are treated” (IP3)
Finally, having routines and a structure in place for supporting staff members after they have been involved in an adverse event was stressed as an important factor in building a good working climate. One of the managers described this in the following way:
” We care for the staff member who has been involved in an adverse event /…/ sit down and talk /…/ listen /…/ provide support/…/” (IP1)
B. Experience of using HSOPSC surveys to guide patient safety improvement work
All the units had participated in the HSOPSC survey and half of the units had already completed it a second time. None of the managers described any systematic use of the patient safety culture measurements as a tool or a guide in their work to promote and improve patient safety culture and patient safety. One of the reasons expressed for not using the survey were that they did not know how to interpret the results.
"Honestly, I actually do not really remember but let me think /../
There was some feedback, we talked about it and the hospital leadership still referred to it occasionally. I think that results were posted on the intranet, well that was it. I remember that when we gave feedback to the staff, I and looked at the bars and circles online. Yes, and as I said, the results were online”/../. (IP2)
The managers admitted that their motivation for working with HSOPSC was low, despite their focus on constantly improving patient safety and awareness of the importance of a strong patient safety culture. Also, the managers described difficulties in getting feedback on survey outcomes and said that they were not given the tools and training in how to interpret and act upon the results. This situation was described in this way by one of the managers:
” I would have liked to have a constructive discussion about all the questions…. also, a plan…what are we aiming at? What are our goals? And a toolbox…how should I interpret this picture... the spider diagram… what am I supposed to do with it? (IP7)
Measurements were said simply to be done to receive financial revenue through the national initiative plan, not as a part of a goal-oriented local improvement plan.
The managers expressed that they were not involved in decisions on when to conduct a survey or in the communication of survey results. Timing of patient safety culture surveys seemed to be set by management higher up in the health care organization without any consultation with first line managers to capture when and what information was needed in order to support and further develop ongoing patient safety initiatives.
Other explanations raised by the managers was the lack of support from higher management in how to improve safety culture. The only exception was one manager who described that the Chief Medical Officer at the hospital had demanded that the survey outcome should be used as a basis for local patient safety improvement plans. Thus, action plans for improved adherence to handoff routines and improved feedback on incidence reporting were developed as an effect of poor outcomes in these areas in the recent patient safety culture survey.
“/… /all units were forced to come up with an action plan based on the survey outcome /…/to show that you had done something.” (IP3)
C. Strategies used by managers to promote patient safety and patient safety culture
C1. Valuing and developing health care professional’s expertise
The managers emphasized the importance of expertise and actively supported the development of health care professionals´ competencies. Many managers saw noticing and recognizing the competencies of individual staff as central task linked to the resilience of the ICU.
”Also, make use of all competencies that each one among staff members possess /…/which makes them feel acknowledged for who they are /…/ what their contributions mean to the whole picture /…/” (IP5)
The managers emphasized the importance of supporting continuous development of staff members, both in medical care and in-patient safety issues, for them to deliver safe care. The managers gave examples of how they incorporated in daily respectful conversations between them as leaders and the unit staff by providing constructive suggestions when/where appropriate and inviting reciprocal recommendations for professional growth. Using the expertise of staff members was also seen as an important strategy for improvement. Sometimes experts were invited to present new evidence or information calling for change of routines. This was said to have a greater impact than the manager giving the information.
” For example, if staff adherence to hygiene routines has been studied in our unit it is much better if an outside expert, involved in the study, comes and gives feedback on the results and not me or anyone else within the unit. Listening and learning will be much better.” (IP1)
C2. Organizing for resilience
The everyday organizing of clinical work seems to dominate the work of the managers in this study. One central aspect in promoting a patient safety, was to secure that enough staff were present during each shift and ensuring that necessary competences were represented by the team.
” It is in the end a patient safety issue that staff is well trained and competent” (IP4)
The managers’ argued that focusing on scheduling the right competencies for a shift was an important precondition for the team’s capability to manage everyday work as well as to reorganize and respond to a variety of expected and unexpected situations in the complex ICU environment without deviating from safe practice. As one manager stated:
” I think that a too heavy workload is absolutely devastating [for patient safety] because then you start to prioritize [and ignore basic safety routines]. And when you do that you are dissatisfied with your work” (IP7)
C3. Being present and setting a good example in daily work
The managers stated unanimously that it was of great importance to be present and, as much as possible, take part in daily, clinical work because, by so doing, opportunities for picking up problems which might not otherwise have been communicated to the manager were created. One of the managers said:
” Two weeks out of four I am dressed in hospital working clothes and I take part in daily work. The other two weeks I wear private clothes and work administratively. When dressed in working clothes, staff members always come up to me and give comments and reflections on experiences and observations during work /…/ and they generally express a wish that I would be present like that every day.” (IP7)
Also, when the managers participated in daily work potential risks were spotted by the manager him- or herself as e.g. shifts in routines having occurred and current opinions on how to execute certain care procedures having occurred:
” It is quite another thing….I sit in the coffee room as one of the staff and listen and then they can ask, and I sort of get a deeper understanding and see it from their perspective…” (IP6)
The saw themselves as role models and that their way of acting and reacting in routine work as well as critical situations was copied by their staff.
