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Acknowledgement
I acknowledge the enormous support morally and spiritually from all the professors in
Erasmus Mundus Masters Programme, most especially from expert advice from Dr. Regina
(ES Saude), Dr. Claudia (Santarem), not forgetting Mr Ezra Trevor Rwakinanga for his
friendly encouragement. I am indeed grateful to have my class mates and friends in
Portugal, Helsinki Metropolia University and EMA leaders who made the Erasmus Master
Experience very rewarding and memorable.
Dedication.
I dedicate this work to my mum retired Nurse Mary Ociru Andiandu, my wife Dianah
Nsasirwe and my children most especially Feni Clinton who was just 4 months old when I
left for studies in 2013. This piece of work is worth your time while I missed all of you back
home in Uganda.
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Contents Abstract ................................................................................................................................ 8
1.0 Introduction .......................................................................................................... 10
1.2 Review of relevant literature for the study .......................................................... 12
1.4 Problem statement .............................................................................................. 24
2.0 Research Purpose ................................................................................................. 26
2.1 Research Objectives ............................................................................................. 26
3.0 Methodology ........................................................................................................ 27
3.1 Research Questions .............................................................................................. 27
3.2 Research method ................................................................................................. 27
3.3 Study design ......................................................................................................... 28
3.4 Study Population .................................................................................................. 28
3.5 Sampling type ....................................................................................................... 28
3.6 Sample size prediction ......................................................................................... 29
3.7 Data gathering process ......................................................................................... 29
3.8 Data analysis ......................................................................................................... 30
3.9 Methods to ensure trustworthiness .................................................................... 30
3.10 Research Limitations ............................................................................................ 31
4.0 RESULTS ................................................................................................................ 33
4.1 Translation and adaptation of SAQ 2006 instruments ......................................... 33
4.2 Data Analysis ........................................................................................................ 37
4.3 Demographic information .................................................................................... 37
4.4 Factor Analysis ...................................................................................................... 39
4.5 Testing for Suitability of Factor Analysis .............................................................. 39
4.6 Testing for significance of variables under study ................................................. 40
4.7 Factor Extraction from study variables ................................................................ 40
4.8 Factor Patterning with study variables ................................................................ 42
4.9 Goodness-of-Fit of the Model .............................................................................. 44
4.10 Reliability of the Model ........................................................................................ 45
4.11 Variability in the Study Model .............................................................................. 45
5.0 Discussion ............................................................................................................. 54
5.1 Translation and adaptation of the SAQ ICU version............................................. 54
5.2 Factor analysis ...................................................................................................... 55
5.3 Factor variability ................................................................................................... 57
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5.4 Conceptual Framework ........................................................................................ 63
5.5 Significance of study ............................................................................................. 64
6.0 Conclusions ........................................................................................................... 67
7.0 Reference ............................................................................................................. 68
Appendixis
Appendix A: Activity plan ......................................................................................................... 74
Appendix B: Authorization letter for data collection for clarity test. ....................................... 75
Appendix C. Permission letter from Hospital 2 (H2) ................................................................ 76
Appendix D: Permission letter from Hospital 3 (H3) ................................................................ 77
Appendix E: Permission letter from Hospital 1 (H1) ................................................................ 78
Appendix F. Permission letter from author of SAQ. ................................................................. 79
Appendix G. The Original Safety Attitude Questionnaire (ICU) Verion. ................................... 80
Appendix 1: Summary Forward & back translation to target language (TL1 & TL 2) ............... 81
Appendix 2: SAQ ICU Clarity Test tool (Portuguese Version) ………………………………………..………96
Appendix 3(a): Information about the Study ................................................................................ 98
Appendix 3(b): Informed Consent Form .................................................................................... 100
Appendix 3 c): Final SAQ Portuguese Version ............................................................................ 101
Appendix 3 (d): Table 4.2 Communalities Kaiser-Meyer-Olking (KMO) ...................................... 104
Appendix 3 (e): Chi-Square test statistic for the 6-factor model ................................................. 106
Appendix 3 (f): Table 4.4b Rotated Component Matrix ..………………………………………………………..109
LIST OF FIGURES Figure 1 Conceptual Frame work …………………………………………………………………………23 Figure 4.0 Scree Plot for Study Variables …………………………………………………………………41 Figure 2 Recommendations for improving patient safety culture .......................... 53 Figure 3 Proposed Patient Satey Model ………………………………………………………………63 LIST OF TABLES Table 4.1 Descriptive Frequency of Professional experience within hospitals ……….38 Table 4.3 Eigen Values for Component extraction ………………………………………………...41 Table 4.4a Showing Component of factor structure ................................................... 43 Table 4.5a Difficulty to speak up in case of a problem at all 3 hospitals .................... 46 Table 4.5b Difficulty to speak up in case of a problem at Polyvalent clinical area ..... 46 Table 4.5c Difficulty to speak up in case of a problem at Cardiology clinical area ..... 46 Table 4.6 Factor Variability in all hospitals (N = 73) .................................................. 47 Table 4.7 Feedback and the Quality of Collaboration with the Chief Nurse ............. 49 Table 4.8 Feedback and the Quality of Collaboration with the Chief Nurse ............. 52
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Abstract Background: Patient safety still remains a global public health problem but how it is
addressed may differ depending on local setting, culture and availability of resources.
Safety attitude questionnaire (Bondevik, Hofoss, Hansen, & Deilkås 2014) is one of the
instrument that measures patient safety culture in a clinical setting such as ICU. We sought
to understand how nurses working in ICU perceive their patient safety practices through
the application of a translated SAQ (2004) ICU version into Portuguese language among
critical care nurses at three hospitals in Portugal.
Methods: The original Sexton’s 2004 SAQ ICU Version (Appendix G, page 80) was translated
to Portuguese language using the back translation techniques and tested in 37 graduate
nurses in Portugal. A quantitative data was collected among 103 nurses at intensive care
unit in three hospitals in Portugal. Non-random probability technique and criterion
sampling was used to obtain data with supervised self-completion process.
Results: All 37 participants filled the pre-test for clarity test; reliability Cronbach’s Alpha of
.71 (64 items) with strong correlation of .000 - .463 (p<0.05). About 74 (72%) of the 103
nurses participated and 98.6% (73) fully completed the questionnaire. Items correlated
with KMO = 0.6, df 741 at p<.05, forming an identity matrix suitable for factor analysis. Six
factors were extracted explaining 56.2% total variance: management perception
(15.145%), safety climate (9.576%), teamwork climate (8.708%), job satisfaction (7.849%),
stress recognition (7.56%) and work condition (7.420%). A good reliability Cronbach’s Alpha
of 0.819 was obtained and there were variability in all the 6 factors.
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Conclusion: We conclude that translation of the SAQ to Portuguese showed satisfactory
internal psychometric properties. The translated SAQ to Portuguese language can be used
to measure nurses’ attitude regarding the six patient safety culture related domains in ICU.
Key wards: patient safety culture, ICU, translation, adaptation, SAQ.
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1.0 Introduction
In the world over the image of an institution is determined by the attributes its culture. A
good account of the culture of an institution involves an understanding of the shared
norms, values, behaviour patterns, rituals and traditions of its employees as part of
organizational culture (Profit et al., 2012); which are further reflected in the attitudes of its
employees. Halligan & Zecevic, 2011 defined the culture of safety as “the product of
individual and group values, attitudes, perceptions, competencies and patterns of
behaviour that determine the commitment to, and the style and proficiency of, an
organization’s health and safety management”
This study aims at understanding and describing the characteristics of how patient safety
culture is perceived among critical care nurses at intensive care units in three hospitals in
Portugal. The study of “Patient Safety Culture among Critical Care Nurses at Intensive Care
Units in three Hospitals in Portugal” was chosen because understanding the attitudes of
nursing staff at ICU offers prospects to identify areas that need to be strengthened to
improve quality of care at ICU.
The terms Safety culture and safety climate have been used interchangeably to mean the
same. For instance, we refer to patient safety culture as individual behaviour regarding
efforts to reduce risks, address and reduce incidents and accidents that may negatively
impact health care consumers (Bryan Sexton et al., 2011). Since two decades ago, the
popular IOM (1999) report on “to error is human” has made high risk organizations
including health industry to shift their attention to improving safety practices in order to
prevent adverse events. Therefore one of the goal of patient safety culture in the health
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care industry now focuses to promote a behaviour pattern among staff that aims to reduce
and prevent adverse events during care. By and large there is a tendency to assume that in
every hospital, patients are expected to receive care that is free from exposure to danger
and be protected from occurrence of risk or injury with optimal precautions at workplace.
This requires employees of every hospitals are expected to acquire and adopt to an
established organizational philosophy in the form of mission, vision and core values so as
deliver safe health care.
Well-developed health organizations deliberately establish core values and strategies that
articulate how they intend to deliver safe care to their client through a habit of achieving
the desired value hence provoking specific patterns of behaviour and practices referred to
as culture. However, translating the core values of an organization into actions depends on
many behavioural factors including leadership style, communication, attitudes to
teamwork and safety and well as having staff who are satisfied with their job in an
environment which are believed to impact positively on the patient safety (Bryan Sexton et
al., 2011). For instance, in 2006, Bryan Sexton declares that the behavioural factors of
individual health worker ought to reduce risks, address and reduce incidents and accidents
that may negatively impact health care consumers and he labelled this as “patient safety
culture”.
In this study, we targeted nurses working in intensive care unit from whom quantitative
data was collected with supervised self-administered questionnaire using the Sexton’s
2004 SAQ (ICU version) to collect data; a tool which was derived from the Flight
Management Attitude Questionnaire (Göras, Wallentin, Nilsson, & Ehrenberg). This tool
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has been derived from human factor survey used to measure cockpit culture in commercial
aviation (John Bryan Sexton & Keryn Vella, 2006).
The SAQ ICU version 2006 was chosen for this study because of its ability to focuses on
safety climate and probing healthcare teams to describe their attitudes to six domains using
Likert scale (Carifio & Perla, 2008; Celenza & Rogers, 2011; Hadjibalassi et al., 2012; Hartley
& MacLean, 2006; Hasson & Arnetz, 2005; Spigelman, Debono, Oates, Dunn, & Braithwaite,
2012; Wisniewski et al., 2007; Zimmermann et al., 2013) to score. According to Sexton
2006, the six domains such as teamwork climate, job satisfaction, perceptions of
management, safety climate, working conditions and stress recognition describe the
characteristic behaviour within a unit or department. The SAQ tool has readily available
data for its psychometric properties already tested in over 500 hospitals in the United
States, the United Kingdom and New Zealand. The tools has been validated for use in critical
care, operating rooms, pharmacy, ambulatory clinics, labour and delivery, and general
inpatient settings (Sexton, Thomas, & Helmreich, 2000) as well as well as being rigorously
validated for measuring safety climate in healthcare in different countries.
1.2 Review of relevant literature for the study
We reviewed publications related to patient safety culture and associated domains of the
research topic. According to Polit and Becks, 2010, literature review deliberates on critical
analysis of published sources, or literature on a particular topic within the context of
previous knowledge. It also offers an assessment of the available works so as to provide a
summary, classification, comparison and evaluation of the situation under study. Here we
describe the already known facts about approaches of nurses towards patient safety
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culture in order to understand what they perceive about their safety practices in the ICU
work environment.
The explanation of the term “safety culture” dates back in 1987 when INSAG (1988) first
described it in the Nuclear Agency report on the 1986 Chernobyl disaster and published in
WHO (2006) where they concluded that: … “The April 1986 disaster at the Chernobyl
nuclear power plant in Ukraine was the product of a flawed Soviet reactor design coupled
with serious mistakes made by the plant operators as a direct consequence of Cold War
isolation and the resulting lack of any safety culture”…
Since then there is a growing interest to the understanding of safety culture by organization
and more particularly high risk occupations such as the health care industry.
In this study, attempts were made to review the historical background of how safety culture
has been described by various authors in order to understand the current definitions of
patient safety culture. Within the available literature, the term ‘culture’ as described by
Uttar (1983) refers to “shared values and beliefs that interact with an organization’s
structures and control systems to produce behavioural norms”, while Cullen W.D, (1990)
loosely defined safety culture as “the corporate atmosphere or culture in which safety is
understood to be, and is accepted as the number one priority” (Cooper, 2002).
Available literature shows that culture of patient safety is closely linked to describing and
understanding the ability of healthcare staff to prevent error and adverse events (Singla,
Kitch, Weissman, & Campbell, 2006). It can be argued that safety culture may perhaps be
considered as representing health workers’ understanding of the hazards at the place of
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work as well as carrying out specific steps during care in order to provide safe care to
patients resulting into safe working area at the heart of a safety culture (Griffith, Livesey,
& Clayton, 2010).
Theoretical concept of safety culture has been applied in many fields. Components such as
giving safety first significance at all levels of the organizational hierarchy, a pledge to safety
at the administrative level, providing resources needed to achieve quality and safety, the
open and constructive handling and learning from errors, and focusing on improving
systems rather than individual blame are commonly acknowledged as essential to ensuring
safety at workplace (Geller, 1994; Pidgeon, 1998; Singer et al., 2003). The domains which
make safety culture visible have been identified by Sexton 2006 as teamwork climate, job
satisfaction, perception of management, safety climate, working condition and stress
management practices on the organization (John B Sexton & Keryn Vella3, 2006). These
domains were identified through a confirmatory factor analysis on SPSS of the SAQ ICU
version 2006. The perception of the six domains offers an understanding of how healthcare
workers view their safety practices at work place by responding to the SAQ.
Since the SAQ tool has the ability to measure workers safety climate, the tool is being
translated and adapted to different culturally diverse settings and linguistics at different
parts of the world by different researchers (Bondevik et al., 2014; Chaboyer et al., 2013;
Devriendt et al., 2012; Etchegaray & Thomas, 2012; France et al., 2010; Göras et al., 2013;
Haugen et al., 2010; Kaya, Barsbay, & Karabulut, 2010; Li, 2013). In another study by
Raftopoulos, 2013, it was found that the perception of health workers towards the six
domains of Sexton’s 2004 SAQ vary from one hospital to another.
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The use of the SAQ is able to identify defects in patient safety climate resulting negative
outcomes such as the lack of teamwork, job stress to workers, adverse events to patients,
communication breakdown and an apparent lack of patient satisfaction (Bryan Sexton et
al., 2011). However, practices such as identification of errors, effective communication of
errors, early detection of risks, and open communication between the health care team,
improvement of working condition, cooperation with and support from the management
team, promotion of a safe working condition stimulates an overall job satisfaction
(Raftopoulos & Pavlakis, 2013). Good culture of patient safety results into quality care,
reduced adverse events, patient satisfaction and overall provision of healthcare that is free
from errors and adverse events.
Ensuring patient safety is a deliberate effort by individual staff to promote patient safety at
work place in the areas of teamwork, management practices, conducive work environment,
ensuring safe and stress free work climate in order to promote job satisfaction among staff.
Teamwork climate: It is well known and stated in literature that medical care today is
undeniably a team effort. Team effort makes it easy to complete the continuum of car
especially when there is effective communication, cooperation and coordination (Salas
2008). A team is an identifiable set of two or more individual interacting within a large
organizational context to reach a common goal through specific interdependent roles and
task boundaries (Salas 1992 and Kozlowst 2003). In various literature, teamwork has been
defined in terms of behaviours, closed loop communication, cognition and attitudes
(cohesion and collective efficacy) that makes interdependent performance possible.
