Erasmus Mundus Master Course in Emergency and Critical ...

Erasmus Mundus Master Course in Emergency and Critical Care Nursing

http://www.masternursing.eu/inicio



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Acknowledgement

I acknowledge the enormous support morally and spiritually from all the professors in

Erasmus Mundus Masters Programme, most especially from expert advice from Dr. Regina

(ES Saude), Dr. Claudia (Santarem), not forgetting Mr Ezra Trevor Rwakinanga for his

friendly encouragement. I am indeed grateful to have my class mates and friends in

Portugal, Helsinki Metropolia University and EMA leaders who made the Erasmus Master

Experience very rewarding and memorable.

Dedication.

I dedicate this work to my mum retired Nurse Mary Ociru Andiandu, my wife Dianah

Nsasirwe and my children most especially Feni Clinton who was just 4 months old when I

left for studies in 2013. This piece of work is worth your time while I missed all of you back

home in Uganda.




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Contents Abstract ................................................................................................................................ 8

1.0 Introduction .......................................................................................................... 10

1.2 Review of relevant literature for the study .......................................................... 12

1.4 Problem statement .............................................................................................. 24

2.0 Research Purpose ................................................................................................. 26

2.1 Research Objectives ............................................................................................. 26

3.0 Methodology ........................................................................................................ 27

3.1 Research Questions .............................................................................................. 27

3.2 Research method ................................................................................................. 27

3.3 Study design ......................................................................................................... 28

3.4 Study Population .................................................................................................. 28

3.5 Sampling type ....................................................................................................... 28

3.6 Sample size prediction ......................................................................................... 29

3.7 Data gathering process ......................................................................................... 29

3.8 Data analysis ......................................................................................................... 30

3.9 Methods to ensure trustworthiness .................................................................... 30

3.10 Research Limitations ............................................................................................ 31

4.0 RESULTS ................................................................................................................ 33

4.1 Translation and adaptation of SAQ 2006 instruments ......................................... 33

4.2 Data Analysis ........................................................................................................ 37

4.3 Demographic information .................................................................................... 37

4.4 Factor Analysis ...................................................................................................... 39

4.5 Testing for Suitability of Factor Analysis .............................................................. 39

4.6 Testing for significance of variables under study ................................................. 40

4.7 Factor Extraction from study variables ................................................................ 40

4.8 Factor Patterning with study variables ................................................................ 42

4.9 Goodness-of-Fit of the Model .............................................................................. 44

4.10 Reliability of the Model ........................................................................................ 45

4.11 Variability in the Study Model .............................................................................. 45

5.0 Discussion ............................................................................................................. 54

5.1 Translation and adaptation of the SAQ ICU version............................................. 54

5.2 Factor analysis ...................................................................................................... 55

5.3 Factor variability ................................................................................................... 57




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5.4 Conceptual Framework ........................................................................................ 63

5.5 Significance of study ............................................................................................. 64

6.0 Conclusions ........................................................................................................... 67

7.0 Reference ............................................................................................................. 68

Appendixis

Appendix A: Activity plan ......................................................................................................... 74

Appendix B: Authorization letter for data collection for clarity test. ....................................... 75

Appendix C. Permission letter from Hospital 2 (H2) ................................................................ 76

Appendix D: Permission letter from Hospital 3 (H3) ................................................................ 77

Appendix E: Permission letter from Hospital 1 (H1) ................................................................ 78

Appendix F. Permission letter from author of SAQ. ................................................................. 79

Appendix G. The Original Safety Attitude Questionnaire (ICU) Verion. ................................... 80

Appendix 1: Summary Forward & back translation to target language (TL1 & TL 2) ............... 81

Appendix 2: SAQ ICU Clarity Test tool (Portuguese Version) ………………………………………..………96

Appendix 3(a): Information about the Study ................................................................................ 98

Appendix 3(b): Informed Consent Form .................................................................................... 100

Appendix 3 c): Final SAQ Portuguese Version ............................................................................ 101

Appendix 3 (d): Table 4.2 Communalities Kaiser-Meyer-Olking (KMO) ...................................... 104

Appendix 3 (e): Chi-Square test statistic for the 6-factor model ................................................. 106

Appendix 3 (f): Table 4.4b Rotated Component Matrix ..………………………………………………………..109

LIST OF FIGURES Figure 1 Conceptual Frame work …………………………………………………………………………23 Figure 4.0 Scree Plot for Study Variables …………………………………………………………………41 Figure 2 Recommendations for improving patient safety culture .......................... 53 Figure 3 Proposed Patient Satey Model ………………………………………………………………63 LIST OF TABLES Table 4.1 Descriptive Frequency of Professional experience within hospitals ……….38 Table 4.3 Eigen Values for Component extraction ………………………………………………...41 Table 4.4a Showing Component of factor structure ................................................... 43 Table 4.5a Difficulty to speak up in case of a problem at all 3 hospitals .................... 46 Table 4.5b Difficulty to speak up in case of a problem at Polyvalent clinical area ..... 46 Table 4.5c Difficulty to speak up in case of a problem at Cardiology clinical area ..... 46 Table 4.6 Factor Variability in all hospitals (N = 73) .................................................. 47 Table 4.7 Feedback and the Quality of Collaboration with the Chief Nurse ............. 49 Table 4.8 Feedback and the Quality of Collaboration with the Chief Nurse ............. 52




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Abstract Background: Patient safety still remains a global public health problem but how it is

addressed may differ depending on local setting, culture and availability of resources.

Safety attitude questionnaire (Bondevik, Hofoss, Hansen, & Deilkås 2014) is one of the

instrument that measures patient safety culture in a clinical setting such as ICU. We sought

to understand how nurses working in ICU perceive their patient safety practices through

the application of a translated SAQ (2004) ICU version into Portuguese language among

critical care nurses at three hospitals in Portugal.

Methods: The original Sexton’s 2004 SAQ ICU Version (Appendix G, page 80) was translated

to Portuguese language using the back translation techniques and tested in 37 graduate

nurses in Portugal. A quantitative data was collected among 103 nurses at intensive care

unit in three hospitals in Portugal. Non-random probability technique and criterion

sampling was used to obtain data with supervised self-completion process.

Results: All 37 participants filled the pre-test for clarity test; reliability Cronbach’s Alpha of

.71 (64 items) with strong correlation of .000 - .463 (p<0.05). About 74 (72%) of the 103

nurses participated and 98.6% (73) fully completed the questionnaire. Items correlated

with KMO = 0.6, df 741 at p<.05, forming an identity matrix suitable for factor analysis. Six

factors were extracted explaining 56.2% total variance: management perception

(15.145%), safety climate (9.576%), teamwork climate (8.708%), job satisfaction (7.849%),

stress recognition (7.56%) and work condition (7.420%). A good reliability Cronbach’s Alpha

of 0.819 was obtained and there were variability in all the 6 factors.




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Conclusion: We conclude that translation of the SAQ to Portuguese showed satisfactory

internal psychometric properties. The translated SAQ to Portuguese language can be used

to measure nurses’ attitude regarding the six patient safety culture related domains in ICU.

Key wards: patient safety culture, ICU, translation, adaptation, SAQ.




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1.0 Introduction

In the world over the image of an institution is determined by the attributes its culture. A

good account of the culture of an institution involves an understanding of the shared

norms, values, behaviour patterns, rituals and traditions of its employees as part of

organizational culture (Profit et al., 2012); which are further reflected in the attitudes of its

employees. Halligan & Zecevic, 2011 defined the culture of safety as “the product of

individual and group values, attitudes, perceptions, competencies and patterns of

behaviour that determine the commitment to, and the style and proficiency of, an

organization’s health and safety management”

This study aims at understanding and describing the characteristics of how patient safety

culture is perceived among critical care nurses at intensive care units in three hospitals in

Portugal. The study of “Patient Safety Culture among Critical Care Nurses at Intensive Care

Units in three Hospitals in Portugal” was chosen because understanding the attitudes of

nursing staff at ICU offers prospects to identify areas that need to be strengthened to

improve quality of care at ICU.

The terms Safety culture and safety climate have been used interchangeably to mean the

same. For instance, we refer to patient safety culture as individual behaviour regarding

efforts to reduce risks, address and reduce incidents and accidents that may negatively

impact health care consumers (Bryan Sexton et al., 2011). Since two decades ago, the

popular IOM (1999) report on “to error is human” has made high risk organizations

including health industry to shift their attention to improving safety practices in order to

prevent adverse events. Therefore one of the goal of patient safety culture in the health




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care industry now focuses to promote a behaviour pattern among staff that aims to reduce

and prevent adverse events during care. By and large there is a tendency to assume that in

every hospital, patients are expected to receive care that is free from exposure to danger

and be protected from occurrence of risk or injury with optimal precautions at workplace.

This requires employees of every hospitals are expected to acquire and adopt to an

established organizational philosophy in the form of mission, vision and core values so as

deliver safe health care.

Well-developed health organizations deliberately establish core values and strategies that

articulate how they intend to deliver safe care to their client through a habit of achieving

the desired value hence provoking specific patterns of behaviour and practices referred to

as culture. However, translating the core values of an organization into actions depends on

many behavioural factors including leadership style, communication, attitudes to

teamwork and safety and well as having staff who are satisfied with their job in an

environment which are believed to impact positively on the patient safety (Bryan Sexton et

al., 2011). For instance, in 2006, Bryan Sexton declares that the behavioural factors of

individual health worker ought to reduce risks, address and reduce incidents and accidents

that may negatively impact health care consumers and he labelled this as “patient safety

culture”.

In this study, we targeted nurses working in intensive care unit from whom quantitative

data was collected with supervised self-administered questionnaire using the Sexton’s

2004 SAQ (ICU version) to collect data; a tool which was derived from the Flight

Management Attitude Questionnaire (Göras, Wallentin, Nilsson, & Ehrenberg). This tool




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has been derived from human factor survey used to measure cockpit culture in commercial

aviation (John Bryan Sexton & Keryn Vella, 2006).

The SAQ ICU version 2006 was chosen for this study because of its ability to focuses on

safety climate and probing healthcare teams to describe their attitudes to six domains using

Likert scale (Carifio & Perla, 2008; Celenza & Rogers, 2011; Hadjibalassi et al., 2012; Hartley

& MacLean, 2006; Hasson & Arnetz, 2005; Spigelman, Debono, Oates, Dunn, & Braithwaite,

2012; Wisniewski et al., 2007; Zimmermann et al., 2013) to score. According to Sexton

2006, the six domains such as teamwork climate, job satisfaction, perceptions of

management, safety climate, working conditions and stress recognition describe the

characteristic behaviour within a unit or department. The SAQ tool has readily available

data for its psychometric properties already tested in over 500 hospitals in the United

States, the United Kingdom and New Zealand. The tools has been validated for use in critical

care, operating rooms, pharmacy, ambulatory clinics, labour and delivery, and general

inpatient settings (Sexton, Thomas, & Helmreich, 2000) as well as well as being rigorously

validated for measuring safety climate in healthcare in different countries.

1.2 Review of relevant literature for the study

We reviewed publications related to patient safety culture and associated domains of the

research topic. According to Polit and Becks, 2010, literature review deliberates on critical

analysis of published sources, or literature on a particular topic within the context of

previous knowledge. It also offers an assessment of the available works so as to provide a

summary, classification, comparison and evaluation of the situation under study. Here we

describe the already known facts about approaches of nurses towards patient safety




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culture in order to understand what they perceive about their safety practices in the ICU

work environment.

The explanation of the term “safety culture” dates back in 1987 when INSAG (1988) first

described it in the Nuclear Agency report on the 1986 Chernobyl disaster and published in

WHO (2006) where they concluded that: … “The April 1986 disaster at the Chernobyl

nuclear power plant in Ukraine was the product of a flawed Soviet reactor design coupled

with serious mistakes made by the plant operators as a direct consequence of Cold War

isolation and the resulting lack of any safety culture”…

Since then there is a growing interest to the understanding of safety culture by organization

and more particularly high risk occupations such as the health care industry.

In this study, attempts were made to review the historical background of how safety culture

has been described by various authors in order to understand the current definitions of

patient safety culture. Within the available literature, the term ‘culture’ as described by

Uttar (1983) refers to “shared values and beliefs that interact with an organization’s

structures and control systems to produce behavioural norms”, while Cullen W.D, (1990)

loosely defined safety culture as “the corporate atmosphere or culture in which safety is

understood to be, and is accepted as the number one priority” (Cooper, 2002).

Available literature shows that culture of patient safety is closely linked to describing and

understanding the ability of healthcare staff to prevent error and adverse events (Singla,

Kitch, Weissman, & Campbell, 2006). It can be argued that safety culture may perhaps be

considered as representing health workers’ understanding of the hazards at the place of




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work as well as carrying out specific steps during care in order to provide safe care to

patients resulting into safe working area at the heart of a safety culture (Griffith, Livesey,

& Clayton, 2010).

Theoretical concept of safety culture has been applied in many fields. Components such as

giving safety first significance at all levels of the organizational hierarchy, a pledge to safety

at the administrative level, providing resources needed to achieve quality and safety, the

open and constructive handling and learning from errors, and focusing on improving

systems rather than individual blame are commonly acknowledged as essential to ensuring

safety at workplace (Geller, 1994; Pidgeon, 1998; Singer et al., 2003). The domains which

make safety culture visible have been identified by Sexton 2006 as teamwork climate, job

satisfaction, perception of management, safety climate, working condition and stress

management practices on the organization (John B Sexton & Keryn Vella3, 2006). These

domains were identified through a confirmatory factor analysis on SPSS of the SAQ ICU

version 2006. The perception of the six domains offers an understanding of how healthcare

workers view their safety practices at work place by responding to the SAQ.

Since the SAQ tool has the ability to measure workers safety climate, the tool is being

translated and adapted to different culturally diverse settings and linguistics at different

parts of the world by different researchers (Bondevik et al., 2014; Chaboyer et al., 2013;

Devriendt et al., 2012; Etchegaray & Thomas, 2012; France et al., 2010; Göras et al., 2013;

Haugen et al., 2010; Kaya, Barsbay, & Karabulut, 2010; Li, 2013). In another study by

Raftopoulos, 2013, it was found that the perception of health workers towards the six

domains of Sexton’s 2004 SAQ vary from one hospital to another.




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The use of the SAQ is able to identify defects in patient safety climate resulting negative

outcomes such as the lack of teamwork, job stress to workers, adverse events to patients,

communication breakdown and an apparent lack of patient satisfaction (Bryan Sexton et

al., 2011). However, practices such as identification of errors, effective communication of

errors, early detection of risks, and open communication between the health care team,

improvement of working condition, cooperation with and support from the management

team, promotion of a safe working condition stimulates an overall job satisfaction

(Raftopoulos & Pavlakis, 2013). Good culture of patient safety results into quality care,

reduced adverse events, patient satisfaction and overall provision of healthcare that is free

from errors and adverse events.

Ensuring patient safety is a deliberate effort by individual staff to promote patient safety at

work place in the areas of teamwork, management practices, conducive work environment,

ensuring safe and stress free work climate in order to promote job satisfaction among staff.

Teamwork climate: It is well known and stated in literature that medical care today is

undeniably a team effort. Team effort makes it easy to complete the continuum of car

especially when there is effective communication, cooperation and coordination (Salas

2008). A team is an identifiable set of two or more individual interacting within a large

organizational context to reach a common goal through specific interdependent roles and

task boundaries (Salas 1992 and Kozlowst 2003). In various literature, teamwork has been

defined in terms of behaviours, closed loop communication, cognition and attitudes

(cohesion and collective efficacy) that makes interdependent performance possible.

Teamwork has been linked to patient safety outcomes such as reduced risk and job




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satisfaction since the workers tend to support each other and work to achieve a common

goal (O'Byrne, Worthy, Ravelo, Webb, & Cole, 2014; Redden & Evans, 2014). Promoting

teamwork utilizes complex inter-professional collaboration and the effectiveness to

produce desired outcome depends shared goals, partnership, mutual respect and power

sharing with other professional in the organization (Louise et al, 2011). Louise 2011 declares

that teamwork is continuously changing in ICU owing to the large staff numbers, work shift,

staff rotation to other departments and different professionals working together at varying

times. Despite the fact that ICU requires a unified team working together to provide safe

care, achieving and sustaining it in practice is challenging due inter-professional conflict

and the tendency of staff moving from one job to another. Louise 2011 asserts that job shift

are common due to the dynamic socioeconomic disparity in the health care industry.

However there is evidence that power sharing alone tends to reduce conflict that arise due

to ownership of specialized skills and technical/clinical territory compounded by the notion

that patients are owned by particular clinical speciality as illustrated by Louise 2011. The

correlation of teamwork climate (inter-professional collaboration) with patient safety

culture underscores the importance to identify alternative ways to improving safety in ICU

through research.

Safety climate: Safety climate and safety culture has been used interchangeably by many

scholars to mean “the product of individual and group values, attitudes, perceptions,

competencies, and patterns of behaviour that determine the commitment to, and the style

and proficiency of, an organization’s health and safety management (Sorra 2004 and

Wendy 2011)”. Some authors such as Davies et al (2000) observed that, culture is … “the




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way we do things around here”… is now accepted by many as simple description of the

safety climate. While Carney et al (2010) described safety culture as “a professional culture

that promotes effective and efficient communication among clinicians and not hampered

by hierarchical status or personality differences”. The Health and Safety Committee and

Advisory Committee on the Safety of Nuclear Installations of UK in 1993; declares that

institutions with a constructive safety culture are branded by communications established

on shared trust, common perceptions of the importance of safety, and by self-assurance in

the efficacy of precautionary measures. Thus at present, certain industries such as aviation

and chemical have maintained an assured safety based on the above standard resulting in

few cases of adverse events and accident hence organization gradually adopting them in

the health industry. The fact that patients admitted to ICU have complex conditions has

been found to be associated with predictable medication errors, nurse back injuries,

urinary tract infections, reduced patient satisfaction, patient perceptions of nurse

responsiveness and nurse satisfaction (Abstoss et al., 2011; Belela, Peterlini, & Pedreira,

2011; Bohomol, Ramos, & D'Innocenzo, 2009; Brady, Malone, & Fleming, 2009).

