Organizational conditions for engagement in quality and safety improvement: a longitudinal qualitative study of community pharmacies.

BACKGROUND: While efforts have been made to bring about quality and safety improvement in healthcare, it remains by no means certain that an improvement project will succeed. This suggests a need to better understand the process and conditions of improvement. The current study addresses this question by examining English community pharmacies attempting to undertake improvement activities. METHOD: The study used a longitudinal qualitative design, involving a sample of ten community pharmacies. Each pharmacy took part in a series of improvement workshops, involving use of the Manchester Patient Safety Framework (MaPSaF), over a twelve-month period. Qualitative data were collected from the workshops, from follow-up focus groups and from field notes. Template analysis was used to identify themes in the data. RESULTS: The progress made by pharmacies in improving their practice can be described in terms of a behavioural change framework, consisting of contemplation (resolving to make changes if they are required), planning (deciding how to carry out change) and execution (carrying out and reflecting on change). Organizational conditions supporting change were identified; these included the prioritisation of improvement, a commitment to change, a trusting and collaborative relationship between staff and managers, and knowledge about quality and safety issues to work on. CONCLUSIONS: Our study suggests a process by which healthcare work units might undergo improvement. In addition to recognising and providing support for this process, it is important to establish an environment that fosters improvement, and for work units to ensure that they are prepared for undergoing improvement activities.

Assessing the safety culture of care homes: a multimethod evaluation of the adaptation, face validity and feasibility of the Manchester Patient Safety Framework.

BACKGROUND: Understanding the cultural characteristics of healthcare organisations is widely recognised to be an important component of patient safety. A growing number of vulnerable older people are living in care homes but little attention has been paid to safety culture in this sector. In this study, we aimed to adapt the Manchester Patient Safety Framework (MaPSaF), a commonly used tool in the health sector, for use in care homes and then to test its face validity and preliminary feasibility as a tool for developing a better understanding of safety culture in the sector. METHODS: As part of a wider improvement programme to reduce the prevalence of common safety incidents among residents in 90 care homes in England, we adapted MaPSaF and carried out a multimethod participatory evaluation of its face validity and feasibility for care home staff. Data were collected using participant observation, interviews, documentary analysis and a survey, and were analysed thematically. RESULTS: MaPSaF required considerable adaptation in terms of its length, language and content in order for it to be perceived to be acceptable and useful to care home staff. The changes made reflected differences between the health and care home sectors in terms of the local context and wider policy environment, and the expectations, capacity and capabilities of the staff. Based on this preliminary study, the adapted tool, renamed 'Culture is Key', appears to have reasonable face validity and, with adequate facilitation, it is usable by front-line staff and useful in raising their awareness about safety issues. CONCLUSIONS: 'Culture is Key' is a new tool which appears to have acceptable face validity and feasibility to be used by care home staff to deepen their understanding of the safety culture of their organisations and therefore has potential to contribute to improving care for vulnerable older people.

Job characteristics, well-being and risky behaviour amongst pharmacists.

Healthcare practitioners' fitness to practise has often been linked to their personal and demographic characteristics. It is possible that situational factors, such as the work environment and physical or psychological well-being, also have an influence on an individual's fitness to practise. However, it is unclear how these factors might be linked to behaviours that risk compromising fitness to practise. The aim of this study was to examine the association between job characteristics, well-being and behaviour reflecting risky practice amongst a sample of registered pharmacists in a region of the United Kingdom. Data were obtained from a cross-sectional self-report survey of 517 pharmacists. These data were subjected to principal component analysis and path analysis, with job characteristics (demand, autonomy and feedback) and well-being (distress and perceived competence) as the predictors and behaviour as the outcome variable. Two aspects of behaviour were found: Overloading (taking on more work than one can comfortably manage) and risk taking (working at or beyond boundaries of safe practice). Separate path models including either job characteristics or well-being as independent variables provided a good fit to the data-set. Of the job characteristics, demand had the strongest association with behaviour, while the association between well-being and risky behaviour differed according to the aspect of behaviour being assessed. The findings suggest that, in general terms, situational factors should be considered alongside personal factors when assessing, judging or remediating fitness to practise. They also suggest the presence of different facets to the relationship between job characteristics, well-being and risky behaviour amongst pharmacists.