Teamwork has been linked to patient safety outcomes such as reduced risk and job
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satisfaction since the workers tend to support each other and work to achieve a common
goal (O'Byrne, Worthy, Ravelo, Webb, & Cole, 2014; Redden & Evans, 2014). Promoting
teamwork utilizes complex inter-professional collaboration and the effectiveness to
produce desired outcome depends shared goals, partnership, mutual respect and power
sharing with other professional in the organization (Louise et al, 2011). Louise 2011 declares
that teamwork is continuously changing in ICU owing to the large staff numbers, work shift,
staff rotation to other departments and different professionals working together at varying
times. Despite the fact that ICU requires a unified team working together to provide safe
care, achieving and sustaining it in practice is challenging due inter-professional conflict
and the tendency of staff moving from one job to another. Louise 2011 asserts that job shift
are common due to the dynamic socioeconomic disparity in the health care industry.
However there is evidence that power sharing alone tends to reduce conflict that arise due
to ownership of specialized skills and technical/clinical territory compounded by the notion
that patients are owned by particular clinical speciality as illustrated by Louise 2011. The
correlation of teamwork climate (inter-professional collaboration) with patient safety
culture underscores the importance to identify alternative ways to improving safety in ICU
through research.
Safety climate: Safety climate and safety culture has been used interchangeably by many
scholars to mean “the product of individual and group values, attitudes, perceptions,
competencies, and patterns of behaviour that determine the commitment to, and the style
and proficiency of, an organization’s health and safety management (Sorra 2004 and
Wendy 2011)”. Some authors such as Davies et al (2000) observed that, culture is … “the
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way we do things around here”… is now accepted by many as simple description of the
safety climate. While Carney et al (2010) described safety culture as “a professional culture
that promotes effective and efficient communication among clinicians and not hampered
by hierarchical status or personality differences”. The Health and Safety Committee and
Advisory Committee on the Safety of Nuclear Installations of UK in 1993; declares that
institutions with a constructive safety culture are branded by communications established
on shared trust, common perceptions of the importance of safety, and by self-assurance in
the efficacy of precautionary measures. Thus at present, certain industries such as aviation
and chemical have maintained an assured safety based on the above standard resulting in
few cases of adverse events and accident hence organization gradually adopting them in
the health industry. The fact that patients admitted to ICU have complex conditions has
been found to be associated with predictable medication errors, nurse back injuries,
urinary tract infections, reduced patient satisfaction, patient perceptions of nurse
responsiveness and nurse satisfaction (Abstoss et al., 2011; Belela, Peterlini, & Pedreira,
2011; Bohomol, Ramos, & D'Innocenzo, 2009; Brady, Malone, & Fleming, 2009).
Job satisfaction: Job satisfaction is another safety climate domain which refers to a state
of personal satisfaction relative to the work situation (Bryan Sexton et al., 2011; Devriendt
et al., 2012). The term was first used to describe individual experience regarding the
fulfilment of a need or state of being satisfied. Job satisfaction and quality of work of nurses
depends on the type of units in which they work and in relation to the levels of depression,
anxiety and stress. A study by Abd El-aal and Hassan, 2009 found a significant negative weak
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correlation between the mean total score percentage of staff nurses' satisfaction and the
quality of work, stress and their depression level in critical care units.
Work condition: Work conditions of a health institution are defined by established norms
and provide an observable picture of safety conditions. Promotion of a good culture of
patient safety in an organization is regarded (Saha, Beach, & Cooper, 2008) as a key to
promotion of quality service and customer satisfaction. Hence patient safety culture refer
to the behaviour of health workers at the work environment that promotes members
responsibility to prevent, learn and encourage the reporting of errors so that they do not
happen again(Armellino, Quinn Griffin, & Fitzpatrick, 2010; Armstrong & Laschinger, 2006;
Bosch et al., 2011; Currie & Richens, 2009). A good working condition correlates positively
with job satisfaction and patients agreeing with quality of care.
The attributes of safety culture in an organization and institution is defined by norms,
values, expected behaviour patterns, rituals and traditions of its employees (Profit et al.,
2012) similarly defined as ‘the product of individual and group values, attitudes,
perceptions, competencies and patterns of behaviour that determine the commitment to,
and the style and proficiency of an organization’s health and safety management’ (Health
and Safety Commission 1993, Nieva & Sorra 2003). Hence patient safety culture is not
tangible but can be observed as behaviour pattern of individuals in the institution. The
benefits of patient safety culture cannot be seen directly by observing the employee but
will be seen as an outcome of safety climate.
The outcomes of patient safety culture is linked to the capacity of healthcare staff to
prevent error (Singla, Kitch, Weissman, & Campbell, 2006). A safety culture could be
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considered as representing the workers’ understanding of hazards in their workplace, and
the norms and roles leading to safe working area at the heart of a safety culture (Griffith et
al., 2010). The theoretical concept of a safety culture has been applied in many fields.
Components such as giving safety first significance at all levels of the organizational
hierarchy, a pledge to safety at the administrative level, providing the resources needed to
achieve quality and safety, the open and constructive handling of errors, organizational
learning, and focusing on improving systems rather than individual blame are commonly
acknowledged as essential to safety culture (Geller, 1994; Pidgeon, 1998; Singer et al.,
2003). The domains which make safety culture become more visible have been identified
in a study by Sexton 2006 as having an attitude working as a team, being satisfied with job,
management supporting the safety practice, having a safe working climate, having an
appropriate working condition and stress management practices within the organization
(John B Sexton & Keryn Vella3, 2006). The practice and perception of the six domains of
patient safety culture provides an understanding of how healthcare workers view their
safety practices while delivering health care. The outcomes of the patient safety practices
indirectly translate to identification of errors, effective communication of errors, early
detection of risks, and open communication between the health care team, improvement
of working condition, cooperation with and support from the management team,
promotion of a safe working condition and overall job satisfaction. Decent culture of
patient safety results into quality care, reduced adverse events, patient satisfaction and
overall provision of healthcare that is free from errors and adverse events.
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According Hughes, (2008), patient safety refers to “the prevention of harm to patients”…
with emphasis placed on the system of care delivery that prevents errors; learns from the
errors that do occur; and is built on a culture of safety that involves health care
professionals, organizations, and patients. The prevention and learning from the errors is
the pivot on which an organization builds a culture of safe practices of care. Professional
culture of safety is rooted to the implementation of core values, vision and the goal of
delivering services that is free from adverse events.
Patient safety remains a serious concern in intensive care unit because of the fragile
conditions of patients admitted with potential organ failure and threat to life. The
professional culture of safety in ICU has an important effect on the recovery of patients in
critical conditions. Little is known about how nurses in ICU perceive patient safety practices
at typical hospitals in Portugal. The term ‘Safety Culture’ has been defined by many scholars
as the product of shared values and beliefs towards patient safety (Zimmermann et al.),
Cox and Cox (Aagja & Garg), Pidgeon (Aagja & Garg), Berends (1996), Lee (1996) and
Summier C. E 2009). For the purpose of this survey the definition by Sexton (2006) shall be
used; “Safety culture as "the product of individual and group values, attitudes, perceptions,
competencies, and patterns of behaviour that determine the commitment to, and the style
and proficiency of, an organization's health and safety management” The above definition
may mean that a safety culture comprises of a complex set of individuals’ behavioural
attributes that can promote an effective patient safety culture in an organization.
Therefore, any deficiency in safety practice of an individual worker may give rise to adverse
events such as falls, medication errors, nosocomial infections, delayed recovery, high
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health cost and lack of patient satisfaction to services (Abstoss et al., 2011; Armitage, 2009;
de Melo et al., 2013; Maher-Griffiths, 2011; Mansour, James, & Edgley, 2012; Rodrigues &
Oliveira, 2010; Wu, Yu, Lan, & Tang, 2012).
In critical care units, all health care workers are expected to prevent errors that may occur
in the course of duty. Although there is similarity in the general set up of all intensive care
units in terms of infrastructure, staffing, nature of patients admitted as well as the
management, little is known about the perceived differences in care practices with other
intensive care units being considered offering better services in the perspective of service
users. These may be largely as a result various factors such as leadership and management
of the units, work culture at organizational level and the level of motivation of the staff to
providing yet little is known how these domains impact on safety culture among critical
care nurses in Portugal.
Generically, health workers are anxious to provide care that is safe and free from harm in
order to meet the health care needs of the patients. It is assumed that all health workers
will always deliver care that will not cause harm to patients. Although providing safe care
is the responsibility of the organization and its workers, individuals clients will always seek
to find out how the services of a particular institution is described in terms of cure success,
positive patient testimony or even how the staffs are perceived in the manner in which
they provide services.
Most scholars in their definition consider patient safety culture or safety climate as
deliberate efforts to reduce risk, to address and reduce incidents and accidents that may
negatively impact healthcare consumers (Cox and Cox (1991), Pidgeon (1991), Ostron
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2003), Cooper and Phillips 1994, Niskanen (1994), Coyles (1995), Barends (1996), Lee and
Williamson 1997). Although medical error reporting is considered essential for patient
safety, Kagan (2013) found that many errors go unreported and the level of patient safety
culture (PSC) was positively correlated with the rate of error reporting and that the level of
the PSC at both organizational and departmental levels predicted the error reporting rate.
This demonstrates that a positive PSC can enhance error reporting while a negative PSC
may act as a reporting barrier. Measuring culture of patient safety in ICU gives an
understanding of unit conditions such as team work climate, job satisfaction, perception of
management, safety climate, working conditions and related factors that lead to adverse
events and patient harms (Albert et al., 2014).
Conceptual Framework
Patient safety is influenced by different factors including both individual and organizational
factors. All the influencing factors are dependent on each other. For instance, deficit in one
of the domain will subsequently have an influence another domain such as if the
management does not support the staff in their effort to address errors effectively, it leads
to unsafe practices and subsequent adverse events; where as if management handles
errors appropriately and use it as a learning opportunity, the next time such an error will
be prevent or managed appropriately.
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Figure 1: Conceptual Framework
Patient
safety
culture
INDIVIDUAL FACTORS Age, Gender, Level of education / job category, Years / Experience / service, Duty shift, Type of job
Teamwork
Climate
Job satisfaction
Stress recognition
Perception of
management
Safety Climate
Work conditions Defective Safety culture Adverse events
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1.4 Problem statement Patient safety still remains a serious global public health problem but how it is handled
differ depending on local settings, culture of the organization and availability of resources
. WHO (2014) estimates indicated that in developed countries, as many as one in 10
patients is harmed while receiving hospital care and for every 100 hospitalized patients at
any given time, 7 from develped countries and 10 in developing countries acquire health
care associated infections. It has been recommended by WHO (2012) that the current
global focus should be on prospect to improving patient safety through culture
transformation. The culture of patient safety remains one of the most important nursing
care element in all intensive care units however, implementing professional safety culture
in ICU has been used as effort to improve safety among nursing staff.
Promoting professional nursing safety culture has an important effect on patient safety
since such measures among nursing team at ICU positively impacts on recovery of patients
(Hughes, 2008). Errors in medication, procedures, and falls are some of the commonest
indicators of the existence of failures in patient safety practices in healthcare. Making an
error is inherent to human nature and behaviour (IOM, 1999 and Genival 2013) yet
provoking a sense of insecurity during care. Studies have found that the rate of potential
adverse events in ICU per 1000 patient-days was at 276, whereas the rate of preventable
ADEs per 1000 patient-days was at 9.2 with medication errors as the leading ADEs. This
trend remains a serious concern because evidence shows that certain behaviour of
healthcare team are responsible for the adverse events in ICU (Hughes, 2008). Despite a lot
of effort being placed on improving safety of patients, 32% of medication errors continue
to occur during ordering and 39% occur during administration of drugs (mostly
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implemented by nurses). Studies by Pascale (2008), indicate that in 16–24% of potential
and preventable ADEs and clusters of errors occurred either as a sequence of errors (delay
in medication dispensing leading to delay in medication administration) or grouped errors
(route and frequency errors in the order for a medication). These are serious safety related
adverse events which are purely preventable during the medication management process
and requires behaviour that is able to prevent and learn from errors.
Hence the study will seek to find out how Nurses working in ICU perceive their safety
practices towards patients in intensive care units at three hospitals in Portugal. The
understanding of critical care nurses’ perception and attitudes towards patient safety will
be able to predict the safety climate or safety culture in the clinical area with the majority
being nurses.
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2.0 Research Purpose
The purpose of this study is two folds; first to describe how Nurses working in ICU perceive
their safety practices towards patients at three hospitals in Portugal in order to generate
recommendation on how to improve patient safety in intensive care unit in the three
hospitals. Secondly to translate and validate the Sexton’s 2004 Safety Attitude Question into
Portugese language.
2.1 Research Objectives
We intended to achieve the following objectives in this study:
To identify factors that influence patient safety practices among critical care nurses
in three hospitals in Portugal.
To compare the patient safety cultures among critical care nurses in intensive care
units in the three hospitals in Portugal.
To identify recommendation for improving patient safety culture in ICU in the three
hospitals.
To translate and validate the tool Sexton’s 2004 Safety Attitude questionnaire (SAQ)
to Portuguese reality.
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3.0 Methodology Introduction: This section will be describing the approaches that will be used to answer the
research question. Polit and Becks, (2014) asserts that research methodology specifically
describes the techniques and procedures used to answer the research questions. These
approaches will be describing the research design, determination of population size, sample
size prediction, sampling type, data gathering process and analysis as well as describing the
scope of the study and limitations.
3.1 Research Questions
What factors influence patient safety practices among critical care nurses in three
hospitals in Portugal?
How does the patient safety cultures among critical care nurses in intensive care
units compare in the three hospitals in Portugal?
What are the recommendation for improving patient safety culture in ICU in the
three hospitals?
What is the Portuguese version of Sexton’s 2004 Safety Attitude questionnaire (SAQ)
ICU?
3.2 Research method
A quantitative research method was implemented using the descriptive research design
process. A quantitative methods emphasise on objective measurements and numerical
analysis of data collected through polls, questionnaires or surveys and focuses on gathering
numerical data and generalizing it across groups of people (Babbie, et al 2010). The main
goal will be to determine the relationship between patient safety culture among ICU nurses
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in the dimensions of teamwork, job satisfaction, perception of management, working
conditions, safety climate and (6) stress recognition Sexton et al, 2006.
3.3 Study design
A descriptive research design is chosen in order to gain more information about how Nurses
working in ICU perceive their safety practices towards patients in intensive care units at
three hospitals in Portugal. Study design is the overall plan for obtaining answers to the
research questions and for handling challenges that can undermine the study evidence with
the main goal of minimizing bias, how data will be collected, what type of comparison will
be made and where study will take place (Polit and Becks, 2014). The greatest motivation
to choose this method was due to the fact it will allow the researcher use questionnaire to
explore factors that influence patient safety culture among critical care nurses. A study by
Sorra, Nieva, Fastman, Kaplan, Schreiber, and King (2008) used descriptive design to study
staff attitudes about reporting and patient safety culture in hospital transfusion services.
3.4 Study Population
The term population refers to all individuals or subjects with common, defining
characteristics that meet a designated set of criteria for inclusion in a study (Polit and Beck,
2014). The target population are nurses working in intensive care units for the last six
months by November 2014 in the three hospitals.
3.5 Sampling type
The researcher used two sampling types; non-random probability and criterion sampling.
Non-random probability sampling method was be used to draw nurses from ICU into the
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study. The second technique; criterion sampling, as Polit and Beck (2010:320) explains,
consisted of the researcher consciously selecting participants from the target population
who will meet established criteria of having: been working in ICU for the last one month,
consented to participate and share their views in the study and accepted to fill the
structured questionnaire.
A sample of 103 adult male and female nurses working at ICU for the last six months were
eligible to participate in the study from the three hospitals A, B and C. In hospital A 45 nurses
were eligible, hospital B there were 22 nurses and hospital C had 36 eligible nurses. In terms
of implementing the exclusion criteria, nurses with physical illness and are unable to read
and write were considered ineligible for the study.