Job satisfaction: Job satisfaction is another safety climate domain which refers to a state

of personal satisfaction relative to the work situation (Bryan Sexton et al., 2011; Devriendt

et al., 2012). The term was first used to describe individual experience regarding the

fulfilment of a need or state of being satisfied. Job satisfaction and quality of work of nurses

depends on the type of units in which they work and in relation to the levels of depression,

anxiety and stress. A study by Abd El-aal and Hassan, 2009 found a significant negative weak




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correlation between the mean total score percentage of staff nurses' satisfaction and the

quality of work, stress and their depression level in critical care units.

Work condition: Work conditions of a health institution are defined by established norms

and provide an observable picture of safety conditions. Promotion of a good culture of

patient safety in an organization is regarded (Saha, Beach, & Cooper, 2008) as a key to

promotion of quality service and customer satisfaction. Hence patient safety culture refer

to the behaviour of health workers at the work environment that promotes members

responsibility to prevent, learn and encourage the reporting of errors so that they do not

happen again(Armellino, Quinn Griffin, & Fitzpatrick, 2010; Armstrong & Laschinger, 2006;

Bosch et al., 2011; Currie & Richens, 2009). A good working condition correlates positively

with job satisfaction and patients agreeing with quality of care.

The attributes of safety culture in an organization and institution is defined by norms,

values, expected behaviour patterns, rituals and traditions of its employees (Profit et al.,

2012) similarly defined as ‘the product of individual and group values, attitudes,

perceptions, competencies and patterns of behaviour that determine the commitment to,

and the style and proficiency of an organization’s health and safety management’ (Health

and Safety Commission 1993, Nieva & Sorra 2003). Hence patient safety culture is not

tangible but can be observed as behaviour pattern of individuals in the institution. The

benefits of patient safety culture cannot be seen directly by observing the employee but

will be seen as an outcome of safety climate.

The outcomes of patient safety culture is linked to the capacity of healthcare staff to

prevent error (Singla, Kitch, Weissman, & Campbell, 2006). A safety culture could be




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considered as representing the workers’ understanding of hazards in their workplace, and

the norms and roles leading to safe working area at the heart of a safety culture (Griffith et

al., 2010). The theoretical concept of a safety culture has been applied in many fields.

Components such as giving safety first significance at all levels of the organizational

hierarchy, a pledge to safety at the administrative level, providing the resources needed to

achieve quality and safety, the open and constructive handling of errors, organizational

learning, and focusing on improving systems rather than individual blame are commonly

acknowledged as essential to safety culture (Geller, 1994; Pidgeon, 1998; Singer et al.,

2003). The domains which make safety culture become more visible have been identified

in a study by Sexton 2006 as having an attitude working as a team, being satisfied with job,

management supporting the safety practice, having a safe working climate, having an

appropriate working condition and stress management practices within the organization

(John B Sexton & Keryn Vella3, 2006). The practice and perception of the six domains of

patient safety culture provides an understanding of how healthcare workers view their

safety practices while delivering health care. The outcomes of the patient safety practices

indirectly translate to identification of errors, effective communication of errors, early

detection of risks, and open communication between the health care team, improvement

of working condition, cooperation with and support from the management team,

promotion of a safe working condition and overall job satisfaction. Decent culture of

patient safety results into quality care, reduced adverse events, patient satisfaction and

overall provision of healthcare that is free from errors and adverse events.




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According Hughes, (2008), patient safety refers to “the prevention of harm to patients”…

with emphasis placed on the system of care delivery that prevents errors; learns from the

errors that do occur; and is built on a culture of safety that involves health care

professionals, organizations, and patients. The prevention and learning from the errors is

the pivot on which an organization builds a culture of safe practices of care. Professional

culture of safety is rooted to the implementation of core values, vision and the goal of

delivering services that is free from adverse events.

Patient safety remains a serious concern in intensive care unit because of the fragile

conditions of patients admitted with potential organ failure and threat to life. The

professional culture of safety in ICU has an important effect on the recovery of patients in

critical conditions. Little is known about how nurses in ICU perceive patient safety practices

at typical hospitals in Portugal. The term ‘Safety Culture’ has been defined by many scholars

as the product of shared values and beliefs towards patient safety (Zimmermann et al.),

Cox and Cox (Aagja & Garg), Pidgeon (Aagja & Garg), Berends (1996), Lee (1996) and

Summier C. E 2009). For the purpose of this survey the definition by Sexton (2006) shall be

used; “Safety culture as "the product of individual and group values, attitudes, perceptions,

competencies, and patterns of behaviour that determine the commitment to, and the style

and proficiency of, an organization's health and safety management” The above definition

may mean that a safety culture comprises of a complex set of individuals’ behavioural

attributes that can promote an effective patient safety culture in an organization.

Therefore, any deficiency in safety practice of an individual worker may give rise to adverse

events such as falls, medication errors, nosocomial infections, delayed recovery, high




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health cost and lack of patient satisfaction to services (Abstoss et al., 2011; Armitage, 2009;

de Melo et al., 2013; Maher-Griffiths, 2011; Mansour, James, & Edgley, 2012; Rodrigues &

Oliveira, 2010; Wu, Yu, Lan, & Tang, 2012).

In critical care units, all health care workers are expected to prevent errors that may occur

in the course of duty. Although there is similarity in the general set up of all intensive care

units in terms of infrastructure, staffing, nature of patients admitted as well as the

management, little is known about the perceived differences in care practices with other

intensive care units being considered offering better services in the perspective of service

users. These may be largely as a result various factors such as leadership and management

of the units, work culture at organizational level and the level of motivation of the staff to

providing yet little is known how these domains impact on safety culture among critical

care nurses in Portugal.

Generically, health workers are anxious to provide care that is safe and free from harm in

order to meet the health care needs of the patients. It is assumed that all health workers

will always deliver care that will not cause harm to patients. Although providing safe care

is the responsibility of the organization and its workers, individuals clients will always seek

to find out how the services of a particular institution is described in terms of cure success,

positive patient testimony or even how the staffs are perceived in the manner in which

they provide services.

Most scholars in their definition consider patient safety culture or safety climate as

deliberate efforts to reduce risk, to address and reduce incidents and accidents that may

negatively impact healthcare consumers (Cox and Cox (1991), Pidgeon (1991), Ostron




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2003), Cooper and Phillips 1994, Niskanen (1994), Coyles (1995), Barends (1996), Lee and

Williamson 1997). Although medical error reporting is considered essential for patient

safety, Kagan (2013) found that many errors go unreported and the level of patient safety

culture (PSC) was positively correlated with the rate of error reporting and that the level of

the PSC at both organizational and departmental levels predicted the error reporting rate.

This demonstrates that a positive PSC can enhance error reporting while a negative PSC

may act as a reporting barrier. Measuring culture of patient safety in ICU gives an

understanding of unit conditions such as team work climate, job satisfaction, perception of

management, safety climate, working conditions and related factors that lead to adverse

events and patient harms (Albert et al., 2014).

Conceptual Framework

Patient safety is influenced by different factors including both individual and organizational

factors. All the influencing factors are dependent on each other. For instance, deficit in one

of the domain will subsequently have an influence another domain such as if the

management does not support the staff in their effort to address errors effectively, it leads

to unsafe practices and subsequent adverse events; where as if management handles

errors appropriately and use it as a learning opportunity, the next time such an error will

be prevent or managed appropriately.




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Figure 1: Conceptual Framework

Patient

safety

culture

INDIVIDUAL FACTORS Age, Gender, Level of education / job category, Years / Experience / service, Duty shift, Type of job

Teamwork

Climate

Job satisfaction

Stress recognition

Perception of

management

Safety Climate

Work conditions Defective Safety culture Adverse events




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1.4 Problem statement Patient safety still remains a serious global public health problem but how it is handled

differ depending on local settings, culture of the organization and availability of resources

. WHO (2014) estimates indicated that in developed countries, as many as one in 10

patients is harmed while receiving hospital care and for every 100 hospitalized patients at

any given time, 7 from develped countries and 10 in developing countries acquire health

care associated infections. It has been recommended by WHO (2012) that the current

global focus should be on prospect to improving patient safety through culture

transformation. The culture of patient safety remains one of the most important nursing

care element in all intensive care units however, implementing professional safety culture

in ICU has been used as effort to improve safety among nursing staff.

Promoting professional nursing safety culture has an important effect on patient safety

since such measures among nursing team at ICU positively impacts on recovery of patients

(Hughes, 2008). Errors in medication, procedures, and falls are some of the commonest

indicators of the existence of failures in patient safety practices in healthcare. Making an

error is inherent to human nature and behaviour (IOM, 1999 and Genival 2013) yet

provoking a sense of insecurity during care. Studies have found that the rate of potential

adverse events in ICU per 1000 patient-days was at 276, whereas the rate of preventable

ADEs per 1000 patient-days was at 9.2 with medication errors as the leading ADEs. This

trend remains a serious concern because evidence shows that certain behaviour of

healthcare team are responsible for the adverse events in ICU (Hughes, 2008). Despite a lot

of effort being placed on improving safety of patients, 32% of medication errors continue

to occur during ordering and 39% occur during administration of drugs (mostly




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implemented by nurses). Studies by Pascale (2008), indicate that in 16–24% of potential

and preventable ADEs and clusters of errors occurred either as a sequence of errors (delay

in medication dispensing leading to delay in medication administration) or grouped errors

(route and frequency errors in the order for a medication). These are serious safety related

adverse events which are purely preventable during the medication management process

and requires behaviour that is able to prevent and learn from errors.

Hence the study will seek to find out how Nurses working in ICU perceive their safety

practices towards patients in intensive care units at three hospitals in Portugal. The

understanding of critical care nurses’ perception and attitudes towards patient safety will

be able to predict the safety climate or safety culture in the clinical area with the majority

being nurses.




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2.0 Research Purpose

The purpose of this study is two folds; first to describe how Nurses working in ICU perceive

their safety practices towards patients at three hospitals in Portugal in order to generate

recommendation on how to improve patient safety in intensive care unit in the three

hospitals. Secondly to translate and validate the Sexton’s 2004 Safety Attitude Question into

Portugese language.

2.1 Research Objectives

We intended to achieve the following objectives in this study:

To identify factors that influence patient safety practices among critical care nurses

in three hospitals in Portugal.

To compare the patient safety cultures among critical care nurses in intensive care

units in the three hospitals in Portugal.

To identify recommendation for improving patient safety culture in ICU in the three

hospitals.

To translate and validate the tool Sexton’s 2004 Safety Attitude questionnaire (SAQ)

to Portuguese reality.




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3.0 Methodology Introduction: This section will be describing the approaches that will be used to answer the

research question. Polit and Becks, (2014) asserts that research methodology specifically

describes the techniques and procedures used to answer the research questions. These

approaches will be describing the research design, determination of population size, sample

size prediction, sampling type, data gathering process and analysis as well as describing the

scope of the study and limitations.

3.1 Research Questions

What factors influence patient safety practices among critical care nurses in three

hospitals in Portugal?

How does the patient safety cultures among critical care nurses in intensive care

units compare in the three hospitals in Portugal?

What are the recommendation for improving patient safety culture in ICU in the

three hospitals?

What is the Portuguese version of Sexton’s 2004 Safety Attitude questionnaire (SAQ)

ICU?

3.2 Research method

A quantitative research method was implemented using the descriptive research design

process. A quantitative methods emphasise on objective measurements and numerical

analysis of data collected through polls, questionnaires or surveys and focuses on gathering

numerical data and generalizing it across groups of people (Babbie, et al 2010). The main

goal will be to determine the relationship between patient safety culture among ICU nurses




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in the dimensions of teamwork, job satisfaction, perception of management, working

conditions, safety climate and (6) stress recognition Sexton et al, 2006.

3.3 Study design

A descriptive research design is chosen in order to gain more information about how Nurses

working in ICU perceive their safety practices towards patients in intensive care units at

three hospitals in Portugal. Study design is the overall plan for obtaining answers to the

research questions and for handling challenges that can undermine the study evidence with

the main goal of minimizing bias, how data will be collected, what type of comparison will

be made and where study will take place (Polit and Becks, 2014). The greatest motivation

to choose this method was due to the fact it will allow the researcher use questionnaire to

explore factors that influence patient safety culture among critical care nurses. A study by

Sorra, Nieva, Fastman, Kaplan, Schreiber, and King (2008) used descriptive design to study

staff attitudes about reporting and patient safety culture in hospital transfusion services.

3.4 Study Population

The term population refers to all individuals or subjects with common, defining

characteristics that meet a designated set of criteria for inclusion in a study (Polit and Beck,

2014). The target population are nurses working in intensive care units for the last six

months by November 2014 in the three hospitals.

3.5 Sampling type

The researcher used two sampling types; non-random probability and criterion sampling.

Non-random probability sampling method was be used to draw nurses from ICU into the




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study. The second technique; criterion sampling, as Polit and Beck (2010:320) explains,

consisted of the researcher consciously selecting participants from the target population

who will meet established criteria of having: been working in ICU for the last one month,

consented to participate and share their views in the study and accepted to fill the

structured questionnaire.

A sample of 103 adult male and female nurses working at ICU for the last six months were

eligible to participate in the study from the three hospitals A, B and C. In hospital A 45 nurses

were eligible, hospital B there were 22 nurses and hospital C had 36 eligible nurses. In terms

of implementing the exclusion criteria, nurses with physical illness and are unable to read

and write were considered ineligible for the study.

3.6 Sample size prediction All nurses working in ICU were eligible to participate in the study. The power of statistics

was used to predict and estimate the suitable sample size. A total of 74 (71.2%) nurses

participated in the data collection from the three ICUs. The sample size for translation and

validation of the tool was determined according recommendation by Sousa et al, 2011

where 10-40 participants is adequate for testing the clarity of the instrument/tool in the

target language.

3.7 Data gathering process

The researcher gathered data by using a supervised self-completion or self-administered

questionnaire using the translated version of Sexton’s 2004 SAQ in Portuguese. Bryman

(2008:232) describes self-administered questionnaire as a process where respondents

answer questions by completing the questionnaire themselves. All respondents were




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provided with research information sheet describing what is involved in the study. A

consent form attached the end of the information sheet were signed by the respondents

who are willing to participate in the study. On signing the consent form, each respondent

is provided with the questionnaire. Questionnaires were given only to those nurses who

signed the consent form. For the purpose of ensuring confidentiality, each respondents was

provided with an envelope to place the completed questionnaires and seal it before

returning it to the supervisor selected within each ICU. The sealed envelope containing the

filled questionnaire were kept under lock and key in the office of the ICU supervisor before

being collected by the researcher after ten days. The researcher has chosen this supervised

self-completion questionnaire because it is cheaper, quicker to complete, there is absence

of interviewer effect, no interviewer variability and convenient for the respondents

(Bryman, 2008:233-4).

3.8 Data analysis

Data was analysed using SPSS software package version 16. The result of the study are

described in text and illustrated with frequencies, tables and figures.

3.9 Methods to ensure trustworthiness

Ethical consideration: Approval of the study was sought from the Director of Escola

Superior de Saude de Santarem for clarity test, authority and permission for data collection

was obtained from each of the Management and Research Committee of the three

hospital.

Scope of the Research: The scope of the study is limited to understanding and describing

the Perception of Patient Safety Culture among Critical Care Nurses at Intensive Care Units




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in three hospitals in Portugal. The study is also further restricted to achieving the objectives

of translating, validating and adapting the SAQ ICU version into Portuguese language for

data collection as well as generating recommendation for improving patient safety culture

among critical care nurses in three hospitals in Portugal. Data collection for this study only

involves Nurses working in ICU at the three selected hospitals in Portugal.

3.10 Research Limitations

Brutus and Stéphane (2013: 48-75), defined limitations of the study as those characteristics

of design or methodology that impacted or influenced the application or interpretation of

results of a study. They further explained that limitations are the restrictions on

generalizability and usefulness of findings that are the result of the ways in which the

researcher chose to design the study and/or the method used to establish internal

and external validity. Despite efforts to ensure accuracy, the researcher is aware of the

study’s shortcomings, because as Bryman (2012:178-9 and 205) explains that quantitative

research studies such as this, however well intentioned, still involves certain deficits

especially in relation to the research conditions; data generation process; the study

method; and researchers’ analysis of the study results.

Limitation related to research situation: The researcher is further aware that the

quantitative method research is incapable to capture all the information related to the how

critical care nurses perceive their safety culture practices in the three hospitals in this study.

In order to inform the readers about the perception of the patient safety culture among

nurses in ICU, the researcher intends to obtain opinion of the respondents using the

translated version of Sexton’s SAQ ICU version (2004) into Portuguese language. This tool is




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chosen due to the fact that there is available data on the psychometric properties that has

been validated in over 500 hospitals across the world including Norway, Sweden, Germany

United Kingdom and USA (Carney, Mills, Bagian, & Weeks, 2010; Chaboyer et al., 2013;

Devriendt et al., 2012; Etchegaray & Thomas, 2012; France et al., 2010; Göras et al., 2013;

Hamdan, 2013; Haugen et al., 2010; Hoffmann et al., 2011; Kaya et al., 2010); providing a

wide view to describe and benchmark the findings.

Limitation related to researchers’ interpretation: The researcher is aware that all research

data can be interpreted in different ways and using different types of methods of analysing

research variables (Bryman 2012:330-50). Although there are many computer software

packages for data analysis, the researcher choose to use SPSS version 16 and STATA for data

analysis. This implies that the researcher will be exercising caution on deciding how to

interpret the variables in this study using the SPSS making sure to use not only be credible

approach but to recognize the variations in the views and opinions of the respondents

depending on the findings. The researcher therefore intends to communicate the findings

in a manner that will illustrate similarities and differences between this study and other

studies on patient safety culture (Abstoss et al., 2011; Ballangrud, Hedelin, & Hall-Lord,

2012; Kreimer, 2014; Patterson et al., 2010; Profit et al., 2012; Sammer, Lykens, Singh,

Mains, & Lackan, 2010).




