Exploring the working environment of Hospital Managers: a mixed methods study investigating stress, stereotypes, psychological safety and individual resilience.

BACKGROUND: Hospital managers are responsible for the delivery of organisational strategy, development of clinical services and maintaining quality standards. There is limited research on hospital managers, in particular how stress manifests and impacts managers and the presence of individual resilience. Managers must work closely with clinical colleagues, however these relationships can be hindered by the perception of stereotyping and differing priorities. This study aimed to explore the working environment of hospital managers, focusing upon the unique stresses faced, psychological safety and the presence of resilience. METHODS: This study utilised mixed methodology using an embedded approach. Participants were purposively recruited from all levels of hospital management within one National Health Service Trust in London, United Kingdom. An exploration of managers experiences was undertaken using semi-structured qualitative interviews. Psychological safety and individual resilience were additionally assessed using validated surveys. Qualitative data were analysed iteratively using inductive thematic analysis, and triangulated with quantitative data. Kruskal-Wallis statistical analysis was performed to evaluate differences in resilience and psychological safety according to seniority and background experience. RESULTS: Twenty-two managers were recruited and interviewed, with 20 returning completed surveys. Key findings from the thematic analysis included the importance of good working relationships with clinical colleagues, the persistence of some stereotyping, and feeling unsupported in times of challenge. Stresses described included the bureaucracy involved when delivering change, conflict with colleagues and target driven expectations. Participants described their own psychological safety as lower than desired, supported by quantitative data; but recognised its importance and strived to create it within their own teams. Sixteen participants had 'normal' scores for resilience, with senior managers more likely to have higher scores than those more junior (p=0.011). CONCLUSION: Positive working relationships, high psychological safety and individual resilience are important for organisational safety and individual wellbeing. Our data illustrate unique stressors faced by hospital managers, provide detail on sometimes challenging working relationships, and demonstrate scope to improve both the psychological safety and resilience of those in managerial positions. A map for senior healthcare leaders was constructed, facilitating the identification of modifiable areas within their organisation to promote good working relationships and improve the working environment of hospital managers.

Exploring the factors that promote or diminish a psychologically safe environment: a qualitative interview study with critical care staff.

OBJECTIVES: This study aimed to quantify the presence of psychological safety (defined as an environment 'safe for interpersonal risk taking') in critical care staff, exploring the ways in which this manifested. DESIGN: Qualitative interview study incorporating a short quantitative survey. SETTING: Three intensive care units within one National Health Service Trust in London. PARTICIPANTS: Thirty participants were recruited from all levels of seniority and roles within the multidisciplinary team. A purposive sampling technique was used, with recruitment ceasing at the point of thematic saturation. INTERVENTIONS: Semistructured interviews explored attitudes towards psychological safety and contained a quantitative assessment measuring the climate of psychological safety present. RESULTS: Twenty-eight participants agreed that it was easy to ask for help, with 20 agreeing it is safe to take a risk on the team, demonstrating a strong perception of psychological safety in this group.Our thematic analysis highlighted areas where the context influenced an individual's psychological safety including personality, culture and leadership. Possible negative consequences of psychological safety included distraction and fatigue for the team leader. We demonstrated that speaking up can be influenced by motivations other than patient safety, such as undermining or self-promotion. CONCLUSIONS: Our data demonstrate reassuring levels of psychological safety within the participants studied. This allowed us to explore in depth the participant experience of working within a psychologically safe environment. We add to the current literature by uniquely demonstrating there can be negative consequences to a psychologically safe environment in the healthcare setting. We expand on the influence of context on psychological safety by developing a model, allowing leaders to identify which elements of context can be modified in order to promote speaking up. Team leaders can use these data to help foster a culture of openness, innovation and error prevention while minimising the risk of negative implications.

Exploratory study of staff perceptions of shift safety in the critical care unit and routinely available data on workforce, patient and organisational factors.

OBJECTIVES: To explore bedside professional reported (BPR) perceptions of safety in intensive care staff and the relationships between BPR safety, staffing, patient and work environment characteristics. DESIGN: An exploratory study of self-recorded staff perceptions of shift safety and routinely collected data. SETTING: A large teaching hospital comprising 70 critical care beds. PARTICIPANTS: All clinical staff working in adult critical care. INTERVENTIONS: Staff recorded whether their shift felt 'safe, unsafe or very unsafe' for 29 consecutive days. We explored these perceptions and relationships between them and routine data on staffing, patient and environmental characteristics. OUTCOME MEASURES: Relationships between BPR safety and staffing, patient and work environment characteristics. RESULTS: 2836 BPR scores were recorded over 29 consecutive days (response rate 57.7%). Perceptions of safety varied between staff, including within the same shift. There was no correlation between perceptions of safety and two measures of staffing: care hours per patient day (r=0.13 p=0.108) and Safecare Allocate (r=-0.19 p=0.013). We found a significant, positive relationship between perceptions of safety and the percentage of level 3 (most severely ill) patients (r=0.32, p=0.0001). There was a significant inverse relationship between perceptions of safety and the percentage of level 1 patients on a shift (r=-0.42, p<0.0001). Perceptions of safety correlated negatively with increased numbers of patients (r=-0.44, p=0.0006) and higher percentage of patients located side rooms (r=0.63, p<0.0001). We found a significant relationship between perceptions of safety and the percentage of staff with a specialist critical care course (r=0.42. p=0.0001). CONCLUSION: Existing staffing models, which are primarily influenced by staff-to-patient ratios, may not be sensitive to patient need. Other factors may be important drivers of staff perceptions of safety and should be explored further.