” Always setting a good example /…/ in clinical work, in patient care/…/ For instance never deter from basic hygiene rules /…/ but also in my attitudes /…/ expressing a will to communicate and to speak up /…/ demonstrating an attitude /…/” (IP3)
Also, it gave the managers excellent opportunities to exert a direct influence on attitudes and manners, as was expressed by one of the managers in this way:
” Communication /…/ and daring to take part in daily work, showing how things should be done /…/ that is really the most important part [of patient safety work]” (IP8
C4. Encouraging individual and organizational learning from incidence reporting
Fostering an active incidence reporting, preferably via the electronic system was mentioned as an important part of the first line managers´ efforts to maintain and develop patient safety within the unit. One of the informants described the necessity of sharing information on adverse events like this:
” It is done to make staff aware about what has happened, and that this is something that we need to be extra careful about” (IP1)
Analysis of the reports was generally handled by one or more members of the unit including – in case of a serious incident – the head of the department. The suggestions for improvement emerging from these analyses were subsequently implemented through existing forums. The first line managers expressed an ambition to provide both a written feedback to each individual employee who had filed a report and also, orally, inform all staff members, in conjunction with staff meetings, about the outcome of the analysis of the incidence report and what measures that had been taken or were to be taken in order to prevent this incidence and similar others from occurring again. Due to an overload of reports, however, the ambition to analyze and give feedback on all reports that had been filed was not always possible to live up to. Those reports which were regarded as “minor” incidents thus had to be left unattended. This was generally regarded as a failure since windows for improvement might have been left unused.
Further, to deepen the understanding of how patient safety is treated, the employees were not only provided with feedback from analyses of adverse events but also invited to take part in root cause analyses (RCA) teams or improvement efforts in order to learn the methodology and get a deeper understanding of the risks in health care and how to prevent harm.
” I think a lot of how I can reach as many as possible of my staff about ongoing patient safety work, but it is not that easy. So, what I can do is to tell them about the outcomes of the root cause analyses that we have done /…/. Also, I try to get as many members of my staff as possible included in root cause analyses teams as a learning opportunity” (IP6)
Sometimes, groups of employees were given the opportunity to analyze an incident on their own and afterwards compare their conclusions and suggestions with those of the formal RCA group. Involving co-workers in RCA activities or in group discussions around the results of such analyses was said to stimulate creativity among staff members i.e. further develop their capacity for solving problems and finding ways to provide safer care. This was described in the following way by one of the first line managers:
“ It is formally me who makes the final registration in the system, but in this way we get more staff members engaged in the discussion on how to find good solutions on how to move ahead” (IP7)
The managers, however, regretted that their aim to create continuous learning often rested unattended since little or no time was set aside for performing follow up on changes that had been made. One of the managers formulated it like this:
” We are good at starting new projects, but we never evaluate the ones that we already have started” IP5
C5. Balancing adherence to and questioning of standardized operative procedures
However, the mangers described how they found the task to keep all guidelines updated, communicated and adhered to challenging. They described that they sometimes took the responsibility not to introduce documents on standard operative procedures sent out from top management of the hospital because the procedures advocated from this level according to their opinion were not always applicable to intensive care. One manager said:
Also, in certain situations, when unexpected things happened and no written guidelines fully applied to the situation, the managers expressed a wish for employees not to be too dependent on guidelines but instead use their own creativity and try to focus on the best way of solving the situation without harm being done and then, afterwards, decide whether a new guideline was needed or the old one was obsolete and in need of updating.
” We encourage staff members to act like this and then afterwards to engage in discussions and analysis of the situation. Maybe guidelines applicable to this type of situation need to be changed or there is need for a new guideline?” (IP2)
On the other hand, too creative staff members could also pose a risk and the managers underlined the importance of matching creativity with an explicit process for how to eventually decide on and launch a new routine in order to prevent uncontrolled methods and ways of working entering the scene. One of the managers formulated it like this:
” This [strategy] leads to my staff being fairly good at solving problems. But this can of course be hazardous, so you must have structures for how to handle such situations” (IP2)