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4.0 RESULTS

Introduction: In this section, we report the findings of the study based upon the

methodology applied to gather information (Burton and Neil, 2009). The results simply

states the findings of the research arranged in a logical sequence without bias or

interpretation. Here data generated from this study are briefly described in text, tables and

figures.

4.1 Translation and adaptation of SAQ 2006 instruments The tool “Safety attitude questionnaire” (SAQ ICU Version in Appendix G, page 80) was first

developed in English language by Bryan Sexton in 2004 (Bryan Sexton et al., 2011) at the

University of Texas in USA. In their study the researcher sought to undertake a study in ICU

regarding the perception of patient safety culture among critical care nurses in Portugal and

using the SAQ as the research tool. The major spoken language being Portuguese in Portugal

with English language disenfranchisement1 rate of 65% (Ginsburgh & Weber, 2005), it was

imperative to translate and adapt the SAQ tool into the equivalent of the target language

(TL) before being used in this study.

The aim of this process was to achieve different language versions of the English SAQ

instrument that is conceptually equivalent in the target country/culture (Göras et al., 2013;

Zimmermann et al., 2013). This would mean that the tool should be equally natural and

acceptable and should practically perform in the same way (Herdman 1998, Beaton, 2000,

Jones, 2001, Bowden 2003, Nilsson 2013 and Sperber 2013) as the original version. The

focus of this process is on cross-cultural and conceptual, rather than on linguistic/literal

1Language disenfranchisement in European Union refers to the percentage of citizens who would lose their ability to understand EU documents and some discussions if English language were chosen as a working language (Reeves, N. (1990)




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equivalence. A well-established technique to achieve this goal is to use forward-translations

and back-translation method. Translation and adaptation studies by Herdman 1998,

Beaton, 2000, Göras, 2013 and Nilsson Kajermo 2013; all used the forward translation

technique with aspects of expert panel back translation, pre-test and cognitive questioning

to produce the final version (Göras et al., 2013; Nilsson Kajermo et al., 2013).

The steps of the forward and back translation involves seven steps as recommended by

(Valmi D. Sousa and Wilaiporn Rojjanasrirat 2010; - Step 1: translation of the original

instrument into the target language (forward translation or one-way translation), Step 2:

comparison of the two translated versions of the instrument (TL1 and TL2), Step 3: blind

back-translation (blind backward translation or blind double translation) of the preliminary

initial translated version of the instrument, Step 4: comparison of the two back-translated

versions of the instrument (B-TL1 and B-TL2), Step 5: pilot testing of the pre-final version of

the instrument in the target language with a monolingual sample: cognitive debriefing, Step

6: preliminary psychometric testing of the pre-final version of the translated instrument

with a bilingual sample and Step 7: full psychometric testing of the pre-final version of the

translated instrument in a sample of the target population.

As recommended by (Emanuela Fontenele Lima de Carvalho & De Bortoli Cassiani, 2012;

Göras et al., 2013; Sousa & Rojjanasrirat, 2011) the forward translation was performed by

two bilingual and bicultural translators whose mother language is the desired target

language (Portuguese). The two translators were having distinct backgrounds of one being

knowledgeable about health terminology and the content area of patient safety culture of

the instrument in the target language 1 (TL1). The second translator being knowledgeable

about the cultural and linguistic nuances of the target language and is working as a




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freelance language translator of Portuguese-English pairs for over six years and produced

the second version in the target language (TL2). The two forward translators produced two

forward-translated versions of the instrument in the target language (TL1 & TL2) as shown

in the summary in appendix 1.

A third independent translator was used to compare the two versions of TL1 & TL2

instrument, and to compare both the TL1 and TL2 with the source language of the

instrument to produce a summary of the pre-final language (PL). A committee approach

(third independent individual the two translators who participated in Step 1, and

investigator plus one other member who is familiar with cultural and linguistic nuances)

was used to resolve ambiguities and discrepancies to derive the PL-TL version. The pre-final

version was back translated by two translators; one of whom is knowledgeable about health

terminology and the content area of the construct of the instrument in the SL and the other

translator being knowledgeable about the cultural and linguistic nuances of the SL as

recommended by (Sousa & Rojjanasrirat, 2011) to produce two versions of the back

translated version of the pre-final target language version 1 and 2 without having to see the

original SAQ tool in the source language.

The two back translated pre-final version was compared by a multidisciplinary committee

composed of the researcher, one methodologist, one of the translator in forward

translation and a member of the research team. The aim of this process was to compare

between the two back-translations (B-TL1 and B-TL2) of the instrument with the original SL

instrument in order to evaluate similarity of the instructions, items and response format

regarding wording, sentence structure, meaning and relevance. At this stage, minor

ambiguities and discrepancies in the response format, instructions and sentence structure




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were resolved without changing the meaning from the source language to produce the pre-

final translated version in Portuguese (PF summary) ready for testing as shown in appendix

2.

The pre-final version of the instrument in the target language was tested with 37

monolingual participants who were purposively drawn from graduate nursing students. It

is recommended (Sousa & Rojjanasrirat, 2011) that a sample size of 10–40 participants is

adequate for pilot testing of a translated tool, hence the 37 participants in this pilot test is

considered adequate. The goal of the pilot testing was to evaluate the instructions, items

and response format clarity. Participants were asked to respond by stating if the instructions

and items were “clear” or “not clear” as well as asking them for suggestions regarding those

instructions and items which were not clear to them (as shown in table in appendix 2).

Analysis of the pre-test: After applying the tool to 37 graduate nurses, we tested the results

with SPSS version 16 for reliability test. The result showed a scale reliability (Cronbach’s

alpha) value of .71 for all the 64 items in the scale and inter item correlation was considered

strong based on standard deviation that ranged from .000 to .463. Minor adjustments such

as spellings and instructions were made to produce the final tool shown in appendix 3c.

Data Management and Processing

The Questionnaires were read into data editor of SPSS software, producing a dataset / file

for analysis. The Likert-scale (1 = Disagree Strongly, 2 = Disagree Slightly, 3 = Neutral, 4 =

Agree Slightly, 5 = Agree Strongly) was used to score each of the 64 items. The 3 negatively

worded items (item12, item26 and item56) were reverse-scored so that their valence

harmonized with the positively-worded items in the same questionnaire (Sexton et al.

(2006).




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4.2 Data Analysis

Introduction: Every working area, especially in clinical areas, possesses a distinctive social

fabric, leading respondents who work within the same clinical area to respond more

similarly than respondents who are members of different clinical areas. As a result, Sexton

et al. (2006) advises that it is important to control for the non-independence of responses

gathered from the same clinical area via performing analyses that address the multilevel

nature of the data in order to obtain accurate model test statistics and scale reliability

estimates. Therefore, we run a model via multilevel exploratory factor analysis using SPSS

version 16 as well as generating demographic frequencies of the data.

4.3 Demographic information

In total, 103 critical care nurses were asked to participate in the study from three hospitals

in the Central region of Portugal; two public hospital (HA 45 nurses, HC 22 nurses) and one

public private partnership hospital (HB 37 nurses). Out of the 103 eligible nurses, 74

willingly participated in the study, resulting in a response rate of 72%. Of the 74 who

responded, 98.6% (73) completed the survey in its totality and were used for the data

analysis. Among the 73 nurses who fully completed the survey, 55 (74.3%) were female and

18 (24.3%) males. Regarding the job categories of the nurses, 68 (91.9%) are employed as

critical care nurses, 3 (4.1%) as chief nurse as well as 3 (4.1%) nurse managers (one in each

of the three hospital). Of the 74 nurses who responded, 28 (37.8%) are aged 25-34 years,

26 (35.1%) are 35-44 years old, 16 (21.6%) are 45-54 years of age, 2 (2.7%) are less than 25

years old and only one nurses is above the age of 55 years. Considering professional




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experience of the nurses of participated, 43 (58.9%) have 1-10 years’ experience, 23

(31.5%) have 11-20 years’ experience

Table 4.1 Descriptive Frequency of Professional experience within hospitals

PROFESSIONAL EXPERIENCE

Total Less than one year

1 - 10 years

11 - 20 years

Above 20 years

Hospital A (HA)

Count 1 18 17 0 36

% within hospital 2.8% 50.0% 47.2% 0.0% 100.0%

% within Professional Experience 16.7% 41.9% 73.9% 0.0% 49.3%

Hospital B (HB)

Count 5 15 3 0 23

% within hospital 21.7% 65.2% 13.0% 0.0% 100.0%


Hospital C (HC)

Count 0 10 3 1 14

% within hospital 0.0% 71.4% 21.4% 7.1% 100.0%


Count within professional Experience 6 43 23 1 73


Total 100.0% 100.0% 100.0% 100.0% 100.0%

Results in the table above shows that 43 (58.9%) of the nurses have 1-10 years professional

experience however considering individual hospitals, 17 (47.2%) of the 36 nurses in HA

have 11-20 years professional experience, 15 (65.2%) of the 23 nurses in HC have 1-10 years

of professional experience and there is only one nurse from HB with above 20 years of

professional experience.

Besides professional experience we also investigated years of experience of the nurses in

ICU and found that 48 (65.8%) of the nurses have worked in ICU for 1 -10 years, 11 (13.1%)

for less than one year while 14 (19.2%) of the nurses have worked for 11-20 years in the

three hospitals.

We also generated the experience of nurse managers/supervisors working in the three

hospital and the results indicate that 2 of the nurse supervisors have 1-10 years’ experience

in ICU supervising 48 (65.8%) nurses with 1-10 years of experience.




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4.4 Factor Analysis

Introduction: We refer to Factor Analysis as a method of grouping together variables which

have something in common which enables the researcher to take a set of variables and

reduce them to a smaller number of underlying factors (latent variables) which account for

as many variables as possible (Brown et al, 2006). Factor analysis concept was first

developed by Charles Spearman together with Raymound Cattel and Karl Peason in 1901.

The application of factor analysis concept emphasis that hidden concepts or construct

(unobservable) cause something to happen such attitudes, risk taking behaviours (Brown

et al, 2006).

Since such a study has never been done in Portugal’s clinical environment, it is fitting to run

an Exploratory Factor Analysis (EFA) instead of a Confirmatory Factor Analysis (Alappat et

al.) as recommended by (Alappat et al.). They assert that EFA determines apriori the factors

or components that form the variables under study. This means that CFA is more stringent

in testing a well-known set of factors against a hypothesized model of groupings and

relationships. It is worth noting that the Exploratory Factor Analysis (EFA) was used mainly

to explore previously unknown groupings of variables typical in Portugal’s ICU setting in

order to seek underlying patterns, clusters and groups (Spearman et al, 1901 and Brown,

2006).

4.5 Testing for Suitability of Factor Analysis

The suitability of factor analysis was tested using the Kaiser-Meyer-Olking (KMO) which

helps in assessing sampling adequacy and evaluates the correlations and partial

correlations to determine if the data are likely to amalgamate on components. Kaiser




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(1974) recommends accepting values greater than 0.5 as acceptable since values below this

should lead you to either collect more data or rethink which variables to include. The

Bartlett's test was also used to evaluate whether or not our correlation matrix is an identity

matrix and it tests the null hypothesis that the correlation matrix is an identity matrix. Our

results show that KMO of 0.6 (1dp) is sufficient since our Bartlett's test is 1538.77; df 741

which is statistically significant (p < .05) indicating that our correlation matrix (of items)

formed an identity matrix. We conclude that the variables under study are suitable for

factor analysis.

4.6 Testing for significance of variables under study

The proportion of each variable's variance that can be explained by the factors was

assessed and the results in appendix 6a Show that communalities Kaiser-Meyer-Olking

(KMO) extract ranged from .426 - .676 using the Principal component Analysis. Appendix

6b shows the sum of squared factor loadings for the variables or communalities of the final

study variables after those variables with an Extraction value (2nd column of Table 4.2 in

appendix 3d) less than 0.3 were eliminated. An item with an Extraction value less than 0.3

implies that the item is a poor fit in the specified model (Spearman et al 1901 and Brown

2006).

4.7 Factor Extraction from study variables

Extracting the factors or components required that the Eigen values associated with each

component or factor before extraction, after extraction and after rotation be obtained.

Using the SPSS software, and running the Exploratory Factor Analysis with 64 variables, 11

factors were identified whose Eigen values were greater than 1. After analysing the Scree




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Plot (Figure 4.0) however, results revealed that the slope of the plot starts to level after the

6th component which meant that 6-factor-model was plausible.

Figure 4.0 Scree Plot for Study Variables

The 6 factors when fitted, the Eigen values associated with each factor represent the

variance explained by that particular linear component and are shown in Table 4.3.

Table 4.3 Eigen Values for Component extraction

Total Variance Explained

Component Initial Eigenvalues Extraction Sums of Squared Loadings

Rotation Sums of Squared Loadings

Total % of Variance

Cumulative %

Total % of Variance

Cumulative %

Total % of Variance

Cumulative %

1 7.117 18.248 18.248 7.117 18.248 18.248 5.907 15.146 15.146

2 4.557 11.684 29.932 4.557 11.684 29.932 3.735 9.576 24.722

3 2.918 7.481 37.414 2.918 7.481 37.414 3.396 8.708 33.430

4 2.869 7.355 44.769 2.869 7.355 44.769 3.061 7.849 41.279

5 2.475 6.345 51.114 2.475 6.345 51.114 2.949 7.561 48.840

6 2.007 5.147 56.261 2.007 5.147 56.261 2.894 7.420 56.261

Extraction Method: Principal Component Analysis.

From Table 4.3, the Eigen values for the first 6 factors extracted explain 56.261% of total

variance after rotation. Results also show that these 6 factors extracted explain more than




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half of the total variance compared to the 33 remaining factors which explain the

remainder variance thus asserting the importance of these 6 factors extracted.

4.8 Factor Patterning with study variables

After the extraction of factors that are suitable for analysis, the study variables associated

with each factor had to be found. In this study, we chose to use the Rotated Component

Matrix produced by the SPSS software as shown in table 4.4b

Finally, the Rotated Component Matrix (Table 4.4b in appendix 3f) shows the factor

loadings for each variable. For each factor (column), the coloured (yellow) box corresponds

to those variables in that specific factor. These are the factors that each variable loaded

most strongly on. According to Sexton et al, (2006), a factor requires a minimum of three

items to form a component. Based on these factor loadings, we suggest these factors to

represent the following summary of domains as shown in the table 4.4c below. We named

these domains according to the items that formed the factors in the second column.




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Table 4.4c showing Component of factor structure Items in the component to form the factor structure. Name of the factor

(Domains)

Factor 1: {9, 10, 11, 15, 18, 21, 24, 28, 31, 42, 43, 53, 58}

9. The administration of this hospital is doing a good job

10. Hospital administration supports my daily efforts

11. I receive appropriate feedback about my performance.

15. This hospital is a good place to work

18. Hospital management does not knowingly compromise the safety of patients

21. This hospital encourages teamwork and cooperation among its personnel.

24. This hospital deals constructively with problem personnel

28. I am provided with adequate, timely information about events in the hospital that

might affect my work

31. I am proud to work at this hospital

42. Very high levels of workload stimulate and improve my performance

43. Truly professional personnel can leave personal problems behind when working

53. Interactions in this ICU are collegial, rather than hierarchical.

58. Information obtained through incident reports is used to make patient care safer in

this ICU

Perception of management

The items in this domain

consists of statements

that form part of

management roles.

Hence we named this

component as

corresponding to

management

perception.

Factor 2: {6, 23, 36, 45, 54, and 55}

6. This hospital does a good job of training new personnel.

23. The culture in this ICU makes it easy to learn from the errors of others

36. I have the support I need from other personnel to care for patients

45. Trainees in my discipline are adequately supervised

54. Important issues are well communicated at shift changes

55. There is widespread adherence to clinical guidelines and evidence-based criteria in

this ICU

Safety Climate

The items that form this domain

consists of statements

that consist of

Factor 3: {3, 4, 20, 32, 37, and 40}

3. Nurse input is well received in this ICU

4. I would feel safe being treated here as a patient

20. Decision-making in this ICU utilizes input from relevant personnel

32. Disagreements in this ICU are resolved appropriately (i.e., not who is right but what

is best for the patient).

37. It is easy for personnel in this ICU to ask questions when there is something that

they do not understand

40. The physicians and nurses here work together as a well-coordinated team

Teamwork Climate

Factor 4: {13, 17, 25, 27, 30, 33, and 38}

13. Briefings (e.g., patient report at shift change) are important for patient safety

17. All the personnel in my ICU take responsibility for patient safety

25. The medical equipment in this ICU is adequate

27. When my workload becomes excessive, my performance is impaired.

30. I know the proper channels to direct questions regarding patient safety in this ICU

33. I am less effective at work when fatigued

38. Disruptions in the continuity of care (e.g., shift changes, patient transfers, etc.) can

be detrimental to patient safety.

Job satisfaction

Factor 5: {34, 35, 49, and 50}

34. I am more likely to make errors in tense or hostile situations.

35. Stress from personal problems adversely affects my performance.

49. Fatigue impairs my performance during emergency situations (e.g. emergency resuscitation,

seizure).

50. Fatigue impairs my performance during routine care (e.g., medication review,

ventilator checks, transfer orders)

Stress recognition

Factor 6: {46, 48, and 51}

46. I know the first and last names of all the personnel I worked with during my last

shift

48. Staff physicians/intensivist in this ICU are doing a good job.

51. If necessary, I know how to report errors that happen in this ICU

Work condition




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4.9 Goodness-of-Fit of the Model

This study used the entire sample of all respondents in order to make the maximum

number from all areas (n = 74) available for parameter estimation at the clinical area level.

