The impact of nurse empowerment program on patient safety culture in general public hospital in Indonesia

Abstract

Background

Patient safety is crucial to health-care quality and is one of the major parameters monitored by all health-care organizations around the world. Nurses play a critical role in improving the quality of care and patient safety because of their intensity in caring patients and families.

Objectives

This study aimed to determine the impact of nurse empowerment program on patient safety culture in general public hospital in Indonesia.

Methods

This study was designed as a quasi-experimental design in Indonesia. This program was conducted for three months with a five-day workshop (4 h for each day), followed by hanging up posters and handing out informative pamphlets to the experimental group's nurses and supervisors at their place of work in three common place that visited by nurses such as changing room, nurse station and near toilet.

Results

In the intervention group, patient safety culture practice score was significantly increased from 3.11(standard deviation [SD] = 1.43) before intervention to 4.89 (SD = 1.33) after three-month intervention (T2), with the t was 5.78, and p = .001. While in the control group, no significant increased score of patient safety culture practice before intervention and after three months intervention (3.05 ± 1.49 vs. 3.09 ± 1.25, t = 0.76, p = .516).

Conclusion

The implementation of this innovative empowerment program, which included nurses and supervisors, resulted in an increase in patient safety culture scores as well as growth in domain score. Therefore, this program can be used to advance these critical facets of patient safety culture, which are currently underdeveloped.

Keywords

Nurse empowerment patient safety culture intervention

Introduction

Many healthcare-related medical practices and risks are emerging as major challenges to patient safety and contribute significantly to the burden of harm due to insecure care. The prevalence of medical errors occurring in the health care system remains a concern despite the concerted focus on improving patient safety over the past 15.¹ Recent evidence suggests that 134 million adverse events occur each year due to unsafe care in hospitals in low- and middle-income countries, resulting in 2.6 million deaths annually.² Similarly, studies showed approximately 10–15% of patients experience an adverse event (unintended harm during treatment) in hospital, with half of such events being preventable and 14% resulting in disability or death.³ An accurate estimate of the economic burden of medication error is required to inform interventions focusing on its reduction. In terms of economic impact, the mean costs per medication error per study ranged from €2.58 to €111 7274.

Some studies have evaluated the culture of patient safety across professions,⁴ units,⁵ hospitals,⁶ and countries.^7,8 Moreover, evaluation of patient safety culture in different care unit was also assessed by many scholars with different measurement tools.^9–11 For example, previous study evaluated patient safety culture in intensive care units (ICUs).⁵ Previous study found that the workload was high in all units except the intermediate care unit and that it was connected with the incidence of adverse events.¹² Then, other study conducted in outpatient setting to measure patient safety culture found that strong unit teamwork could decreased treatment errors and improve quality of care.¹³

Efforts to improve patient safety culture aim to reduce adverse events and ensure patient safety. Patient safety culture is a multidimensional concept defined in the context of health care as the good or service of individual and group behavioral values, attitudes, perceptions, competences and standards that determine the administration's commitment, style and skill in managing patient safety.^14,15 A culture of safety necessitates an understanding of the values, attitudes, beliefs and conventions that are important to health care organizations, as well as what attitudes and actions are appropriate and expected of patients.¹⁶ Various methods, such as evaluations of medical or nursing records, objective observation, reporting systems, nurses’ assessments and patient interviews, have been employed to measure adverse events, and each method has advantages and disadvantages.¹⁷ Moreover, evaluations of nurses’ voluntary reporting of adverse occurrences, such as medication errors, enable hospital administrators and policymakers to enhance the quality of care given.¹⁸ In a review, the executive walk rounds by nurse managers has positive effects of enhancing routine safety culture evaluation.¹⁹ Such approaches can, therefore, be strengthened by participating nurse managers in the preparation and execution of interventions to strengthen the culture of patient safety.²⁰ Nevertheless, interventions that could strengthen the culture of patient safety are not well established.²¹