Measurement tools and process indicators of patient safety culture in primary care. A mixed methods study by the LINNEAUS collaboration on patient safety in primary care.

BACKGROUND: There is little guidance available to healthcare practitioners about what tools they might use to assess the patient safety culture. OBJECTIVE: To identify useful tools for assessing patient safety culture in primary care organizations in Europe; to identify those aspects of performance that should be assessed when investigating the relationship between safety culture and performance in primary care. METHODS: Two consensus-based studies were carried out, in which subject matter experts and primary healthcare professionals from several EU states rated (a) the applicability to their healthcare system of several existing safety culture assessment tools and (b) the appropriateness and usefulness of a range of potential indicators of a positive patient safety culture to primary care settings. The safety culture tools were field-tested in four countries to ascertain any challenges and issues arising when used in primary care. RESULTS: The two existing tools that received the most favourable ratings were the Manchester patient safety framework (MaPsAF primary care version) and the Agency for healthcare research and quality survey (medical office version). Several potential safety culture process indicators were identified. The one that emerged as offering the best combination of appropriateness and usefulness related to the collection of data on adverse patient events. CONCLUSION: Two tools, one quantitative and one qualitative, were identified as applicable and useful in assessing patient safety culture in primary care settings in Europe. Safety culture indicators in primary care should focus on the processes rather than the outcomes of care.

Patient safety initiatives in Central and Eastern Europe: A mixed methods approach by the LINNEAUS collaboration on patient safety in primary care.

BACKGROUND: Despite patient safety being recognized as an important healthcare issue in the European Union, there has been variable implementation of patient safety initiatives in Central and Eastern Europe (CEE). OBJECTIVE: To assess the status of patient safety initiatives in countries in CEE; to describe a process of engagement in Poland, which can serve as a template for the implementation of patient safety initiatives in primary care. METHODS: A mixed methods design was used. We conducted a review of literature focusing on publications from CEE, an inventory of patient safety initiatives in CEE countries, interviews with key informants, international survey, review of national reporting systems, and pilot demonstrator project in Poland with implementation of patient safety toolkits assessment. RESULTS: There was no published patient safety research from Albania, Belarus, Greece, Latvia, Lithuania, Romania, or Russia. Nine papers were found from Bulgaria, Croatia, the Czech Republic, Poland, Serbia, and Slovenia. In most of the CEE countries, patient safety had been addressed at the policy level although the focus was mainly in hospital care. There was a dearth of activity in primary care. The use of patient improvement strategies was low. CONCLUSION: International cooperation as exemplified in the demonstrator project can help in the development and implementation of patient safety initiatives in primary care in changing the emphasis away from a blame culture to one where greater emphasis is placed on improvement and learning.

Career breaks and changes of sector: challenges for the revalidation of pharmacists.

BACKGROUND: Taking a career break or moving between sectors of practice (for example, between patient-facing and non-patient-facing roles) often has been assumed to pose a risk for pharmacists' fitness to practice. However, it is not clear what the nature of that risk is, or what its implications are for professional revalidation. OBJECTIVES: To explore: (i) the experiences of pharmacists who either return to practice following a career break or move from one sector of practice to another; and (ii) the experiences of those who support or observe pharmacists undergoing one of these changes. METHODS: Eighteen registered pharmacists in Northern Ireland, all of whom had either undergone a change in practice themselves or had supported another pharmacist through a change in practice, took part in a telephone-based interview. During the interviews, each participant was invited to reflect upon his or her experiences of the change and suggest ways in which such processes should be handled in the future. The interview transcripts were thematically analysed using template analysis. RESULTS: A number of themes captured the issues discussed relating to changes in practice. Firstly, there is a variety of circumstances surrounding a change in practice; secondly, there are various ways in which a pharmacist can prepare for a change in practice; thirdly, a number of factors were thought to facilitate or hinder the process. Finally, training and development needs were identified for pharmacists undergoing a change. CONCLUSIONS: A revalidation scheme for pharmacists should make provision for registrants who have taken a career break or changed sector. Such registrants would benefit from resources to support them through the change in practice; these resources could come from peers, employers, or the regulator.