To evaluate the overall fit of each model to the data, we used the Chi-square test of model

fit which follows a procedure that tabulates a variable into categories and computes a chi-

square statistic (Maydeu-Olivares et al 2010).

The chi-square test is always testing the null hypothesis, which states that there is no

significant difference between the expected and observed result. This Null Hypothesis is

only rejected when the p value for the calculated is p < 0.05 and concludes that there is

significant difference between the expected and observed result.

This goodness-of-fit test compares the observed and expected frequencies in each category

to tests that all categories contain the same proportion of values or test that each category

contains a user-specified proportion of values. The findings revealed that all variables

included in the model were fitting in the model except item18 and item42 (appendix 3e).

We initially fit a 6-factor exploratory factor analysis model that contained the 64 items

retained in previous studies that explored the SAQ's construct validity (for instance Sexton,

2006). Items or variables with weak factor-item associations at the clinical area level or

individual level were then deleted sequentially via a backward elimination procedure until

satisfactory model fit was attained.




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4.10 Reliability of the Model

Once satisfactory model fit was obtained, we used the model results to compute composite

scale reliability using Alpha (Cronbach) which is a model of internal consistency, based on

the average inter-item correlation. We used the reliability analysis to study the properties

of measurement scales and the items that compose the scales.

It is worth noting that Raycov (1997) asserts that the Coefficient alpha; the usual statistic

used to estimate scale reliability, assumes that all items' factor loadings are identical, a

restrictive assumption that biases scale reliability estimates and provides Raykov's ñ

statistic as an alternative test statistic which relaxes this assumption hence yielding more

accurate reliability estimates. However, this study used Alpha (Cronbach) and not Raykov's

ñ statistic because the latter is not found in SPSS 16 version of the software that we used.

Accordingly, we report Alpha here below as the scale reliability estimate for the SAQ.

The value of Cronbach's alpha which is an estimate of the true alpha is reported in the

Reliability Statistics shows Cronbach’s Alpha value of 0.819 which in turn is a lower value

bound for the true reliability. These results indicate a strong reliability of the SAQ. Overall,

this finding, in conjunction with the multi-level factor analyses demonstrated that the SAQ

has very good psychometric properties.

4.11 Variability in the Study Model

More analysis was conducted using STATA-8.0 software. There was substantial variability

across the 5 ICU clinical areas at the item level for all hospitals. In total (Table 4.5a), for

instance, 59 percent of all respondents disagreed with an assertion that it is not difficult to




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speak up if they perceive a problem with patient care, but at the clinical area level, the

percent of respondents who disagree ranged from 56% (Table 4.5b) to 81% (Table 4.5c).

Table 4.5a Difficulty to speak up in case of a problem at all 3 hospitals

In this ICU it is NOT difficult to speak up if I perceive a problem with care

Freq. Percent Cum.

Disagree strongly 12 16.22 16.22

Disagree slightly 32 43.24 59.46

Neutral 5 6.76 66.22

Agree slightly 21 28.38 94.59

Agree strongly 3 4.05 98.65

no answer 1 1.35 100

Total 74 100

Table 4.5b Difficulty to speak up in case of a problem at Polyvalent clinical area

Freq. Percent Cum.

Disagree strongly 11 19.3 19.3


Neutral 4 7.02 63.16

Agree slightly 17 29.82 92.98

Agree strongly 3 5.26 98.25

no answer 1 1.75 100

Total 57 100

Table 4.5c Difficulty to speak up in case of a problem at Cardiology clinical area

Freq. Percent Cum.


Neutral 1 9.09 81.82

Agree slightly 2 18.18 100

Total 11 100

In other words, half respondents reported difficulty speaking up in some clinical areas,

while in other clinical areas, almost all the caregivers reported difficulty speaking up.

Variability in the Study Model




47 | P a g e

We also conducted analyses on mean scores for all 6 factors and converted the means into

percent agreement to facilitate understanding of the items and scales. The percentage of

all respondents reporting "agree slightly" or "agree strongly" for each of the items within a

given scale were charted as the percent positive as recommended by Sexton 2006 and he

percentage of all respondents reporting "disagree slightly" or "disagree strongly" for each

of the items within a given scale were charted as the percent negative as shown in the table

4.6.

Table 4.6 Factor Variability in all hospitals (N = 73)

Factors % Negative Neutral % Positive

Working condition 41.1% 18.2% 76.7%

Job satisfaction 2.7% 37.0% 60.3%

Teamwork climate 1.4% 47.9% 50.7%

Safety climate 1.4% 57.5% 41.1%

Stress recognition 17.8% 54.8% 27.4%

Management perception 9.6% 83.6% 6.8%

The researcher investigated the influence of the new-found factor structure by analyzing

some variables within those factors using a sample from all the hospitals.

Hospital ICU nursing staff were asked about their perception on management’s

commitment on safety and this factor received the least percent positive of 6.8% amongst

all factors (Table 4.6) an issue that tells much about the safety environment in the 3

hospitals. The results essentially indicate that management has not fulfilled its roles as far

as safety is concerned. Findings in reveal that 50.0% of hospital staffs in the ICU do not

receive an appropriate feedback about performance which most probably demotivates




48 | P a g e

them. In addition, majority (37.8%) of respondents disagreed with a statement that “This

hospital deals constructively with problems of personnel” and this is not to be taken lightly.

Hospital ICU staffs were asked about their perception of the safety climate within their

hospital ICUs and this factor received the least percent negative of 1.4% amongst all factors

(Table 4.6) which implies that they still have faith in the safety of patients at the three

hospitals.

Regarding adherence to clinical guideline, the results indicate that culture in this ICU makes

it easy to learn from errors of others as half of respondents (51.35%) supported it compared

to the minority who disagreed at 27.03% of all respondents. In addition, an overwhelming

majority (74.33%) of respondents agreed that there is widespread adherence to clinical

guidelines within their respective ICU and this is good news as far as patient safety is

concerned.

Hospital ICU staffs were asked about their teamwork environment within their places of

work and this factor received the least percent negative of 1.4% amongst all factors (Table

4.6) which implies that they work together harmoniously even when they show some

weaknesses emanating from management side.

Our results indicates that it is easy for personnel in ICU to ask questions as 71.62% of

respondents agreed and this is consistent with findings in about how easy it is to learn from

errors of others. Moreover, 67.56% of all interviewed hospital staffs agree that the

physicians and nurses work together as a coordinated team compared to 24.33% who




49 | P a g e

disagreed. The reason could be that decision making in these ICUs utilizes input from

relevant personnel as shown by the support of 70.27% of all respondents.

Job Satisfaction of ICU staffs within the three hospitals

Hospital ICU staffs were asked to respond about their job satisfaction since it is a vital

element that determines patient safety and this factor received the second highest percent

positive of 60.3% (Table 4.7) which implies that other than a few issues with management,

they are quite satisfied with their jobs which is good news.

Table 4.7 Feedback and the Quality of Collaboration with the Chief Nurse Chi-Square Tests

Value df Asymp. Sig. (2-sided)

Pearson Chi-Square 30.312a 16 .016

Likelihood Ratio 28.928 16 .024

Linear-by-Linear Association 7.297 1 .007

N of Valid Cases 73

a. 20 cells (80.0%) have expected count less than 5. The minimum expected count is .03.

The results indicate that the medical equipment in ICU is adequate as it is overwhelmingly

supported by respondents at 86.49% and this is a crucial ingredient of job satisfaction since

it makes nurses and physicians comfortable while doing their jobs. And as a result, almost

all (90.54%) of respondents concurred that all the personnel in ICU take responsibility for

patient safety. These findings are in agreement with the general picture of literature where

work equipment and staff remuneration are adequate.

Stress Recognition within the three hospitals

Hospital ICU staffs were asked to respond about their stress recognition elements since it

is a vigorous component that determines patient safety and this factor ranked highly on




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the negative side with a percent negative of 17.8% showing an idea of what this factor is

capable of among respondents performance regarding patient safety at work (Table 4.7).

The results indicate that fatigue impairs staff performance during emergency situation as

it is supported by majority (59.46%) of respondents and if not recognized, this negatively

affects patient safety chances. To know that fatigue is not only dangerous emergency

situations, 67.57% of all respondents agreed that fatigue impairs staff performance even

during routine care which puts an alarm on stress recognition among staff to improve

patient safety environment within these three hospitals

Associations of factors on patient safety within three hospitals

We also assessed feedback and the Quality of Collaboration with the Chief Nurse. With this

study aiming at analysing the influence the factors have on patient safety practices among

critical care nurses in three hospitals in Portugal, hospital staffs were asked to describe the

quality of collaboration and communication they experienced with the Chief Nurse. Results

show that majority of respondents 41.1% (30 out of 73) reported adequate quality of

collaboration and communication. This was supported by the joint respondents at 47.9%

of all respondents who recorded high and very high quality of collaboration and

communication with the Chief Nurse.

Table 4.7 Feedback and the Quality of Collaboration with the Chief Nurse Chi-Square Tests





N of Valid Cases 73




51 | P a g e

Chi-Square Tests





a. 20 cells (80.0%) have expected count less than 5. The minimum expected count is .03.

In order to analyze the links between staff perceptions about management and

communication, the study employed the Pearson Chi-Square test statistic from the cross-

tabulations of selected variables. Study findings in show that majority (56.2%) of those who

reported very high quality of collaboration/communication with the chief Nurse also

agreed that they receive appropriate feedback about their performance. While, this is good

news for management, majority (57.3%) of those who reported low quality of

collaboration/communication with the chief Nurse also claimed that they do not receive

appropriate feedback about their performance. All these associations were statistically

significant at 95% confidence level since the p-value was less than 0.05 (Table 4.5b).




52 | P a g e

Table 4.8 Feedback and the Quality of Collaboration with the Chief Nurse

Chief Nurse * I receive an appropriate feedback about my performance Cross tabulation

I receive an appropriate feedback about my performance

Total Disagree

strongly Disagree slightly Neutral

Agree slightly

Agree strongly

Chief Nurse

Low Count 4 2 0 1 0 7

% within Chief Nurse 57.1% 28.6% .0% 14.3% .0% 100.0%

% of Total 5.5% 2.7% .0% 1.4% .0% 9.6%

Adequate Count 3 11 8 8 0 30

% within Chief Nurse 10.0% 36.7% 26.7% 26.7% .0% 100.0%

% of Total 4.1% 15.1% 11.0% 11.0% .0% 41.1%

High Count 2 9 3 2 0 16

% within Chief Nurse 12.5% 56.2% 18.8% 12.5% .0% 100.0%

% of Total 2.7% 12.3% 4.1% 2.7% .0% 21.9%

Very high Count 3 3 1 10 2 19

% within Chief Nurse 15.8% 15.8% 5.3% 52.6% 10.5% 100.0%

% of Total 4.1% 4.1% 1.4% 13.7% 2.7% 26.0%

Not applicable

Count 0 0 0 1 0 1

% within Chief Nurse .0% .0% .0% 100.0% .0% 100.0%

% of Total .0% .0% .0% 1.4% .0% 1.4%

Total Count 12 25 12 22 2 73

% within Chief Nurse 16.4% 34.2% 16.4% 30.1% 2.7% 100.0%

% of Total 16.4% 34.2% 16.4% 30.1% 2.7% 100.0%

Fatigue and the Quality of Collaboration with the Intensive Care Nurse

With this study aiming at analyzing the influence the factors have on patient safety

practices among critical care nurses in three hospitals in Portugal, hospital staffs were

asked to describe the quality of collaboration and communication they experienced with

the Intensive Care Nurse. We found that majority of respondents 27.4% reported adequate

quality of collaboration and communication. This was supported by the joint respondents

at 37.0% who recorded high and very high quality of collaboration and communication with

the Chief Nurse.




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In this study, we gave an open ended questions and asked the respondents for their top three

recommendations regarding how to improve patient safety at their ICU. Among the 74 participants,

17 (23%) participants gave 50 recommendations. Majority of the recommendations were given by

nurses from HB1. The contents of the recommendations were deductively analysed and five major

themes identified as teamwork climate (33%), human resource improvement (21%), working

environment (19%), safety climate (17%) and training/competence strengthening (10%) as

illustrated in figure 2 below.

Figure 2. Recommendations for improving patient safety culture

21%19%

17%

33%

10%

0%

5%

10%

15%

20%

25%

30%

35%

Human Resource Work Environment Safety Climate Teamwork Climate Competence and

Training

Per

ceta

ga

e o

f R

esp

on

ses

(%)

Recommendations

R e c o m m e n d a t i o n s f o r i m p r o v i n g p a t i e n t s a f e t y c u l t u r e

( n = 1 7 )




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5.0 Discussion

Introduction: In this section, the results of the study are explained focussing on the relevant

results from the data obtained in comparison to previous study. We also describe how the

findings fit the existing theories and other research in the field of patient safety culture. We

discussed the result based on the objective of the study and comparing with the available

literature.

5.1 Translation and adaptation of the SAQ ICU version to Portuguese

language

We performed translation and adaptation of SAQ tool into Portuguese language using

forward and backward translation process as recommended by Sousa and Rojjanasrirat,

2011. This method was chosen because of its simple structure and easy approach. The

translation and adaptation process was relatively easy because we were able to get

multilingual individuals to forward translate the tool into Portuguese language besides

having difficulty in getting the required number of bilingual participants for testing the tool

(Sousa and Rojjanasrirat (2011). This problem was overcome by using a committee

approach for comparing the two back-translated versions of the instrument (B-TL1 and B-

TL2) as an alternative method to produce the final tool.

The strength of this study is in two folds; 1). The study sample is representative for the

translation and adaptation process of the tool in which we tested the pre-final tool with 37

participants. This is considered representative because Rojjanasrirat 2011 recommends a

sample of 10-40 participants to be representative for pretesting. The test sample showed

strong reliability (Cronbach’s alpha of .71) for 44 items out of the 64 items on the original




55 | P a g e

tool. 2). In the application of the final translated tool to the study sample to nurses working

at ICU in three hospitals, 72% of the nurses responded and 98.6% answered the

questionnaire to completion.

To our knowledge, this is the first study that has translated and adopted the SAQ ICU version

in a sample of Portugal’s critical care unit targeting nurses only in three different hospitals.

The high response rate in this study is believed to reflect the typical view of nurses in critical

care unit hence reflecting the safety climate at the three ICUs.

In general the SAQ ICU version is psychometrically sound in assessing the six safety related

climate domains. In this study the Cronbach’s alpha of .71 at pre-test and .819 during final

application of the translated tool are considered strong because the bench mark values of

Cronbach alpha ranging from .68 to .90 whereas the alpha value for each domains are also

deemed acceptable.

5.2 Factor analysis

Factor analysis concept was first developed by Charles Spearman together with Raymound

Cattel and Karl Peason in 1901. We performed factor analysis by grouping together variables

which have something in common in order to find out if we can obtain the original 6

domains as identified by Sexton 2006. This enabled the researcher to take a set of variables

and reduce them to a smaller number of underlying factors (latent variables) which account

for as many variables as possible. We found that our data set amalgamated on components

(Kaiser 1974) to form an identity matrix with KMO because the sample was adequate on

performing Bartlett’s test.




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Out factor extraction yielded 6 component (domains) with the Eigen values for the first 6

factors extracted explaining 56.3% of total variance in our study. These 6 factors extracted

explain more than half of the total variance compared to the 33 remaining factors explaining

the remainder variance. The variables loaded strongly on six factors namely management

perception (15.146%) as the strongest factor, safety climate (9.576%), teamwork climate

(8.708%), job satisfaction (7.849%), stress recognition (7.561%) and working condition

(7.420%). We noted that there is variability in the items that form the factors in this study.

We attribute the difference to four possibilities; first of all, there sample in this study

targeted nurses only unlike in other studies which involved all health care professionals such

as doctors, anaesthetist, administrators, physicians hence the difference especially the

items that loaded for management perception. Secondly we believe that our sample size

was also small as compared studies by Sexton in 2006 in which they used over 2000

participants. Thirdly, we believe that demographic characteristics of the participants could

have influenced the outcome of the domains. Fourthly, to our knowledge, using a

confirmatory factor analysis to determine the components of the items gave the freedom

to match the items randomly hence confirming that there is a difference in the perception

of the nurses working a typical Portuguese ICU compared to those studies in other countries

(Bondevik et al., 2014; Chaboyer et al., 2013; Devriendt et al., 2012; Etchegaray & Thomas,

2012; France et al., 2010; Göras et al., 2013; Hamdan, 2013; Hoffmann et al., 2011; Kaya et

al., 2010; Profit et al., 2012) . Lastly, since we performed cultural translation and validation

for Portuguese population, this could have contributed to the variation.




57 | P a g e

We established that there is variability in the perception of the patient safety culture in

typical ICU in Portugal. The nurses in the three ICUs perceive management as the strongest

domain that influences patient safety in their ICU because the nurses believe that the

hospital supports their daily effort especially management providing adequate and timely

information about events in the hospital that might affect their work. Despite the fact that

management perception received the least percent positive, the nurses strongly feel proud

to work at this hospital because the administration is doing a good job by providing

appropriate feedback on nurse’s performance and dealing constructively with problems

(Aagja & Garg, 2010; Allen, Chiarella, & Homer, 2010; Armellino et al., 2010; Bondevik et

al., 2014)

5.3 Factor variability

When individual attitudes are aggregated by clinical area, the SAQ provides a snapshot of

the climate in a given clinical area. Sexton et al (2006) in his study asserts that one attitude

is an opinion, but the aggregate attitudes of everyone in a clinical area is climate hence

indicating the culture in that clinical area. In the whole environment (sample), study results

show that working conditions is the most influential factor with a percent positive of 76.7%

followed by job satisfaction with 60.3%. We attribute this high percentage positive of

working condition to efforts by the administration to ensure they have adequate

equipment, safe clinical environment, rigorous review of policy and regular clinical audit

since the two public private partnership hospitals are accredited to international quality

standards (Raftopoulos, 2013).