Nurse empowerment was recommended to be implemented in order to ensure patient safety.²² Theories of empowerment that have influenced nursing practice, education and research from a variety of perspectives, including structural, psychological and population.²³ Many studies have identified the impact of nurse empowerment programs on the culture of patient safety with different strategies. For example, the used educational program using online tutorial as strategies to empower nurse; the results showed that intervention could improves two dimensions of the patient safety culture.²⁴ Another strategy using teamwork teaching showed improvement on nurse patient safety culture.²⁵ Moreover, strategy using speak up in a situation of threat to patient safety improved nurse actions towards patient safety.²⁶ A recent study investigating the effect of empowering nurses and supervisors through an educational program on patient safety culture in adult ICU found that empowering nurses and supervisors could improve the overall patient safety culture. Additional actions are required to improve areas such as reporting the events and non-punitive response to errors.²⁷

Interventions which could strengthen the patient safety culture specific in nursing practices are not well defined.²⁸ A previous systematic review in primary healthcare showed that the majority of intervention on patient safety were focused to avoid serious side effects to the medications or medication errors, few on improving patient safety culture.²⁵ On the other hand, another review indicated multiple component approach such as team training, communication and executive participants in walk rounds were provided the best evidence of patient safety intervention.²³ Recommendations include the empowerment of nurses to ensure patient safety.²² However, the effect of the empowerment of nurses and quality outcomes, defined as the quality, safety, effectiveness, efficiency and patient-centeredness of patient care, is lacking.²³ In addition, the level of evidence in previous studies was moderates effect on the efficacy of patient safety in health care and not specific on patient safety intervention in nursing practices. This study aimed to evaluate the effect of the nurse empowerment program on the patient safety culture in general public hospital in Indonesia.

Methods

Study design

This study was designed as a quasi-experimental design to assess the effect of the nurse empowerment program on the patient safety culture. A quasi-experimental design is one of the methods of research to determine if there is a causal association between intervention and effect without randomization and blinded intervention and control group.²⁹

Intervention

The intervention group received nurse empowerment program. This program conducted for three months with a five-day education training (4 h for each day), followed by hanging up and handing out informative poster and supervised by nurse manager for three months. Poster were placed for six weeks in three common places visited by nurses such as changing room, nurse station and near toilet. During the following five weeks, one poster in the experimental groups handed out to the nurses each week. Researcher was providing check list for each nurse who already read each content in the poster and researcher visited each room every two days to evaluate utilization of the poster as source of information.

Education training were delivered in four sessions as describe in Table 1. The workshop included education on patient safety education and patient safety culture and Team Strategies and tools to Enhance Performance and Patient Safety (TeamSTEPPS) competencies for speaking out in a situation of threat to patient safety. The workshop consisted of a lecture, group discussion and scenario presentation.

Table 1.

Empowerment program curriculum adopted from (Amiri & Khademian, 2018).

Session	Objectives	Session content	Empowering strategies
First session (Step 1: Power, that is, access to resources, support and information) How frequent is this session	1. Introducing the importance and role of patient safety in ensuring quality of nursing and wellbeing for the patient. 2. Importance of information and expertise on patient safety prevention and management.	Patient safety will be included definition, important of patient safety, complexity of patient safety in nursing care, role model in team, prevention of adverse event, risk management of patient safety, involving patient and family in nursing care, infectious disease prevention and management, patient safety in invasive procedure and drug administration.	- Lecture, questions and answers, group discussion and sharing experiences. - PowerPoint presentations. - Educational module.
First session (Step 2: Power, that is, access to resources, support and information)	To believe in the enhancement of speaking out in a situation of threat to patient safety.	Believing in speaking out in a situation of threat to patient safety.	- Educational module. - Case presentation. - Sharing experience
Third session (Step 3: Opportunity, that is, access to challenge, growth and development)	1. To enhance performance and patient safety	- Self-confidence and ability regarding on Team Strategies and tools to Enhance Performance and Patient Safety (Team STEPPS)	- Lecture, questions and answers, group discussion and sharing experiences. - Educational booklet - Counseling and telephone follow-up at home.
Fourth session (Step 4: follow up and evaluation)	To assess both the method and the final result of the program	Hanging up posters and handing out informative pamphlets to the experimental group's nurses and supervisors at their place of work in three common place that visited by nurses such as changing room, nurse station, near toilet, etc. The workshop's educational content and posters matched up.	Daily book to daily report on watching and understanding the contents of poster

Control group were recruited from other ward or department (oncological medical surgical, neurological and orthopedic department) that not include in the intervention group. The control group was received information regarding the important of current data of patient safety through pamphlet.