3.6 Sample size prediction All nurses working in ICU were eligible to participate in the study. The power of statistics
was used to predict and estimate the suitable sample size. A total of 74 (71.2%) nurses
participated in the data collection from the three ICUs. The sample size for translation and
validation of the tool was determined according recommendation by Sousa et al, 2011
where 10-40 participants is adequate for testing the clarity of the instrument/tool in the
target language.
3.7 Data gathering process
The researcher gathered data by using a supervised self-completion or self-administered
questionnaire using the translated version of Sexton’s 2004 SAQ in Portuguese. Bryman
(2008:232) describes self-administered questionnaire as a process where respondents
answer questions by completing the questionnaire themselves. All respondents were
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provided with research information sheet describing what is involved in the study. A
consent form attached the end of the information sheet were signed by the respondents
who are willing to participate in the study. On signing the consent form, each respondent
is provided with the questionnaire. Questionnaires were given only to those nurses who
signed the consent form. For the purpose of ensuring confidentiality, each respondents was
provided with an envelope to place the completed questionnaires and seal it before
returning it to the supervisor selected within each ICU. The sealed envelope containing the
filled questionnaire were kept under lock and key in the office of the ICU supervisor before
being collected by the researcher after ten days. The researcher has chosen this supervised
self-completion questionnaire because it is cheaper, quicker to complete, there is absence
of interviewer effect, no interviewer variability and convenient for the respondents
(Bryman, 2008:233-4).
3.8 Data analysis
Data was analysed using SPSS software package version 16. The result of the study are
described in text and illustrated with frequencies, tables and figures.
3.9 Methods to ensure trustworthiness
Ethical consideration: Approval of the study was sought from the Director of Escola
Superior de Saude de Santarem for clarity test, authority and permission for data collection
was obtained from each of the Management and Research Committee of the three
hospital.
Scope of the Research: The scope of the study is limited to understanding and describing
the Perception of Patient Safety Culture among Critical Care Nurses at Intensive Care Units
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in three hospitals in Portugal. The study is also further restricted to achieving the objectives
of translating, validating and adapting the SAQ ICU version into Portuguese language for
data collection as well as generating recommendation for improving patient safety culture
among critical care nurses in three hospitals in Portugal. Data collection for this study only
involves Nurses working in ICU at the three selected hospitals in Portugal.
3.10 Research Limitations
Brutus and Stéphane (2013: 48-75), defined limitations of the study as those characteristics
of design or methodology that impacted or influenced the application or interpretation of
results of a study. They further explained that limitations are the restrictions on
generalizability and usefulness of findings that are the result of the ways in which the
researcher chose to design the study and/or the method used to establish internal
and external validity. Despite efforts to ensure accuracy, the researcher is aware of the
study’s shortcomings, because as Bryman (2012:178-9 and 205) explains that quantitative
research studies such as this, however well intentioned, still involves certain deficits
especially in relation to the research conditions; data generation process; the study
method; and researchers’ analysis of the study results.
Limitation related to research situation: The researcher is further aware that the
quantitative method research is incapable to capture all the information related to the how
critical care nurses perceive their safety culture practices in the three hospitals in this study.
In order to inform the readers about the perception of the patient safety culture among
nurses in ICU, the researcher intends to obtain opinion of the respondents using the
translated version of Sexton’s SAQ ICU version (2004) into Portuguese language. This tool is
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chosen due to the fact that there is available data on the psychometric properties that has
been validated in over 500 hospitals across the world including Norway, Sweden, Germany
United Kingdom and USA (Carney, Mills, Bagian, & Weeks, 2010; Chaboyer et al., 2013;
Devriendt et al., 2012; Etchegaray & Thomas, 2012; France et al., 2010; Göras et al., 2013;
Hamdan, 2013; Haugen et al., 2010; Hoffmann et al., 2011; Kaya et al., 2010); providing a
wide view to describe and benchmark the findings.
Limitation related to researchers’ interpretation: The researcher is aware that all research
data can be interpreted in different ways and using different types of methods of analysing
research variables (Bryman 2012:330-50). Although there are many computer software
packages for data analysis, the researcher choose to use SPSS version 16 and STATA for data
analysis. This implies that the researcher will be exercising caution on deciding how to
interpret the variables in this study using the SPSS making sure to use not only be credible
approach but to recognize the variations in the views and opinions of the respondents
depending on the findings. The researcher therefore intends to communicate the findings
in a manner that will illustrate similarities and differences between this study and other
studies on patient safety culture (Abstoss et al., 2011; Ballangrud, Hedelin, & Hall-Lord,
2012; Kreimer, 2014; Patterson et al., 2010; Profit et al., 2012; Sammer, Lykens, Singh,
Mains, & Lackan, 2010).
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4.0 RESULTS
Introduction: In this section, we report the findings of the study based upon the
methodology applied to gather information (Burton and Neil, 2009). The results simply
states the findings of the research arranged in a logical sequence without bias or
interpretation. Here data generated from this study are briefly described in text, tables and
figures.
4.1 Translation and adaptation of SAQ 2006 instruments The tool “Safety attitude questionnaire” (SAQ ICU Version in Appendix G, page 80) was first
developed in English language by Bryan Sexton in 2004 (Bryan Sexton et al., 2011) at the
University of Texas in USA. In their study the researcher sought to undertake a study in ICU
regarding the perception of patient safety culture among critical care nurses in Portugal and
using the SAQ as the research tool. The major spoken language being Portuguese in Portugal
with English language disenfranchisement1 rate of 65% (Ginsburgh & Weber, 2005), it was
imperative to translate and adapt the SAQ tool into the equivalent of the target language
(TL) before being used in this study.
The aim of this process was to achieve different language versions of the English SAQ
instrument that is conceptually equivalent in the target country/culture (Göras et al., 2013;
Zimmermann et al., 2013). This would mean that the tool should be equally natural and
acceptable and should practically perform in the same way (Herdman 1998, Beaton, 2000,
Jones, 2001, Bowden 2003, Nilsson 2013 and Sperber 2013) as the original version. The
focus of this process is on cross-cultural and conceptual, rather than on linguistic/literal
1Language disenfranchisement in European Union refers to the percentage of citizens who would lose their ability to understand EU documents and some discussions if English language were chosen as a working language (Reeves, N. (1990)
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equivalence. A well-established technique to achieve this goal is to use forward-translations
and back-translation method. Translation and adaptation studies by Herdman 1998,
Beaton, 2000, Göras, 2013 and Nilsson Kajermo 2013; all used the forward translation
technique with aspects of expert panel back translation, pre-test and cognitive questioning
to produce the final version (Göras et al., 2013; Nilsson Kajermo et al., 2013).
The steps of the forward and back translation involves seven steps as recommended by
(Valmi D. Sousa and Wilaiporn Rojjanasrirat 2010; - Step 1: translation of the original
instrument into the target language (forward translation or one-way translation), Step 2:
comparison of the two translated versions of the instrument (TL1 and TL2), Step 3: blind
back-translation (blind backward translation or blind double translation) of the preliminary
initial translated version of the instrument, Step 4: comparison of the two back-translated
versions of the instrument (B-TL1 and B-TL2), Step 5: pilot testing of the pre-final version of
the instrument in the target language with a monolingual sample: cognitive debriefing, Step
6: preliminary psychometric testing of the pre-final version of the translated instrument
with a bilingual sample and Step 7: full psychometric testing of the pre-final version of the
translated instrument in a sample of the target population.
As recommended by (Emanuela Fontenele Lima de Carvalho & De Bortoli Cassiani, 2012;
Göras et al., 2013; Sousa & Rojjanasrirat, 2011) the forward translation was performed by
two bilingual and bicultural translators whose mother language is the desired target
language (Portuguese). The two translators were having distinct backgrounds of one being
knowledgeable about health terminology and the content area of patient safety culture of
the instrument in the target language 1 (TL1). The second translator being knowledgeable
about the cultural and linguistic nuances of the target language and is working as a
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freelance language translator of Portuguese-English pairs for over six years and produced
the second version in the target language (TL2). The two forward translators produced two
forward-translated versions of the instrument in the target language (TL1 & TL2) as shown
in the summary in appendix 1.
A third independent translator was used to compare the two versions of TL1 & TL2
instrument, and to compare both the TL1 and TL2 with the source language of the
instrument to produce a summary of the pre-final language (PL). A committee approach
(third independent individual the two translators who participated in Step 1, and
investigator plus one other member who is familiar with cultural and linguistic nuances)
was used to resolve ambiguities and discrepancies to derive the PL-TL version. The pre-final
version was back translated by two translators; one of whom is knowledgeable about health
terminology and the content area of the construct of the instrument in the SL and the other
translator being knowledgeable about the cultural and linguistic nuances of the SL as
recommended by (Sousa & Rojjanasrirat, 2011) to produce two versions of the back
translated version of the pre-final target language version 1 and 2 without having to see the
original SAQ tool in the source language.
The two back translated pre-final version was compared by a multidisciplinary committee
composed of the researcher, one methodologist, one of the translator in forward
translation and a member of the research team. The aim of this process was to compare
between the two back-translations (B-TL1 and B-TL2) of the instrument with the original SL
instrument in order to evaluate similarity of the instructions, items and response format
regarding wording, sentence structure, meaning and relevance. At this stage, minor
ambiguities and discrepancies in the response format, instructions and sentence structure
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were resolved without changing the meaning from the source language to produce the pre-
final translated version in Portuguese (PF summary) ready for testing as shown in appendix
2.
The pre-final version of the instrument in the target language was tested with 37
monolingual participants who were purposively drawn from graduate nursing students. It
is recommended (Sousa & Rojjanasrirat, 2011) that a sample size of 10–40 participants is
adequate for pilot testing of a translated tool, hence the 37 participants in this pilot test is
considered adequate. The goal of the pilot testing was to evaluate the instructions, items
and response format clarity. Participants were asked to respond by stating if the instructions
and items were “clear” or “not clear” as well as asking them for suggestions regarding those
instructions and items which were not clear to them (as shown in table in appendix 2).
Analysis of the pre-test: After applying the tool to 37 graduate nurses, we tested the results
with SPSS version 16 for reliability test. The result showed a scale reliability (Cronbach’s
alpha) value of .71 for all the 64 items in the scale and inter item correlation was considered
strong based on standard deviation that ranged from .000 to .463. Minor adjustments such
as spellings and instructions were made to produce the final tool shown in appendix 3c.
Data Management and Processing
The Questionnaires were read into data editor of SPSS software, producing a dataset / file
for analysis. The Likert-scale (1 = Disagree Strongly, 2 = Disagree Slightly, 3 = Neutral, 4 =
Agree Slightly, 5 = Agree Strongly) was used to score each of the 64 items. The 3 negatively
worded items (item12, item26 and item56) were reverse-scored so that their valence
harmonized with the positively-worded items in the same questionnaire (Sexton et al.
(2006).
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4.2 Data Analysis
Introduction: Every working area, especially in clinical areas, possesses a distinctive social
fabric, leading respondents who work within the same clinical area to respond more
similarly than respondents who are members of different clinical areas. As a result, Sexton
et al. (2006) advises that it is important to control for the non-independence of responses
gathered from the same clinical area via performing analyses that address the multilevel
nature of the data in order to obtain accurate model test statistics and scale reliability
estimates. Therefore, we run a model via multilevel exploratory factor analysis using SPSS
version 16 as well as generating demographic frequencies of the data.
4.3 Demographic information
In total, 103 critical care nurses were asked to participate in the study from three hospitals
in the Central region of Portugal; two public hospital (HA 45 nurses, HC 22 nurses) and one
public private partnership hospital (HB 37 nurses). Out of the 103 eligible nurses, 74
willingly participated in the study, resulting in a response rate of 72%. Of the 74 who
responded, 98.6% (73) completed the survey in its totality and were used for the data
analysis. Among the 73 nurses who fully completed the survey, 55 (74.3%) were female and
18 (24.3%) males. Regarding the job categories of the nurses, 68 (91.9%) are employed as
critical care nurses, 3 (4.1%) as chief nurse as well as 3 (4.1%) nurse managers (one in each
of the three hospital). Of the 74 nurses who responded, 28 (37.8%) are aged 25-34 years,
26 (35.1%) are 35-44 years old, 16 (21.6%) are 45-54 years of age, 2 (2.7%) are less than 25
years old and only one nurses is above the age of 55 years. Considering professional
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experience of the nurses of participated, 43 (58.9%) have 1-10 years’ experience, 23
(31.5%) have 11-20 years’ experience
Table 4.1 Descriptive Frequency of Professional experience within hospitals
PROFESSIONAL EXPERIENCE
Total Less than one year
1 - 10 years
11 - 20 years
Above 20 years
Hospital A (HA)
Count 1 18 17 0 36
% within hospital 2.8% 50.0% 47.2% 0.0% 100.0%
% within Professional Experience 16.7% 41.9% 73.9% 0.0% 49.3%
Hospital B (HB)
Count 5 15 3 0 23
% within hospital 21.7% 65.2% 13.0% 0.0% 100.0%
% within Professional Experience 83.3% 34.9% 13.0% 0.0% 31.5%
Hospital C (HC)
Count 0 10 3 1 14
% within hospital 0.0% 71.4% 21.4% 7.1% 100.0%
% within Professional Experience 0.0% 23.3% 13.0% 100.0% 19.2%
Count within professional Experience 6 43 23 1 73
% within Professional Experience 8.2% 58.9% 31.5% 1.4% 100.0%
Total 100.0% 100.0% 100.0% 100.0% 100.0%
Results in the table above shows that 43 (58.9%) of the nurses have 1-10 years professional
experience however considering individual hospitals, 17 (47.2%) of the 36 nurses in HA
have 11-20 years professional experience, 15 (65.2%) of the 23 nurses in HC have 1-10 years
of professional experience and there is only one nurse from HB with above 20 years of
professional experience.
Besides professional experience we also investigated years of experience of the nurses in
ICU and found that 48 (65.8%) of the nurses have worked in ICU for 1 -10 years, 11 (13.1%)
for less than one year while 14 (19.2%) of the nurses have worked for 11-20 years in the
three hospitals.
We also generated the experience of nurse managers/supervisors working in the three
hospital and the results indicate that 2 of the nurse supervisors have 1-10 years’ experience
in ICU supervising 48 (65.8%) nurses with 1-10 years of experience.
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4.4 Factor Analysis
Introduction: We refer to Factor Analysis as a method of grouping together variables which
have something in common which enables the researcher to take a set of variables and
reduce them to a smaller number of underlying factors (latent variables) which account for
as many variables as possible (Brown et al, 2006). Factor analysis concept was first
developed by Charles Spearman together with Raymound Cattel and Karl Peason in 1901.
The application of factor analysis concept emphasis that hidden concepts or construct
(unobservable) cause something to happen such attitudes, risk taking behaviours (Brown
et al, 2006).
Since such a study has never been done in Portugal’s clinical environment, it is fitting to run
an Exploratory Factor Analysis (EFA) instead of a Confirmatory Factor Analysis (Alappat et
al.) as recommended by (Alappat et al.). They assert that EFA determines apriori the factors
or components that form the variables under study. This means that CFA is more stringent
in testing a well-known set of factors against a hypothesized model of groupings and
relationships. It is worth noting that the Exploratory Factor Analysis (EFA) was used mainly
to explore previously unknown groupings of variables typical in Portugal’s ICU setting in
order to seek underlying patterns, clusters and groups (Spearman et al, 1901 and Brown,
2006).
