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Are improvements in occupationalhealth and safety for hospital staffassociated with improvements in

patient health and safety?

Summary of an evidence scoping review

Dr Kate Gibson

Date: 21 December 2015

Research report # 164-1215-R01



2Research report # 164-1215-R01

Summary of an evidence scoping review

Background/problem

Health care workers experience some of the highest rates of nonfatal occupational illness and injury.In particular, musculoskeletal disorders (MSD) associated with patient handling constitute a significant

proportion of work-related pain and injury in hospital staff. Although convincing evidence exists that

safe patient handling interventions and programs result in fewer and less severe injuries to hospital

staff, the evidence linking these interventions to patient outcomes is less well explored.

Purpose

The current review aims to identify whether there is evidence investigating the potential association

between improvements in occupational health and safety (OHS) for hospital staff and patient health

and wellbeing outcomes.

Specifically this scoping review aimed to identify evidence to address the following questions;

1. Is there a relationship between occupational health and safety interventions to prevent/reduce

the risk of manual handling based musculoskeletal disorders in hospital staff and patient

health and wellbeing outcomes?

2. If this association exists, what are the patient outcomes which are improved following positive

health and safety for hospital staff?

Evidence review process

A scoping review, which provides an overview of the state of current evidence on a particular topic,

was conducted to identify original research papers and systematic reviews examining the association

between OHS initiatives for staff and patient outcomes. Five electronic databases were searched;

Pubmed, Embase, Scopus, CINAHL, Cochrane Library and Google Scholar. All publications were

identified using a predesigned search strategy (see Evidence Review Plan for details) and were

screened for relevance using title, abstract and in some cases full-text analysis. Publications reporting

on MSD related OHS interventions or patient safety culture and patient outcomes were included in the

review. Only English language full text papers published since 2005 were included.

Results

What the review found – major themesThe search identified over 1,000 publications of interest. After title and/or abstract screening, 248

papers were identified as potentially relevant to the association between OHS interventions for staff

and patient outcomes. Of the studies identified, the number relating specifically to MSD related OHS

interventions was relatively low.

The following themes, including the primary area of interest, emerged from the literature.

Themes identified Number ofstudies

Patient handling interventions (primary research question)

Interventions included in the studies were; 1) patient handling equipment such asceiling and floor based lifts, sit-to-stand assists, ambulation aides, and lateral slides,2) safe patient handling programs which generally consist of administrativepolicies/procedures and patient handling equipment, and 3) other patient handlinginitiatives such as adaptive clothing and scheduled toileting.

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Safety climate or culture increase patient safety While not a specific OHS intervention, safety climate/culture appears to be asignificant theme in the literature linking worker and patient safety. Details of the

evidence around safety culture have therefore been included in this review wherepatient outcomes have been measured/reported.

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3

Human factors and ergonomics approaches in the hospital setting increase patientsafety

A number of studies were identified that address the relationship between the designand implementation of technologies, processes, workflow and teams with patientsafety outcomes.

6

Healthcare worker conditions impact on patient safety and clinical outcomes

There is a large body of work in the literature that addresses the relationship betweenhospital working conditions and patient outcomes. For example hospital staffworkload and fatigue.

44

Improvements in work environment improve patient experience and safetyThere is also a large body of work that examines the relationship between otherelements of the work environment and patient outcomes. For example improvedcommunication, healthy work environments, and violence prevention.

31

Patient handling interventions and programsNine original research papers (1-9) and three systematic reviews (10-12) were identified as relevant

to MSD related OHS interventions for staff and patient outcomes. Most studies were conducted in

America in long-term care or rehabilitation settings. The study methods include case studies, cross-sectional surveys, and one retrospective cohort analysis. Both directly measured patient outcomes

and provider reported patient outcomes have been reported in these studies (refer to evidence table

in Appendix).

The evidence suggests that there is a relationship between MSD related OHS interventions for

hospital staff and patient health and wellbeing outcomes.

Eight papers reported a positive effect on patient outcomes from various MSD related OHS

programs or interventions for hospital staff. The patient outcomes included increased comfort

during patient handling activity (1, 6, 9), improved functional recovery during rehabilitation (2,

3), independence in self-care/mobility (4), patient safety (reduced falls) (8, 9), reduced

complications of immobility (such as pressure ulcers, depression, urinary incontinence) (6-8)

and length of stay (not statistically significant) (2). One paper (5) reported a negative relationship between MSD related OHS interventions and

patient health and wellbeing outcomes. This observational study noted that skin and fall

related adverse events occur in the setting of safe patient handling programs and provides

recommendations for reducing the risk of these adverse events.