Pharmacists subjected to disciplinary action: characteristics and risk factors.

OBJECTIVE To establish whether there are any characteristics of pharmacists that predict their likelihood of being subjected to disciplinary action. METHODS The setting was the Royal Pharmaceutical Society of Great Britain's Disciplinary Committee. One hundred and seventeen pharmacists, all of whom had been referred to the Disciplinary Committee, were matched with a quota sample of 580 pharmacists who had not been subjected to disciplinary action but that matched the disciplined pharmacists on a set of demographic factors (gender, country of residence, year of registration). Frequency analysis and regression analysis were used to compare the two groups of pharmacists in terms of sector of work, ethnicity, age and country of training. Descriptive statistics were also obtained from the disciplined pharmacists to further explore characteristics of disciplinary cases and those pharmacists who undergo them. KEY FINDINGS While a number of characteristics appeared to increase the likelihood of a pharmacist being referred to the disciplinary committee, only one of these - working in a community pharmacy - was statistically significant. Professional misconduct accounted for a greater proportion of referrals than did clinical malpractice, and approximately one-fifth of pharmacists who went before the Disciplinary Committee had previously been disciplined by the Society. CONCLUSIONS This study provides initial evidence of pharmacist characteristics that are associated with an increased risk of being disciplined, based upon the data currently available. It is recommended that follow-up work is carried out using a more extensive dataset in order to confirm the statistical trends identified here.

Symmetric relationship between self and others in aggressive driving across gender and countries.

OBJECTIVE: It was hypothesized that the combination of self-reported aggressive behaviors committed by the driver himself/herself ("self" scale) and perceiving himself/herself as an object of other drivers' aggressive acts ("other" scale) increases road accident involvement risk across gender and countries. The aim of this study was, therefore, to investigate this symmetric relationship between aggressive driving of self and other and its relationship on accident involvement among British, Dutch, Finnish, and Turkish drivers. METHODS: Survey studies of 3673 drivers were carried out in four countries; that is in Finland, Great Britain, The Netherlands, and Turkey. Analyses were conducted separately for men and women. RESULTS: Overall, the interaction among aggressive warnings, hostile aggression, and revenge factors indicated that aggressive warnings might have a potential to release anger and escalate aggression both "within drivers" and "between drivers." Symmetric interpersonal aggression between aggressive warnings and hostile aggression and revenge factors of self and others created a serious risk for road accident involvement in every country except among British male and Finnish female drivers. CONCLUSIONS: The other driver's aggressive behavior is significantly associated with increased accidents, except for Turkish male drivers. It seems that another driver's aggressive behavior can be important in predicting crashes-even more important than aggressive behavior on the part of the driver him- or herself.

Determinants of intention to deviate from clinical practice guidelines.

The volitional nature of procedural violations in work systems creates a challenge for human factors research and practice. In order to understand how violations are caused and what can be done to mitigate them, there is a need to determine the influence of workers' beliefs about rules and guidelines. This study demonstrates the use of a social psychological approach to investigate the beliefs of anaesthetists about clinical practice guidelines. A survey was completed by 629 consultant anaesthetists, who rated their beliefs about deviation from three guidelines (performing pre-operative visits; checking anaesthetic equipment; handling intravenous fluid bags). Regression analysis indicated that the belief ratings predicted self-rated intention to deviate from the guidelines. Implications for understanding anaesthetists' adherence to guidelines are discussed. STATEMENT OF RELEVANCE: This study builds upon previous work by the authors, presenting a more detailed insight into potential causes of procedural violations in healthcare. The study also demonstrates the use of a social psychological method to the investigation of violations. Hence, it is of interest to researchers and practitioners interested in human reliability, especially in healthcare.