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The working condition were considered favorable due positive factors such as teamwork

(50.7%) however the negative factors such as stress recognition, safety climate and

management perception are considered by the nurses as hindering effort to provide safe

patient care because they have negative percentage. Teamwork climate (50.7%) is

considered average in this study because the nurses report adequate to high level of

collaboration and communication with manager and physicians. Other studies reported

similar variations in their findings (AbuAlRub, Gharaibeh, & Bashayreh, 2012).

Management perception of respondents received the least percent positive (6.8%), an

issue that should be analyzed further to know the causes even though respondents seemed

to have some job satisfaction levels. Even though the management perception received the

least percent positive, stress recognition was ranked highly on the negative side with a

percent negative of 17.8% showing an idea of what this factor is capable of among

respondents performance at work. This results concurs with literature that ICU

environment is often stressful due to the critical nature of the patient that requires close

attention and monitoring (Alkire, 2005; Chung & Chung, 2009; France et al., 2010; Goetz,

Beutel, Mueller, Trierweiler-Hauke, & Mahler, 2012; Göras et al., 2013; Sexton et al., 2000)

Job satisfaction relates to that influence staff morale, feeling empowered with important

information about patient safety, fellow staff taking responsibility for patient safety, having

adequate equipment to work with at ICU, being able work effectively even if the work load

is high and acknowledge being less effective when fatigued.




59 | P a g e

The study results essentially indicate that management has not fulfilled its roles as far as

safety is concerned. We found that 50.0% of hospital staffs in the ICU do not receive an

appropriate feedback about performance which most probably demotivates them. In

addition, majority (37.8%) of respondents disagreed with a statement that “This hospital

deals constructively with problems of personnel”; this should not to be taken lightly and

needs to be investigated further since similar findings in Australia were predictive of defects

in safety of patients (Allen, Chiarella, & Homer, 2010).

Safety Environment within the three hospitals ICU has been perceived to be least percent

negative of 1.4% amongst all factors (Table 4.7) which implies that they still have faith in

the safety of patients at the three hospitals. The nurses also concur that culture in this ICU

makes it easy to learn from errors of others as half of respondents (51.35%) supported it

compared to the minority who disagreed at 27.03% of all respondents. In addition, an

overwhelming majority (74.33%) of respondents agreed that there is widespread

adherence to clinical guidelines and EB criteria within their respective ICU and this is good

news as far as patient safety is concerned.

Teamwork Environment within the three hospitals also received the least percent negative

of 1.4% amongst all factors which implies that nurse work harmoniously even when they

show some weaknesses emanating from management side. Studies show that strong

teamwork strengthens the weak points within the work environment because the staff

tends to support each other (AbuAlRub et al., 2012; Anderson, Thorpe, Heney, & Petersen,

2009; Bell & Pontin, 2010; Chaboyer et al., 2013). This is further supported by the fact it is

easy for personnel in ICU to ask questions as 71.62% of respondents agreed, consistent




60 | P a g e

with findings that it is easy to learn from errors of others. Moreover, 67.56% of all

interviewed hospital staffs agree that the physicians and nurses work together as a

coordinated team compared to 24.33% who disagreed. The reason could be that decision

making in these ICUs utilizes input from relevant personnel as shown by the support of

70.27% of all respondents.

Job Satisfaction of ICU staffs within hospitals is a vital element that that has an impact on

patient safety (Wicks, Lynda St, & Kinney, 2007) and this factor received the second highest

percent positive of 60.3%. This implies that other than a few issues with management, the

nurses are quite satisfied with their jobs which is good news. Factors such resources to use

at work place have been known to influence job satisfaction. We found that medical

equipment in ICU is adequate as it is overwhelmingly supported by respondents at 86.49%

and this is a crucial ingredient of job satisfaction since it makes nurses and physicians

comfortable while doing their jobs especially at ICU which depends on high technology for

providing all round care the ill patients. And as a result, almost all (90.54%) of respondents

concurred that all the personnel in ICU take responsibility for patient safety. These findings

are in agreement with the general picture of literature where work equipment and staff

remuneration are adequate. Literature has shown that availability of resources,

management style, remuneration and team collaboration enhances job satisfaction

(AbuAlRub et al., 2012; Anderson et al., 2009).

Stress Recognition within the three hospitals is a strong component that determines

patient safety and this factor ranked highly on the negative side with a percent negative

regarding patient safety at work. This figure is supported by nurses who agreed that fatigue




61 | P a g e

impairs staff performance during emergency situation as it is supported by majority

(59.46%) of respondents and if not recognized, this negatively affects patient safety

chances. To know that fatigue is not only dangerous in emergency situations, 67.57% of all

respondents agreed that fatigue impairs staff performance even during routine care which

puts an alarm on stress recognition among staff to improve patient safety environment

within these three hospitals (Allen et al., 2010; Huang et al., 2007; Kaya et al., 2010; Profit

et al., 2012; Weaver, Wang, Fairbanks, & Patterson, 2012).

With this study aiming at analysing the influence of these factors on patient safety practices

at the three hospitals in Portugal, the nurses were asked to describe the quality of

collaboration and communication experienced with the Chief Nurse. Results show that

majority of respondents 41.1% (30 out of 74) reported adequate quality of collaboration

and communication. This was supported by the joint respondents at 47.9% of all

respondents who recorded high and very high quality of collaboration and communication

with the Chief Nurse. We know that communication and collaboration are the key elements

of teamwork but we cannot be sure why management perception received the least overall

percentage positive (6.8%) among all the factors hence requiring further investigation.

In order to analyze the links between staff perceptions about management and

communication, the study employed the Pearson Chi-Square test statistic from the cross-

tabulations of selected variables. Study findings show that majority (56.2%) of those who

reported very high quality of collaboration/communication with the chief Nurse also

agreed that they receive appropriate feedback about their performance. While, this is good

news for management, majority (57.3%) of those who reported low quality of




62 | P a g e

collaboration/communication with the chief Nurse also claimed that they do not receive

appropriate feedback about their performance. All these associations were statistically

significant at 95% confidence level since the p-value was less than 0.05. We strongly believe

that the nurse manager is unable to find opportunity to communicate to all the staff in the

department. However, the fatigue and the Quality of Collaboration with the Intensive Care

Nurse was rated at 27.4% reporting adequate quality of collaboration and communication.

This was also supported by the joint respondents at 37.0% of all respondents who recorded

high and very high quality of collaboration and communication.

Based on our understanding of the factor structure obtained in this study, we recommend

a model to further understand how patient safety culture in ICU can be modeled. To our

knowledge, many researchers have taken studies on this subject with serious interest and

we would like to contribute by suggestion a simple model which we call “Patient Safety

Torch” as illustrated below for conceptualizing patient safety:




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5.4 Conceptual Framework Patient safety is influenced by different factors including both individual and organizational factors.

All the influencing factors are dependent on each other. For instance, deficit in one of the domain

will subsequently have an influence another domain such as if the management does not support

the staff in their effort to address errors effectively, it leads to unsafe practices where as if

management handles errors appropriately and use it as a learning opportunity, the next time such

an error will be prevent or managed appropriately.

Figure 3: Proposed “THE PATIENT SAFETY TORCH MODEL”

A torch typically consists of a power source (battery); in this case “patient”, the body

(individual staff), the bulb (the patient safety), reflector (five domains) and the glass

filter/switch (management).

In this proposed model, management is considered as a filter responsible for ensuring that

conditions necessary for patient safety are identified. These condition are the factors that

are unique to each department or unit within ICU. Such factors may include teamwork

climate, stress recognition, working conditions and safety climate or even others. The

Patient

safety

culture

INDIVIDUAL characteristics Age, Gender, job category, Years / Experience / service, Duty shift, Type of job

Teamwork

Climate

Job satisfaction

Stress recognition

Perception of management: The unit manager as an

implementer of organizational Policy, is perceived as being

the most important person to ensure implementation by

switching on the light for patient safety in the unit.

Safety Climate

Work conditions




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influence of these factors depend on the individual characteristics such as age, gender, level

of experience and professional expertise. How each staff responds to the factors depends

largely on how the management implements the mission, vison and core values of the

organisation. We refer to this model as the “patient safety torch model” where the

manager is the torch holder and switches the torch to light up patient safety in the unit or

department.

5.5 Significance of study

The study may be significant directly or indirectly to the clinical nursing practice, hospital

policy, nursing education, and patient’s family and critical care nurses in the three hospitals

in Portugal. The findings may have the potential to contribute positively in the following

areas:

Significance to clinical nursing practice: The findings may generate new understanding of

how ICU nurses perceive their patient safety practices in the three hospitals in Portugal. The

findings of the study in the areas of error reporting, teamwork, work environment and

communication, recommendations for improvement and job satisfaction could be used for

improving patient safety strategies, especially enhancing efforts to provide safe ICU care in

the three hospitals. As Hughes (2008) claims if an organization’s culture is based on secrecy,

defensive behaviours, professional protectionism, and inappropriate deference to

authority, the culture invites threats to patient safety and poor-quality care.




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Significance to health policy: The research may contribute towards development of nursing

policies and protocols towards patient safety practices in ICU in the three hospitals in

Portugal. The finding may be used as pilot results for policy initiatives.

Significance to nursing education: The views of the respondents in this study may provide

a basis for redesigning strategies of how to provide safe care at ICU. It may also provide a

baseline survey for further studies on large scale in Portugal. The translation of the SAQ ICU

version into English may provide an initial opportunity for Portuguese nurses to use the tool

for educational purpose in future and for monitoring the safety culture practices in ICU in

Portugal. Those interested in the subject may want to understand patient safety using or

proposed concept.

Significance to the public: The study identified factors that influence patient safety culture

among critical care nurses hence suggest recommendation for improving safety practices in

ICU. The deeper understanding of culture of patient safety in the ICUs of the three hospitals

unlocks opportunities for the management to make improvement in the six domains of

attitudes toward patient safety such as teamwork climate, job satisfaction, and perception

of management, safety climate, working conditions, and stress recognition (Thomas et al,

2003). Any effort to improve patient safety as a result of the findings of this study will

directly and indirectly benefit the public through receiving safe care from intensive care

units.

Significance to nursing research: The findings of this study may have the potential to

contribute additional information regarding the culture of patient safety in ICU. Such a study




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may have the potential to generate new inquiry into the area of safety culture in ICU. We

believe that the findings may motivate other researchers to pick interest on patient safety

culture in Portugal and other parts of the world.




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6.0 Conclusions

The SAQ ICU version is psychometrically valid in Portuguese culture and can be used to

measure patient safety culture. Understanding patient safety requires an approach where

management at all levels needs to engage with frontline workers in other to instil the values

of the organization in promoting safe care. We names the new tool as SAQ Version for ICU

Nurses (QUESTIONÁRIO DE ATITUDES DE SEGURANÇA PARA ENFERMEIRAS EM UCI).

There is significant similarities in the factors or domains that influence patient safety in a

typical Portuguese intensive care unit and further studies are recommended in the area of

patient safety culture using the validated SAQ Portuguese version.




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7.0 Reference

Aagja, J. P., & Garg, R. (2010). Measuring perceived service quality for public hospitals (PubHosQual) in the Indian context. International Journal of Pharmaceutical and Healthcare Marketing, 4(1), 60-83. doi: http://dx.doi.org/10.1108/17506121011036033

Abstoss, K. M., Shaw, B. E., Owens, T. A., Juno, J. L., Commiskey, E. L., & Niedner, M. F. (2011). Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit. BMJ Quality & Safety, 20(11), 914-922.

AbuAlRub, R. F., Gharaibeh, H. F., & Bashayreh, A. E. I. (2012). The Relationships Between Safety Climate, Teamwork, and Intent to Stay at Work Among Jordanian Hospital Nurses. Nursing Forum, 47(1), 65-75. doi: 10.1111/j.1744-6198.2011.00253.x

Alappat, C., Siu, G., Penfold, A., McGovern, B., McFarland, J., Raman, S., & Landry, M. D. (2007). Role of Canadian physical therapists in global health initiatives: SWOT analysis. Physiotherapy Canada, 59(4), 272-285.

Albert, N. M., Slifcak, E., Roach, J. D., Bena, J. F., Horvath, G., Wilson, S., . . . Murray, T. (2014). INFECTION RATES IN INTENSIVE CARE UNITS BY ELECTROCARDIOGRAPHIC LEAD WIRE TYPE: DISPOSABLE VS REUSABLE. American Journal of Critical Care, 23(6), 460-468. doi: 10.4037/ajcc2014362

Alkire, S. (2005). Subjective Quantitative Studies of Human Agency. Social Indicators Research, 74(1), 217-260. doi: http://dx.doi.org/10.1007/s11205-005-6525-0

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Appendix A: Activity plan

ACTIVITIES JULY 2014

SEPTEMBER 2014 OCTOBER 2014

NOVEMBER 2014

DECEMBER 2014 JANUARY 2014 FEBRUARY 2015

WEEKS

4 weeks

1 a

2 a

3 a

4 a

1 a

2 a

3 a

4 a

1 a

2 a

3 a

4 a

1 a

2 a

3 a

4 a

1 a

2 a

3 a

4 a

1 a

2 a

3 a

4 a

Topic approval

Bibliographic revision

Authorisation

Data gathering

Data treatment

Report writing

Report delivery

Thesis defence




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Appendix B: Authorization letter for data collection for clarity test.




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Appendix C. Permission letter from Hospital 2 (H2)

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Appendix D: Permission letter from Hospital 3 (H3)

Aprovação - Percepção da Cultura de Segurança do Doente entre Enfermeiros em

Unidades de Cuidados Intensivos

Inbox x

11/20/14

To: [email protected],

Boa tarde, Serve o presente para informar que o estudo abaixo identificado foi aprovado, em sede de comissão executiva, no dia de ontem 19.11.2014.

“Estudo descritivo (já apreciado pela CES em sentido favorável) de recolha de dados

para dissertação, com base em questionários auto-administrados, intitulado:

“Percepção da Cultura de Segurança do Doente entre Enfermeiros em Unidades de

Cuidados Intensivos” no âmbito do Curso de Master Mundus em Enfermagem de

Emergência e Cuidados Críticos (EMMECC), na Escola Superior de Saúde de Santarém,

tendo como investigador principal Cliff Asher Aliga”. MC, Direcção Jurídica

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Appendix E: Permission letter from Hospital 1 (H1)

Enviada: 21 de outubro de 2014 10:02

Para: José Amendoeira - ESSaude

Assunto: RE: Solicitação para colheita de dados

Bom Dia,

Em resposta ao solicitado, somos a informar que se encontra autorizado.

Com os melhores cumprimentos.

Secretariado do Conselho de Administração

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Appendix F. Permission letter from author of SAQ.

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Appendix G: The Original SAQ ICU Version 2004

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Appendix 1: Summary Forward & back translation to target

language (TL1 & TL 2) Portuguese

ORIGINAL SAQ VERSION

FORWARD TRANSLATION TL1

FORWARD TRANSLATION TL2

Summary of Blind back translation

Safety Attitudes Questionnaire (ICU Version)

Questionário De Atitudes De Segurança (Versão De UCI)

Questionário de Atitudes de Segurança (Versão UCI: Unidade de Cuidados Intensivos)

Safety Attitudes Questionnaire (ICU Version: Intensive care unit)

A = Disagree strongly B = Disagree slightly C = Neutral D = Agree slightly E = Agree strongly

A = Discordo Totalmente B = Discordo Parcialmente C = Não concordo nem discordo D = Concordo Parcialmente. E = Concordo Totalmente

A = Concordo Plenamente B = Discordo Ligeiramente C = Sem Opinião D = Concordo Ligeiramente E = Concordo Plenamente

A= agree totally B= Agree slightly C= No opinion D=Agree slightly E= agree totally

Please answer the following questions with respect to your specific ICU. Mark your response using the scale above.

Por favor, responda às seguintes perguntas relativamente à Unidade de Cuidados Intensivos (UCI) onde trabalha. Selecione a sua resposta utilizando a escala acima apresentada.

Por favor, responda às seguintes perguntas relativamente à sua UCI (Unidade de Cuidados Intensivos). Selecione a sua resposta utilizando a escala acima apresentada.

Please answer the questions about your ICU (Intensive Care Unit) Select your answer using the scale show above

1. High levels of workload are common in this ICU

1. Esta UCI tem níveis de trabalho elevados.

1. Cargas horárias elevadas são comuns nesta UCI.

1. Many working hours are common in this ICU

2. I like my job. 2. Gosto do meu trabalho

2. Gosto do meu trabalho

2. I enjoy my work

3. Nurse input is well received in this ICU.

3. As indicações por parte das Enfermeiras sobre os cuidados ao doente são bem recebidas nesta UCI.

3. O contributo dos enfermeiros é bem recebido nesta UCI

3. The contribution of nurses is welcome at this ICU

4. I would feel safe being treated here as a patient

4. Sentir-me-ia seguro se fosse um doente aqui.

4. Eu sentir-me-ia seguro(a) como doente nesta UCI.

4. I will feel secure as patient in this ICU

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5. Medical errors* are handled appropriately in this ICU. *Medical error is defined as any mistake in the delivery of care, by any healthcare professional regardless of outcome.

5. Os erros clínicos* são resolvidos de forma adequada nesta UCI.

*Erro Clínico é definido como qualquer erro que ocorre no processo de prestação de cuidados, por qualquer profissional de saúde, independentemente do resultado.

5. Erros médicos* são encarados apropriadamente nesta UCI.

*O erro médico é definido como qualquer erro na prestação de cuidado, por qualquer profissional de saúde, independentemente do seu resultado.

5. Medical errors* are seen appropriately in this ICU

*Medical error is defined as any error in care giving, by any health professional, regardless of its outcome.