Safety climate or culture increases patient safetySafety culture or safety climate (used interchangeably in the literature) is defined as staff perceptions

about the extent to which healthcare organisations value safety (for workers and patients), commit

resources to safety-related initiatives and equipment, and promote safe behaviors.(13)

Eleven original research papers (including a meta-analysis) (14-24) and a systematic review (25)were identified as relevant to hospital safety culture and patient outcomes. Most studies were

conducted in America or Europe in acute healthcare inpatient settings, particularly intensive care

units. Safety culture/climate was measured most often using a validated questionnaire or survey and

interventions varied widely and included staff training, team communication initiatives, interdisciplinary

walk rounds, and general safety programs.

Ten papers reported a positive relationship between safety culture or climate and patient

outcomes. The patient outcomes included composite patient safety indicators (21, 22), rates

of patient injury and adverse events (such as pressure ulcers, medication errors, falls,

hospital acquired infection) (14, 15, 17, 21, 23, 24), patient/family satisfaction (15, 16),

readmission rates (16, 19), mortality rates (16, 20) and length of stay (20).

One paper (18) reported that patient safety climate was not significantly related to any of thepatient outcomes studied.



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Gaps in the evidence

While evidence of a relationship between MSD related OHS interventions for hospital staff and patient

health and wellbeing outcomes was identified, the interventions and the patient outcomes measured

or reported were highly heterogeneous. There is consequently a gap in our understanding of which

interventions improve different patient outcomes. In addition, as most of the evidence has been

generated in the long-term care or rehabilitation setting, there is limited evidence relating to the acutehealthcare setting.

A relatively low number of papers addressing the relationship between MSD related OHS

interventions for hospital staff and patient health and wellbeing outcomes were found. Further

evidence may be held within grey literature documents and other unpublished information such as

internal organisational audits and anecdotes.

Scoping review implications

The scoping review highlights the following key findings:

There is a relationship between OHS interventions to prevent or reduce the risk of manual

handling based MSD in hospital staff and patient health and wellbeing outcomes. The patient outcomes which are improved following positive musculoskeletal health and

safety for hospital staff are largely related to comfort and mobility, however there is a gap in

our understanding of which staff interventions improve which patient outcomes.

The evidence is currently limited, only 9 studies relevant to the research questions were

identified.

Most studies provided a snapshot at a given point in time rather than following up study

participants over time which would provide better evidence of a causal relationship between

OHS interventions and patient outcomes, and most studies were undertaken in the long-term

care or rehabilitation setting.

Given the high level of heterogeneity in staff OHS interventions, measured/reported patient

outcomes and study designs, a full evidence review which includes quality assessment of the

research evidence is required with the following benefits;o this approach will provide a detailed and objective assessment and synthesis of the

current research evidence relating to MSD related OHS interventions for hospital staff

and patient health and wellbeing outcomes,

o inclusion of grey literature and other unpublished sources would provide valuable

evidence of relevance and increase our ability to draw conclusions, and

o the findings would provide insights into which interventions/approaches improve

which patient outcomes and result in the greatest improvements in patient outcomes.

Use of the evidence

In the setting of limited health care resources, evidence that MSD related OHS interventions have adirect impact on both worker and patient outcomes adds weight to value of these interventions from

an organisational perspective. The findings identified in this review, or a full evidence review if it were

undertaken, may provide a suitable evidence-base to support policy decisions and develop

communication tools.




Appendix - Evidence Table

Specifically this scoping review aimed to identify evidence to address the following questions;

Is there a relationship between occupational health and safety interventions to prevent/reduce the risk of manual handling based musculoskeletal disorders in

hospital staff and patient health and wellbeing outcomes?

If this association exists, what are the patient outcomes which are improved following positive health and safety for hospital staff?

The search identified over 1,000 publications of interest. After title and/or abstract screening, 248 papers were identified as potentially relevant to the

association between OHS intervention and patient outcomes. To address the above research question the papers relating specifically to MSD related OHSinterventions (12) and safety culture (12) are outlined in the following table.

Study details Populationand setting

Research objective Patient Outcome Result Notes

Patient handling programs and assist devices

Alamgir, H., et al. (2009)."Evaluation of ceiling lifts:Transfer time, patientcomfort and staffperceptions." Injury 40(9):987-992. (1)

County: Canada

Aim: The purpose of thisstudy was to evaluateceiling lifts in comparison to

floor lifts based on transfertime, patient comfort andstaff perceptions in threelong-term care facilities withvarying ceiling lift coverage

Design: Observationalstudy

Residents oflong term carefacilities inBritishColumbia.

