‘How do top-down patient safety initiatives permeate through organisational culture within an NHS Foundation Trust’?

Since the 1990s patient safety has been recognised as a major concern within healthcare worldwide, as well as within the UK National Health Service (NHS). There is evidence to suggest that contact with healthcare can cause avoidable harm and unnecessary death. In the literature, these significant safety failings have often been linked to the prevailing organisational culture in the UK NHS. However, the exact nature of this culture and its connection to maintaining patient safety is unclear, despite the reported implementation of strategies to improve patient safety across the healthcare system. As a key staff group within the NHS, nurses have a crucial role to play in protecting the public and keeping them safe. However, the lack of clarity relating to the links between culture and patient safety initiatives potentially compromises the degree to which nurses can have a positive influence. This qualitative Doctoral study therefore aimed to better understand, from a nursing perspective, the links between organisational culture and the implementation of patient safety initiatives in one NHS Foundation Trust in England. The following research question provided a focus for the study:

‘How do top-down patient safety initiatives permeate through organisational culture within an NHS Foundation Trust’?

A naturalistic inquiry methodology was used to gain an insight into the socially-constructed safety culture within the NHS Trust. A purposive sampling method was used to recruit 16 participants. The sample comprised participants from the Trust executive team, the Trust operational management team, and 2 clinical ward teams, in order to capture staff perspectives from “board to ward”. Data collection included individual interviews and focus groups with the participants about patient safety generally, and their involvement in a selected range of patient safety initiatives including: falls, medications, infection, recognising the sick patient, and pressure sores. Data were collected via direct observation of participants’ practice in addition to a focus group and secondary data analysis of minutes from a range of Trust meetings.

Thematic analysis of the data yielded seven themes: cultural consistency; safety initiatives and focus; communication; measurement; development; leading and shaping; and communities of practice. It was also evident from the analysis that only one of the five safety initiatives had fully permeated from board to ward (falls), demonstrating an inefficient flow of information through the Trust. The outcome of the study suggested that “climate”, rather than “culture”, was perhaps a more sensitive indicator of the receptivity of the ward team to the implementation of top-down patient safety initiatives in the NHS Trust studied.

It is suggested that rather than focussing on the intangible notion of a “safety culture” as an indicator of safety risk, “safety climate” perhaps offers a more appropriate alternative. Assessing the safety climate of an organisation, and settings within it, offers the opportunity to focus on concrete issues such as nursing staff behaviour and communication mechanisms. This allows identification of

organisational barriers to information permeation, and implementation of change. This, in turn, will improve the patient safety climate in the NHS. Perhaps international research could use the approach and findings from this study to explore their own safety climate. Dr Tony Conner tony.conner@northumbria.ac.uk

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