Evaluating the relationship between safety culture and the quality of patient handover between the ambulance and emergency department from the viewpoints of hospital emergency nurses and emergency medical personnel in northwest Iran

doi:10.21203/rs.3.rs-4114618/v1

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Evaluating the relationship between safety culture and the quality of patient handover between the ambulance and emergency department from the viewpoints of hospital emergency nurses and emergency medical personnel in northwest Iran

https://doi.org/10.21203/rs.3.rs-4114618/v1

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Aims: The present study aimed to evaluate the relationship between safety culture and the quality of patient handover between the ambulance and emergency.

Background: Evaluating the patient safety culture significantly affects the quality of patient handover, medical, and care services in different hospital units, especially the emergency department.

Methods: The present correlational study was conducted on all nurses working in the emergency departments of educational-medical centers (N=220) and medical emergency personnel of Ardabil city (N=92) using the census method. The data were collected using the Leif et al. (2018) Hospital Survey on Patient Safety Questionnaire and the Golling et al. (2022) Quality of Patient Handover between Ambulance and Emergency Department Questionnaire. The collected data were analyzed in SPSS software (26) using descriptive statistics, independent t-test, analysis of variance, Pearson correlation coefficients, and linear regression logistic model.

Results: The results revealed that the quality of patient safety culture in emergency nurses (90.5%) and emergency medical personnel (89.1%) was at a moderate level. The mean patient safety culture in emergency nurses (17.75±151.43) was higher than in emergency medical personnel (148.37±18.48) and this difference was statistically significant (P<0.04). The quality of patient handover among emergency nurses (71.7%) and emergency medical personnel (83.7%) was also moderate and it was statistically significant (P<0.04). There was a positive and significant correlation between the patient safety culture and the quality of patient handover between the ambulance and emergency department (P<0.01). The stepwise multiple linear regression model showed that "teamwork between organizational units" was a stronger predictor than other variables in the quality of patient handover between the ambulance and emergency department.

Conclusion: The results revealed that by increasing the level of patient safety culture in emergency nurses, the quality of patient handover increases. Therefore, it is recommended that the policymakers in the health area take the necessary measures by holding briefing workshops to promote the culture of patient safety and strengthen teamwork among the emergency department personnel.

Safety culture

Patient handover quality

Nurse

Medical emergency

Emergency

Hospitals are one of the most vital components of the healthcare system. Its primary mission is to provide quality care for patients. Quality of care is a multidimensional concept and patient safety is one of its most crucial dimensions (1). Making efforts to improve the safety of patients is one of the vital practices for health organizations at the beginning of the 21st century (2). It has been considered a key priority for healthcare systems, especially in the last few years (3). One of the basic measures in the area of achieving patient safety is to observe the culture of patient safety among healthcare staff (4). Currently, most of the developed countries have realized that simply having management systems and advanced technology is not enough to achieve sustainable development (5). The way to prevent incidents is by promoting safe behaviors of staff, their values, beliefs, and attitudes toward safety, and the attitude of the organization toward safety, which forms their safety culture (6).Establishing a culture of patient safety in the organization and replacing it with a culture of silence by creating an open space for reporting errors and increasing organizational learning improves patient safety (7). In light of patient safety culture, staff can report errors and unwanted complications without fear (8) and gain the opportunity to learn from their mistakes, which in turn prevents systematic errors and increases patient safety (9). A positive safety culture directs the behaviors of health service providers so patient safety becomes one of their highest priorities (10). Also, in the area of healthcare and medical activities, the emergency medical system (pre-hospital emergency) in all countries in the world is considered one of the key components of providing medical services (11). The most important goal of this system is to provide services in the shortest possible time based on the latest scientific standards of the world (12).Experts consider pre-hospital emergency services as a bridge between society and medical services (13). After the patient enters this unit from the ambulance, the responsibility of patient care is transferred from the emergency medical technicians to the emergency nursing personnel (14). This process may also occur in the hospital setting during the change of medical personnel shifts when the patient is handover between different hospital units, or even when the patient is handover between medical centers. This process is called "patient handover" (11). The primary goal of this process is to ensure the accurate transfer of information about the patient's condition and care plan since one of the most crucial steps in ensuring the continuity of patient care is the professional responsibility transfer (15).It has been estimated that ineffective information transfer accounts for about 40% of hospital complications such as treatment errors and patient mortality (16). The emergency department is one of the most vital departments of the hospital. The handover process in this department includes changes in the healthcare team and the physical location of the patient (17). The emergency department setting and the processes governing it can negatively and potentially affect the effectiveness and efficiency of this process. since the emergency department is described as a complex, risky, and chaotic clinical setting (18). Most of the studies conducted in this area have focused on patient handover between nurses and have not addressed the potential problems and communication barriers that are unique to the emergency department. Additionally, the studies conducted on patient handover from the pre-hospital emergency room are very nascent. Thus, given the existing conditions and the vital and key role of the patient handover process from the medical emergency team to the emergency department of the hospital, it is essential to investigate the viewpoints of the primary personnel involved in this process, i.e. ambulance personnel and hospital emergency department personnel, to carefully explore the interactions of personnel during this process and find the causes and factors involved in this process, including its relationship with the perception of patient safety culture among the personnel.