The objectives were: (1) tomeasure and compare the timespent to perform various patienttransfer tasks using ceiling liftsor floor lifts, (2) to determine theimpact of ceiling lifts on patientcomfort levels compared to floorlifts, and (3) to determinehealthcare workers’ perceptionson use of transfer devices foroptimal patient handling.

The time required to transfer orreposition patients along withpatient comfort levels wererecorded for 119 transfers.

In the three facilities, 143healthcare workers weresurveyed on their perceptions of

Comfort(measuredaccording to astandarddiscomfort andpain scale)

Transfers performed withceiling lifts required onaverage less time (bed tochair transfers: 156.9seconds for ceiling lift, 273.6seconds for floor lift) andwere found to be morecomfortable for patients(p<0.001).

Interpretation ofcomfort wasundertaken byresearchobservers ratherthan self-reportingby patients.



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patient handling tasks andequipment.

Campo, M., et al. (2013)."Effect of a safe patienthandling program onrehabilitation outcomes." Archives of PhysicalMedicine and Rehabilitation94(1): 17-22. (2)

County: USA

Aim: To evaluate the effectof a safe patient handling(SPH) program onrehabilitation mobilityoutcomes

Design: Retrospectivecohort study

Patientswithout a SPHprogram inplace (n=507)and patientswith a SPHprogram in

place (n=784)in arehabilitationunit in ahospitalsystem.

The objective of the study wasto determine the effect of a SPHprogram on patient functionalmobility outcomes, the SPHprogram consisted ofadministrative policies andpatient handling technologies.

The policies limited manualpatient handling. Equipmentincluded ceiling- and floor-based dependent lifts, sit-to-stand assists, ambulation aides,friction-reducing devices,motorized hospital beds andshower chairs, and multi-handled gait belts.

Patient functionalstatus (asmeasured by themobility subscaleof the FIM)

No statistically significantdifference was observedbetween groups in dischargemobility scores. A significant differencebetween groups was notedfor patients with initial

mobility FIM scores of 15.1and higher, after controllingfor initial mobility FIM score,age, length of stay, anddiagnosis - these patientsperformed better with a SPHin place.

While notstatisticallysignificantpatients with aSPH programachieved ashorter length of

hospital stay.

SPH programs donot appear toinhibit recovery(one hypothesis isthat the use oflifting equipmentmay lead todependence andimpede patientrecovery/rehab).

Darragh, A. R., et al.(2013). "Safe-patient-handling equipment intherapy practice:Implications forrehabilitation." American

Journal of OccupationalTherapy 67(1): 45-53. (3)

Country: USA

Aim: to determine howsafe-patient-handling (SPH)equipment is used inrehabilitation and how it

Thirty-fiveoccupationaland physicaltherapistpractitionersfrom three

inpatient rehabfacilities usingSPH programsparticipated instructuredfocus groupdiscussions.

The project addressed thefollowing questions: (1) how isSPH equipment used byoccupational and physicaltherapy personnel inrehabilitation, and (2) how does

the use of equipment affectrehabilitation practice?

Patient mobilityand functionalrecovery (asreported bytherapists – notdirectly measured)

Three themes emerged fromthe analysis:

Choice; therapistsengage in a highlyindividualized, complexprocess of decision

making when selectingand using SPH.

Potential; to treat agreater range of patientssuch as bariatric orcomplex medical patientsand to mobilise patientsearlier.

Qualitativemethodology notgeneralisable.

Indirectmeasurement of

patient outcomes.



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affects therapists, patients,and therapy practice

Design: Qualitative,instrumental case study

Safety; reduced numberof patient falls andcomplications ofimmobility.

Darragh, A. R., et al.(2014). "Effects of a safepatient handling andmobility program on patient

self-care outcomes." American Journal ofOccupational Therapy68(5): 589-596. (4)

Country: USA

Aim: to determine the effectof a safe patient handlingand mobility (SPHM)program on patient self-care outcomes

Design: Retrospectivecohort study design

Electronicmedicalrecords of1,292 patients

receivinginpatientrehabilitationservices

To compare self-care scores forpatients who participated inrehabilitation beforeimplementation of an SPHM

program (n=507) with thescores of patients whoparticipated afterimplementation of the SPHMprogram (n=785).

Patient self-careperformance asmeasured by theself-care subscale

of the FIM.

No difference in self-carescores observed betweengroups.