Patient safety assessment was measured three time in both intervention and control group. Baseline assessment was conducted one week before intervention and post-test 1 (T1) was conducted one month after intervention, while follow up test (T2) measured three months after interventions.

Sample

The study population was nurse who work in inpatients department of general public hospital in West Java, Indonesia. The criteria for inclusion were: senior nurses who (a) work in either clinical or managerial positions (this subset [senior nurses] includes rotating shifts in nurses, direct ward/unit supervisors [head nurses], rotating shift nursing supervisors, nurse educators, nurse managers and nurse executives), have at least three years of nursing diploma, have at least six months of current workplace experience and have no plans to leave the center within the next six months. The exclusion criteria were nurse who takes leave due to sick or maternity leave, nurse who already received training on patient safety, unwillingness to participate and failure to complete the pre-test, and lack of participation in training sessions.

The sample size for this analysis has been determined according to tables from Cohen. It has been estimated that 64 participants need to have confidence in the results at a medium-effect size,³⁰ which is widely used in the social sciences, and a power estimate of 0.8, with an alpha of 0.05. In total, 154 sample with 20% attrition rate is needed. Convenience sampling technique was conducted to select participants.

Instruments

The socio-demographic, data including gender (male and female), age in year, level of education, marital status, working position, working unit and working experience in year.

The Hospital Survey on Patient Safety Culture developed by Agency for Healthcare Research and Quality U.S. Department of Health and Human Service (2016) was used operationally to measure perceptions of patient safety culture. This instrument consists of 12 composites of safety culture with a total of 42 items rated on a 5-point Likert scale ranging from ‘5 = strongly agree’ to ‘1 = strongly disagree’ or a 5-point frequency scale wherein 5 = always and 1 = never before. The 12 composites are reporting frequency of events; overall perceptions of health; attitudes and behavior of the supervisor/manager encouraging safety; organizational learning-continuous improvement; collaboration in hospital units; openness to communication; input and communication on error; non-punitive response to error; staffing; patient safety management support; coordination through hospital units; and hands-off and transfers. In the current study, the Cronbach Alpha was more than 0.70.³¹

Data analysis

Data demographic and work-related characteristics was analyzed using frequency, percentage, mean and standard deviation (SD). The normal distribution tested using a Kolmogorov–Smirnov test. At baseline analysis, the differences between the experimental and control groups in the age, length of work as a nurse in months, length of work in the current unit in months, number of patients in care during the shift evaluated using an independent t test for continuous data and for categoric variables such as position, state of job, type of shift, area of work, type of medication order communication, equipped medication safety guidelines established medication error reporting protocol, then be evaluated using Fisher exact test (table 2 × 3) and chi-square test (table 2 × 2). Pair t test was used to measure patient safety culture before and after intervention. After accounting for age and pre-test score as a covariate the discrepancies in outcome variables between the experimental and control groups examined with general equation estimation. Alpha less than 0.05 was considered as a statistically significant. The data collected was analyzed using SPSS (version 22.0, SPSS, Chicago, IL, USA).

Ethical consideration

This study was approved by Institutional Review Board of Universitas Horizon Indonesia (ETIK/09.22.098/III). Inform consent comprises of written explanations regarding the protection of participants, including anonymity, the unidentified signature box to preserve confidentiality, and a statement that any information submitted would be used exclusively for academic purposes. The researcher submitted the questionnaire to respondents after they had obtained written consent. Participants also have a right to withdraw if they feel inconvenience from this study. The questionnaire is anonymous and no personal identification data and the completed questionnaires were then returned in sealed envelopes to the researcher.

Results

About 220 nurses participated at enrollment, resulting in a response rate of 91.7% at baseline. About 8 (3.3%) nurses refused to participate and 12 (5%) did not meet inclusion criteria due to maternity or sick leave. In total for data analysis, 110 nurses were at intervention group and 110 nurses in the control group (Figure 1).

Figure 1.

Study flow diagram of participants’ recruitment and analysis.

