Patient safety and environment
How far does the environment of care affect patient safety? And I don’t just mean is it clean! Discussions with UK colleagues over recent days about nursing in critical care units, in A&E, and in care homes have highlighted for me what seems to be a gap in our thinking about patient safety as it is viewed and understood by researchers and policy makers.
Search for patient safety and environment of care and you first find reports relating to the physical environment. The Royal College of Nursing in the UK (2015) report that ‘one of the most longstanding concerns associated with the patient environment is its potential role in the transmission of infection.’ The physical environment is particularly identified as linked in a variety of ways to the transmission of Hospital Acquired Infections. These include multiple occupancy rooms, ventilation systems, units with difficult surfaces to clean, limited or poorly sited access points to basins, sanitiser points etc. The physical environment has also been flagged in relation to medication safety – for example in light levels, noise levels, use of space to minimise interruptions and distractions, and the way in which the space is organised.
Another way in which ‘environment’ is understood in some of the patient safety literature is exemplified in Aiken et al’s 2012 paper looking at patient safety, satisfaction, and quality of hospital care through cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. It focuses on the quality of the work environment. The paper reports that in all the countries examined, the professional profile of nurse staffing and the quality of the hospital work environment – which included support from managers, positive doctor-nurse relationships, opportunity for nurses to engage in decision-making, and organisational priorities for quality of care – were significantly associated with patient satisfaction, quality and safety of care, and workforce outcomes.
The gap, it seems, is in the failure to look further at the different experiences and stories behind good care and ‘adverse events’ in different care settings. Aiken et al, like most others examining patient safety, focussed on general (acute care) hospitals. These are of course the biggest contributor to patient safety statistics. In 2015/16 in England and Wales there were 1,342,061 reported patient safety ‘incidents’ in acute hospitals. In mental health facilities there were only 230,842, and in community nursing, medical and therapy services, only 203,334. In general practice, there were only 8,944. Most ‘incidents’ do not result in serious harm to patients, but they still matter to care. However, if you think about the settings I mentioned at the start of this piece – critical care units, A&E and care homes – let alone patients in their own homes – each is a very different environment for care.
In critical care there are usually between 1 and 2 nurses for each patient, at least at Level 3. There is a high level of expertise and a strong collaborative ethos. Patients may be in the unit for many days, with relatives and friends in frequent communication. Most services come to the patient: they stay put. Everything is monitored. In A&E, the pace of activity can be very fast. Multidisciplinary teams of staff flow around a changing patient population, their primary aim to stabilise and dispatch each patient out of the unit. Staff and patients are constantly on the move. The same equipment is used again and again for different patients. Staff knowledge about patients is usually through a brief summary. Care homes, or Nursing homes are different again, with small numbers of qualified staff, and more health care assistants. Patients live in these settings 24 hours a day, 7 days a week and their circumstances are usually known to staff. They are usually seen as residents with rights and responsibilities and may participate in meaningful ways in the available day-to-day activity, as well as being part of shared decision making.
Recent research has indicated that a concerning number of adverse events occur in the home or care home, particularly after discharge from hospital, with a Canadian study (Forster et al 2004) finding 23% of patients suffered an adverse event post discharge. Understanding more about these contexts (as for example Bradway et al 2011 show in work on Transitional Care) can help practitioners to intervene appropriately. In SLIPPS we will be gathering students’ experiences and stories about both ‘good care’ and ‘adverse events’ in different care settings and across Europe. We will have the opportunity to learn more and do more to improve patient safety.
 Patients receiving Advanced Respiratory Support alone OR Patients receiving a minimum of 2 organs supported – as defined in Intensive Care Society 2009 Standards and Guidelines, UK. Most ICUs.