Patients who receivedinpatient rehabilitationservices with an SPHMprogram were as likely toachieve at least modifiedindependence in self-care asthose who received inpatientrehabilitation services withoutan SPHM program.

Elnitsky, C. A., et al.(2014). "Implications forpatient safety in the use of

safe patient handlingequipment: A nationalsurvey." Int J Nurs Stud51(12): 1624-1633. (5)

Country: USA

Aim: To explore adversepatient events andapproaches to preventing

A conveniencesample of safepatient

handlingprogrammanagersfrom 51 USDepartment ofVeterans Affairs medicalcentres

The objective of this study wasto explore adverse patientevents associated with SPH

programs and preventiveapproaches in US Veterans Affairs medical centres.

Patient injury:skin-related andfall-related adverse

patient events asreported by SPHprogrammanagers.

Both skin- and fall-relatedadverse patient eventsoccurred in the setting of a

SPH program.

Skin-related events includedabrasions, contusions,pressure ulcers andlacerations.

Fall-related events includedsprains and strains, fractures,concussions and bleeding.

The findings haveimplications forhow nursing

professionals canimplement safepatient handlingprograms in waysthat are safe forboth staff andpatients.



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events where a safe patienthandling (SPH) programhas been implemented

Design: Cross sectionalsurvey design

(Negative outcome butprovides recommendedmitigation strategies)

Griffiths, H. (2012)."Adverse risk: a 'dynamicinteraction model of patient

moving and handling'." JNurs Manag 20(6): 713-736. (6)

Country: UK

Aim: The aim of the studywas to examine patientadverse events associatedwith sub-optimal patientmoving and handling.

Design: Narrative literaturereview and development ofa conceptual model ofpatient handling

60 peerreviewedpublications

published1992 to 2010that report onpatient manualhandling

The objective was toconsolidate a conceptual modelof patient moving and handling

from a narrative literaturereview for an orthopaedicrehabilitation setting.

Search terms forthis reviewincluded: pain, fear

and functionalposition of thepatient

Five predominant themesemerged from the narrativeliterature review: 'patient's

need to know aboutanalgesics prior tomovement/ambulation';'comfort care'; 'mastery ofand acceptance of mobilityaids/equipment';'psychological adjustment tofear of falling'; and 'the needfor movement to preventtissue pressure damage'.

This review citesevidence ofincreased patient

comfort andreduced pressureulcers associatedwith use ofmechanical lifting.

Gucer, P. W., et al. (2013)."Sit-stand powered

mechanical lifts in long-term care and residentquality indicators." Journalof Occupational andEnvironmental Medicine55(1): 36-44. (7)

Country: USA

Nursing homeresidents

(Medicare &MedicaidServices data)and Directorsof Nursing (n=271) of long-term carefacilitiesNationwide.

To explore the relationshipbetween resident quality

indicators of well-being and (1)the safe lifting policies andprocedures and (2) theavailability of different kinds ofpowered mechanical lift assistequipment.

Mobility-relatedresident outcomes

(6 QualityIndicators; physicalrestraint, chemicalrestraint, bedfast,pressure ulcers,falls and fractures)

Number of PMLsper 100 residents

Safe lift practices and liftassist device are associated

with benefits to residents oflong term care facilities.

Four of six derived residentquality indicators improvedwith the number of PMLs(physical restraint, chemicalrestraint, bedfast, pressureulcers).



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Aim: To determineassociations between long-term care poweredmechanical lift (PML)availability and mobility-related resident outcomes

Design: Data linkage study

Falls and fractures werefound to be more frequentwith more lift use, howeverthis risk was mitigated by acomprehensive safe liftprogram (policies andprocedures).

Nelson, A., et al. (2008).

"Link between safe patienthandling and patientoutcomes in long-termcare." Rehabil Nurs 33(1):33-43. (8)

Country: USA

Aim: To examine therelationship between safepatient handling and qualityof care measures

Design: Retrospectiveobservational design

111 residents

living on 24units in sixVeterans Administrationnursinghomes.

The objective of this study was

to test the hypothesis thatquality of care would improvewith implementation of anevidence-based patient careergonomics program.

Quality of patient

care asdemonstrated by10 qualitydomains; patientdemographics,cognition,depression,physicalfunctioning,continence, fallrisk, higherengagement inactivities, higherlevels of alertnessduring the day,discharge potentialand health careutilization.

Following implementation of

the program statisticallysignificant improvementswere noted; lower levels ofdepression, improved urinarycontinence, higherengagement in activities,lower fall risk, and higherlevels of alertness during theday. Additionally, four areasshowed a decline in function:pain, combativeness,locomotion, and cognition.