Purpose of the study: The present study aimed to evaluate the relationship between safety culture and the quality of patient handover between the ambulance and emergency. department from the viewpoints of hospital emergency nurses and emergency medical personnel in northwest Iran.

Study design: The present Correlational study was conducted on all emergency department nurses and emergency medical personnel working in the northwest region of Iran.

Participants: They were selected using a census method. The inclusion criteria of the study included all nurses and emergency medical personnel with any type of employment status, bachelor's degree and above, who had at least 6 months of employment history and were willing to participate in the study. The inclusion criterion included withdrawal at each stage of the research, incomplete filling out of questionnaire questions (failure to answer more than 5% of the questions), and taking leave during the sampling period.

Data collection: The data collection tool was a three-part questionnaire:

A (Socio-demographic profile: it includes 12 questions and information about age, gender, marital status, job title and status, level of education, field of study, history of participating in patient handover workshop, employment status, and general employment history and work in the emergency department.

B) Quality of patient handover between ambulance and emergency department questionnaire: This tool was first designed by Golling et al. (2022) (19). It contains 23 questions scored on a five-point Likert, ranging from strongly disagree to strongly agree. The range of scores is between 23 and 115. This tool has 5 domains:

1- The status of teamwork in the patient handover between the ambulance and the emergency department: (Questions 1-6)

2- The status of information transfer in patient handover (Questions 7-11).

3- Knowledge of the patient's condition during handover (Questions 12-14).

4- The status of respectful interactions in patient handover (Questions 15-18).

5-The status of the working environment during patient handover (Questions 19-23)

In this tool, if a subject’s score is to 115, the quality of patient handover between ambulance and the emergency department will be better. The validity and reliability of the tool were confirmed in the study conducted by the designer of the tool (19). In the present study, the reliability of the tool using Cronbach's alpha method was obtained at 0.86.

C) Hospital survey on patient safety culture (HSOPS):

This tool was designed by the Agency for Healthcare Research and Quality in 2004. Then, it was reviewed by Leif Inge K Sørskår et al. (2018) to evaluate the state of patient safety culture in emergency medical personnel and emergency department nurses (20). It includes 46 five-point Likert questions ranging from strongly disagree to strongly agree. The range of scores is between 46 and 230. This tool has 13 subcomponents:

1-Management expectations and management in line with patient safety (Questions 1-4)

2- Organizational learning (Questions 5-7).

3- Teamwork within organizational units (Questions 8-11).

4- non-punitive response to the errors (Questions 12-14).

5- Overall perception of patient safety (Questions 15-18).

6- Issues related to staff (Questions 19-22).

7- Management support for patient safety (Questions 23-25).

8- Teamwork between organizational units (Questions 26-28).

9- Exchange and transmission of information (Questions 29-33).

10- Open communication channels (Questions 34-36).