4.5 Testing for Suitability of Factor Analysis
The suitability of factor analysis was tested using the Kaiser-Meyer-Olking (KMO) which
helps in assessing sampling adequacy and evaluates the correlations and partial
correlations to determine if the data are likely to amalgamate on components. Kaiser
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(1974) recommends accepting values greater than 0.5 as acceptable since values below this
should lead you to either collect more data or rethink which variables to include. The
Bartlett's test was also used to evaluate whether or not our correlation matrix is an identity
matrix and it tests the null hypothesis that the correlation matrix is an identity matrix. Our
results show that KMO of 0.6 (1dp) is sufficient since our Bartlett's test is 1538.77; df 741
which is statistically significant (p < .05) indicating that our correlation matrix (of items)
formed an identity matrix. We conclude that the variables under study are suitable for
factor analysis.
4.6 Testing for significance of variables under study
The proportion of each variable's variance that can be explained by the factors was
assessed and the results in appendix 6a Show that communalities Kaiser-Meyer-Olking
(KMO) extract ranged from .426 - .676 using the Principal component Analysis. Appendix
6b shows the sum of squared factor loadings for the variables or communalities of the final
study variables after those variables with an Extraction value (2nd column of Table 4.2 in
appendix 3d) less than 0.3 were eliminated. An item with an Extraction value less than 0.3
implies that the item is a poor fit in the specified model (Spearman et al 1901 and Brown
2006).
4.7 Factor Extraction from study variables
Extracting the factors or components required that the Eigen values associated with each
component or factor before extraction, after extraction and after rotation be obtained.
Using the SPSS software, and running the Exploratory Factor Analysis with 64 variables, 11
factors were identified whose Eigen values were greater than 1. After analysing the Scree
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Plot (Figure 4.0) however, results revealed that the slope of the plot starts to level after the
6th component which meant that 6-factor-model was plausible.
Figure 4.0 Scree Plot for Study Variables
The 6 factors when fitted, the Eigen values associated with each factor represent the
variance explained by that particular linear component and are shown in Table 4.3.
Table 4.3 Eigen Values for Component extraction
Total Variance Explained
Component Initial Eigenvalues Extraction Sums of Squared Loadings
Rotation Sums of Squared Loadings
Total % of Variance
Cumulative %
Total % of Variance
Cumulative %
Total % of Variance
Cumulative %
1 7.117 18.248 18.248 7.117 18.248 18.248 5.907 15.146 15.146
2 4.557 11.684 29.932 4.557 11.684 29.932 3.735 9.576 24.722
3 2.918 7.481 37.414 2.918 7.481 37.414 3.396 8.708 33.430
4 2.869 7.355 44.769 2.869 7.355 44.769 3.061 7.849 41.279
5 2.475 6.345 51.114 2.475 6.345 51.114 2.949 7.561 48.840
6 2.007 5.147 56.261 2.007 5.147 56.261 2.894 7.420 56.261
Extraction Method: Principal Component Analysis.
From Table 4.3, the Eigen values for the first 6 factors extracted explain 56.261% of total
variance after rotation. Results also show that these 6 factors extracted explain more than
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half of the total variance compared to the 33 remaining factors which explain the
remainder variance thus asserting the importance of these 6 factors extracted.
4.8 Factor Patterning with study variables
After the extraction of factors that are suitable for analysis, the study variables associated
with each factor had to be found. In this study, we chose to use the Rotated Component
Matrix produced by the SPSS software as shown in table 4.4b
Finally, the Rotated Component Matrix (Table 4.4b in appendix 3f) shows the factor
loadings for each variable. For each factor (column), the coloured (yellow) box corresponds
to those variables in that specific factor. These are the factors that each variable loaded
most strongly on. According to Sexton et al, (2006), a factor requires a minimum of three
items to form a component. Based on these factor loadings, we suggest these factors to
represent the following summary of domains as shown in the table 4.4c below. We named
these domains according to the items that formed the factors in the second column.
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Table 4.4c showing Component of factor structure Items in the component to form the factor structure. Name of the factor
(Domains)
Factor 1: {9, 10, 11, 15, 18, 21, 24, 28, 31, 42, 43, 53, 58}
9. The administration of this hospital is doing a good job
10. Hospital administration supports my daily efforts
11. I receive appropriate feedback about my performance.
15. This hospital is a good place to work
18. Hospital management does not knowingly compromise the safety of patients
21. This hospital encourages teamwork and cooperation among its personnel.
24. This hospital deals constructively with problem personnel
28. I am provided with adequate, timely information about events in the hospital that
might affect my work
31. I am proud to work at this hospital
42. Very high levels of workload stimulate and improve my performance
43. Truly professional personnel can leave personal problems behind when working
53. Interactions in this ICU are collegial, rather than hierarchical.
58. Information obtained through incident reports is used to make patient care safer in
this ICU
Perception of management
The items in this domain
consists of statements
that form part of
management roles.
Hence we named this
component as
corresponding to
management
perception.
Factor 2: {6, 23, 36, 45, 54, and 55}
6. This hospital does a good job of training new personnel.
23. The culture in this ICU makes it easy to learn from the errors of others
36. I have the support I need from other personnel to care for patients
45. Trainees in my discipline are adequately supervised
54. Important issues are well communicated at shift changes
55. There is widespread adherence to clinical guidelines and evidence-based criteria in
this ICU
Safety Climate
The items that form this domain
consists of statements
that consist of
Factor 3: {3, 4, 20, 32, 37, and 40}
3. Nurse input is well received in this ICU
4. I would feel safe being treated here as a patient
20. Decision-making in this ICU utilizes input from relevant personnel
32. Disagreements in this ICU are resolved appropriately (i.e., not who is right but what
is best for the patient).
37. It is easy for personnel in this ICU to ask questions when there is something that
they do not understand
40. The physicians and nurses here work together as a well-coordinated team
Teamwork Climate
Factor 4: {13, 17, 25, 27, 30, 33, and 38}
13. Briefings (e.g., patient report at shift change) are important for patient safety
17. All the personnel in my ICU take responsibility for patient safety
25. The medical equipment in this ICU is adequate
27. When my workload becomes excessive, my performance is impaired.
30. I know the proper channels to direct questions regarding patient safety in this ICU
33. I am less effective at work when fatigued
38. Disruptions in the continuity of care (e.g., shift changes, patient transfers, etc.) can
be detrimental to patient safety.
Job satisfaction
Factor 5: {34, 35, 49, and 50}
34. I am more likely to make errors in tense or hostile situations.
35. Stress from personal problems adversely affects my performance.
49. Fatigue impairs my performance during emergency situations (e.g. emergency resuscitation,
seizure).
50. Fatigue impairs my performance during routine care (e.g., medication review,
ventilator checks, transfer orders)
Stress recognition
Factor 6: {46, 48, and 51}
46. I know the first and last names of all the personnel I worked with during my last
shift
48. Staff physicians/intensivist in this ICU are doing a good job.
51. If necessary, I know how to report errors that happen in this ICU
Work condition
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4.9 Goodness-of-Fit of the Model
This study used the entire sample of all respondents in order to make the maximum
number from all areas (n = 74) available for parameter estimation at the clinical area level.
To evaluate the overall fit of each model to the data, we used the Chi-square test of model
fit which follows a procedure that tabulates a variable into categories and computes a chi-
square statistic (Maydeu-Olivares et al 2010).
The chi-square test is always testing the null hypothesis, which states that there is no
significant difference between the expected and observed result. This Null Hypothesis is
only rejected when the p value for the calculated is p < 0.05 and concludes that there is
significant difference between the expected and observed result.
This goodness-of-fit test compares the observed and expected frequencies in each category
to tests that all categories contain the same proportion of values or test that each category
contains a user-specified proportion of values. The findings revealed that all variables
included in the model were fitting in the model except item18 and item42 (appendix 3e).
We initially fit a 6-factor exploratory factor analysis model that contained the 64 items
retained in previous studies that explored the SAQ's construct validity (for instance Sexton,
2006). Items or variables with weak factor-item associations at the clinical area level or
individual level were then deleted sequentially via a backward elimination procedure until
satisfactory model fit was attained.
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4.10 Reliability of the Model
Once satisfactory model fit was obtained, we used the model results to compute composite
scale reliability using Alpha (Cronbach) which is a model of internal consistency, based on
the average inter-item correlation. We used the reliability analysis to study the properties
of measurement scales and the items that compose the scales.
It is worth noting that Raycov (1997) asserts that the Coefficient alpha; the usual statistic
used to estimate scale reliability, assumes that all items' factor loadings are identical, a
restrictive assumption that biases scale reliability estimates and provides Raykov's ñ
statistic as an alternative test statistic which relaxes this assumption hence yielding more
accurate reliability estimates. However, this study used Alpha (Cronbach) and not Raykov's
ñ statistic because the latter is not found in SPSS 16 version of the software that we used.
Accordingly, we report Alpha here below as the scale reliability estimate for the SAQ.
The value of Cronbach's alpha which is an estimate of the true alpha is reported in the
Reliability Statistics shows Cronbach’s Alpha value of 0.819 which in turn is a lower value
bound for the true reliability. These results indicate a strong reliability of the SAQ. Overall,
this finding, in conjunction with the multi-level factor analyses demonstrated that the SAQ
has very good psychometric properties.
4.11 Variability in the Study Model
More analysis was conducted using STATA-8.0 software. There was substantial variability
across the 5 ICU clinical areas at the item level for all hospitals. In total (Table 4.5a), for
instance, 59 percent of all respondents disagreed with an assertion that it is not difficult to
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speak up if they perceive a problem with patient care, but at the clinical area level, the
percent of respondents who disagree ranged from 56% (Table 4.5b) to 81% (Table 4.5c).
Table 4.5a Difficulty to speak up in case of a problem at all 3 hospitals
In this ICU it is NOT difficult to speak up if I perceive a problem with care
Freq. Percent Cum.
Disagree strongly 12 16.22 16.22
Disagree slightly 32 43.24 59.46
Neutral 5 6.76 66.22
Agree slightly 21 28.38 94.59
Agree strongly 3 4.05 98.65
no answer 1 1.35 100
Total 74 100
Table 4.5b Difficulty to speak up in case of a problem at Polyvalent clinical area
Freq. Percent Cum.
Disagree strongly 11 19.3 19.3
Disagree slightly 21 36.84 56.14
Neutral 4 7.02 63.16
Agree slightly 17 29.82 92.98
Agree strongly 3 5.26 98.25
no answer 1 1.75 100
Total 57 100
Table 4.5c Difficulty to speak up in case of a problem at Cardiology clinical area
Freq. Percent Cum.
Disagree slightly 8 72.73 72.73
Neutral 1 9.09 81.82
Agree slightly 2 18.18 100
Total 11 100
In other words, half respondents reported difficulty speaking up in some clinical areas,
while in other clinical areas, almost all the caregivers reported difficulty speaking up.
Variability in the Study Model
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We also conducted analyses on mean scores for all 6 factors and converted the means into
percent agreement to facilitate understanding of the items and scales. The percentage of
all respondents reporting "agree slightly" or "agree strongly" for each of the items within a
given scale were charted as the percent positive as recommended by Sexton 2006 and he
percentage of all respondents reporting "disagree slightly" or "disagree strongly" for each
of the items within a given scale were charted as the percent negative as shown in the table
4.6.
Table 4.6 Factor Variability in all hospitals (N = 73)
Factors % Negative Neutral % Positive
Working condition 41.1% 18.2% 76.7%
Job satisfaction 2.7% 37.0% 60.3%
Teamwork climate 1.4% 47.9% 50.7%
Safety climate 1.4% 57.5% 41.1%
Stress recognition 17.8% 54.8% 27.4%
Management perception 9.6% 83.6% 6.8%
The researcher investigated the influence of the new-found factor structure by analyzing
some variables within those factors using a sample from all the hospitals.
Hospital ICU nursing staff were asked about their perception on management’s
commitment on safety and this factor received the least percent positive of 6.8% amongst
all factors (Table 4.6) an issue that tells much about the safety environment in the 3
hospitals. The results essentially indicate that management has not fulfilled its roles as far
as safety is concerned. Findings in reveal that 50.0% of hospital staffs in the ICU do not
receive an appropriate feedback about performance which most probably demotivates
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them. In addition, majority (37.8%) of respondents disagreed with a statement that “This
hospital deals constructively with problems of personnel” and this is not to be taken lightly.
Hospital ICU staffs were asked about their perception of the safety climate within their
hospital ICUs and this factor received the least percent negative of 1.4% amongst all factors
(Table 4.6) which implies that they still have faith in the safety of patients at the three
hospitals.
Regarding adherence to clinical guideline, the results indicate that culture in this ICU makes
it easy to learn from errors of others as half of respondents (51.35%) supported it compared
to the minority who disagreed at 27.03% of all respondents. In addition, an overwhelming
majority (74.33%) of respondents agreed that there is widespread adherence to clinical
guidelines within their respective ICU and this is good news as far as patient safety is
concerned.
Hospital ICU staffs were asked about their teamwork environment within their places of
work and this factor received the least percent negative of 1.4% amongst all factors (Table
4.6) which implies that they work together harmoniously even when they show some
weaknesses emanating from management side.
Our results indicates that it is easy for personnel in ICU to ask questions as 71.62% of
respondents agreed and this is consistent with findings in about how easy it is to learn from
errors of others. Moreover, 67.56% of all interviewed hospital staffs agree that the
physicians and nurses work together as a coordinated team compared to 24.33% who
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disagreed. The reason could be that decision making in these ICUs utilizes input from
relevant personnel as shown by the support of 70.27% of all respondents.
Job Satisfaction of ICU staffs within the three hospitals
Hospital ICU staffs were asked to respond about their job satisfaction since it is a vital
element that determines patient safety and this factor received the second highest percent
positive of 60.3% (Table 4.7) which implies that other than a few issues with management,
they are quite satisfied with their jobs which is good news.
Table 4.7 Feedback and the Quality of Collaboration with the Chief Nurse Chi-Square Tests
Value df Asymp. Sig. (2-sided)
Pearson Chi-Square 30.312a 16 .016
Likelihood Ratio 28.928 16 .024
Linear-by-Linear Association 7.297 1 .007
N of Valid Cases 73
a. 20 cells (80.0%) have expected count less than 5. The minimum expected count is .03.
The results indicate that the medical equipment in ICU is adequate as it is overwhelmingly
supported by respondents at 86.49% and this is a crucial ingredient of job satisfaction since
it makes nurses and physicians comfortable while doing their jobs. And as a result, almost
all (90.54%) of respondents concurred that all the personnel in ICU take responsibility for
patient safety. These findings are in agreement with the general picture of literature where
work equipment and staff remuneration are adequate.
Stress Recognition within the three hospitals
Hospital ICU staffs were asked to respond about their stress recognition elements since it
is a vigorous component that determines patient safety and this factor ranked highly on
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the negative side with a percent negative of 17.8% showing an idea of what this factor is
capable of among respondents performance regarding patient safety at work (Table 4.7).
The results indicate that fatigue impairs staff performance during emergency situation as
it is supported by majority (59.46%) of respondents and if not recognized, this negatively
affects patient safety chances. To know that fatigue is not only dangerous emergency
situations, 67.57% of all respondents agreed that fatigue impairs staff performance even
during routine care which puts an alarm on stress recognition among staff to improve
patient safety environment within these three hospitals
Associations of factors on patient safety within three hospitals
We also assessed feedback and the Quality of Collaboration with the Chief Nurse. With this
study aiming at analysing the influence the factors have on patient safety practices among
critical care nurses in three hospitals in Portugal, hospital staffs were asked to describe the
quality of collaboration and communication they experienced with the Chief Nurse. Results
show that majority of respondents 41.1% (30 out of 73) reported adequate quality of
collaboration and communication. This was supported by the joint respondents at 47.9%
of all respondents who recorded high and very high quality of collaboration and
communication with the Chief Nurse.