Table 2 shows demographic profile of respondents from intervention and control group. In the intervention group, the mean age of nurse was 36.98 (SD = 9.52), 69.6% female, 54.5% had diploma III, 63.6% married, 57.3% nurse at level 2–5 and 33.6% working in internal or department, and had working experience about 13.76 ± 4.09 year. While in the control group, the mean age of nurse was 35.62 ± 8.66, 68.2% female, 50.9% had diploma III degree, 68.2% married, 51.2% nurse at level 2–5 and 29.1% working in internal medicine department and had working experience about 14.08 ± 5.73 year. No significant difference in terms of demographic profile between intervention and control group (p > .05).

Table 2.

Demographic comparison between intervention and control group (n = 220).

Variables	Intervention group	Control group
Variables	n = 110 (%)	n = 110 (%)
Age, Mean ± SD	36.98 ± 9.52	35.62 ± 8.66
Gender
Male	40 (36.4)	35 (31.8)
Female	70 (63.6)	75 (68.2)
Education level
Diploma III	60 (54.5)	56 (50.9)
Bachelor degree	50 (45.5)	54 (49.1)
Marital status
Married	70 (63.6)	75 (68.2)
Single	40 (36.4)	35 (31.8)
Working position
Nurse level 1–2	47 (42.7)	53 (48.2)
Nurse level 2–5	63 (57.3)	57 (51.8)
Working unit
Inpatient department	37 (33.6)	32 (29.1)
Outpatient department	27 (24.5)	28 (25.5)
Surgery department	35 (31.8)	25 (22.7)
Emergency department	11 (10.0)	19 (17.30
Working experience (year), Mean ± SD	13.76 ± 4.09	14.08 ± 5.73

Table 3 shows the difference of patient safety culture practice before and after intervention in both groups. In the intervention group, patient safety culture practice score was significantly increased from 3.11 (SD = 1.43) before intervention to 4.89 (SD = 1.33) after three-month intervention (T2), with the t was 5.78, and p = .001. While in the control group, no significant increased score of patient safety culture practice before intervention and after three months intervention (3.05 ± 1.49 vs. 3.09 ± 1.25, t = 0.76, p = .516).

Table 3.

The effect of nurse empowerment on patient safety culture practice before and after intervention in the experimental and control group (N = 220).

Variables	Pre test Mean ± SD	Posttest 2 Mean ± SD	Mean difference	t	p value
Intervention group	3.11 ± 1.43	4.89 ± 1.33	1.78	5.78	.000***
Control group	3.05 ± 1.49	3.09 ± 1.25	0.04	0.76	.516

Note: *p < .01, **p < .05, ***p < .001, p value obtained from pair t test.

Table 4 shows estimated difference-in-differences (DID) for intent-to-treat, results from linear regressions with level fixed effects. The nurse empowerment program improved outcomes relative to the control at T1, patient safety culture increased (95% CI 1.14–5.37). At T2, improved outcomes relative to the control were observed in patient safety culture (DID coefficient 3.68 (95% CI 1.17–6.53).

Table 4.

Estimated difference-in-differences (DID) for intention-to-treat (ITT).

Variables	Pretest – Posttest 1 DID coefficient (95% CI)	Pretest – Posttest 2 DID coefficient (95% CI)
Patient safety culture	2.15** (1.14–5.37)	3.68** (1.17–6.53)

*p < .05, **p < .01, ***p < .001.

Discussion

The findings indicate that the nurse empowerment program had a positive impact on the overall score of the patient safety culture compared to control group. However, the significant improvement might be due to that control group only receive an information using pamphlet while the intervention group received more attention with five days of training, checklists etc. Similar to previous study reported a significant improvement of patient safety culture after receiving nurse empowerment program.³² A previous study reported that nurse empowerment programs can take many forms, one of which is educational in nature and makes use of an online tutorial to address patient safety while increasing nurses’ positive ratings in two dimensions of the patient safety culture.³³ A study in Egypt found a significant difference in patient safety culture between those who received training and those who did not.³⁴ A study in Iran suggests that empowering nurses and supervisors can enhance patient safety culture, but further actions are needed to improve reporting of incidents and non-punitive error response.²⁷ The scoping review indicates that empowering program enhance nurses’ quality outcomes, including patient care quality, effectiveness, safety, efficiency and patient-centeredness in hospitals.³⁵

The study found that a pre-test focused on teamwork within units and handoffs and transitions as the most important aspects of patient safety culture. After the intervention, improvements were observed in the experimental group, leading to a strong evaluation dimension. Similar findings were found in a previous study, indicating that developing teamwork skills, using the SBAR tool and implementing interventions based on HSOPSC domains improved teamwork within units.¹³ However, in other studies,^36,37 no improvement in performance was observed after the training period. Other studies, which were similar to the present study showed that handoffs and transitions were improved as a result of the intervention.¹³ So we could propose a similar empowerment program in order to improve unit collaboration, handoffs and transitions.

