This study aimed to identify the predictors of patient safety activities among RNs and NAs working in 33 in LTC facilities nationwide. Our results found that RNs have the most important influence on patient safety activities compared to NAs and the level of patient safety activities of RNs and NAs showed significant differences. Hence, as health professionals providing bedside care for residents in LCT facilities, RNs are key personnel in charge of residents’ health and safety management [5, 6]. A study by Shin [14] on Korea's LTC facilities showed that with increasing care time per resident compared to other nursing staff, the more effective is the quality of care (e.g. preventing falls, decreasing tube feeding and also aggressive behavior). In addition, a study by Bostick et al [12], which systematically analyzed 87 government documents published from 1975 to 2003 in the United States, found that the higher the number of RNs in a nursing home, the better improve are resident outcomes (e.g. functional availability, pressure ulcers, weight loss). Hence, the proportion of RNs was emphasized as the most important factor in patient safety activities in LTC facilities [40].
These studies showed that replacing RNs with NAs is extremely unreasonable as there is a substantial gap in education and qualification. Therefore, the current article of the Welfare of Senior Citizens Act that stipulating RNs and NAs to be at an equivalent level without distinguishing their qualifications must be amended to better ensure safety and quality of care for LTC facility residents. In addition, the proportion of RNs employed at LTC facilities in Korea is 0.1%, significantly lower compared to other countries (e.g., United States = 34.3%, Netherlands = 28.2%, Germany = 50.9%, Japan = 20.7%) [44]. Due to the low standards of RNs, more than seven out of ten facilities have no RNs at all. [22, 23]. Among our participants, 73.6% had reported a safety incident in the past year. These results show the seriousness of residents’ safety at LTC facilities in Korea [10]. Therefore, in order to reduce adverse events of residents in LTC facilities, the mandatory placement of RNs to assess and effectively manage residents at risk should be legally stipulated [6, 12, 18]. Despite the challenge of keeping current with nursing staffing standards for LTC facilities in developed countries for Korea, the current nursing staffing allocation standard should be revised to a minimum standard of at least one RN per a 24-hour period [18]. Further, the evaluation criteria for LTC facilities must include indicators of patient safety outcomes such as the prevalence of falls, pressure ulcers, restraints, medication errors incidence, catheter-related infections, and medication errors, to promote patient safety activities and improve the quality of care [42]. Modification of the current RNs’ staffing standard for LTC facilities in Korea is also essential for a comprehensive management of such safety quality indicators for the LTC facility residents.
PSC influences attitudes and behaviors of employees, regarding adherence of patient safety regulation and the practice of patient safety activities within the organization [43]. In this study, an organizational safety system of PSC was a second predictor of patient safety activities in line with a previous finding that system factors including organizational factors are more important than individual factors in PSC [23]. Regarding organizational systems of PSC, developed countries have long recognized the significance of a patient safety reporting system and have implemented such (or they have enacted laws stipulating the mandatory reporting of serious events) and have provided information through evaluation [44]. The purpose of such patient safety reporting systems is to alter the learning culture to one where staff members learn from their failures by identifying the cause of safety incidents and apply such learnings to practice. The most important aspect of learning from experience is to establish an organizational culture with an open reporting system, including actual adverse events and near misses [45, 46]. An effective reporting system identifies safe behaviors that should be adapted to prevent errors, encompassing the individuals’ adherence to their safety responsibilities, promises to maintain patient safety, efforts to acquire the latest knowledge on patient safety, and their learnings based on errors to achieve safety goals [47]. Further, noting the finding that administering a patient safety education program to nursing home staff led to a reduction of potential safety incidents (e.g., falls and pressure ulcers) by increasing the staff’s awareness of PSC [48], establishing a standardized educational system for nursing home staff is crucial. Thus, teamwork and personnel management founded on open communication, trust, and cooperation within the organization are warranted [49].