Table 4.7 Feedback and the Quality of Collaboration with the Chief Nurse Chi-Square Tests
Value df Asymp. Sig. (2-sided)
Pearson Chi-Square 30.312a 16 .016
Likelihood Ratio 28.928 16 .024
Linear-by-Linear Association 7.297 1 .007
N of Valid Cases 73
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Chi-Square Tests
Value df Asymp. Sig. (2-sided)
Pearson Chi-Square 30.312a 16 .016
Likelihood Ratio 28.928 16 .024
Linear-by-Linear Association 7.297 1 .007
a. 20 cells (80.0%) have expected count less than 5. The minimum expected count is .03.
In order to analyze the links between staff perceptions about management and
communication, the study employed the Pearson Chi-Square test statistic from the cross-
tabulations of selected variables. Study findings in show that majority (56.2%) of those who
reported very high quality of collaboration/communication with the chief Nurse also
agreed that they receive appropriate feedback about their performance. While, this is good
news for management, majority (57.3%) of those who reported low quality of
collaboration/communication with the chief Nurse also claimed that they do not receive
appropriate feedback about their performance. All these associations were statistically
significant at 95% confidence level since the p-value was less than 0.05 (Table 4.5b).
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Table 4.8 Feedback and the Quality of Collaboration with the Chief Nurse
Chief Nurse * I receive an appropriate feedback about my performance Cross tabulation
I receive an appropriate feedback about my performance
Total Disagree
strongly Disagree slightly Neutral
Agree slightly
Agree strongly
Chief Nurse
Low Count 4 2 0 1 0 7
% within Chief Nurse 57.1% 28.6% .0% 14.3% .0% 100.0%
% of Total 5.5% 2.7% .0% 1.4% .0% 9.6%
Adequate Count 3 11 8 8 0 30
% within Chief Nurse 10.0% 36.7% 26.7% 26.7% .0% 100.0%
% of Total 4.1% 15.1% 11.0% 11.0% .0% 41.1%
High Count 2 9 3 2 0 16
% within Chief Nurse 12.5% 56.2% 18.8% 12.5% .0% 100.0%
% of Total 2.7% 12.3% 4.1% 2.7% .0% 21.9%
Very high Count 3 3 1 10 2 19
% within Chief Nurse 15.8% 15.8% 5.3% 52.6% 10.5% 100.0%
% of Total 4.1% 4.1% 1.4% 13.7% 2.7% 26.0%
Not applicable
Count 0 0 0 1 0 1
% within Chief Nurse .0% .0% .0% 100.0% .0% 100.0%
% of Total .0% .0% .0% 1.4% .0% 1.4%
Total Count 12 25 12 22 2 73
% within Chief Nurse 16.4% 34.2% 16.4% 30.1% 2.7% 100.0%
% of Total 16.4% 34.2% 16.4% 30.1% 2.7% 100.0%
Fatigue and the Quality of Collaboration with the Intensive Care Nurse
With this study aiming at analyzing the influence the factors have on patient safety
practices among critical care nurses in three hospitals in Portugal, hospital staffs were
asked to describe the quality of collaboration and communication they experienced with
the Intensive Care Nurse. We found that majority of respondents 27.4% reported adequate
quality of collaboration and communication. This was supported by the joint respondents
at 37.0% who recorded high and very high quality of collaboration and communication with
the Chief Nurse.
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In this study, we gave an open ended questions and asked the respondents for their top three
recommendations regarding how to improve patient safety at their ICU. Among the 74 participants,
17 (23%) participants gave 50 recommendations. Majority of the recommendations were given by
nurses from HB1. The contents of the recommendations were deductively analysed and five major
themes identified as teamwork climate (33%), human resource improvement (21%), working
environment (19%), safety climate (17%) and training/competence strengthening (10%) as
illustrated in figure 2 below.
Figure 2. Recommendations for improving patient safety culture
21%19%
17%
33%
10%
0%
5%
10%
15%
20%
25%
30%
35%
Human Resource Work Environment Safety Climate Teamwork Climate Competence and
Training
Per
ceta
ga
e o
f R
esp
on
ses
(%)
Recommendations
R e c o m m e n d a t i o n s f o r i m p r o v i n g p a t i e n t s a f e t y c u l t u r e
( n = 1 7 )
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5.0 Discussion
Introduction: In this section, the results of the study are explained focussing on the relevant
results from the data obtained in comparison to previous study. We also describe how the
findings fit the existing theories and other research in the field of patient safety culture. We
discussed the result based on the objective of the study and comparing with the available
literature.
5.1 Translation and adaptation of the SAQ ICU version to Portuguese
language
We performed translation and adaptation of SAQ tool into Portuguese language using
forward and backward translation process as recommended by Sousa and Rojjanasrirat,
2011. This method was chosen because of its simple structure and easy approach. The
translation and adaptation process was relatively easy because we were able to get
multilingual individuals to forward translate the tool into Portuguese language besides
having difficulty in getting the required number of bilingual participants for testing the tool
(Sousa and Rojjanasrirat (2011). This problem was overcome by using a committee
approach for comparing the two back-translated versions of the instrument (B-TL1 and B-
TL2) as an alternative method to produce the final tool.
The strength of this study is in two folds; 1). The study sample is representative for the
translation and adaptation process of the tool in which we tested the pre-final tool with 37
participants. This is considered representative because Rojjanasrirat 2011 recommends a
sample of 10-40 participants to be representative for pretesting. The test sample showed
strong reliability (Cronbach’s alpha of .71) for 44 items out of the 64 items on the original
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tool. 2). In the application of the final translated tool to the study sample to nurses working
at ICU in three hospitals, 72% of the nurses responded and 98.6% answered the
questionnaire to completion.
To our knowledge, this is the first study that has translated and adopted the SAQ ICU version
in a sample of Portugal’s critical care unit targeting nurses only in three different hospitals.
The high response rate in this study is believed to reflect the typical view of nurses in critical
care unit hence reflecting the safety climate at the three ICUs.
In general the SAQ ICU version is psychometrically sound in assessing the six safety related
climate domains. In this study the Cronbach’s alpha of .71 at pre-test and .819 during final
application of the translated tool are considered strong because the bench mark values of
Cronbach alpha ranging from .68 to .90 whereas the alpha value for each domains are also
deemed acceptable.
5.2 Factor analysis
Factor analysis concept was first developed by Charles Spearman together with Raymound
Cattel and Karl Peason in 1901. We performed factor analysis by grouping together variables
which have something in common in order to find out if we can obtain the original 6
domains as identified by Sexton 2006. This enabled the researcher to take a set of variables
and reduce them to a smaller number of underlying factors (latent variables) which account
for as many variables as possible. We found that our data set amalgamated on components
(Kaiser 1974) to form an identity matrix with KMO because the sample was adequate on
performing Bartlett’s test.
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Out factor extraction yielded 6 component (domains) with the Eigen values for the first 6
factors extracted explaining 56.3% of total variance in our study. These 6 factors extracted
explain more than half of the total variance compared to the 33 remaining factors explaining
the remainder variance. The variables loaded strongly on six factors namely management
perception (15.146%) as the strongest factor, safety climate (9.576%), teamwork climate
(8.708%), job satisfaction (7.849%), stress recognition (7.561%) and working condition
(7.420%). We noted that there is variability in the items that form the factors in this study.
We attribute the difference to four possibilities; first of all, there sample in this study
targeted nurses only unlike in other studies which involved all health care professionals such
as doctors, anaesthetist, administrators, physicians hence the difference especially the
items that loaded for management perception. Secondly we believe that our sample size
was also small as compared studies by Sexton in 2006 in which they used over 2000
participants. Thirdly, we believe that demographic characteristics of the participants could
have influenced the outcome of the domains. Fourthly, to our knowledge, using a
confirmatory factor analysis to determine the components of the items gave the freedom
to match the items randomly hence confirming that there is a difference in the perception
of the nurses working a typical Portuguese ICU compared to those studies in other countries
(Bondevik et al., 2014; Chaboyer et al., 2013; Devriendt et al., 2012; Etchegaray & Thomas,
2012; France et al., 2010; Göras et al., 2013; Hamdan, 2013; Hoffmann et al., 2011; Kaya et
al., 2010; Profit et al., 2012) . Lastly, since we performed cultural translation and validation
for Portuguese population, this could have contributed to the variation.
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We established that there is variability in the perception of the patient safety culture in
typical ICU in Portugal. The nurses in the three ICUs perceive management as the strongest
domain that influences patient safety in their ICU because the nurses believe that the
hospital supports their daily effort especially management providing adequate and timely
information about events in the hospital that might affect their work. Despite the fact that
management perception received the least percent positive, the nurses strongly feel proud
to work at this hospital because the administration is doing a good job by providing
appropriate feedback on nurse’s performance and dealing constructively with problems
(Aagja & Garg, 2010; Allen, Chiarella, & Homer, 2010; Armellino et al., 2010; Bondevik et
al., 2014)
5.3 Factor variability
When individual attitudes are aggregated by clinical area, the SAQ provides a snapshot of
the climate in a given clinical area. Sexton et al (2006) in his study asserts that one attitude
is an opinion, but the aggregate attitudes of everyone in a clinical area is climate hence
indicating the culture in that clinical area. In the whole environment (sample), study results
show that working conditions is the most influential factor with a percent positive of 76.7%
followed by job satisfaction with 60.3%. We attribute this high percentage positive of
working condition to efforts by the administration to ensure they have adequate
equipment, safe clinical environment, rigorous review of policy and regular clinical audit
since the two public private partnership hospitals are accredited to international quality
standards (Raftopoulos, 2013).
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The working condition were considered favorable due positive factors such as teamwork
(50.7%) however the negative factors such as stress recognition, safety climate and
management perception are considered by the nurses as hindering effort to provide safe
patient care because they have negative percentage. Teamwork climate (50.7%) is
considered average in this study because the nurses report adequate to high level of
collaboration and communication with manager and physicians. Other studies reported
similar variations in their findings (AbuAlRub, Gharaibeh, & Bashayreh, 2012).
Management perception of respondents received the least percent positive (6.8%), an
issue that should be analyzed further to know the causes even though respondents seemed
to have some job satisfaction levels. Even though the management perception received the
least percent positive, stress recognition was ranked highly on the negative side with a
percent negative of 17.8% showing an idea of what this factor is capable of among
respondents performance at work. This results concurs with literature that ICU
environment is often stressful due to the critical nature of the patient that requires close
attention and monitoring (Alkire, 2005; Chung & Chung, 2009; France et al., 2010; Goetz,
Beutel, Mueller, Trierweiler-Hauke, & Mahler, 2012; Göras et al., 2013; Sexton et al., 2000)
Job satisfaction relates to that influence staff morale, feeling empowered with important
information about patient safety, fellow staff taking responsibility for patient safety, having
adequate equipment to work with at ICU, being able work effectively even if the work load
is high and acknowledge being less effective when fatigued.
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The study results essentially indicate that management has not fulfilled its roles as far as
safety is concerned. We found that 50.0% of hospital staffs in the ICU do not receive an
appropriate feedback about performance which most probably demotivates them. In
addition, majority (37.8%) of respondents disagreed with a statement that “This hospital
deals constructively with problems of personnel”; this should not to be taken lightly and
needs to be investigated further since similar findings in Australia were predictive of defects
in safety of patients (Allen, Chiarella, & Homer, 2010).
Safety Environment within the three hospitals ICU has been perceived to be least percent
negative of 1.4% amongst all factors (Table 4.7) which implies that they still have faith in
the safety of patients at the three hospitals. The nurses also concur that culture in this ICU
makes it easy to learn from errors of others as half of respondents (51.35%) supported it
compared to the minority who disagreed at 27.03% of all respondents. In addition, an
overwhelming majority (74.33%) of respondents agreed that there is widespread
adherence to clinical guidelines and EB criteria within their respective ICU and this is good
news as far as patient safety is concerned.
Teamwork Environment within the three hospitals also received the least percent negative
of 1.4% amongst all factors which implies that nurse work harmoniously even when they
show some weaknesses emanating from management side. Studies show that strong
teamwork strengthens the weak points within the work environment because the staff
tends to support each other (AbuAlRub et al., 2012; Anderson, Thorpe, Heney, & Petersen,
2009; Bell & Pontin, 2010; Chaboyer et al., 2013). This is further supported by the fact it is
easy for personnel in ICU to ask questions as 71.62% of respondents agreed, consistent
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with findings that it is easy to learn from errors of others. Moreover, 67.56% of all
interviewed hospital staffs agree that the physicians and nurses work together as a
coordinated team compared to 24.33% who disagreed. The reason could be that decision
making in these ICUs utilizes input from relevant personnel as shown by the support of
70.27% of all respondents.
Job Satisfaction of ICU staffs within hospitals is a vital element that that has an impact on
patient safety (Wicks, Lynda St, & Kinney, 2007) and this factor received the second highest
percent positive of 60.3%. This implies that other than a few issues with management, the
nurses are quite satisfied with their jobs which is good news. Factors such resources to use
at work place have been known to influence job satisfaction. We found that medical
equipment in ICU is adequate as it is overwhelmingly supported by respondents at 86.49%
and this is a crucial ingredient of job satisfaction since it makes nurses and physicians
comfortable while doing their jobs especially at ICU which depends on high technology for
providing all round care the ill patients. And as a result, almost all (90.54%) of respondents
concurred that all the personnel in ICU take responsibility for patient safety. These findings
are in agreement with the general picture of literature where work equipment and staff
remuneration are adequate. Literature has shown that availability of resources,
management style, remuneration and team collaboration enhances job satisfaction
(AbuAlRub et al., 2012; Anderson et al., 2009).
Stress Recognition within the three hospitals is a strong component that determines
patient safety and this factor ranked highly on the negative side with a percent negative
regarding patient safety at work. This figure is supported by nurses who agreed that fatigue
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impairs staff performance during emergency situation as it is supported by majority
(59.46%) of respondents and if not recognized, this negatively affects patient safety
chances. To know that fatigue is not only dangerous in emergency situations, 67.57% of all
respondents agreed that fatigue impairs staff performance even during routine care which
puts an alarm on stress recognition among staff to improve patient safety environment
within these three hospitals (Allen et al., 2010; Huang et al., 2007; Kaya et al., 2010; Profit
et al., 2012; Weaver, Wang, Fairbanks, & Patterson, 2012).
With this study aiming at analysing the influence of these factors on patient safety practices
at the three hospitals in Portugal, the nurses were asked to describe the quality of
collaboration and communication experienced with the Chief Nurse. Results show that
majority of respondents 41.1% (30 out of 74) reported adequate quality of collaboration
and communication. This was supported by the joint respondents at 47.9% of all
respondents who recorded high and very high quality of collaboration and communication
with the Chief Nurse. We know that communication and collaboration are the key elements
of teamwork but we cannot be sure why management perception received the least overall
percentage positive (6.8%) among all the factors hence requiring further investigation.
In order to analyze the links between staff perceptions about management and
communication, the study employed the Pearson Chi-Square test statistic from the cross-
tabulations of selected variables. Study findings show that majority (56.2%) of those who
reported very high quality of collaboration/communication with the chief Nurse also
agreed that they receive appropriate feedback about their performance. While, this is good
news for management, majority (57.3%) of those who reported low quality of
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collaboration/communication with the chief Nurse also claimed that they do not receive
appropriate feedback about their performance. All these associations were statistically
significant at 95% confidence level since the p-value was less than 0.05. We strongly believe
that the nurse manager is unable to find opportunity to communicate to all the staff in the
department. However, the fatigue and the Quality of Collaboration with the Intensive Care
Nurse was rated at 27.4% reporting adequate quality of collaboration and communication.