Following the intervention, staffing and work pace were significantly improved, as were organizational learning – continuous improvement, supervisor, manager or clinical leader support for patient safety, handoffs and information exchange as well as overall patient satisfaction and safety. As part of the empowerment program, we included supervisors as well as nurses to reinforce their role in improving the patient safety culture. As a result of empowering supervisors, we anticipated that unit coordination and collaboration would improve. The results may be explained by the small number of supervisors who participated in the survey. Keep in mind that this dimension was stable prior to the intervention; however, we expected it to improve even more after the intervention. Furthermore, in other studies where education was the primary intervention, ‘cross-unit collaboration’ did not show a significant improvement.¹³

A statistically significant increase in the dimensions of reporting patient safety events and responding to errors was observed in the experimental group. This group's results, on the other hand, did not differ statistically from those of the control group. As a result, we can say that the intervention had a positive impact on this dimension. The ‘non-punitive response to errors’ in a previous study showed an improvement, but the ‘reported event frequency’ remained the same.¹³ According to another study, the only two dimensions that improved as a result of safety training were ‘non-punitive response to errors’ and ‘the frequency of reported events’.¹³ The current findings do not allow us to draw the conclusion that education can improve non-punitive error response. The result is that collaboration between all team members and leaders is required in order to solve problems and increase the number of events that are reported to authorities. It appears that the involvement of nurses and supervisors in the empowerment program was insufficient to achieve improvements in three critical dimensions: staffing, error reporting and non-punitive response to errors. The result is that in the future, we recommend that higher-level hospital executives be included as participants in empowerment programs.

The implementation of this innovative empowerment program, which included nurses and supervisors, resulted in an increase in patient safety culture scores as well as growth in domain score. Following the intervention, communication openness, handoffs and transitions, unit collaboration, learning and continuous improvement, manager expectations and actions promoting patient safety all saw significant improvements. Therefore, this program can be used to advance these critical facets of patient safety culture, which are currently underdeveloped. Patients’ safety culture was found to be lacking in several dimensions throughout the study, including staffing, ‘non-punitive response to errors’, and ‘frequency of reported events’. As a result, conducting long-term studies as well as taking additional actions are required in order to improve these dimensions further. With regard to patient safety, it is recommended that healthcare managers and hospital policymakers prioritize error reporting and adequate staffing, both of which are critical components of patient safety. Nurse manager or policy makers should be must concerned that all interventions in other sectors or healthcare disciplines are not suitable for converting to nursing. It is also critical to identify priority areas for patient safety by analyzing available data on adverse events and their implications, as well as developing clinical care recommendations to address these issues.

Study limitation

There are some limitations to this study. First, given the current characteristics of the sample, the insignificance of the results may be attributable to the small sample size. In addition, there was no measure of program adherence, so the intervention validity could not be determined. Lastly, despite the lack of randomization, there was no significant difference in demographic characteristics between the groups at baseline showing the homogeneity of the study participants.

Conclusion

The nurse empowerment program improved patient safety culture cross time. Further research is required to better understand the impact of interventions on nursing care practices in terms of creating safety cultures. Understanding the mechanisms underlying patient safety cultural dynamics might help to improve hospital safety. Nursing researchers must collaborate with academics from other disciplines to develop concepts for enhancing patient safety through the use of common methods and an agreed-upon taxonomy. An increasing number of studies have assessed the culture of patient safety and thus reveal differences in the culture of patient safety across professions, units, hospitals and countries.

Footnotes

Acknowledgments

The authors thank the Horizon University Indonesia for allowing us to introduce the research study to the women before their delivery who were potential participants.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Lilis Suryani was nominated as a guarantor for the word. The guarantor accepts full responsibility for the work and/or the conduct of the study, had access to the data and controlled the decision to publish.

ORCID iD

Lilis Suryani

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