Medication safety in community pharmacy: a qualitative study of the sociotechnical context.

BACKGROUND: While much research has been conducted on medication safety, few of these studies have addressed primary care, despite the high volume of prescribing and dispensing of medicines that occurs in this setting. Those studies that have examined primary care dispensing emphasised the need to understand the role of sociotechnical factors (that is, the interactions between people, tasks, equipment and organisational structures) in promoting or preventing medication incidents. The aim of this study was to identify sociotechnical factors that community pharmacy staff encounter in practice, and suggest how these factors might impact on medication safety. METHODS: Sixty-seven practitioners, working in the North West of England, took part in ten focus groups on risk management in community pharmacy. The data obtained from these groups was subjected to a qualitative analysis to identify recurrent themes pertaining to sociotechnical aspects of medication safety. RESULTS: The findings indicated several characteristics of participants' work settings that were potentially related to medication safety. These were broadly classified as relationships involving the pharmacist, demands on the pharmacist and management and governance of pharmacists. CONCLUSION: It is recommended that the issues raised in this study be considered in future work examining medication safety in primary care.

Managing risk in healthcare: understanding your safety culture using the Manchester Patient Safety Framework (MaPSaF).

AIM: To provide sufficient information about the Manchester Patient Safety Framework (MaPSaF) to allow healthcare professionals to assess its potential usefulness. BACKGROUND: The assessment of safety culture is an important aspect of risk management, and one in which there is increasing interest among healthcare organizations. Manchester Patient Safety Framework offers a theory-based framework for assessing safety culture, designed specifically for use in the NHS. CONCLUSIONS: The framework covers multiple dimensions of safety culture, and five levels of safety culture development. This allows the generation of a profile of an organization's safety culture in terms of areas of relative strength and challenge, which can be used to identify focus issues for change and improvement. IMPLICATIONS FOR NURSING MANAGEMENT: Manchester Patient Safety Framework provides a useful method for engaging healthcare professionals in assessing and improving the safety culture in their organization, as part of a programme of risk management.

Identifying violation-provoking conditions in a healthcare setting.

Procedural violations (intentional deviations from established protocols) are prone to occur in many occupational settings, with a potentially detrimental effect on quality or safety. They are thought to result from organisational practices and the social characteristics of rule-related behaviour. This study makes use of qualitative methods to investigate the nature and causes of violations in anaesthetic practice. Twenty-three consultant anaesthetists took part in the study, which involved naturalistic observations and semi-structured interviews. Several factors influencing anaesthetic violations were identified. These include the nature of the rule, the anaesthetist (both as an individual and as a professional group) and the situation. Implications for the understanding and management of human reliability issues within an organisation are discussed. This study provides an insight into procedural violations, which pose a threat to organisational safety but are distinct from human errors. The study also demonstrates the value of qualitative methods in ergonomics research. It is of relevance to researchers and practitioners interested in human reliability and error, especially in healthcare.

Improvements to suicide prevention training for prison staff in England and Wales.

Suicide prevention training for the prison service in England and Wales has been criticized. STORM is a package emphasizing the practice and review of interactions with suicidal persons and was evaluated in a pilot study for use in prisons. Trainees completed questionnaires immediately before and after training and at 6 to 8 months follow-up. Training significantly improved attitudes, knowledge, and confidence, and improvements were maintained at follow-up. Satisfaction with training was very high. STORM was successfully adapted for prison settings, and showed good effects among staff trained. It should be provided to the wider prison estate, with regular refresher training.

Patient safety culture in primary care: developing a theoretical framework for practical use.