This was also supported by the joint respondents at 37.0% of all respondents who recorded
high and very high quality of collaboration and communication.
Based on our understanding of the factor structure obtained in this study, we recommend
a model to further understand how patient safety culture in ICU can be modeled. To our
knowledge, many researchers have taken studies on this subject with serious interest and
we would like to contribute by suggestion a simple model which we call “Patient Safety
Torch” as illustrated below for conceptualizing patient safety:
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5.4 Conceptual Framework Patient safety is influenced by different factors including both individual and organizational factors.
All the influencing factors are dependent on each other. For instance, deficit in one of the domain
will subsequently have an influence another domain such as if the management does not support
the staff in their effort to address errors effectively, it leads to unsafe practices where as if
management handles errors appropriately and use it as a learning opportunity, the next time such
an error will be prevent or managed appropriately.
Figure 3: Proposed “THE PATIENT SAFETY TORCH MODEL”
A torch typically consists of a power source (battery); in this case “patient”, the body
(individual staff), the bulb (the patient safety), reflector (five domains) and the glass
filter/switch (management).
In this proposed model, management is considered as a filter responsible for ensuring that
conditions necessary for patient safety are identified. These condition are the factors that
are unique to each department or unit within ICU. Such factors may include teamwork
climate, stress recognition, working conditions and safety climate or even others. The
Patient
safety
culture
INDIVIDUAL characteristics Age, Gender, job category, Years / Experience / service, Duty shift, Type of job
Teamwork
Climate
Job satisfaction
Stress recognition
Perception of management: The unit manager as an
implementer of organizational Policy, is perceived as being
the most important person to ensure implementation by
switching on the light for patient safety in the unit.
Safety Climate
Work conditions
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influence of these factors depend on the individual characteristics such as age, gender, level
of experience and professional expertise. How each staff responds to the factors depends
largely on how the management implements the mission, vison and core values of the
organisation. We refer to this model as the “patient safety torch model” where the
manager is the torch holder and switches the torch to light up patient safety in the unit or
department.
5.5 Significance of study
The study may be significant directly or indirectly to the clinical nursing practice, hospital
policy, nursing education, and patient’s family and critical care nurses in the three hospitals
in Portugal. The findings may have the potential to contribute positively in the following
areas:
Significance to clinical nursing practice: The findings may generate new understanding of
how ICU nurses perceive their patient safety practices in the three hospitals in Portugal. The
findings of the study in the areas of error reporting, teamwork, work environment and
communication, recommendations for improvement and job satisfaction could be used for
improving patient safety strategies, especially enhancing efforts to provide safe ICU care in
the three hospitals. As Hughes (2008) claims if an organization’s culture is based on secrecy,
defensive behaviours, professional protectionism, and inappropriate deference to
authority, the culture invites threats to patient safety and poor-quality care.
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Significance to health policy: The research may contribute towards development of nursing
policies and protocols towards patient safety practices in ICU in the three hospitals in
Portugal. The finding may be used as pilot results for policy initiatives.
Significance to nursing education: The views of the respondents in this study may provide
a basis for redesigning strategies of how to provide safe care at ICU. It may also provide a
baseline survey for further studies on large scale in Portugal. The translation of the SAQ ICU
version into English may provide an initial opportunity for Portuguese nurses to use the tool
for educational purpose in future and for monitoring the safety culture practices in ICU in
Portugal. Those interested in the subject may want to understand patient safety using or
proposed concept.
Significance to the public: The study identified factors that influence patient safety culture
among critical care nurses hence suggest recommendation for improving safety practices in
ICU. The deeper understanding of culture of patient safety in the ICUs of the three hospitals
unlocks opportunities for the management to make improvement in the six domains of
attitudes toward patient safety such as teamwork climate, job satisfaction, and perception
of management, safety climate, working conditions, and stress recognition (Thomas et al,
2003). Any effort to improve patient safety as a result of the findings of this study will
directly and indirectly benefit the public through receiving safe care from intensive care
units.
Significance to nursing research: The findings of this study may have the potential to
contribute additional information regarding the culture of patient safety in ICU. Such a study
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may have the potential to generate new inquiry into the area of safety culture in ICU. We
believe that the findings may motivate other researchers to pick interest on patient safety
culture in Portugal and other parts of the world.
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6.0 Conclusions
The SAQ ICU version is psychometrically valid in Portuguese culture and can be used to
measure patient safety culture. Understanding patient safety requires an approach where
management at all levels needs to engage with frontline workers in other to instil the values
of the organization in promoting safe care. We names the new tool as SAQ Version for ICU
Nurses (QUESTIONÁRIO DE ATITUDES DE SEGURANÇA PARA ENFERMEIRAS EM UCI).
There is significant similarities in the factors or domains that influence patient safety in a
typical Portuguese intensive care unit and further studies are recommended in the area of
patient safety culture using the validated SAQ Portuguese version.
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7.0 Reference
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Appendix A: Activity plan
ACTIVITIES JULY 2014
SEPTEMBER 2014 OCTOBER 2014
NOVEMBER 2014
DECEMBER 2014 JANUARY 2014 FEBRUARY 2015
WEEKS
4 weeks
1 a
2 a
3 a
4 a
1 a
2 a
3 a
4 a
1 a
2 a
3 a
4 a
1 a
2 a
3 a
4 a
1 a
2 a
3 a
4 a
1 a
2 a
3 a
4 a
Topic approval
Bibliographic revision
Authorisation
Data gathering
Data treatment
Report writing
Report delivery
Thesis defence
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Appendix B: Authorization letter for data collection for clarity test.
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Appendix C. Permission letter from Hospital 2 (H2)
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Appendix D: Permission letter from Hospital 3 (H3)
Aprovação - Percepção da Cultura de Segurança do Doente entre Enfermeiros em
Unidades de Cuidados Intensivos
Inbox x
11/20/14
To: [email protected],
Boa tarde, Serve o presente para informar que o estudo abaixo identificado foi aprovado, em sede de comissão executiva, no dia de ontem 19.11.2014.
“Estudo descritivo (já apreciado pela CES em sentido favorável) de recolha de dados
para dissertação, com base em questionários auto-administrados, intitulado:
“Percepção da Cultura de Segurança do Doente entre Enfermeiros em Unidades de
Cuidados Intensivos” no âmbito do Curso de Master Mundus em Enfermagem de
Emergência e Cuidados Críticos (EMMECC), na Escola Superior de Saúde de Santarém,
tendo como investigador principal Cliff Asher Aliga”. MC, Direcção Jurídica
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Appendix E: Permission letter from Hospital 1 (H1)
Enviada: 21 de outubro de 2014 10:02
Para: José Amendoeira - ESSaude
Assunto: RE: Solicitação para colheita de dados
Bom Dia,
Em resposta ao solicitado, somos a informar que se encontra autorizado.
Com os melhores cumprimentos.
Secretariado do Conselho de Administração
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Appendix F. Permission letter from author of SAQ.
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Appendix G: The Original SAQ ICU Version 2004
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Appendix 1: Summary Forward & back translation to target
language (TL1 & TL 2) Portuguese
ORIGINAL SAQ VERSION
FORWARD TRANSLATION TL1
FORWARD TRANSLATION TL2
Summary of Blind back translation
Safety Attitudes Questionnaire (ICU Version)
Questionário De Atitudes De Segurança (Versão De UCI)
Questionário de Atitudes de Segurança (Versão UCI: Unidade de Cuidados Intensivos)
Safety Attitudes Questionnaire (ICU Version: Intensive care unit)
A = Disagree strongly B = Disagree slightly C = Neutral D = Agree slightly E = Agree strongly
A = Discordo Totalmente B = Discordo Parcialmente C = Não concordo nem discordo D = Concordo Parcialmente. E = Concordo Totalmente
A = Concordo Plenamente B = Discordo Ligeiramente C = Sem Opinião D = Concordo Ligeiramente E = Concordo Plenamente
A= agree totally B= Agree slightly C= No opinion D=Agree slightly E= agree totally
Please answer the following questions with respect to your specific ICU. Mark your response using the scale above.
Por favor, responda às seguintes perguntas relativamente à Unidade de Cuidados Intensivos (UCI) onde trabalha. Selecione a sua resposta utilizando a escala acima apresentada.
Por favor, responda às seguintes perguntas relativamente à sua UCI (Unidade de Cuidados Intensivos). Selecione a sua resposta utilizando a escala acima apresentada.
Please answer the questions about your ICU (Intensive Care Unit) Select your answer using the scale show above
1. High levels of workload are common in this ICU
1. Esta UCI tem níveis de trabalho elevados.
1. Cargas horárias elevadas são comuns nesta UCI.
1. Many working hours are common in this ICU
2. I like my job. 2. Gosto do meu trabalho
2. Gosto do meu trabalho
2. I enjoy my work
3. Nurse input is well received in this ICU.
3. As indicações por parte das Enfermeiras sobre os cuidados ao doente são bem recebidas nesta UCI.
3. O contributo dos enfermeiros é bem recebido nesta UCI
3. The contribution of nurses is welcome at this ICU
4. I would feel safe being treated here as a patient
4. Sentir-me-ia seguro se fosse um doente aqui.
4. Eu sentir-me-ia seguro(a) como doente nesta UCI.
4. I will feel secure as patient in this ICU
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5. Medical errors* are handled appropriately in this ICU. *Medical error is defined as any mistake in the delivery of care, by any healthcare professional regardless of outcome.
5. Os erros clínicos* são resolvidos de forma adequada nesta UCI.
*Erro Clínico é definido como qualquer erro que ocorre no processo de prestação de cuidados, por qualquer profissional de saúde, independentemente do resultado.
5. Erros médicos* são encarados apropriadamente nesta UCI.
*O erro médico é definido como qualquer erro na prestação de cuidado, por qualquer profissional de saúde, independentemente do seu resultado.
5. Medical errors* are seen appropriately in this ICU
*Medical error is defined as any error in care giving, by any health professional, regardless of its outcome.
6. This hospital does a good job of training new personnel.
6. Este hospital faz um bom trabalho na formação de novos profissionais.
6. Este hospital forma bons profissionais de saúde.
6. This hospital forms good health professionals
7. All the necessary information for diagnostic and therapeutic decisions is routinely available to me.
7. Toda a informação necessária tanto para o diagnóstico como para decisões terapêuticas está disponível.
7. Toda a informação necessária para decisões de diagnóstico ou terapêuticas está disponível. Faz parte da rotina ter acesso a toda a informação necessária para decisão diagnóstica ou terapêutica.
7. Any information necessary for diagnostic or therapeutic decisions are available. It is part of the routine to have access to all information necessary for diagnostic or therapeutic decision.
8. Working in this hospital is like being part of a large family
8. Trabalhar neste hospital é como fazer parte de uma grande família.
8. Trabalhar neste hospital é como fazer parte de uma grande família.
8. Working in this hospital is like being part of a big family.
9. The administration of this hospital is doing a good job.
9. A administração deste hospital está a fazer um bom trabalho.
9. A administração deste hospital está a fazer um bom trabalho.
9. The administration of this hospital is doing a good job
10. Hospital administration
10. A administração do hospital apoia
10. A administração do hospital apoia o meu esforço diário.
10. The hospital administration supports
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supports my daily efforts
os meus esforços diários.
my daily efforts.
11. I receive appropriate feedback about my performance.
11. Recebo o feedback apropriado sobre o meu desempenho.
11. Eu recebo feedback apropriado acerca do trabalho que realizo.
11. I receive appropriate feedback about the work I do.
12. In this ICU, it is difficult to discuss errors.
12. Nesta UCI, é difícil discutir erros clínicos.
12. Nesta UCI, é difícil discutir erros.
12. In this ICU, it is difficult to discuss errors.
13. Briefings (e.g., patient report at shift change) are important for patient safety
13. As reuniões de equipa ou breefings (por ex. partilha de informação sobre o doente nas mudanças de turno) são importantes para a segurança dos doentes.
13. Breves informações/ instruções (ex. apontamento sobre doente na mudança de turno) são importantes para a segurança dos doentes.
13. Brief information / instructions (eg. notes about the patient in the shift change) are important for patient safety
14. Thorough briefings are common in this ICU.
14. Os breefings pormenorizados são frequentes nesta UCI.
14. Informações/ Instruções detalhadas são comuns nesta UCI.
14. Information / Detailed instructions are common in this ICU
15. This hospital is a good place to work
15. Este hospital é um bom local para trabalhar.
15. Este hospital é um bom local de trabalho.
15. This hospital is a good place to work.
16. When I am interrupted, my patients’ safety is not affected.
16. Quando sou interrompido, a segurança do doente não fica afetada.
16. Quando sou interrompido(a) a segurança dos meus doentes não é afetada.
16. When I am stopped the safety of my patients is not affected
17. All the personnel in my ICU take responsibility for patient safety
17. Todos os trabalhadores nesta UCI assumem responsabilidade pela segurança do doente.
17. Todos os funcionários na minha UCI são responsáveis pela segurança dos doentes
17. All staff in my ICU are responsible for patient safety
18. Hospital management does not knowingly compromise the safety of patients
18. A administração do hospital não compromete conscientemente a
18. A administração do hospital não compromete a segurança dos doentes.
18. The hospital administration does not compromise
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segurança dos doentes.
patient safety
19. The levels of staffing in this ICU are sufficient to handle the number of patients
19. O pessoal nesta UCI é suficiente para o número de doentes.
19. O número de funcionários nesta UCI é suficiente para assegurar o número de doentes.
19. The number of staff in this ICU is sufficient for the number of patients.
20. Decision-making in this ICU utilizes input from relevant personnel
20. As tomadas de decisão nesta UCI baseiam-se em indicações de profissionais relevantes nesse domínio.
20. A tomada de decisão nesta UCI faz uso do contributo relevante dos seus funcionários.
20. Decision making in this UCI makes use of the important contribution of its employees
21. This hospital encourages teamwork and cooperation among its personnel.
21. Este hospital promove o trabalho em equipa e a cooperação entre os seus trabalhadores.
21. Este hospital incentiva o trabalho de equipa e cooperação entre os seus funcionários.
21. This hospital encourages teamwork and cooperation among its employees.
22. I am encouraged by my colleagues to report any patient safety concerns I may have.
22. Sou encorajado pelos colegas a apresentar qualquer preocupação que tenha relacionada com a segurança dos doentes.
22. Sou incentivado(a) pelos meus colegas a dar a conhecer quaisquer preocupações que eu possa ter relativamente à segurança dos doentes.
22. I am encouraged by my colleagues to provide information about any concerns I may have regarding patient safety.
23. The culture in this ICU makes it easy to learn from the errors of others
23. A cultura nesta UCI facilita a aprendizagem através dos erros dos outros.
23. A política nesta UCI facilita a aprendizagem através dos erros dos outros.
23. The policy of this ICU facilitates learning from mistakes.
24. This hospital deals constructively with problem personnel.
24. Este hospital lida construtivamente com profissionais de saúde e funcionários problemáticos.
24. Este hospital lida de forma construtiva com problemas de funcionários.
24. This hospital deals constructively with employee problems.
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25. The medical equipment in this ICU is adequate
25. O equipamento médico disponível nesta UCI é adequado.
25. O equipamento médico nesta UCI é adequado.
25. The medical equipment in this ICU is appropriate.
26. In this ICU, it is difficult to speak up if I perceive a problem with patient care
26. Nesta UCI é difícil falar se me apercebo de um problema relacionado com os cuidados ao doente.
26. Nesta UCI, é difícil expor algum problema que surja relativamente aos cuidados dos doentes.
26. In this ICU, it is difficult to expose a problem that arises in relation to the care of patients.
27. When my workload becomes excessive, my performance is impaired.
27. Quando a carga de trabalho se torna excessiva, o meu desempenho profissional é afetado.
27. Quando o volume de trabalho é excessivo, a minha prestação é prejudicada/inadequada.
27. When the workload is excessive, my performance is impaired / inadequate
28. I am provided with adequate, timely information about events in the hospital that might affect my work.
28. Recebo adequada e atempadamente informação sobre eventos no hospital que podem afetar o meu trabalho.
28. É-me providenciada, atempadamente, informação sobre situações no hospital que possam afetar o meu trabalho.