Findings from this study maybe useful in enhancingorganizational support forsafe patient-handlingprograms and could be usedto build a business case forimproving caregiver safety.

Yassi, A. and T. Hancock(2005). "Patient safety--worker safety: building aculture of safety to improvehealthcare worker andpatient well-being." HealthcQ 8 Spec No: 32-38. (9)

To examine several major OHSinitiatives launched by theOccupational Health and Safety Agency for Healthcare(OHSAH) in British Columbia toimprove the healthcareworkplace: the promotion ofsafe patient handling (ceiling

Improved patientsafety and comfort(self-reported andstaff perceptions)

Results of the projects are atvarious stages of completion,but ample evidence has beenobtained to indicate thatlooking after the well-being ofhealthcare workers results insafer and better qualitypatient care.



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Country: Canada

Aim: To examine how therate of health care workerinjury has declined and linkthe OHS factors addressedto patient safety.

Design: Policy/program

analysis

lifts); adaptive clothing;scheduled toileting; strokemanagement training;measures to improvemanagement of aggressivebehaviour; and infection control.

Patient handling reviews

Hallmark, B., et al. (2015)."Ergonomics: safe patienthandling and mobility."Nurs Clin North Am 50(1):153-166. (10)

Country: USA

Aim: To investigate currentstandards of practice in thearea of safe patienthandling and movement inaddition to outliningevidenced-basedrecommendations forclinical practice.

Design: Literature review

This article reviews andinvestigates the issuessurrounding ergonomics, with aspecific focus on safe patienthandling and mobility.

No patientoutcomes but hascost outcomes &SPHM programimplementationrecommendations

Safe patient handling andmobility is on the forefront ofthe movement to improvepatient safety.

Organisations estimate thatthey can save 60% to 80% ofworkers compensation costsrelated to patient handling ifthey have a SPH program(Celona J Making thebusiness case for a SPHM program. Am Nurse Today2014:9(9);26-9).

Kay, K., et al. (2014). "It'snot about the hoist: Anarrative literature review ofmanual handling inhealthcare." Journal ofResearch in Nursing 19(3):226-245. (11)

This paper reviews thecontemporary internationalliterature regarding manualhandling interventions notingthe unique context for injuryprevention strategies withinhealthcare. The review includes

No patientoutcomes

The complexity of manualhandling in healthcare hasresulted in a theoretical shiftfrom single factorinterventions based ontechnique training towards anemerging multidimensional



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Country: Australia

Aim: To comprehensivelyreview the literature on boththe contemporary practicesof manual handling and theinjury preventioninterventions adopted

within health care settings

Design: Narrative literaturereview

the recognition of underlyingassumptions inherent in theconceptualisation of manualhandling and its management,and the preponderance of thepost-positivist paradigm in thisfield.

approach. However the keyelements for sustainablesolutions to reduce nurses'manual handling injurieshave not yet been identifiedand consensus is lackingregarding the implementationand appropriate evaluation ofinjury prevention

programmes.

Thomas, D. R. and Y. L. N.Thomas (2014)."Interventions to reduceinjuries when transferringpatients: A critical appraisalof reviews and a realistsynthesis." Int J Nurs Stud51(10): 1381-1394. (12)

Country: New Zealand

Design: Critical appraisal ofsystematic reviews and arealist synthesis to identifybest practices for movingand handling programmes

A literaturesearch of fivedatabases(Medline,EMBASE,CINAHL,PsycINFO andScienceDirect)located 150reportsassessingprogrammeoutcomespublished inrefereed journalsbetween 2000and 2013.

The objective was to assess theeffectiveness of interventions inreducing back pain and injuriesamong healthcare staff. Thecritical appraisal included sixsystematic reviews. The realistsynthesis included 47 studiesthat provided descriptiveinformation about programmemechanisms.

Given the absence ofexperimental trials for multi-component programmes, thebest available evidence for theeffectiveness of multi-component programmes is frompre-post studies and large-scalesurveys.

The realist synthesis provideddetailed information about thecore components for effectiveprogrammes.

No patientoutcomes

Five of the six systematicreviews covered interventionsinvolving either staff trainingor training and equipmentsupply. One review coveredmulti-componentinterventions. All concludedthat training staff by itself wasineffective.

The realist synthesis notedthe need for managementcommitment and support,and six core programmecomponents; a policyrequiring safe transferpractices, ergonomicassessment of spaces wherepeople are transferred,transfer equipment includinglifts, specific risk assessmentprotocols, adequate trainingof all care staff, and



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coordinators coaches orresource staff.