11- Communication and giving feedback about errors (Questions 37-39)

12- Frequency of reporting events (Questions 40-42)

13-Specific questions from emergency medical personnel (Questions 43-46)

The validity and reliability of the tool were confirmed in the study by the designer of the tool (20). In this study, the reliability of the tool using Cronbach's alpha method was obtained at 0.81. The questions about the quality of patient handover between the ambulance and the emergency department and patient safety culture questionnaires were translated into Persian and re-translated into English by an expert. Their face and content validities were confirmed by ten university faculty members using the Waltez and Basel technique (quality of patient handover (CVR=0.92, CVI=0.98), patient safety culture (CVR=0.85, CVI=0.97). The rule of quartiles was used to determine the quality of patient handover between the ambulance and the emergency department and patient safety culture. The mean scores of questions related to the quality of patient handover between the ambulance and the emergency department and patient safety culture and their sub-components were compared with the criterion score. The following formula was used to calculate the criterion score:

The maximum score minus the minimum score divided by two plus the minimum score (21).

Data analysis: The data were entered into SPSS-26 software. Qualitative variables were displayed as frequencies, and mean and standard deviation were calculated for quantitative variables. One-sample t-tests, independent t-tests, and one-way analysis of variance were used to investigate the relationship between the socio-demographic characteristics of nurses and the quality of patient handover between and patient safety culture. Also, the Pearson-Spearman correlation coefficient test and linear regression logistic model were used to investigate the relationship between the quality of patient handover and patient safety culture.

The response rate (RR) was 95.6% among emergency nurses and 91.08 among emergency medical personnel. Among the participants, 53.2% of emergency nurses and 51.1% of emergency medical personnel were officially employed. Also, 36.3% of emergency nurses and 51.1% of emergency medical personnel had a history of participating in the patient handover workshops. Table 1 presents other demographic information of the samples.

The results revealed that the statues of quality of handover in hospital emergency nurses (26%) was better than in emergency medical personnel (13%), and this difference was statistically significant (P<0.04). The mean patient safety culture in emergency nurses (151.43 ± 17.75) was higher than emergency medical personnel (148 ± 18.48) and this difference was statistically significant (P < 0.04) (Table 2).

There was a statistically significant correlation between the mean quality of patient handover and marital status, nurses' employment status, history of participating in the patient handover workshops, and employment history of nurses in the emergency department (P<0.05). In emergency medical personnel, there was a statistically significant relationship between the mean quality of patient handover and the age, employment history, and employment status of the personnel (P<0.05). Patient safety culture was also statistically significantly related to the level of education, employment status, age, and employment history of emergency department nurses. A statistically significant relationship was observed between patient safety culture, marital status, level of education, and job status in the group of emergency medical personnel (P<0.05) (Table 3).

The results revealed a positive correlation (R=0.13) between the safety culture and the quality of patient handover between the ambulance and emergency department (P<0.01). A stepwise multiple linear regression model was used to investigate the relationship between all the studied variables and the quality of patient handover between the ambulance and emergency department in emergency nurses. The results revealed that all variables significantly affect the quality of patient handover between the ambulance and emergency department nurses. The variable "teamwork between organizational units" was a stronger predictor than other variables in the quality of patient handover between the ambulance and emergency department. Teamwork between organizational units explains 9% of the quality of patient handover (Table 4).

The present study evaluates the relationship between safety culture and the quality of patient handover between the ambulance and emergency department from the viewpoints of hospital emergency nurses and emergency medical personnel in northwest Iran. The results revealed that the quality of patient safety culture in emergency nurses and emergency medical personnel was at a moderate level, and the mean patient safety culture among the emergency nurses was higher than that of emergency medical personnel. This result is in line with that of the study by Jung Hee Kim et al. (2021), Asadi et al. (2019), and Hassan Kazemi et al. (2021). The results of their studies also revealed that the patient safety culture of the subjects was at the moderate level (22–24). Also, the study by Dolatabadi et al. (2021) reported the safety culture of nurses was at a weak level (1). This difference is due to the cultural-social context and management governing nursing and emergency medicine in the relevant units. The results also revealed that the quality of patient handover between emergency nurses and emergency medical personnel was at a moderate level and the quality of patient handover was at a good level. Also, the overall score of quality of patient handover was higher in hospital emergency nurses than in emergency medical personnel. In the studies by Dadashzadeh et al. (2021), Troyer et al. (2020), and Salehi et al. (2016), the process of patient handover between the emergency department and the emergency medical personnel was at a moderate level, which is consistent with the results of the present study (25–27).