OBJECTIVE: Great importance has been attached to a culture of safe practice in healthcare organisations, but it has proved difficult to engage frontline staff with this complex concept. The present study aimed to develop and test a framework for making the concept of safety culture meaningful and accessible to managers and frontline staff, and facilitating discussion of ways to improve team/organisational safety culture. SETTING: Eight primary care trusts and a sample of their associated general practices in north west England. METHODS: In phase 1 a comprehensive review of the literature and a postal survey of experts helped identify the key dimensions of safety culture in primary care. Semistructured interviews with 30 clinicians and managers explored the application of these dimensions to an established theory of organisational maturity. In phase 2 the face validity and utility of the framework was assessed in 33 interviews and 14 focus groups. RESULTS: Nine dimensions were identified through which safety culture is expressed in primary care organisations. Organisational descriptions were developed for how these dimensions might be characterised at five levels of organisational maturity. The resulting framework conceptualises patient safety culture as multidimensional and dynamic, and seems to have a high level of face validity and utility within primary care. It aids clinicians' and managers' understanding of the concept of safety culture and promotes discussion within teams about their safety culture maturity. CONCLUSIONS: The framework moves the agenda on from rhetoric about the importance of safety culture to a way of understanding why and how the shared values of staff working within a healthcare organisation may be operationalised to create a safe environment for patient care.

Application of the theory of planned behaviour to the prediction of objectively assessed breaking of posted speed limits.

In two studies the Theory of Planned Behaviour (TPB) including moral norms, anticipated regret and past behaviour was applied to predicting intention to exceed the posted speed limit across different roads and objectively assessed speeding behaviour. All measures except behaviour were taken by self-report questionnaires referring to different driving scenarios. The behaviour measures were based on performance in a simulator (Study 1) or unobtrusive on-road speed camera assessment taken without driver awareness (Study 2) across roads with varying posted speed limits. Results are reported averaged across road types in both studies. In Study 1 (N=83), 82% of the variance in intentions to speed was explained, with attitudes, subjective norms, perceived behavioural control (PBC), moral norms, anticipated regret and past behaviour being significant predictors. A total of 35% of the variance in speed as assessed on a driving simulator was accounted for with intentions, PBC, moral norms and previous accidents being significant predictors. In Study 2 (N=303), 76% of the variance in intentions to speed was explained with attitudes, moral norms, anticipated regret and past behaviour being significant predictors. A total of 17% of the variance in speed as assessed on-road was accounted for with intentions and moral norms being significant. Practical implications of the findings for road safety are discussed.

Beyond cognition: predicting health risk behaviors from instrumental and affective beliefs.

OBJECTIVE: Two studies assessed the relative contribution of affective and instrumental beliefs to the prediction of 2 risk behaviors: driving above the speed limit and smoking. DESIGN: Both studies took the form of large-scale questionnaire surveys (Study 1, N=292; Study 2, N=500) measuring instrumental and affective beliefs and self-reported behavior. In both cases, behavior was also measured objectively. OUTCOME MEASURES: In Study 1, speeding behavior was measured via infrared camera along sections of road with 30 mph, 40 mph, and 60 mph speed limits. Self-reports of speeding in these same contexts represented a 2nd dependent variable. In Study 2, level of smoking was measured via a carbon monoxide monitor, and participants were asked to indicate the number of cigarettes they smoked in a week. RESULTS: In Study 1, positive and negative instrumental and affective beliefs were significant predictors of self-reported speed. The most powerful predictor was negative affective beliefs. Observed speed was predicted by negative affective beliefs only. In Study 2, the significant predictors of self-reported smoking and objective measures of smoking were positive and negative affective beliefs. CONCLUSION: The findings indicate the importance of affective beliefs across 2 health risk behaviors. Implications for social cognition models and interventions are discussed.

Pharmacists' changing views of their supplementary prescribing authority.