6. This hospital does a good job of training new personnel.

6. Este hospital faz um bom trabalho na formação de novos profissionais.

6. Este hospital forma bons profissionais de saúde.

6. This hospital forms good health professionals

7. All the necessary information for diagnostic and therapeutic decisions is routinely available to me.

7. Toda a informação necessária tanto para o diagnóstico como para decisões terapêuticas está disponível.

7. Toda a informação necessária para decisões de diagnóstico ou terapêuticas está disponível. Faz parte da rotina ter acesso a toda a informação necessária para decisão diagnóstica ou terapêutica.

7. Any information necessary for diagnostic or therapeutic decisions are available. It is part of the routine to have access to all information necessary for diagnostic or therapeutic decision.

8. Working in this hospital is like being part of a large family

8. Trabalhar neste hospital é como fazer parte de uma grande família.

8. Trabalhar neste hospital é como fazer parte de uma grande família.

8. Working in this hospital is like being part of a big family.

9. The administration of this hospital is doing a good job.

9. A administração deste hospital está a fazer um bom trabalho.

9. A administração deste hospital está a fazer um bom trabalho.

9. The administration of this hospital is doing a good job

10. Hospital administration

10. A administração do hospital apoia

10. A administração do hospital apoia o meu esforço diário.

10. The hospital administration supports

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supports my daily efforts

os meus esforços diários.

my daily efforts.

11. I receive appropriate feedback about my performance.

11. Recebo o feedback apropriado sobre o meu desempenho.

11. Eu recebo feedback apropriado acerca do trabalho que realizo.

11. I receive appropriate feedback about the work I do.

12. In this ICU, it is difficult to discuss errors.

12. Nesta UCI, é difícil discutir erros clínicos.

12. Nesta UCI, é difícil discutir erros.

12. In this ICU, it is difficult to discuss errors.

13. Briefings (e.g., patient report at shift change) are important for patient safety

13. As reuniões de equipa ou breefings (por ex. partilha de informação sobre o doente nas mudanças de turno) são importantes para a segurança dos doentes.

13. Breves informações/ instruções (ex. apontamento sobre doente na mudança de turno) são importantes para a segurança dos doentes.

13. Brief information / instructions (eg. notes about the patient in the shift change) are important for patient safety

14. Thorough briefings are common in this ICU.

14. Os breefings pormenorizados são frequentes nesta UCI.

14. Informações/ Instruções detalhadas são comuns nesta UCI.

14. Information / Detailed instructions are common in this ICU

15. This hospital is a good place to work

15. Este hospital é um bom local para trabalhar.

15. Este hospital é um bom local de trabalho.

15. This hospital is a good place to work.

16. When I am interrupted, my patients’ safety is not affected.

16. Quando sou interrompido, a segurança do doente não fica afetada.

16. Quando sou interrompido(a) a segurança dos meus doentes não é afetada.

16. When I am stopped the safety of my patients is not affected

17. All the personnel in my ICU take responsibility for patient safety

17. Todos os trabalhadores nesta UCI assumem responsabilidade pela segurança do doente.

17. Todos os funcionários na minha UCI são responsáveis pela segurança dos doentes

17. All staff in my ICU are responsible for patient safety

18. Hospital management does not knowingly compromise the safety of patients

18. A administração do hospital não compromete conscientemente a

18. A administração do hospital não compromete a segurança dos doentes.

18. The hospital administration does not compromise

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segurança dos doentes.

patient safety

19. The levels of staffing in this ICU are sufficient to handle the number of patients

19. O pessoal nesta UCI é suficiente para o número de doentes.

19. O número de funcionários nesta UCI é suficiente para assegurar o número de doentes.

19. The number of staff in this ICU is sufficient for the number of patients.

20. Decision-making in this ICU utilizes input from relevant personnel

20. As tomadas de decisão nesta UCI baseiam-se em indicações de profissionais relevantes nesse domínio.

20. A tomada de decisão nesta UCI faz uso do contributo relevante dos seus funcionários.

20. Decision making in this UCI makes use of the important contribution of its employees

21. This hospital encourages teamwork and cooperation among its personnel.

21. Este hospital promove o trabalho em equipa e a cooperação entre os seus trabalhadores.

21. Este hospital incentiva o trabalho de equipa e cooperação entre os seus funcionários.

21. This hospital encourages teamwork and cooperation among its employees.

22. I am encouraged by my colleagues to report any patient safety concerns I may have.

22. Sou encorajado pelos colegas a apresentar qualquer preocupação que tenha relacionada com a segurança dos doentes.

22. Sou incentivado(a) pelos meus colegas a dar a conhecer quaisquer preocupações que eu possa ter relativamente à segurança dos doentes.

22. I am encouraged by my colleagues to provide information about any concerns I may have regarding patient safety.

23. The culture in this ICU makes it easy to learn from the errors of others

23. A cultura nesta UCI facilita a aprendizagem através dos erros dos outros.

23. A política nesta UCI facilita a aprendizagem através dos erros dos outros.

23. The policy of this ICU facilitates learning from mistakes.

24. This hospital deals constructively with problem personnel.

24. Este hospital lida construtivamente com profissionais de saúde e funcionários problemáticos.

24. Este hospital lida de forma construtiva com problemas de funcionários.

24. This hospital deals constructively with employee problems.

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25. The medical equipment in this ICU is adequate

25. O equipamento médico disponível nesta UCI é adequado.

25. O equipamento médico nesta UCI é adequado.

25. The medical equipment in this ICU is appropriate.

26. In this ICU, it is difficult to speak up if I perceive a problem with patient care

26. Nesta UCI é difícil falar se me apercebo de um problema relacionado com os cuidados ao doente.

26. Nesta UCI, é difícil expor algum problema que surja relativamente aos cuidados dos doentes.

26. In this ICU, it is difficult to expose a problem that arises in relation to the care of patients.

27. When my workload becomes excessive, my performance is impaired.

27. Quando a carga de trabalho se torna excessiva, o meu desempenho profissional é afetado.

27. Quando o volume de trabalho é excessivo, a minha prestação é prejudicada/inadequada.

27. When the workload is excessive, my performance is impaired / inadequate

28. I am provided with adequate, timely information about events in the hospital that might affect my work.

28. Recebo adequada e atempadamente informação sobre eventos no hospital que podem afetar o meu trabalho.

28. É-me providenciada, atempadamente, informação sobre situações no hospital que possam afetar o meu trabalho.

28. It provided me with timely, information on conditions in the hospital that may affect my work

29. I have seen others make errors that had the potential to harm patients.

29. Já vi cometerem-se erros com potencial de causar danos nos doentes.

29. Tenho presenciado outras pessoas cometerem erros que colocaram em causa a segurança dos doentes.

29. I have seen other people make mistakes that questioned the safety of patients

30. I know the proper channels to direct questions regarding patient safety in this ICU

30. Sei quais são os canais apropriados para dirigir questões relacionadas com a segurança dos doentes nesta UCI.

30. Eu tenho conhecimento dos meios adequados para colocar questões referentes à segurança dos doentes nesta UCI.

30. I am aware of the appropriate steps to questions concerning the safety of patients in this ICU

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31. I am proud to work at this hospital.

31. Sinto orgulho em trabalhar neste hospital.

31. Tenho orgulho de trabalhar neste hospital.

31. I am proud to work in this hospital

32. Disagreements in this ICU are resolved appropriately (i.e., not who is right but what is best for the patient).

32. Desacordos nesta UCI são resolvidos adequadamente (por ex. não quem está certo, mas o que é melhor para o doente).

32. As divergências nesta UCI são resolvidas apropriadamente (i.e. não quem tem razão, mas sim o que é o melhor para o doente).

32. The differences in this ICU are resolved properly (i.e. not who is right, but what is best for the patient).

33. I am less effective at work when fatigued

33. Sou menos eficiente quando estou fatigado.

33. Sou menos eficaz no trabalho quando estou cansado(a).

33. I am less effective at work when I'm tired

34. I am more likely to make errors in tense or hostile situations.

34. Sou mais propenso a cometer erros em situações tensas ou hostis.

34. É mais provável cometer erros em situações tensas ou hostis.

34. It is more likely to make mistakes in tense or hostile situations

35. Stress from personal problems adversely affects my performance.

35. O stress relacionado com problemas pessoais afeta negativamente o meu desempenho.

35. O stress, fruto de problemas pessoais, afeta o meu desempenho.

35. The stress, the result of personal problems affect my performance.

36. I have the support I need from other personnel to care for patients

36. Tenho o apoio necessário de outros colegas nos cuidados aos doentes.

36. Tenho o apoio que necessito de outros funcionários para cuidar dos doentes.

36. I have the support I need from other staff to care for the sick.

37. It is easy for personnel in this ICU to ask questions when there is something that they do not understand.

37. É fácil, para os profissionais desta UCI, colocar questões quando existe algo que não compreendem.

37. É fácil para os funcionários desta UCI colocar questões quando lhes surge alguma dúvida.

37. It is easy for employees of this UCI questions when they arise any questions.

38. Disruptions in the continuity of care (e.g., shift changes, patient transfers,

38. Interrupções na continuidade de cuidados (por ex. mudanças de

38. As interrupções durante a continuidade dos cuidados (ex.

38. Interruptions for continuity of care (e.g.

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etc.) can be detrimental to patient safety.

turno, transferência de doentes) podem prejudicar a segurança do doente.

mudanças de turno, transferência de doentes, etc.) podem por em causa a segurança do doente.

Shift changes, transfer of patients, etc.) can jeopardize patient safety.

39. During emergencies, I can predict what other personnel are going to do next.

39. Durante situações de emergência, consigo prever o que os outros profissionais vão realizar em seguida.

39. Durante as urgências, consigo prever o que os outros funcionários irão fazer de seguida.

39. During the emergency, I can anticipate what the other staff will do next.

40. The physicians and nurses here work together as a well-coordinated team

40. O pessoal Médico e de Enfermagem trabalham em conjunto como uma equipa bem coordenada.

40. Aqui, os médicos e enfermeiros trabalham em conjunto como um grupo bem coordenado.

40. Here, the doctors and nurses work together as a well-coordinated group

41. I am frequently unable to express disagreement with staff physicians/intensivists in this ICU

41. Sou frequentemente incapaz de expressar a minha discordância com médicos da equipa/intensivistas nesta UCI.

41. Sou frequentemente incapaz de expressar desacordo com os médicos “intensivistas” nesta UCI.

41. I am often unable to express disagreement with doctors "intensive" in this ICU

42. Very high levels of workload stimulate and improve my performance

42. Níveis elevados de trabalho estimulam e melhoram o meu desempenho.

42. Níveis muito elevados de volume de trabalho estimulam e melhoram a minha prestação.

42. Very high levels of workload stimulate and enhance my performance

43. Truly professional personnel can leave personal problems behind when working

43. Os profissionais podem verdadeiramente ignorar os problemas pessoais quando estão a trabalhar.

43. Funcionários, verdadeiramente profissionais, conseguem colocar de parte os seus problemas pessoais quando se encontram em serviço.

43. Staff, truly professional, they can put aside their personal problems when they are in service

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44. Morale in this ICU is high.

44. A moral é elevada nesta UCI.

44. A moral nesta UCI é elevada.

44. The moral in this ICU is high

45. Trainees in my discipline are adequately supervised

45. Os estagiários e internos, na minha especialidade, são bem supervisionados.

45. Os estagiários, da minha disciplina, são adequadamente supervisionados.

45. Trainees within my discipline, are adequately supervised

46. I know the first and last names of all the personnel I worked with during my last shift

46. Sei o primeiro e último nome de todo o pessoal da equipa com quem trabalhei no último turno.

46. Tenho conhecimento de os primeiros e últimos nomes de todos os funcionários com quem trabalhei no meu último turno.

46. I know the first and last names of all employees who worked on my last turn

47. I have made errors that had the potential to harm patients

47. Cometi erros com potencial de provocar danos nos doentes.

47. Cometi erros que tiveram o potencial de prejudicar o doente.

47. I made mistakes that had the potential to harm the patient.

48. Staff physicians/intensivists in this ICU are doing a good job.

48. Os médicos/intensivistas da equipa nesta UCI estão a realizar um bom trabalho.

48. A equipa de médicos especialistas/ de plantão desta UCI está a fazer um bom trabalho.

48. The team of medical specialists / on call this ICU is doing a good job.

49. Fatigue impairs my performance during emergency situations (e.g. emergency resuscitation, seizure).

49. O cansaço afeta o meu desempenho durante situações de emergência (por ex. reanimações, perdas de consciência, convulsões).

49. O cansaço prejudica o meu desempenho durante situações de urgência (ex.: reanimação, convulsões).

49. The fatigue affects my performance during emergency situations (ex.: resuscitation, seizures).

50. Fatigue impairs my performance during routine care (e.g., medication review, ventilator checks, transfer orders)

50. O cansaço afeta o meu desempenho durante a prestação de cuidados de rotina (por ex. revisão de medicação, revisão de ventiladores, ordens de transferência).

50. O cansaço prejudica o meu desempenho durante o serviço de cuidados de rotina (ex.: revisão de medicação, verificação de ventiladores, pedidos de transferência).

50. The fatigue affects my performance during the routine care service (e.x.: medication review, checking fans, transfer requests).

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51. If necessary, I know how to report errors that happen in this ICU

51. Se necessário, eu sei como comunicar os erros que acontecem nesta UCI.

51. Se necessário, tenho conhecimento da forma como denunciar erros que possam ocorrer nesta UCI.

51. If necessary, I am aware of how to report errors that may occur in this ICU

52. Patient safety is constantly reinforced as the priority in this ICU.

52. A segurança dos doentes é constantemente reforçada como prioridade nesta UCI.

52. A segurança do doente é constantemente reforçada como a prioridade desta UCI.

52. Patient safety is constantly reinforced as the priority of this ICU

53. Interactions in this ICU are collegial, rather than hierarchical.

53. As relações nesta UCI são colegiais e não hierárquicas.

53. As interações nesta UCI são colegiais e não hierárquicas.

53. The interactions in this ICU are collegial and not hierarchical.

54. Important issues are well communicated at shift changes.

54. Os assuntos importantes são bem comunicados nas mudanças de turno.

54. Os assuntos importantes são bem comunicados aquando da mudança de turno.

54. The important issues are well communicated at the time of shift change.

55. There is widespread adherence to clinical guidelines and evidence-based criteria in this ICU

55. Há adesão generalizada às normas de orientação e critérios baseados na evidência, relativos à segurança dos doentes nesta UCI.

55. Nesta UCI, há uma elevada aderência às diretrizes clinicas e a critérios baseados na evidência.

55. In this ICU, there is a high adherence to clinical guidelines and criteria based on the evidence

56. Personnel are not punished for errors reported through incident reports

56. Os profissionais não são penalizados pelos erros comunicados através dos relatórios de incidentes.

56. Os funcionários não são punidos por erros denunciados através de relatórios de incidentes.

56. Employees are not punished for errors reported through incident reports.

57. Error reporting is rewarded in this ICU

57. A comunicação de erros é recompensada nesta UCI.

57. A denúncia de erros é bem aceite nesta UCI.

57. The reporting of errors is well

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accepted in the ICU.

58. Information obtained through incident reports is used to make patient care safer in this ICU.

58. A informação obtida através dos relatórios de incidentes é usada para tornar mais seguros os cuidados prestados nesta UCI.

58. A informação obtida através da denúncia de incidentes é usada para tornar mais seguros os cuidados a ter com o doente.

58. The information obtained from the reporting of incidents is used to make safer the care of the patient.

59. During emergency situations (e.g., emergency resuscitations), my performance is not affected by working with inexperienced or less capable personnel.

59. Durante situações de emergência (por ex. reanimações), o meu desempenho não é afetado por trabalhar com pessoal menos experiente ou menos capaz.

59. Durante situações de urgência (ex.: reanimação), o meu desempenho não é afetado por trabalhar com funcionários inexperientes ou menos capazes.

59. During emergency situations (ex.: resuscitation), my performance is not affected by working with inexperienced employees or less capable.

60. Personnel frequently disregard rules or guidelines (e.g., handwashing, treatment protocols/clinical pathways, sterile field, etc.) that are established for this ICU.

60. Os profissionais ignoram frequentemente as regras ou normas de orientação (por ex. lavagem das mãos, protocolos de tratamento/percursos clínicos, zonas estéreis, etc.) estabelecidos para esta UCI.

60. Os funcionários, frequentemente, desrespeitam as regras ou linhas orientadoras (ex.: lavagem de mãos, tratamento de protocolos, orientações clinicas e a área de esterilização, etc.) que estão estabelecidas para esta UCI.

60. Employees often break the rules or guidelines (ex.: hand washing, treatment protocols, clinical guidelines and sterilization area, etc.) that are established for this ICU.

61. Communication breakdowns which lead to delays in delivery of care are common.

61. Problemas de comunicação, que originam atrasos na prestação de cuidados, são frequentes.

61. São comuns as falhas de comunicação que levam a atrasos na prestação de cuidados.

61. It is common communication failures that lead to delays in care.

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62. Communication breakdowns which negatively affect patient care are common.

62. Problemas de comunicação, que afetam negativamente os cuidados ao doente, são frequentes.

62. São comuns as falhas de comunicação que afetam, negativamente, o tratamento dos doentes.

62. It is common communication failures that affect negatively the treatment of patients.

63. A confidential reporting system that documents medical incidents is helpful for improving patient safety.

63. Um sistema de comunicação confidencial para documentar erros clínicos é útil na melhoria da segurança do doente.

63. Um sistema de denúncias confidencial que permita registar incidentes médicos é útil para melhorar a segurança do doente.

63. A confidential reporting system that provides a record of medical incidents is useful for improving patient safety.

64. I may hesitate to use a reporting system for medical incidents because I am concerned about being identified.

64. Eu hesitaria em usar um sistema que documenta os erros clínicos, porque me preocupo com o facto de poder ser identificado.