28. It provided me with timely, information on conditions in the hospital that may affect my work
29. I have seen others make errors that had the potential to harm patients.
29. Já vi cometerem-se erros com potencial de causar danos nos doentes.
29. Tenho presenciado outras pessoas cometerem erros que colocaram em causa a segurança dos doentes.
29. I have seen other people make mistakes that questioned the safety of patients
30. I know the proper channels to direct questions regarding patient safety in this ICU
30. Sei quais são os canais apropriados para dirigir questões relacionadas com a segurança dos doentes nesta UCI.
30. Eu tenho conhecimento dos meios adequados para colocar questões referentes à segurança dos doentes nesta UCI.
30. I am aware of the appropriate steps to questions concerning the safety of patients in this ICU
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31. I am proud to work at this hospital.
31. Sinto orgulho em trabalhar neste hospital.
31. Tenho orgulho de trabalhar neste hospital.
31. I am proud to work in this hospital
32. Disagreements in this ICU are resolved appropriately (i.e., not who is right but what is best for the patient).
32. Desacordos nesta UCI são resolvidos adequadamente (por ex. não quem está certo, mas o que é melhor para o doente).
32. As divergências nesta UCI são resolvidas apropriadamente (i.e. não quem tem razão, mas sim o que é o melhor para o doente).
32. The differences in this ICU are resolved properly (i.e. not who is right, but what is best for the patient).
33. I am less effective at work when fatigued
33. Sou menos eficiente quando estou fatigado.
33. Sou menos eficaz no trabalho quando estou cansado(a).
33. I am less effective at work when I'm tired
34. I am more likely to make errors in tense or hostile situations.
34. Sou mais propenso a cometer erros em situações tensas ou hostis.
34. É mais provável cometer erros em situações tensas ou hostis.
34. It is more likely to make mistakes in tense or hostile situations
35. Stress from personal problems adversely affects my performance.
35. O stress relacionado com problemas pessoais afeta negativamente o meu desempenho.
35. O stress, fruto de problemas pessoais, afeta o meu desempenho.
35. The stress, the result of personal problems affect my performance.
36. I have the support I need from other personnel to care for patients
36. Tenho o apoio necessário de outros colegas nos cuidados aos doentes.
36. Tenho o apoio que necessito de outros funcionários para cuidar dos doentes.
36. I have the support I need from other staff to care for the sick.
37. It is easy for personnel in this ICU to ask questions when there is something that they do not understand.
37. É fácil, para os profissionais desta UCI, colocar questões quando existe algo que não compreendem.
37. É fácil para os funcionários desta UCI colocar questões quando lhes surge alguma dúvida.
37. It is easy for employees of this UCI questions when they arise any questions.
38. Disruptions in the continuity of care (e.g., shift changes, patient transfers,
38. Interrupções na continuidade de cuidados (por ex. mudanças de
38. As interrupções durante a continuidade dos cuidados (ex.
38. Interruptions for continuity of care (e.g.
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etc.) can be detrimental to patient safety.
turno, transferência de doentes) podem prejudicar a segurança do doente.
mudanças de turno, transferência de doentes, etc.) podem por em causa a segurança do doente.
Shift changes, transfer of patients, etc.) can jeopardize patient safety.
39. During emergencies, I can predict what other personnel are going to do next.
39. Durante situações de emergência, consigo prever o que os outros profissionais vão realizar em seguida.
39. Durante as urgências, consigo prever o que os outros funcionários irão fazer de seguida.
39. During the emergency, I can anticipate what the other staff will do next.
40. The physicians and nurses here work together as a well-coordinated team
40. O pessoal Médico e de Enfermagem trabalham em conjunto como uma equipa bem coordenada.
40. Aqui, os médicos e enfermeiros trabalham em conjunto como um grupo bem coordenado.
40. Here, the doctors and nurses work together as a well-coordinated group
41. I am frequently unable to express disagreement with staff physicians/intensivists in this ICU
41. Sou frequentemente incapaz de expressar a minha discordância com médicos da equipa/intensivistas nesta UCI.
41. Sou frequentemente incapaz de expressar desacordo com os médicos “intensivistas” nesta UCI.
41. I am often unable to express disagreement with doctors "intensive" in this ICU
42. Very high levels of workload stimulate and improve my performance
42. Níveis elevados de trabalho estimulam e melhoram o meu desempenho.
42. Níveis muito elevados de volume de trabalho estimulam e melhoram a minha prestação.
42. Very high levels of workload stimulate and enhance my performance
43. Truly professional personnel can leave personal problems behind when working
43. Os profissionais podem verdadeiramente ignorar os problemas pessoais quando estão a trabalhar.
43. Funcionários, verdadeiramente profissionais, conseguem colocar de parte os seus problemas pessoais quando se encontram em serviço.
43. Staff, truly professional, they can put aside their personal problems when they are in service
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44. Morale in this ICU is high.
44. A moral é elevada nesta UCI.
44. A moral nesta UCI é elevada.
44. The moral in this ICU is high
45. Trainees in my discipline are adequately supervised
45. Os estagiários e internos, na minha especialidade, são bem supervisionados.
45. Os estagiários, da minha disciplina, são adequadamente supervisionados.
45. Trainees within my discipline, are adequately supervised
46. I know the first and last names of all the personnel I worked with during my last shift
46. Sei o primeiro e último nome de todo o pessoal da equipa com quem trabalhei no último turno.
46. Tenho conhecimento de os primeiros e últimos nomes de todos os funcionários com quem trabalhei no meu último turno.
46. I know the first and last names of all employees who worked on my last turn
47. I have made errors that had the potential to harm patients
47. Cometi erros com potencial de provocar danos nos doentes.
47. Cometi erros que tiveram o potencial de prejudicar o doente.
47. I made mistakes that had the potential to harm the patient.
48. Staff physicians/intensivists in this ICU are doing a good job.
48. Os médicos/intensivistas da equipa nesta UCI estão a realizar um bom trabalho.
48. A equipa de médicos especialistas/ de plantão desta UCI está a fazer um bom trabalho.
48. The team of medical specialists / on call this ICU is doing a good job.
49. Fatigue impairs my performance during emergency situations (e.g. emergency resuscitation, seizure).
49. O cansaço afeta o meu desempenho durante situações de emergência (por ex. reanimações, perdas de consciência, convulsões).
49. O cansaço prejudica o meu desempenho durante situações de urgência (ex.: reanimação, convulsões).
49. The fatigue affects my performance during emergency situations (ex.: resuscitation, seizures).
50. Fatigue impairs my performance during routine care (e.g., medication review, ventilator checks, transfer orders)
50. O cansaço afeta o meu desempenho durante a prestação de cuidados de rotina (por ex. revisão de medicação, revisão de ventiladores, ordens de transferência).
50. O cansaço prejudica o meu desempenho durante o serviço de cuidados de rotina (ex.: revisão de medicação, verificação de ventiladores, pedidos de transferência).
50. The fatigue affects my performance during the routine care service (e.x.: medication review, checking fans, transfer requests).
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51. If necessary, I know how to report errors that happen in this ICU
51. Se necessário, eu sei como comunicar os erros que acontecem nesta UCI.
51. Se necessário, tenho conhecimento da forma como denunciar erros que possam ocorrer nesta UCI.
51. If necessary, I am aware of how to report errors that may occur in this ICU
52. Patient safety is constantly reinforced as the priority in this ICU.
52. A segurança dos doentes é constantemente reforçada como prioridade nesta UCI.
52. A segurança do doente é constantemente reforçada como a prioridade desta UCI.
52. Patient safety is constantly reinforced as the priority of this ICU
53. Interactions in this ICU are collegial, rather than hierarchical.
53. As relações nesta UCI são colegiais e não hierárquicas.
53. As interações nesta UCI são colegiais e não hierárquicas.
53. The interactions in this ICU are collegial and not hierarchical.
54. Important issues are well communicated at shift changes.
54. Os assuntos importantes são bem comunicados nas mudanças de turno.
54. Os assuntos importantes são bem comunicados aquando da mudança de turno.
54. The important issues are well communicated at the time of shift change.
55. There is widespread adherence to clinical guidelines and evidence-based criteria in this ICU
55. Há adesão generalizada às normas de orientação e critérios baseados na evidência, relativos à segurança dos doentes nesta UCI.
55. Nesta UCI, há uma elevada aderência às diretrizes clinicas e a critérios baseados na evidência.
55. In this ICU, there is a high adherence to clinical guidelines and criteria based on the evidence
56. Personnel are not punished for errors reported through incident reports
56. Os profissionais não são penalizados pelos erros comunicados através dos relatórios de incidentes.
56. Os funcionários não são punidos por erros denunciados através de relatórios de incidentes.
56. Employees are not punished for errors reported through incident reports.
57. Error reporting is rewarded in this ICU
57. A comunicação de erros é recompensada nesta UCI.
57. A denúncia de erros é bem aceite nesta UCI.
57. The reporting of errors is well
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accepted in the ICU.
58. Information obtained through incident reports is used to make patient care safer in this ICU.
58. A informação obtida através dos relatórios de incidentes é usada para tornar mais seguros os cuidados prestados nesta UCI.
58. A informação obtida através da denúncia de incidentes é usada para tornar mais seguros os cuidados a ter com o doente.
58. The information obtained from the reporting of incidents is used to make safer the care of the patient.
59. During emergency situations (e.g., emergency resuscitations), my performance is not affected by working with inexperienced or less capable personnel.
59. Durante situações de emergência (por ex. reanimações), o meu desempenho não é afetado por trabalhar com pessoal menos experiente ou menos capaz.
59. Durante situações de urgência (ex.: reanimação), o meu desempenho não é afetado por trabalhar com funcionários inexperientes ou menos capazes.
59. During emergency situations (ex.: resuscitation), my performance is not affected by working with inexperienced employees or less capable.
60. Personnel frequently disregard rules or guidelines (e.g., handwashing, treatment protocols/clinical pathways, sterile field, etc.) that are established for this ICU.
60. Os profissionais ignoram frequentemente as regras ou normas de orientação (por ex. lavagem das mãos, protocolos de tratamento/percursos clínicos, zonas estéreis, etc.) estabelecidos para esta UCI.
60. Os funcionários, frequentemente, desrespeitam as regras ou linhas orientadoras (ex.: lavagem de mãos, tratamento de protocolos, orientações clinicas e a área de esterilização, etc.) que estão estabelecidas para esta UCI.
60. Employees often break the rules or guidelines (ex.: hand washing, treatment protocols, clinical guidelines and sterilization area, etc.) that are established for this ICU.
61. Communication breakdowns which lead to delays in delivery of care are common.
61. Problemas de comunicação, que originam atrasos na prestação de cuidados, são frequentes.
61. São comuns as falhas de comunicação que levam a atrasos na prestação de cuidados.
61. It is common communication failures that lead to delays in care.
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62. Communication breakdowns which negatively affect patient care are common.
62. Problemas de comunicação, que afetam negativamente os cuidados ao doente, são frequentes.
62. São comuns as falhas de comunicação que afetam, negativamente, o tratamento dos doentes.
62. It is common communication failures that affect negatively the treatment of patients.
63. A confidential reporting system that documents medical incidents is helpful for improving patient safety.
63. Um sistema de comunicação confidencial para documentar erros clínicos é útil na melhoria da segurança do doente.
63. Um sistema de denúncias confidencial que permita registar incidentes médicos é útil para melhorar a segurança do doente.
63. A confidential reporting system that provides a record of medical incidents is useful for improving patient safety.
64. I may hesitate to use a reporting system for medical incidents because I am concerned about being identified.
64. Eu hesitaria em usar um sistema que documenta os erros clínicos, porque me preocupo com o facto de poder ser identificado.
64. Posso hesitar em utilizar um sistema de denúncia de incidentes médicos porque tenho receio de vir a ser identificado.
64. I hesitate to use a reporting system for medical incidents because I am afraid of being identified.
65. Have you completed this survey before? No. Yes. Don’t know.
65. Alguma vez realizou este questionário? Sim, Não Não Sei
66. Já alguma vez havia completado este questionário? Sim, não não sei
65. Have you ever had completed this questionnaire? Yes, no do not know
BACKGROUND INFORMATION
INFORMAÇÃO DE BASE INFORMAÇÃO DE BASE BASIC INFORMATON
Gender: …..Male. …… Female
Sexo: ___masculino ____ feminino
Sexo: ___masculino ____ feminino
Gender: Male__ Female__
ICU Job Status ___ Full-time ___ Part-time ___ Agency ___ Contract
Tipo de vínculo de trabalho na UCI ____ Tempo inteiro ____ Tempo parcial ____ Agência
Tipo de vínculo de trabalho na UCI ____ Tempo inteiro ____ Tempo parcial ____ Agência
Work contract type in the ICU ____ Full time ____ Part time ____ Agency
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____ Contrato ____ Contrato ____ Contract
Usual swift __ Days __ Evenings __ Nights __ Variable shift
Turno Habitual ____ Dias ____ Tardes ____ Noites ____ Turnos variáveis
Turno Habitual ____ Dias ____ Tardes ____ Noites ____ Turnos variáveis
Usual Shift ____ Days ____ Afternoons ____ Nights ____ Shifts variables
How many years of experience do you have in this speciality? How many years have you worked in this ICU (mark 00 if less than 1 year)
Quantos anos de experiência tem nesta especialidade? _____ Á quantos anos trabalha nesta unidade? ______(responda 0 (zero) se inferior a um ano). Idade ____
Quantos anos de experiência tem nesta especialidade? _____ Á quantos anos trabalha nesta unidade? ______(responda 0 (zero) se inferior a um ano). Idade ____
How many years of experience do you have in this skill? _____ How many years are you working in this unit? ______ (answer 0 (zero) if less than one year). age ____
For attending Physicians: On average, how many patients do you admit to this ICU each month?
Para médicos com cargo de chefia: Em média, quantos doentes recebe nesta UCI por mês? _____
Para médicos com cargo de chefia: Em média, quantos doentes recebe nesta UCI por mês? _____
For physicians leading position: On average, how many patients receive this ICU per month? _____
*Optional* collected as part of a cross-cultural study. Citizenship (i.e. Canadian, Filipino, USA etc.) Country of birth (if different): ….