Additionally, a positive and significant correlation was reported between safety culture and the quality of patient handover between the ambulance and emergency department. This result is consistent with the results of studies conducted by Yu et al. (2018). They also showed that the perception of patient safety culture was positively associated with the assessment of patient handover (28). The results of a study by Piper et al. (2018) also showed that the quality of patient handover is significantly associated with the personnel perception of patient safety in rural healthcare centers (29). Also, linear regression analysis showed that "teamwork between organizational units" was a stronger predictor than other variables in the quality of patient handover between the ambulance and emergency department. In the studies by Yu et al. (2018), Asadi et al. (2019), Al-Shyyab et al. (2023), Najar et al. Aouicha et al. (2021), and Buchenek et al. (2023), teamwork in organizational units obtained the highest score (23, 28, 30–32).Their results are consistent with the results of the present study.

The results also revealed a statistically significant relationship between safety culture, level of education, and employment history of emergency department nurses. In the study by Malak et al. (2022) revealed a statistically significant relationship between the patient safety culture and the level of education of emergency nurses in Jordanian hospitals (33). Alquwez et al. (2018) also obtained similar results in their study (34), which is consistent with the results of the present study. The results of a study by Okuyama et al. (2019) revealed that the patient safety culture in experienced nurses has a favorable status (35). There was a statistically significant relationship between the education level of emergency medical personnel and the patient safety culture. Bochenek et al. (2023) also showed the level of education is directly associated with the patient safety culture among emergency medical personnel (36).

A statistically significant relationship was reported between the quality of patient handover between the ambulance and emergency department and participating in the patient handover workshops among emergency nurses. Dúason et al. (2021) identified the factors affecting the quality of patient handover. They showed that there is a statistically significant relationship between the quality of patient handover and the history of participating in the nursing personnel's workshop (37).

Limitation

One of the limitations of this study was the use of the self-reporting method and not having enough time to complete the questionnaire. Accordingly, the researcher tried to solve the problem by selecting the right time, allocating enough time, explaining the importance of the study objectives, and emphasizing this issue.

Generally, the results revealed a positive and statistically significant correlation between the safety culture and the quality of patient handover between the ambulance and emergency department. The stepwise multiple linear regression model showed that "teamwork between organizational units" was a stronger predictor than other variables in the quality of patient handover between the ambulance and emergency department. The status of safety culture and quality of patient handover between emergency nurses and emergency medical personnel were at a moderate level. However, the mean patient safety culture among the emergency nurses was higher than that of emergency medical personnel. Thus, healthcare decision-makers should take the necessary measures by holding training classes and briefing programs to promote patient safety culture and strengthen teamwork in the management system of hospitals and emergency nurses.

Acknowledgments

The present study was derived from a research project of Ardabil University of Medical Sciences with the code of ethics IR.ARUNS.REC.1402.047. We hereby appreciate the nurses working in the emergency department and all those who helped the researchers in conducting this research.

Authors’ contributions

B. D. conceptualized the study; B. D. and MA. M. supervision data collection; MA. M.

Database search strategy; S. A. and MA. M. the data and drafted the first version of the manuscript; S. A. reviewed and edited the manuscript; all authors read the revised the manuscript and approved the final version

Funding

Not applicable.

availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request

Ethics approval and consent to participate

This study strictly followed the principles outlined in the Declaration of Helsinki. The present study was derived from a research project of Ardabil University of Medical Sciences with the code of ethics IR.ARUNS.REC.1402.047. All participants provided written informed consent before the commencement of the study. The consent form gave the participants a clear understanding of the study’s purpose and methods. Participants were also informed of the researchers’ commitment to address any questions or concerns and the confidentiality of their information.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests

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Tables 1 to 4 are available in the Supplementary Files section.

No competing interests reported.

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Evaluating the relationship between safety culture and the quality of patient handover between the ambulance and emergency department from the viewpoints of hospital emergency nurses and emergency medical personnel in northwest Iran

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Abstract

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