64. Posso hesitar em utilizar um sistema de denúncia de incidentes médicos porque tenho receio de vir a ser identificado.

64. I hesitate to use a reporting system for medical incidents because I am afraid of being identified.

65. Have you completed this survey before? No. Yes. Don’t know.

65. Alguma vez realizou este questionário? Sim, Não Não Sei

66. Já alguma vez havia completado este questionário? Sim, não não sei

65. Have you ever had completed this questionnaire? Yes, no do not know

BACKGROUND INFORMATION

INFORMAÇÃO DE BASE INFORMAÇÃO DE BASE BASIC INFORMATON

Gender: …..Male. …… Female

Sexo: ___masculino ____ feminino

Sexo: ___masculino ____ feminino

Gender: Male__ Female__

ICU Job Status ___ Full-time ___ Part-time ___ Agency ___ Contract

Tipo de vínculo de trabalho na UCI ____ Tempo inteiro ____ Tempo parcial ____ Agência

Tipo de vínculo de trabalho na UCI ____ Tempo inteiro ____ Tempo parcial ____ Agência

Work contract type in the ICU ____ Full time ____ Part time ____ Agency

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____ Contrato ____ Contrato ____ Contract

Usual swift __ Days __ Evenings __ Nights __ Variable shift

Turno Habitual ____ Dias ____ Tardes ____ Noites ____ Turnos variáveis

Turno Habitual ____ Dias ____ Tardes ____ Noites ____ Turnos variáveis

Usual Shift ____ Days ____ Afternoons ____ Nights ____ Shifts variables

How many years of experience do you have in this speciality? How many years have you worked in this ICU (mark 00 if less than 1 year)

Quantos anos de experiência tem nesta especialidade? _____ Á quantos anos trabalha nesta unidade? ______(responda 0 (zero) se inferior a um ano). Idade ____

Quantos anos de experiência tem nesta especialidade? _____ Á quantos anos trabalha nesta unidade? ______(responda 0 (zero) se inferior a um ano). Idade ____

How many years of experience do you have in this skill? _____ How many years are you working in this unit? ______ (answer 0 (zero) if less than one year). age ____

For attending Physicians: On average, how many patients do you admit to this ICU each month?

Para médicos com cargo de chefia: Em média, quantos doentes recebe nesta UCI por mês? _____

Para médicos com cargo de chefia: Em média, quantos doentes recebe nesta UCI por mês? _____

For physicians leading position: On average, how many patients receive this ICU per month? _____

*Optional* collected as part of a cross-cultural study. Citizenship (i.e. Canadian, Filipino, USA etc.) Country of birth (if different): ….

*Opcional: recolha de dados para fazer parte de um estudo transcultural Cidadania (i.e., Canadiano, Filipino, EUA, etc.): Natural de (se diferente)

*Opcional: recolha de dados para fazer parte de um estudo transcultural Cidadania (i.e., Canadiano, Filipino, EUA, etc.): Natural de (se diferente)

* Optional: data collection to be part of a cross-cultural study Citizenship (ie, Canadian, Filipine, USA, etc.): Natural (if different)

Use the scales to describe the quality of collaboration and communication you have experienced with:

Utilize as escalas para descrever a qualidade de colaboração e comunicação de que tem tido experiência com:


Use the scales to describe the quality of collaboration and communication that youhave had experience with:

Charge Nurse Pharmacist Nurse manager / Head Nurse Respiratory Therapist Critical café Nurse

Enfermeiro(a) Chefe Farmacêutico(a) Enfermeiro(a) encarregado(a)

Enfermeiro(a) Chefe

Farmacêutico(a)

Enfermeiro(a) encarregado(a)

Head Nurse Head Pharmacist (a) Nurse in charge Therapist of Respiratory System

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Nursing Aide/Assistant Critical Care LVN/LPN Crit Care Attending/Intensivist Ward Clerk/Secretary Crit Care Fellow/Resident Fellow/Resident (Medical) Fellow/Resident (Surgical) Others specify A = Very Low B = Low C = Adequate D = High E = Very High X = Not Applicable

Terapeuta do Sistema Respiratório Enfermeiro especialista em Cuidados Intensivos Auxiliar de enfermagem Técnico(a) credenciado(a) em Enfermagem de Cuidados Intensivos Administrativo(a) / Secretária(o) de enfermaria Médico especialista de plantão nos Cuidados Intensivos Interno (Medicina) Médico Interno dos Cuidados Intensivos Interno (Cirurgia) Médico Chefe de equipa (Medicina) Médico Chefe de equipa (Cirurgia) Outro (especifique) A = Muito baixo B = Baixo C = Adequado D = Elevado E = Muito elevado X = Não aplicável

Terapeuta do Sistema Respiratório

Enfermeiro especialista em Cuidados Intensivos Auxiliar de enfermagem Técnico(a) credenciado(a) em Enfermagem de Cuidados Intensivos Administrativo(a) / Secretária(o) de enfermaria Médico especialista de plantão nos Cuidados Intensivos Interno (Medicina) Médico Interno dos Cuidados Intensivos Interno (Cirurgia) Médico Chefe de equipa (Medicina) Médico Chefe de equipa (Cirurgia) Outro (especifique) A = Muito baixo B = Baixo C = Adequado D = Elevado E = Muito elevado X = Não aplicável

Specialist Nurse in Intensive Care Nursing assistant Technical accredited in Intensive Care Nursing Administrative / Secretary of the ward duty specialist in Medical Intensive Care Internal (Medicine) Internal Practitioner Intensive Care Internal (Surgery) Medical Team Leader (Medicine) Medical Team Leader (Surgery) Other (specify) A = Very Low B = Low C = Suitable D = High E = Very high X = Not applicable

COMMENTS: What are your top three recommendations for improving patient safety in this ICU? If more room for comment is needed, please provide your response on a seperate sheet of papaer.

Comentários: Quais são as três principais recomendações para melhorar a segurança do doente nesta UCI? Se necessita de mais espaço para comentários, por favor escreva a sua resposta numa folha de papel à parte

COMENTÁRIOS: Quais as suas três principais recomendações para que o tratamento dos doentes seja aperfeiçoado nesta UCI? Se necessitar de mais espaço para os seus comentários, por favor providencie a sua resposta numa folha de papel em separado.

COMMENTS: Which are your top three recommendations for the treatment of patients is improved in this ICU? If you need more space for your comments, please provide your answer on a separate sheet of paper.

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Thank you for completing the questionnaire - Your time and participation are greatly appreciated

Obrigado por ter completado o questionário – Grato pela sua participação e tempo dispensado

Obrigado por ter completado o questionário – Grato pela sua participação e tempo dispensado.

Thank you for completing the questionnaire - Thank you for your participation and for your time.

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Appendix 2: SAQ ICU Clarity test tool (Portuguese Version)

QUESTIONÁRIO DE ATITUDES DE SEGURANÇA PARA ENFERMEIRAS EM UCI

Categoria Profissional na UCI (marque apenas uma resposta): (√)

Tipo de UCI (marque apenas uma resposta):

Claro Não está claro

____ Enfermeira Supervisora/Enfermeira-Chefe ____ Enfermeira Responsável ____ Enfermeira de Cuidados Intensivos ____ Assistente Operacional ____ Administrativo da Unidade

___UCI Mista Medicos- cirurgica ___ UCI Cirurgica ___ UCI Medica ___ UCI Pediatrica ___ Outra UCI (especifique) ...............................................

A B C D E Claro Não está claro

DISCORDO TOTALMENTE DISCORDO PARCIALMENTE

SEM OPINIAO

CONCORDO PARCIALMENTE

CONCORDO TOTALMENTE Claro Não está claro

POR FAVOR, RESPONDA ÀS SEGUINTES PERGUNTAS RELATIVAMENTE À SUA UCI (UNIDADE DE CUIDADOS INTENSIVOS). SELECIONE A SUA RESPOSTA UTILIZANDO A ESCALA ACIMA APRESENTADA.

Claro Não está claro

1. Nesta UCI são comuns cargas horárias elevadas. A B C D E

2. Gosto do meu trabalho. A B C D E

3. O contributo dos enfermeiros é bem recebido nesta UCI. A B C D E 4. Eu sentir-me-ia seguro (a) como doente nesta UCI. A B C D E

5. Os erros clínicos* são encarados apropriadamente nesta UCI. A B C D E

*O erro clínico é definido como qualquer erro na prestação de cuidados, por qualquer profissional de saúde, independentemente do seu resultado.

A B C D E

6. Este hospital faz um bom trabalho na formação de novos enfermeiros. A B C D E 7. Toda a informação necessária para decisões de diagnóstico ou terapêuticas está disponível. A B C D E

8. Trabalhar neste hospital é como fazer parte de uma grande família. A B C D E

9. A administração deste hospital faz um bom trabalho. A B C D E 10. A administração do hospital apoia o meu empenho diário. A B C D E 11. Eu recebo feedback apropriado acerca do trabalho que realizo. A B C D E 12. Nesta UCI, é difícil discutir erros. A B C D E

13. Breves informações (ex. apontamento sobre doente na mudança de turno) são importantes para a

segurança dos doentes. A B C D E

14. Informações detalhadas são comuns nesta UCI. A B C D E

15. Este hospital é um bom local de trabalho A B C D E 16. Quando sou interrompido (a) a segurança dos meus doentes não é afetada. A B C D E 17. Todos os enfermeiros na minha UCI são responsáveis pela segurança dos doentes. A B C D E

18. A administração do hospital não compromete a segurança dos doentes. A B C D E 19. O número de enfermeiros nesta UCI é suficiente para assegurar os cuidados ao número de doentes. A B C D E

20. A tomada de decisão nesta UCI baseia-se no contributo relevante dos seus enfermeiros. A B C D E

21. Este hospital incentiva o trabalho de equipa e cooperação entre os seus enfermeiros. A B C D E 22. Sou incentivado (a) pelos meus colegas a dar a conhecer quaisquer preocupações que eu possa ter

relativamente à segurança dos doentes. A B C D E

23. A cultura nesta UCI facilita a aprendizagem através dos erros dos outros. A B C D E 24. Este hospital lida de forma construtiva com problemas de enfermeiros. A B C D E

25. O equipamento médico nesta UCI é adequado. A B C D E

26. Nesta UCI, é difícil expor algum problema que surja relativamente aos cuidados aos doentes A B C D E 27. Quando o volume de trabalho é excessivo, a minha prestação é prejudicada. A B C D E 28. É-me providenciada, atempadamente, informação sobre situações no hospital que possam afetar o meu

trabalho. A B C D E

29. Tenho presenciado outras pessoas cometerem erros que colocaram em causa a segurança dos doentes. A B C D E

30. Eu conheço os meios adequados para colocar questões referentes à segurança dos doentes nesta UCI A B C D E

31. Tenho orgulho de trabalhar neste hospital. A B C D E 32. As divergências nesta UCI são resolvidas apropriadamente (i.e. não quem tem razão, mas sim o que é o

melhor para o doente). A B C D E

33. Sou menos eficaz no trabalho quando estou cansado (a). A B C D E 34. É mais provável cometer erros em situações tensas ou hostis. A B C D E

SN

……………

______

___

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35. O stress, fruto de problemas pessoais, afeta o meu desempenho. A B C D E 36. Tenho o apoio que necessito de outros colaboradores para cuidar dos doentes. A B C D E

37. É fácil para os enfermeiros desta UCI colocar questões quando lhes surge alguma dúvida. A B C D E

38. As interrupções durante a continuidade dos cuidados (ex. mudanças de turno, transferência de doentes, etc.) podem por em causa a segurança do doente.

A B C D E

39. Durante as urgências, consigo prever o que os outros professionais irão fazer de seguida A B C D E

40. Aqui, os médicos e enfermeiros trabalham em conjunto como um grupo bem coordenado. A B C D E

41. Sou frequentemente incapaz de expressar desacordo com os médicos “intensivistas” nesta UCI. A B C D E

42. Níveis muito elevados de volume de trabalho estimulam e melhoram o meu desempenho. A B C D E 43. Os verdadeiros profissionais, conseguem colocar de parte os seus problemas pessoais quando se

encontram em serviço. A B C D E

44. A moral nesta UCI é elevada. A B C D E

45. Os estagiários de enfermagem são adequadamente supervisionados. A B C D E POR FAVOR, RESPONDA ÀS SEGUINTES PERGUNTAS RELATIVAMENTE À SUA UCI (UNIDADE DE CUIDADOS INTENSIVOS). SELECIONE A SUA RESPOSTA UTILIZANDO A ESCALA ACIMA APRESENTADA.

A B C D E Claro Não está claro

46. Conheço os primeiros e últimos nomes de todos os colaboradores com quem trabalhei no meu último

turno. A B C D E

47. Cometi erros que potencialmente prejudicaram o doente. A B C D E 48. A equipa de médicos especialistas desta UCI está a fazer um bom trabalho.

49. O cansaço prejudica o meu desempenho durante situações de urgência (ex.: reanimação, convulsões). A B C D E 50. O cansaço prejudica o meu desempenho durante o serviço de cuidados de rotina (ex.: revisão de

medicação, verificação de ventiladores, pedidos de transferência). A B C D E

51. Se necessário, conheço a forma como comunicar erros que possam ocorrer nesta UCI. A B C D E 52. A segurança do doente é constantemente reforçada como a prioridade desta UCI. A B C D E

53. As interações nesta UCI são colegiais e não hierárquicas. A B C D E

54. Os assuntos importantes são bem comunicados aquando da mudança de turno. A B C D E 55. Nesta UCI, há uma elevada aderência às guidelines clinicas e a critérios baseados na evidência. A B C D E

56. Os profissionais não são punidos por erros denunciados através de relatórios de incidentes. A B C D E 57. A comunicação de erros é bem aceite nesta UCI. A B C D E

58. A informação obtida através da comunicação de incidentes é usada para tornar mais seguros os cuidados a

ter com o doente. A B C D E

59. Durante situações de urgência (ex.: reanimação), o meu desempenho não é afetado por trabalhar com

profissionais inexperientes ou menos capazes. A B C D E

60. Os profissionais, frequentemente, desrespeitam as regras ou guidelines (ex.: lavagem de mãos, tratamento

de protocolos, orientações clinicas e a área de esterilização, etc.) que estão estabelecidas para esta UCI. A B C D E

61. São comuns as falhas de comunicação que levam a atrasos na prestação de cuidados. A B C D E 62. São comuns as falhas de comunicação que afetam, negativamente, o cuidado aos doentes. A B C D E

63. Um sistema de comunicação confidencial que permita registar incidentes clínicos é útil para melhorar a

segurança do doente. A B C D E

64. Posso hesitar em comunicar incidentes clínicos porque tenho receio de vir a ser identificado(a). A B C D E

65. Já alguma vez respondeu a este questionário? sim não não sei

Utilize as escalas para descrever a qualidade de colaboração e comunicação de que tem tido experiência com: Muito

baixo

Baixo Adequado Elevado Muito

elevado

Não aplicável Claro, Não está claro

66. Enfermeiro(a) Chefe

67. Farmacêutico(a)

68. Enfermeiro(a) responsável

69. Fisioterapeuta

70. Enfermeiro especialista em Cuidados

Intensivos

71. Assistenet Operacional

72. Administrativo(a) / Secretária(o) de

enfermaria

73. Médico Especialista em Cuidados

Intensivos

74. Interno (Medicina)

75. Médico Interno dos Cuidados Intensivos

76. Interno (Cirurgia)

77. Médico Chefe de equipa (Medicina)

78. Médico Chefe de equipa (Cirurgia)

79. Outro (especifique)

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DADOS PESSOAIS Claro Não

está

claro 80. Sexo: ____ masculino ____ feminino TURNO HABITUAL: GRUPO ÉTNICO (OPCIONAL)

Tipo de vínculo de trabalho na UCI: 81. ____ Dias 82. ____ Hispânico

83. ____ Tempo inteiro 84. ____ Tardes 85. ____ Raça Negra (não Hispânico)

86. ____ Tempo parcial 87. ____ Noites 88. ____ Asiático/ natural das ilhas do Pacífico

89. ____ Contrato a termo certo 90. ____ Turnos variáveis 91. ____ Multiétnico

92. ____ Contrato a termo incerto

93. ___Contrato de trabalho em funções

públicas

94. Idade atual

95. Quantos anos de experiência tem nesta especialidade?

96. Quantos anos trabalhou neste UCI?

97. Quantos doentes cuida por dia nesta UCI?

Comentários: Quais são as três principais recomendações para melhorar a segurança do doente nesta UCI? 1. ………………………………………………………………………………………………………………………………

………………………………………………………………

2. ………………………………………………………………………………………………………………………………

………………………………………………………………

3. ………………………………………………………………………………………………………………………………

………………………………………………………………

(Muito obrigado por responder a este questionário – O seu tempo e participação são extremamente valorizados.)

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Appendix 3(a): Information about the Study

Purpose of the Study. As part of the requirements for Erusmus Master in Emergency and Critical

Care Nursing degree at ESSaude, I have to carry out a research study. The study is concerned with

“how nurses working in intensive care units perceive their patient safety culture.

What will the study involve? The study will involve participants responding to statements in a

supervised self-administered questionnaire that will last for between 15-30 minutes by choosing

responses from a predetermined statements and writing your opinion briefly.

Why have you been asked to take part? You have been asked because you have been identified

generally suitable to provide information for the study.

Do you have to take part? No! Your participation is voluntary and you will need to sign a consent

form. You will keep the information sheet and a copy of the consent form. You have the option

of withdrawing before the study commences (even if you agreed to participate).

Will your participation in the study be kept confidential? Yes. The questionnaire will be

anonymously filled. I will ensure that no clues to your identity appear in the thesis. Any extracts

from your response that are quoted in the thesis will be entirely anonymous.

What will happen to the information which you give? The data will be kept confidential for the

duration of the study. On completion of the thesis, they will be retained for a further six months

and then destroyed.