Safety climate/culture (attitudes, values, norms and beliefs towards patient safety)

Agnew, C., et al. (2013)."Patient safety climate andworker safety behaviours inacute hospitals inScotland." J Safety Res 45:95-101. (14)

Country: Scotland

Aim: to test whichdimensions of hospitalsafety climate wereassociated with patient andworker safety outcomes.

Design: Cross sectionalsurvey

1,866 NHSclinical staff insix Scottishacute hospitals

To obtain a measure of hospitalsafety climate from a sample ofNational Health Service (NHS)acute hospitals in Scotland andto test whether these scoreswere associated with worker

safety behaviours, and patientand worker injuries.

Staff reportedpatient injury rate(not directlymeasured).

Hospital safety

climatebehaviours, andworker and patientinjuries weremeasured usingthe ScottishHospital SafetyQuestionnaire.

Hospital safety climatescores were significantlycorrelated with clinicalworkers' safety behaviourand patient and worker injurymeasures, although the effect

sizes were smaller for thelatter.

The dimensions of safetyclimate most stronglyassociated with patientinjuries were managementsupport, staffing andteamwork.

Ausserhofer, D., et al.(2013). "The association ofpatient safety climate andnurse-relatedorganizational factors withselected patient outcomes: A cross-sectional survey."

Int J Nurs Stud 50(2): 240-252. (15)

Country: Switzerland

Aim: to explore therelationship betweenpatient safety climate(PSC) and patient

997 patientsand 1630registerednurses (RNs)working in 132surgical,medical and

mixedsurgical-medical unitswithin 35Swiss acutecare hospitals.

The purpose of this study wasto explore the relationshipbetween PSC and patientoutcomes in Swiss acute carehospitals.

PSC was measured with the 9-

item Safety Organizing Scale.

Other organizational variablesmeasured with establishedinstruments included the qualityof the nurse practiceenvironment, implicit rationingof nursing care, nurse staffing,and skill mix levels.

Seven nurse-reported patientoutcomes (notdirectly measured);medication errors,pressure ulcers,patient falls,

urinary tractinfection,bloodstreaminfection,pneumonia; andpatient satisfaction

PSC was not found to be asignificant predictor for any ofthe seven patient outcomesin this patient population.

Other factors, predominantlyrationing of nursing care,

were associated with patientoutcomes.



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outcomes, adjusting formajor organizationalvariables.

Design: Cross sectionalsurvey

DiCuccio, M. H. (2015)."The Relationship BetweenPatient Safety Culture and

Patient Outcomes: ASystematic Review." JPatient Saf 11(3): 135-142.(16)

Country: USA

Aim: to systematicallyreview studies to determineif there are tools, levels ofmeasure and outcomesthat have been shown toresult in significantcorrelations betweenpatient safety culture andpatient outcomes.

Design: Systematic review

The purpose of this review is toevaluate the state of researchconnecting patient safety

culture and patient outcomes todetermine nurse-sensitivepatient outcomes that havebeen significantly correlated toculture of safety and commonlyused tools to measure culture ofsafety in the studies withsignificant correlations.

Only studies thatdirectly measuredpatient outcomes

in relationship topatient safetyculture in hospitalsinvolvingregistered nursesas a participantwere included.

Evidence of relationshipsbetween patient safetyculture and patient outcomes

exist at the hospital(readmission rates, safetyindicators, mortality andpatient satisfaction) andnursing unit (mortality andfamily satisfaction) level ofanalysis.

However, the number ofstudies finding statisticallysignificant correlationsparticularly using nurse-sensitive outcomes is limited.

Farup, P. G. (2015). "Aremeasurements of patientsafety culture and adverseevents valid and reliable?Results from a crosssectional study." BMCHealth Serv Res 15(1). (17)

Country: Norway

185employeesand 272patient recordsfrom themedicaldepartments intwogeographicallyseparated

This study exploredassociations between thepatient safety culture andadverse events, and evaluatedthe validity of the tools used forthe measurements.

A survey on patient safetyculture was performed with avalidated Norwegian version of

Adverse events(retrospectivelyanalyzed frommedical recordsusing a validatedtool, the GlobalTrigger Tool).

The study found a negativeassociation between betterpatient safety culture andadverse events whencomparing two generalmedical departments.

Smallunderpoweredstudy



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Aim: to exploreassociations between thesafety culture and adverseevents

Design: Cross sectionalstudy

hospitals ofInnlandetHospital Trust,Norway

the Hospital Survey on PatientSafety Culture (HSOPSC).