Per the recently enacted Patient Safety Act, Korea has also established an external reporting system to which relevant hospitals report patient safety incidents. The ‘Patient Safety Reporting Learning System’ was utilized as evidence for governmental policymaking and macroscopic improvement activities to enhance patient safety and quality of care by establishing and analyzing a patient safety information database, containing data electronically submitted by hospitals [50]. The reporting system for LTC facilities should also be reinforced to examine the state of safety incidents and relevant problems, based on which appropriate safety improvement activities should be launched. In particular, these suggest that establishing an organizational safety system such as guidelines for actions or emergency treatment protocols (in response to a safety incident) and the computerization of the reporting system in LTC facilities is an effective method.
In this study, the level of patient safety activities increased with increasing perception of PSC for staff in LTC facilities. This is consistent with previous findings that there is a significant correlation between the employee's perception of PSC and the outcomes of patient safety activities [4, 26, 27, 35, 51]. Therefore, as noted by other research, the measurement of PSC in LTC facilities helps improve quality of care and patient safety [35]. However, recent studies indicate a difference in the perception of PSC among staff in LTC facilities and nursing homes [29, 52]. Although administrators are in a position to lead the PSC of LTC facilities, they perceived better PSC than did clinical staff. The latter spend more time with residents and perceived PSC as lower than other employees of the LTC facility [29]. RNs also perceived lower PSC in LTC facilities than NAs [53]. This findings are consistent with our findings. Because participants’ perceptions of PSC reflect the current level of PSC in the LTC facility, these results suggest that RNs have a more critical view of the PSC in their LTC facility compared to NAs. Despite the lower perception of PSC, RNs showed significantly higher levels of patient safety activities. Amid the special situation in Korea where RNs are legally considered replaceable by NAs in LTC facilities [20], these results highlight the importance of RNs, who more critically perceive the current PSC and strive to improve it. Since perceptions of PSC vary widely among staff in LTC facilities, it was recommended that PSC scores should be checked according to occupation for the change and evaluation of PSC in LTC facilities [29]. Therefore, managers of LTC facilities should continually measure perceived patient safety among their employees and utilize the findings as the starting point for improving PSC and increasing compliance with patient safety activities [28].
The Agency for Healthcare Research and Quality (AHRQ) in the United States requires nursing homes to periodically conduct surveys on PSC of employees and submit the results to enhance their acceptance of PSC. This management system aims to encourage employees to recognize the level of PSC and the safety problems of residents in the facilities and to engage in quality improvement activities [25]. Therefore, the institution that manages the LTC facilities in Korea should periodically investigate the perception of PSC by occupation and organize a quality control system so that it can be reflected in safety activities and safety management of residents of LTC facilities.
In this study, shift types were identified as a factor affecting patient safety activities of RNs and NAs in LTC facilities. The fixed night shift, 24-hour rotational shift and on-call shift had greater negative impacts on patient safety activities compared to three day shifts. This may be attributable to staff members who work these shift types to be more likely to work excessive hours, possibly contributing to fatigue. Although no previous study examined the impact of night shift or overtime on patient safety in LTC facilities, studies of acute care hospitals observed that fatigue caused by night shift and overtime increased the incidence of medical errors, mortality, readmission rate, and the incidence of surgical complications [54–56]. In the United States, Germany, and Japan, nursing home staff members generally work three shifts, and staffing standards per work hour are enforced [19]. However, under the current standards of nursing staff in Korea, nurses or nursing assistants cannot take care of residents around the clock. Hence, Korea should also develop a minimum staffing allocation standard based on three shifts. Further, 24-hour patient safety activities are required, as most nursing home residents are older people who are frail or have dementia, with 24-hour supervision by RNs. However, additional studies are needed to pinpoint the cause underlying the impact of shift type on patient safety activities.
Our results are significant in elucidating the need to amend regulations pertinent to RN allocation standards in LTC facilities in Korea, transitioning the current work shift to a three consecutive shifts system, and establish a safety system at the organizational level to promote resident safety in LTC facilities.