What will happen to the results? The results will be presented in the thesis. They will be seen by

my supervisor, a second marker and the external examiner. The thesis may be read by future

students on the course. The study may be published in any research journal.

What are the possible disadvantages of taking part? I don’t envisage any negative consequences

for you in taking part. It is possible that responding to some of the statements talking about your

experience in this way may cause some distress.

What if there is a problem? At the end your participation, the investigator may discuss with you

how you found the experience and how you are feeling. If you subsequently feel distressed, you

should contact the investigator

Who has reviewed this study? The study was reviewed by the Ethics Committee of the Escola

Superior De Saude de Santarem and the Hospitals Ethics Committee. Approval to conduct the

study was obtained from the Escola Superior de Saude de Santarem before studies like this can

take place.

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Any further queries? If you need any further information, you can contact the investigator or his

supervisor on the telephone contacts and email addresses provided. If you agree to take part in

the study, please sign the consent form below.

Appendix 3(b): Informed Consent Form

I……………………………………………………. agree to participate in Cliff Asher’s research study. The purpose and nature of the study has been explained to me in writing and I am participating voluntarily. I give permission for my participation to fill the questionnaire. I understand that I can withdraw from the study, without repercussions, at any time, whether before it starts or while I am participating. I understand that anonymity will be ensured in the write-up by disguising my identity. I understand that disguised extracts from my participation may be quoted in the thesis and any subsequent publications if I give permission below: (Please tick one:

I agree to quotation/publication of extracts from my participation I do not agree to quotation / publication of extracts from my participation

Signed……………………………………. Date………………………………

(Respondent)

Signed: …………………………………. Date: …………………………….

(Researcher)

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Appendix 3c: Final SAQ Portuguese Version

Questionário de Atitudes de Segurança Para Enfermeiros Em UCI

Categoria Profissional na UCI (marque apenas uma resposta): (√) Tipo de UCI (marque apenas uma resposta):

____ Enfermeiro Supervisor/Enfermeiro-Chefe ____ Enfermeiro Responsável ____ Enfermeira de Cuidados Intensivos ____ Assistente Operacional ____ Administrativo da Unidade

___UCI Mista Medico - cirurgica ___ UCI Cirurgica ___ UCI Medica ___ UCI Pediatrica ___ Outra UCI (especifique) ............................................

A B C D E

DISCORDO TOTALMENTE DISCORDO PARCIALMENTE SEM OPINIAO CONCORDO PARCIALMENTE CONCORDO TOTALMENTE


98. Nesta UCI são comuns cargas horárias elevadas. A B C D E

99. Gosto do meu trabalho. A B C D E

100. O contributo dos enfermeiros é bem recebido nesta UCI. A B C D E

101. Eu sentir-me-ia seguro (a) como doente nesta UCI. A B C D E

102. Os erros clínicos são encarados apropriadamente nesta UCI. A B C D E

103. Este hospital faz um bom trabalho na formação de novos enfermeiros. A B C D E

104. Toda a informação necessária para as decisões de diagnóstico ou terapêuticas está disponível. A B C D E

105. Trabalhar neste hospital é como fazer parte de uma grande família. A B C D E

106. A administração deste hospital faz um bom trabalho. A B C D E

107. A administração do hospital apoia o meu empenho diário. A B C D E

108. Eu recebo feedback apropriado acerca do trabalho que realizo. A B C D E

109. Nesta UCI, é difícil discutir erros. A B C D E

110. Informações breves (por ex: na passagem de turno) são importantes para a segurança do doente. A B C D E

111. Informações detalhadas são comuns nesta UCI. A B C D E

112. Este hospital é um bom local de trabalho A B C D E

113. Quando sou interrompido (a) a segurança dos meus doentes não é afetada. A B C D E

114. Todos os enfermeiros na minha UCI são responsáveis pela segurança dos doentes. A B C D E

115. A administração do hospital não compromete a segurança dos doentes. A B C D E

116. O número de enfermeiros nesta UCI é suficiente para assegurar os cuidados ao número de doentes. A B C D E

117. A tomada de decisão neste UCI faz uso de contribuição de profissionais competentes. A B C D E

118. Este hospital incentiva o trabalho de equipa e a cooperação entre os seus enfermeiros. A B C D E

119. Sou incentivado (a) pelos meus colegas a dar a conhecer quaisquer preocupações que eu possa ter relativamente à segurança dos doentes.

A B C D E

120. A cultura nesta UCI facilita a aprendizagem através dos erros dos outros. A B C D E

121. Este hospital trata de forma construtiva com os enfermeiros problemáticos. A B C D E

122. O equipamento médico é adequada nesta UCI. A B C D E

123. Nesta UCI, é difícil expor algum problema que surja relativamente aos cuidados aos doentes A B C D E

124. Quando o volume de trabalho é excessivo, a minha prestação é prejudicada. A B C D E

125. É-me providenciada, atempadamente, informação sobre situações no hospital que possam afetar o meu trabalho. A B C D E

126. Tenho visto outras pessoas cometerem erros que tinham o potencial de prejudicar os doentes. A B C D E

127. Eu conheço os meios adequados para colocar questões referentes à segurança dos doentes nesta UCI A B C D E

128. Tenho orgulho de trabalhar neste hospital. A B C D E

129. As divergências nesta UCI são resolvidas apropriadamente A B C D E

130. Estou menos eficaz no trabalho quando estou estressado. A B C D E

131. Eu sou mais propensos a cometer erros em situações tensas ou hostis. A B C D E

132. Estresse de problema pessoal afetar adversamente o meu desempenho. A B C D E

133. Tenho o apoio que necessito de outros colaboradores para cuidar dos doentes. A B C D E

134. É fácil para as enfermeiras nesta UCI questionar quando há algo que não entendem. A B C D E

135. Interrupção na continuidade de cuidados (ex:, mão-over, transferências de pacientes), pode comprometer a segurança do doente.

A B C D E

V.S.F.F

SN

……………

______

___

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136. Durante as urgências, consigo prever o que os outros professionais irão fazer de seguida A B C D E

137. Aqui, os médicos e enfermeiros trabalham em conjunto como um grupo bem coordenado. A B C D E

138. Sou frequentemente incapaz de expressar desacordo com os médicos “intensivistas” nesta UCI. A B C D E

139. Níveis muito elevados de volume de trabalho estimulam e melhoram o meu desempenho. A B C D E

140. Os verdadeiros profissionais, conseguem colocar de parte os seus problemas pessoais quando se encontram em serviço.

A B C D E

141. A moral nesta UCI é elevada. A B C D E

142. Os estagiários de enfermagem são adequadamente supervisionados. A B C D E


A B C D E

143. Conheço os primeiros e últimos nomes de todos os colaboradores com quem trabalhei no meu último turno. A B C D E

144. Eu cometi erros que tinham o potencial de prejudicar doentes. A B C D E

145. Uma equipe de médicos especialistas desta UCI estão fazendo um bom trabalho.

146. Cansaço prejudica o meu desempenho durante situações de urgência (ex.: reanimação, convulsões). A B C D E

147. O cansaço prejudica o meu desempenho durante o serviço de cuidados de rotina A B C D E

148. Se necessário, eu sei como relatar erros que possam ocorrer neste UCI. A B C D E

149. A segurança do doiente é constantemente reforçada como a prioridade desta UCI. A B C D E

150. As interações nesta UCI são colegiais e não hierárquicas. A B C D E

151. Os assuntos importantes são bem comunicados aquando da mudança de turno. A B C D E

152. Nesta UCI, há uma elevada aderência às guidelines clinicas e a critérios baseados na evidência. A B C D E

153. Os profissionais não são punidos por erros comunicados através de relatórios de incidentes. A B C D E

154. Relatório de erros recompensado nesta UCI. A B C D E

155. A informação obtida através da comunicação de incidentes é usada para tornar mais seguros os cuidados a ter com o doente.

A B C D E

156. Durante situações de urgência (ex.: reanimação), o meu desempenho não é afetado por trabalhar com profissionais inexperientes ou menos experientes.

A B C D E

157. Os profissionais, frequentemente, desrespeitam as regras ou guidelines que estão estabelecidas nesta UCI. A B C D E

158. Falhas de comunicação que levam a atrasos na prestação de cuidados, são comuns. A B C D E

159. Falhas de comunicação que afetam negativamente o atendimento ao doente, são comuns. A B C D E

160. Um sistema de comunicação confidencial que permita registar incidentes clínicos é útil para melhorar a segurança do doente.

A B C D E

161. Posso hesitar em comunicar incidentes clínicos porque tenho receio de vir a ser identificado(a). A B C D E

162. Já alguma vez respondeu a este questionário? sim não não sei


Muito baixo Baixo Adequado Elevado Muito elevado Não aplicável

163. Enfermeiro(a) Chefe

164. Farmacêutico(a)

165. Enfermeiro(a) responsável

166. Fisioterapeuta

167. Enfermeiro especialista em Cuidados Intensivos

168. Assistente Operacional

169. Administrativo(a) / Secretária(o) de unidade

170. Médico Especialista em Cuidados Intensivos

171. Interno (Medicina)

172. Médico Interno dos Cuidados Intensivos

173. Interno (Cirurgia)

174. Médico Chefe de equipa (Medicina)

175. Médico Chefe de equipa (Cirurgia)

176. Outro (especifique)

DADOS PESSOAIS

Sexo: ____ masculino ____ feminino

102 V.S.F.F




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177. Tipo de vínculo de trabalho na UCI: ____ Tempo inteiro ____ Tempo parcial ____ Contrato a termo certo ____ Contrato a termo incerto ____ Contrato de trabalho em funções públicas

178. Turno Habitual: ____ Dias ____ Turnos variáveis ____ Turnos variáveis ____ Tardes ____ Noites

179. Idade atual? Responder: …………………………............ anos

180. Quantos anos de experiência tem nesta especialidade? Responder: ………………………………… anos.

181. Quantos anos trabalhou neste UCI? Responder: ……………................................. anos

182. Comentários: Quais são as três principais recomendações para melhorar a segurança do doente nesta UCI? 1. .................................................................................................................................................................. 2. .................................................................................................................................................................. 3. ..................................................................................................................................................................

Muito obrigado por responder a este questionário – O seu tempo e participação são extremamente valorizados

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Appendix 3 (d): Table 4.2 Communalities Kaiser-Meyer-Olking (KMO)

Communalities

Initial Extraction

Nurse input is well received in this ICU 1.000 .600

I would feel safe being treated here as a patient 1.000 .636

This hospital does a good job of training new personnel 1.000 .597

The administration of this hospital is doing a good job 1.000 .669

Hospital administration supports my daily efforts 1.000 .615

I receive a appropriate feedback about my performance 1.000 .645

Briefings are important for patient safety 1.000 .526

This hospital is a good place to work 1.000 .625

All the personnel in ICU take responsibility for patient safety 1.000 .654

Hospital management does not knowingly compromise the safety of patients 1.000 .634

Decision making in this ICU utilizes input from relevant personnel 1.000 .441

This hospital encourages teamwork and cooperation among personnel 1.000 .595

The culture in this ICU makes it easy to learn from errors of others 1.000 .458

This hospital deals constructively with problem personnel 1.000 .624

The medical equipment in this ICU is adequate 1.000 .436

When my workload becomes excessive, my performance is impaired 1.000 .658

I am provided with adequate, timely information about events in the hospital that might

affect my work

1.000 .474

I know the proper channel to direct questions regarding patient safety 1.000 .550

I am proud to work at this hospital 1.000 .548

Disagreements in this ICU are resolved appropriately 1.000 .581

I am less effective at work when fatigued 1.000 .512

I am more likely to make errors in tense or hostile situations 1.000 .552

Stress from personal problems adversely affect my performance 1.000 .498

I have the support I need from other personnel to care for patients 1.000 .531

It is easy for personnel in ICU to ask questions 1.000 .647

Disruptions in continuity of care can be detrimental to patient safety 1.000 .554

The physicians and nurses here work together as a coordinated team 1.000 .601

Very high level of workload stimulate and improve my performance 1.000 .599

Truly professional personnel can leave personal problems behind when working 1.000 .482

Trainees in my discipline are adequately supervised 1.000 .426

I know the first and last name of all the personnel I work with during my last shift 1.000 .445

Staff physician/ intensivist in this ICU are doing a good job 1.000 .622

Fatigue impairs my performance during emergency situation 1.000 .662

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Fatigue impairs my performance during routine care 1.000 .676

If necessary, I know how to report errors that happen in this ICU 1.000 .436

Interactions in this ICU are collegial, rather than hierarchical 1.000 .477

Important issues are well communicated at shift changes 1.000 .652

There is widespread adherence to clinical guidelines and EB criteria in this ICU 1.000 .516

Information obtained through incident reports is used to make patient care safer in this

ICU

1.000 .485

Extraction Method: Principal Component Analysis.

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Appendix 3 (e): Chi-Square test statistic for the 6-factor model

The

administrati

on of this

hospital is

doing a good

job

Hospital

administrati

on supports

my daily

efforts

I receive

appropriate

feedback

about my

performanc

e

This

hospital

is a good

place to

work

18 Hospital

management

does not

knowingly

compromise the

safety of

patients

This hospital

encourages

teamwork and

cooperation

among

personnel

This

hospital

deals

constructiv

ely with

problem

personnel

I am provided

with adequate,

timely

information

about events in

the hospital

that might

affect my work

I am

proud

to work

at this

hospita

l

Chi-Square 18.986a 26.932a 22.959a 33.027b 3.918a 22.548a 37.479a 23.370a 38.575a

df 4 4 4 3 4 4 4 4 4

Asymp. Sig. .001 .000 .000 .000 .417 .000 .000 .000 .000

a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 14.6.

b. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 18.3.

106




45 Very high level of workload stimulate and improve my performance

Truly professional personnel can leave personal problems behind when working

Interactions in this ICU are collegial, rather than hierarchical

Information obtained through incident reports is used to make patient care safer in this ICU

This hospital does a good job of training new personnel

The culture in this ICU makes it easy to learn from errors of others

I have the support I need from other personnel to care for patients

Trainees in my discipline are adequately supervised

Important issues are well communicated at shift changes

There is widespread adherence to clinical guidelines and EB criteria in this ICU

6.836b 18.164a 19.671a 69.123a 29.808a 30.219a 86.247a 29.521b 66.384a 64.740a

3 4 4 4 4 4 4 3 4 4

.077 .001 .001 .000 .000 .000 .000 .000 .000 .000

Nurse imput is well received in this ICU

I would feel safe being treated here as a patient

Decision making in this ICU utilizes input from relevant personnel

Disagreements in this ICU are resolved appropriately

It is easy for personnel in ICU to ask questions

The physicians and nurses here work together as a coordinated team

Briefings are important for patient safety

All the personnel in ICU take responsibility for patient safety

The medical equipment in this ICU is adequate

When my workload becomes excessive, my performance is impaired

I know the proper channel to direct questions regarding patient safety

I am less effective at work when fatigued

38Disruptions in continuity of care can be detrimental to patient safety

I am more likely to make errors in tense or hostile situations

58.342b

61.192b

39.534a 35.288a 47.205a 54.466a 106.890b 70.945b 70.767a 47.342a 53.370a 61.315a

21.452a 36.932a

3 3 4 4 4 4 3 3 4 4 4 4 4 4

.000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

107




Stress from personal

problems adversely affect

my performance

Fatigue impairs my

performance during

emergency

situation

Fatigue impairs my

performance during

routine care

I know the first and last

name of all the personnel

I work with during my

last shift

Staff

physician/intensivist

in this ICU are doing

a good job

If necessary, I

know how to report

errors that happen

in this ICU

46.658a 41.726a 63.233a 88.589b 45.562a 70.219a

4 4 4 3 4 4

.000 .000 .000 .000 .000 .000 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 14.6. b. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 18.3.

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Appendix 3 (f): Table 4.4b Rotated Component Matrix Rotated Component Matrix a

Component (Factor)

1 2 3 4 5 6

Nurse input is well received in this ICU .746

I would feel safe being treated here as a patient .692

This hospital does a good job of training new personnel .524

The administration of this hospital is doing a good job .751

Hospital administration supports my daily efforts .743

I receive a appropriate feedback about my performance .592

Briefings are important for patient safety .680

This hospital is a good place to work .692

All the personnel in ICU take responsibility for patient safety .742

Hospital management does not knowingly compromise the safety of patients

.748

Decision making in this ICU utilizes input from relevant personnel .459

This hospital encourages teamwork and cooperation among personnel

.683

The culture in this ICU makes it easy to learn from errors of others .485

This hospital deals constructively with problem personnel .713

The medical equipment in this ICU is adequate .568

When my workload becomes excessive, my performance is impaired

.501

I am provided with adequate, timely information about events in the hospital that might affect my work

.544

I know the proper channel to direct questions regarding patient safety

.541

I am proud to work at this hospital .665

Disagreements in this ICU are resolved appropriately .564

I am less effective at work when fatigued .511

I am more likely to make errors in tense or hostile situations .662

Stress from personal problems adversely affect my performance .353

I have the support I need from other personnel to care for patients .536

It is easy for personnel in ICU to ask questions .627

Disruptions in continuity of care can be detrimental to patient safety .379

The physicians and nurses here work together as a coordinated team

.515

Very high level of workload stimulate and improve my performance .479

Truly professional personnel can leave personal problems behind when working

.426

Trainees in my discipline are adequately supervised .605

46I know the first and last name of all the personnel I work with during my last shift

.653

48Staff physician/intensivist in this ICU are doing a good job .684

49Fatigue impairs my performance during emergency situation .802

50Fatigue impairs my performance during routine care .768

51If necessary, i know how to report errors that happen in ICU .531

53Interactions in this ICU are collegial, rather than hierarchical .403

54Important issues are well communicated at shift changes .760

55There is widespread adherence to clinical guidelines and EB criteria in this ICU

.552

58Information obtained through incident reports is used to make patient care safer in this ICU

.446

Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization.

a. Rotation converged in 8 iterations.

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