Groves, P. S. (2014). "Therelationship between safety

culture and patientoutcomes: results from pilotmeta-analyses." West JNurs Res 36(1): 66-83. (18)

Country: USA

Aim: To examine therelationship betweenpatient safety outcomesand safety culture in acutecare hospitals

Design: Meta-analysis

Studies (14)with a

quantitativemeasure ofsafety cultureand directlymeasuredpatientoutcome in anacute-carehospital setting

Five small pilot meta-analyseswere conducted using 10

papers, examining therelationship between safetyculture and each of thefollowing: pressure ulcers, falls,medication errors, nurse-sensitive outcomes, and post-operative outcomes.

Four papers were not includedbecause the outcomes reportedwere not similar enough toinclude in a meta-analysis(Hansen et al 2011, Huang et al2010 and Mardon et al 2010 ).

Pressure ulcers,falls, medication

errors, riskstandardisedreadmission rates,ICU mortality andcomposite patientsafety indicators

No significant relationships ofany size were identified.

A small positive effect wasnoted for pressure ulcers,falls, medication errors and anurse sensitive compositeindicator.

A small negative effect wasnoted for the post-operativecomposite indicator.

Low overall powerdue to lack of

empirical studiesto analyse.

Hansen, L. O., et al. (2011)."Perceptions of hospitalsafety climate andincidence of readmission."

Health Serv Res 46(2):596-616. (19)

Country: USA

Aim: to examine therelationship betweenhospital patient safetyclimate and hospitalreadmission

67 acute-carehospitals withreadmissionoutcomes data

available forselecteddiagnoses(AMI, HF andpneumonia)

To define the relationshipbetween hospital patient safetyclimate (a measure of hospitals'organizational culture as related

to patient safety) and hospitals'rates of readmission within 30days of discharge.

Safety climate was measuredthrough a survey of a randomsample of hospital employees(n=36,375).

30-day risk-standardizedreadmission rates

There was a significantpositive association betweenlower safety climate andhigher readmission rates for

AMI and HF (p<.05 for bothdisease specific models) butnot pneumonia.

The dimensions of safetyclimate that most consistentlydemonstrated significantassociation with readmissionwere; unit safety norms,



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Design: Cross-sectionalstudy

overall emphasis on safety,and collective learning.

Huang, D. T., et al. (2010)."Intensive care unit safetyculture and outcomes: AUS multicenter study."International Journal forQuality in Health Care

22(3): 151-161. (20)

Country: USA

Aim: to determine ifintensive care unit (ICU)safety culture isindependently associatedwith outcomes.

Design: Multicenter cohortstudy

A total of65,978patientsadmittedJanuary 2001-March 2005 in

thirty ICUs and2,103employeesfrom thoseICUs

The objective of this study wasto determine if ICU safetyculture is independentlyassociated with patient hospitalmortality and LOS.

Safety culture was assessedwith the Safety AttitudesQuestionnaire-ICU version, avalidated instrument thatassesses safety culture acrosssix factors.

Hospital mortalityand length of stay(LOS).

Perceptions of managementand safety climate weremoderately associated withpatient outcomes, howeverno associations wereidentified for other domains of

safety culture.

Mardon, R. E., et al. (2010)."Exploring relationshipsbetween hospital patientsafety culture and adverseevents." J Patient Saf 6(4):226-232. (21)

Country: USA

Aim: To test the hypothesisthat hospitals with a morepositive patient safetyculture would have lowerpatient safety indicator(PSI) rates.

179 hospitalsrepresentingdata collectedfrom 56,480staffrespondents

and patientsafetyindicatorsderived fromdischargedata

The objective of this study wasto undertake a systematicanalysis of the relationshipbetween 2 measures: (1) apatient safety culture instrumentand (2) a refined set of patient

safety indicators.

Rates of in-hospitalcomplications andadverse events asmeasured by the AHRQ Patient

Safety Indicators(PSIs).

15 patient safetyculture variablesand a compositemeasure ofadverse clinicalevents based on 8risk-adjusted PSIs

Nearly all of the relationshipstested were in the expecteddirection (negative), and 7(47%) of the 15 relationshipswere statistically significant. All significant relationships

were of moderate size,indicating that hospitals witha more positive patient safetyculture scores had lowerrates of in-hospitalcomplications or adverseevents as measured by PSIs.



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Rosen, A. K., et al. (2010)."Hospital safety climate andsafety outcomes: is there arelationship in the VA?"Medical care research andreview: MCRR 67(5): 590-608. (22)

Country: USA

Aim: to explored thepotential relationshipbetween safety climate andVeterans Health Administration hospitalsafety performance usingthe Patient Safety Indicator(PSI) rates.