OBJECTIVE: To investigate the views and experiences of pharmacists in England before and after they registered as supplementary prescribers. METHOD: Eight pharmacists were recruited from training courses; seven from secondary care and one from primary care and interviewed during training and again after registration. In the first interviews, topics included previous experience, views on current roles, responsibilities and accountability for prescribing and how these might change. In the second interviews, the pharmacists discussed how these had actually changed after gaining supplementary prescribing authority, how their role worked in practice and how they saw it developing in the future. MAIN OUTCOME MEASURE: Descriptions of anticipated and actual changes in their roles, responsibilities and accountability before and after registration as supplementary prescribers RESULTS: The pharmacists anticipated that training would legitimise their current 'informal' prescribing practices, with increased legal responsibility and accountability, but experienced many procedural delays in implementing their new role. Pharmacists who were already heavily involved with prescribing were more likely to work as prescribers, but not necessarily within the clinical management plan framework. The desire to maintain the efficiency of their existing clinical services impacted negatively on the pharmacists' ability or willingness to prescribe in this legally approved manner. CONCLUSION: Clear and realistic expectations need to be set by the pharmacists as to what is achievable and greater attention needs to be paid to minimising delays between the end of training and the beginning of practice, to minimise reduction in motivation and redeployment of staff.

Cross-cultural differences in driving skills: a comparison of six countries.

The first aim of the present study was to investigate the applicability of the two-factor structure (perceptual-motor skills by 11 items, e.g., "fluent driving"; safety skills by 9 items, e.g., "conforming to the speed limits") of the Driver Skill Inventory (DSI) among British, Dutch, Finnish, Greek, Iranian, and Turkish drivers. It was also hypothesized that the combination of self reported high ratings of perceptual-motor skills and low ratings of safety skills creates a serious risk for dangerous driving and road accident involvement. The second aim of this study was, therefore, to investigate this asymmetric relationship between perceptual-motor and safety skills in traffic penalties and accident involvement. Two hundred and forty two drivers were chosen from each of the six countries, matched for age and sex. The results of exploratory factor analyses together with target rotation showed that the two-factor structure of DSI found in "safe" Northern and Western European countries were highly congruent. However, the safety skills factor of DSI in Greece, Iran, and Turkey was relatively incongruent in spite of high factor similarity found in perceptual-motor skills. The asymmetric relationship between perceptual-motor and safety skills on traffic penalties was found in Finland and Turkey. A negative relationship between safety skills and the number of accidents was found both in Greece and Iran while a positive relationship between perceptual-motor skills and the number of accidents was found only in Iran.

The Manchester Driver Behaviour Questionnaire: a cross-cultural study.

The aim of the present study was to investigate if the original factorial structure of the Manchester Driver Behaviour Questionnaire (DBQ) was replicated in Finland and The Netherlands. A postal questionnaire survey of drivers was carried out in Britain, Finland and The Netherlands. Exploratory factor analysis together with target (Procrustes) rotation and factorial agreement indexes were calculated to investigate the applicability of Finnish and Dutch versions of DBQ. Results of the factor comparisons showed that the DBQ four-factor structures found in Finland and The Netherlands were congruent but not perfect with the target structure found in Britain. Reliabilities of the scales were around the same level as in the British data. In addition to the four first-order factors, two second-order factors (deliberate violations and unintentional errors) were found in all three countries which supports the original structure by Reason et al. Issues related to cross-cultural use of traffic behaviour questionnaires are discussed.

Older drivers and road safety: the acceptability of a range of intervention measures.

A survey questionnaire was used to ascertain the views of 1932 UK drivers aged between 50 and 90 on a range of measures designed to promote safer driving among the elderly. Factor analysis of the items produced six factors, relating to statistically distinct types of measure. Differences in acceptability on the basis of age and sex were explored. Ratings of the effectiveness of each measure revealed little consensus about which measures would be most effective. Compulsory re-testing after a driving ban, a police power to require an assessment of the driving of anyone observed driving in a risky manner, and a requirement for opticians to report to the licensing authority any driver with sight problems likely to affect driving emerged as the individual measures offering the best combination of acceptability and perceived effectiveness.