4,581employees of30 VeteransHealth AdministrationHospitals

To test the hypothesis that: (1)higher levels of safety climatewould have lower rates of PSIs,(2) dimensions of safety climatelikely to affect individuals’behaviour the most are mostdirectly related to PSIs, and (3)

safety climate perceptions aremore strongly associated withPSIs for frontline workers thanfor senior managers.

PSIs and a PSIcompositemeasure

Safety climate overall wasnot related to the PSIs or tothe PSI composite.

A few individual dimensionsof safety climate wereassociated with specific PSIs

(greater fear of blame andpunishment for makingmistakes was negativelyassociated with higher ratesof pressure ulcer and deepvein thrombosis” (p < .05 andp < .01, respectively) andoverall emphasis on safetywas negatively associatedwith pressure ulcer andiatrogenic pneumothorax.

Perceptions of frontline staffwere more closely alignedwith PSIs than those ofsenior managers.

Some significantrelationships ofindividual safetyclimatedimensions withselected PSIs,suggest that

efforts to achievea strong safetyclimate arewarranted.

Steyrer, J., et al. (2013)."Attitude is everything? The

impact of workload, safetyclimate, and safety tools onmedical errors: a study ofintensive care units." Healthcare management review38(4): 306-316. (23)

Country: Austria

378 patients in57 intensive

care units

To investigate to what extentproduction pressure (i.e.,

increased staff workload andcapacity utilization) and safetyculture (consisting of safetyclimate among staff and safetytools implemented bymanagement) influence theoccurrence of medical errorsand if/how safety climate andsafety tools interact.

Incidence of errors(error rate was the

ratio of patientsaffected by errorsin a given ICU tothe total number ofpatients in thatunit)

All safety climate scales weresignificantly correlated with

error rate.

Overall conclusions were thatincreased workload andcapacity utilization increasethe occurrence of medicalerror, an effect that can beoffset by a positive safetyclimate but not by formally



17



Aim: to examine the trade-off between production andprotection posited in theliterature for a high-riskhospital setting (intensivecare)

Design: prospective,observational, 48-hour

cross-sectional study

Safety climate was assessedusing a psychometricallyvalidated four-dimensionalquestionnaire.

implemented safetyprocedures and policies.

Taylor, J. A., et al. (2012)."Do nurse and patientinjuries share commonantecedents? An analysisof associations with safetyclimate and workingconditions." BMJ Qualityand Safety 21(2): 101-111.(24)

Country: USA

Aim: To examine therelationship between safetyclimate and both patientand nurse injuries

Design: Cross-sectionalstudy

723 nursesand 28,876patientdischargesfrom an urban,level-onetrauma centre

To examine the association ofunit-level safety climate andspecific nurse workingconditions with injury outcomesfor both nurses and patients in asingle hospital.

Safety climate was measured in2004 using the Safety AttitudesQuestionnaire (SAQ).

Patient injuriesincluded 290 falls,167 pulmonaryembolism/deepvein thrombosis(PE/DVT), and 105decubitus ulcers.

The study found a negativeassociation between twoSAQ domains, Safety andTeamwork, with the odds ofboth decubitus ulcers andnurse injury.

Registered nursing hours perpatient day showed anegative association withpatient falls and decubitusulcers.

Unit turnover was positivelyassociated with nurse injuryand PE/DVT, but negativelyassociated with falls anddecubitus ulcers.

The authorssuggest thatpatient and nursesafety may belinked outcomes.

Weaver, S. J., et al. (2013)."Promoting a culture ofsafety as a patient safetystrategy: a systematicreview." Ann Intern Med158(5 Pt 2): 369-374. (25)

Country: USA

RelevantEnglish-languagestudiespublished fromJanuary 2000to October2012.

Eight studies included executivewalk rounds or interdisciplinaryrounds; 8 evaluatedmulticomponent, unit-basedinterventions; and 20 includedteam training or communicationinitiatives.

Twenty-nine studies reportedsome improvement in safetyculture or patient outcomes,but measured outcomes werehighly heterogeneous.Strength of evidence waslow, and most studies werepre-post evaluations of low to



18



Aim: to identifies andassesses interventionsused to promote safetyculture or climate in acutecare settings.

Design: Systematic review

moderate quality. Withinthese limits, evidencesuggests that interventionscan improve perceptions ofsafety culture and potentiallyreduce patient harm.




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