*Opcional: recolha de dados para fazer parte de um estudo transcultural Cidadania (i.e., Canadiano, Filipino, EUA, etc.): Natural de (se diferente)
*Opcional: recolha de dados para fazer parte de um estudo transcultural Cidadania (i.e., Canadiano, Filipino, EUA, etc.): Natural de (se diferente)
* Optional: data collection to be part of a cross-cultural study Citizenship (ie, Canadian, Filipine, USA, etc.): Natural (if different)
Use the scales to describe the quality of collaboration and communication you have experienced with:
Utilize as escalas para descrever a qualidade de colaboração e comunicação de que tem tido experiência com:
Utilize as escalas para descrever a qualidade de colaboração e comunicação de que tem tido experiência com:
Use the scales to describe the quality of collaboration and communication that youhave had experience with:
Charge Nurse Pharmacist Nurse manager / Head Nurse Respiratory Therapist Critical café Nurse
Enfermeiro(a) Chefe Farmacêutico(a) Enfermeiro(a) encarregado(a)
Enfermeiro(a) Chefe
Farmacêutico(a)
Enfermeiro(a) encarregado(a)
Head Nurse Head Pharmacist (a) Nurse in charge Therapist of Respiratory System
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Nursing Aide/Assistant Critical Care LVN/LPN Crit Care Attending/Intensivist Ward Clerk/Secretary Crit Care Fellow/Resident Fellow/Resident (Medical) Fellow/Resident (Surgical) Others specify A = Very Low B = Low C = Adequate D = High E = Very High X = Not Applicable
Terapeuta do Sistema Respiratório Enfermeiro especialista em Cuidados Intensivos Auxiliar de enfermagem Técnico(a) credenciado(a) em Enfermagem de Cuidados Intensivos Administrativo(a) / Secretária(o) de enfermaria Médico especialista de plantão nos Cuidados Intensivos Interno (Medicina) Médico Interno dos Cuidados Intensivos Interno (Cirurgia) Médico Chefe de equipa (Medicina) Médico Chefe de equipa (Cirurgia) Outro (especifique) A = Muito baixo B = Baixo C = Adequado D = Elevado E = Muito elevado X = Não aplicável
Terapeuta do Sistema Respiratório
Enfermeiro especialista em Cuidados Intensivos Auxiliar de enfermagem Técnico(a) credenciado(a) em Enfermagem de Cuidados Intensivos Administrativo(a) / Secretária(o) de enfermaria Médico especialista de plantão nos Cuidados Intensivos Interno (Medicina) Médico Interno dos Cuidados Intensivos Interno (Cirurgia) Médico Chefe de equipa (Medicina) Médico Chefe de equipa (Cirurgia) Outro (especifique) A = Muito baixo B = Baixo C = Adequado D = Elevado E = Muito elevado X = Não aplicável
Specialist Nurse in Intensive Care Nursing assistant Technical accredited in Intensive Care Nursing Administrative / Secretary of the ward duty specialist in Medical Intensive Care Internal (Medicine) Internal Practitioner Intensive Care Internal (Surgery) Medical Team Leader (Medicine) Medical Team Leader (Surgery) Other (specify) A = Very Low B = Low C = Suitable D = High E = Very high X = Not applicable
COMMENTS: What are your top three recommendations for improving patient safety in this ICU? If more room for comment is needed, please provide your response on a seperate sheet of papaer.
Comentários: Quais são as três principais recomendações para melhorar a segurança do doente nesta UCI? Se necessita de mais espaço para comentários, por favor escreva a sua resposta numa folha de papel à parte
COMENTÁRIOS: Quais as suas três principais recomendações para que o tratamento dos doentes seja aperfeiçoado nesta UCI? Se necessitar de mais espaço para os seus comentários, por favor providencie a sua resposta numa folha de papel em separado.
COMMENTS: Which are your top three recommendations for the treatment of patients is improved in this ICU? If you need more space for your comments, please provide your answer on a separate sheet of paper.
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Thank you for completing the questionnaire - Your time and participation are greatly appreciated
Obrigado por ter completado o questionário – Grato pela sua participação e tempo dispensado
Obrigado por ter completado o questionário – Grato pela sua participação e tempo dispensado.
Thank you for completing the questionnaire - Thank you for your participation and for your time.
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Appendix 2: SAQ ICU Clarity test tool (Portuguese Version)
QUESTIONÁRIO DE ATITUDES DE SEGURANÇA PARA ENFERMEIRAS EM UCI
Categoria Profissional na UCI (marque apenas uma resposta): (√)
Tipo de UCI (marque apenas uma resposta):
Claro Não está claro
____ Enfermeira Supervisora/Enfermeira-Chefe ____ Enfermeira Responsável ____ Enfermeira de Cuidados Intensivos ____ Assistente Operacional ____ Administrativo da Unidade
___UCI Mista Medicos- cirurgica ___ UCI Cirurgica ___ UCI Medica ___ UCI Pediatrica ___ Outra UCI (especifique) ...............................................
A B C D E Claro Não está claro
DISCORDO TOTALMENTE DISCORDO PARCIALMENTE
SEM OPINIAO
CONCORDO PARCIALMENTE
CONCORDO TOTALMENTE Claro Não está claro
POR FAVOR, RESPONDA ÀS SEGUINTES PERGUNTAS RELATIVAMENTE À SUA UCI (UNIDADE DE CUIDADOS INTENSIVOS). SELECIONE A SUA RESPOSTA UTILIZANDO A ESCALA ACIMA APRESENTADA.
Claro Não está claro
1. Nesta UCI são comuns cargas horárias elevadas. A B C D E
2. Gosto do meu trabalho. A B C D E
3. O contributo dos enfermeiros é bem recebido nesta UCI. A B C D E 4. Eu sentir-me-ia seguro (a) como doente nesta UCI. A B C D E
5. Os erros clínicos* são encarados apropriadamente nesta UCI. A B C D E
*O erro clínico é definido como qualquer erro na prestação de cuidados, por qualquer profissional de saúde, independentemente do seu resultado.
A B C D E
6. Este hospital faz um bom trabalho na formação de novos enfermeiros. A B C D E 7. Toda a informação necessária para decisões de diagnóstico ou terapêuticas está disponível. A B C D E
8. Trabalhar neste hospital é como fazer parte de uma grande família. A B C D E
9. A administração deste hospital faz um bom trabalho. A B C D E 10. A administração do hospital apoia o meu empenho diário. A B C D E 11. Eu recebo feedback apropriado acerca do trabalho que realizo. A B C D E 12. Nesta UCI, é difícil discutir erros. A B C D E
13. Breves informações (ex. apontamento sobre doente na mudança de turno) são importantes para a
segurança dos doentes. A B C D E
14. Informações detalhadas são comuns nesta UCI. A B C D E
15. Este hospital é um bom local de trabalho A B C D E 16. Quando sou interrompido (a) a segurança dos meus doentes não é afetada. A B C D E 17. Todos os enfermeiros na minha UCI são responsáveis pela segurança dos doentes. A B C D E
18. A administração do hospital não compromete a segurança dos doentes. A B C D E 19. O número de enfermeiros nesta UCI é suficiente para assegurar os cuidados ao número de doentes. A B C D E
20. A tomada de decisão nesta UCI baseia-se no contributo relevante dos seus enfermeiros. A B C D E
21. Este hospital incentiva o trabalho de equipa e cooperação entre os seus enfermeiros. A B C D E 22. Sou incentivado (a) pelos meus colegas a dar a conhecer quaisquer preocupações que eu possa ter
relativamente à segurança dos doentes. A B C D E
23. A cultura nesta UCI facilita a aprendizagem através dos erros dos outros. A B C D E 24. Este hospital lida de forma construtiva com problemas de enfermeiros. A B C D E
25. O equipamento médico nesta UCI é adequado. A B C D E
26. Nesta UCI, é difícil expor algum problema que surja relativamente aos cuidados aos doentes A B C D E 27. Quando o volume de trabalho é excessivo, a minha prestação é prejudicada. A B C D E 28. É-me providenciada, atempadamente, informação sobre situações no hospital que possam afetar o meu
trabalho. A B C D E
29. Tenho presenciado outras pessoas cometerem erros que colocaram em causa a segurança dos doentes. A B C D E
30. Eu conheço os meios adequados para colocar questões referentes à segurança dos doentes nesta UCI A B C D E
31. Tenho orgulho de trabalhar neste hospital. A B C D E 32. As divergências nesta UCI são resolvidas apropriadamente (i.e. não quem tem razão, mas sim o que é o
melhor para o doente). A B C D E
33. Sou menos eficaz no trabalho quando estou cansado (a). A B C D E 34. É mais provável cometer erros em situações tensas ou hostis. A B C D E
SN
……………
______
___
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35. O stress, fruto de problemas pessoais, afeta o meu desempenho. A B C D E 36. Tenho o apoio que necessito de outros colaboradores para cuidar dos doentes. A B C D E
37. É fácil para os enfermeiros desta UCI colocar questões quando lhes surge alguma dúvida. A B C D E
38. As interrupções durante a continuidade dos cuidados (ex. mudanças de turno, transferência de doentes, etc.) podem por em causa a segurança do doente.
A B C D E
39. Durante as urgências, consigo prever o que os outros professionais irão fazer de seguida A B C D E
40. Aqui, os médicos e enfermeiros trabalham em conjunto como um grupo bem coordenado. A B C D E
41. Sou frequentemente incapaz de expressar desacordo com os médicos “intensivistas” nesta UCI. A B C D E
42. Níveis muito elevados de volume de trabalho estimulam e melhoram o meu desempenho. A B C D E 43. Os verdadeiros profissionais, conseguem colocar de parte os seus problemas pessoais quando se
encontram em serviço. A B C D E
44. A moral nesta UCI é elevada. A B C D E
45. Os estagiários de enfermagem são adequadamente supervisionados. A B C D E POR FAVOR, RESPONDA ÀS SEGUINTES PERGUNTAS RELATIVAMENTE À SUA UCI (UNIDADE DE CUIDADOS INTENSIVOS). SELECIONE A SUA RESPOSTA UTILIZANDO A ESCALA ACIMA APRESENTADA.
A B C D E Claro Não está claro
46. Conheço os primeiros e últimos nomes de todos os colaboradores com quem trabalhei no meu último
turno. A B C D E
47. Cometi erros que potencialmente prejudicaram o doente. A B C D E 48. A equipa de médicos especialistas desta UCI está a fazer um bom trabalho.
49. O cansaço prejudica o meu desempenho durante situações de urgência (ex.: reanimação, convulsões). A B C D E 50. O cansaço prejudica o meu desempenho durante o serviço de cuidados de rotina (ex.: revisão de
medicação, verificação de ventiladores, pedidos de transferência). A B C D E
51. Se necessário, conheço a forma como comunicar erros que possam ocorrer nesta UCI. A B C D E 52. A segurança do doente é constantemente reforçada como a prioridade desta UCI. A B C D E
53. As interações nesta UCI são colegiais e não hierárquicas. A B C D E
54. Os assuntos importantes são bem comunicados aquando da mudança de turno. A B C D E 55. Nesta UCI, há uma elevada aderência às guidelines clinicas e a critérios baseados na evidência. A B C D E
56. Os profissionais não são punidos por erros denunciados através de relatórios de incidentes. A B C D E 57. A comunicação de erros é bem aceite nesta UCI. A B C D E
58. A informação obtida através da comunicação de incidentes é usada para tornar mais seguros os cuidados a
ter com o doente. A B C D E
59. Durante situações de urgência (ex.: reanimação), o meu desempenho não é afetado por trabalhar com
profissionais inexperientes ou menos capazes. A B C D E
60. Os profissionais, frequentemente, desrespeitam as regras ou guidelines (ex.: lavagem de mãos, tratamento
de protocolos, orientações clinicas e a área de esterilização, etc.) que estão estabelecidas para esta UCI. A B C D E
61. São comuns as falhas de comunicação que levam a atrasos na prestação de cuidados. A B C D E 62. São comuns as falhas de comunicação que afetam, negativamente, o cuidado aos doentes. A B C D E
63. Um sistema de comunicação confidencial que permita registar incidentes clínicos é útil para melhorar a
segurança do doente. A B C D E
64. Posso hesitar em comunicar incidentes clínicos porque tenho receio de vir a ser identificado(a). A B C D E
65. Já alguma vez respondeu a este questionário? sim não não sei
Utilize as escalas para descrever a qualidade de colaboração e comunicação de que tem tido experiência com: Muito
baixo
Baixo Adequado Elevado Muito
elevado
Não aplicável Claro, Não está claro
66. Enfermeiro(a) Chefe
67. Farmacêutico(a)
68. Enfermeiro(a) responsável
69. Fisioterapeuta
70. Enfermeiro especialista em Cuidados
Intensivos
71. Assistenet Operacional
72. Administrativo(a) / Secretária(o) de
enfermaria
73. Médico Especialista em Cuidados
Intensivos
74. Interno (Medicina)
75. Médico Interno dos Cuidados Intensivos
76. Interno (Cirurgia)
77. Médico Chefe de equipa (Medicina)
78. Médico Chefe de equipa (Cirurgia)
79. Outro (especifique)
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DADOS PESSOAIS Claro Não
está
claro 80. Sexo: ____ masculino ____ feminino TURNO HABITUAL: GRUPO ÉTNICO (OPCIONAL)
Tipo de vínculo de trabalho na UCI: 81. ____ Dias 82. ____ Hispânico
83. ____ Tempo inteiro 84. ____ Tardes 85. ____ Raça Negra (não Hispânico)
86. ____ Tempo parcial 87. ____ Noites 88. ____ Asiático/ natural das ilhas do Pacífico
89. ____ Contrato a termo certo 90. ____ Turnos variáveis 91. ____ Multiétnico
92. ____ Contrato a termo incerto
93. ___Contrato de trabalho em funções
públicas
94. Idade atual
95. Quantos anos de experiência tem nesta especialidade?
96. Quantos anos trabalhou neste UCI?
97. Quantos doentes cuida por dia nesta UCI?
Comentários: Quais são as três principais recomendações para melhorar a segurança do doente nesta UCI? 1. ………………………………………………………………………………………………………………………………
………………………………………………………………
2. ………………………………………………………………………………………………………………………………
………………………………………………………………
3. ………………………………………………………………………………………………………………………………
………………………………………………………………
(Muito obrigado por responder a este questionário – O seu tempo e participação são extremamente valorizados.)
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Appendix 3(a): Information about the Study
Purpose of the Study. As part of the requirements for Erusmus Master in Emergency and Critical
Care Nursing degree at ESSaude, I have to carry out a research study. The study is concerned with
“how nurses working in intensive care units perceive their patient safety culture.
What will the study involve? The study will involve participants responding to statements in a
supervised self-administered questionnaire that will last for between 15-30 minutes by choosing
responses from a predetermined statements and writing your opinion briefly.
Why have you been asked to take part? You have been asked because you have been identified
generally suitable to provide information for the study.
Do you have to take part? No! Your participation is voluntary and you will need to sign a consent
form. You will keep the information sheet and a copy of the consent form. You have the option
of withdrawing before the study commences (even if you agreed to participate).
Will your participation in the study be kept confidential? Yes. The questionnaire will be
anonymously filled. I will ensure that no clues to your identity appear in the thesis. Any extracts
from your response that are quoted in the thesis will be entirely anonymous.
What will happen to the information which you give? The data will be kept confidential for the
duration of the study. On completion of the thesis, they will be retained for a further six months
and then destroyed.
What will happen to the results? The results will be presented in the thesis. They will be seen by
my supervisor, a second marker and the external examiner. The thesis may be read by future
students on the course. The study may be published in any research journal.
What are the possible disadvantages of taking part? I don’t envisage any negative consequences
for you in taking part. It is possible that responding to some of the statements talking about your
experience in this way may cause some distress.
What if there is a problem? At the end your participation, the investigator may discuss with you
how you found the experience and how you are feeling. If you subsequently feel distressed, you
should contact the investigator
Who has reviewed this study? The study was reviewed by the Ethics Committee of the Escola
Superior De Saude de Santarem and the Hospitals Ethics Committee. Approval to conduct the
study was obtained from the Escola Superior de Saude de Santarem before studies like this can
take place.
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Any further queries? If you need any further information, you can contact the investigator or his
supervisor on the telephone contacts and email addresses provided. If you agree to take part in
the study, please sign the consent form below.
Appendix 3(b): Informed Consent Form
I……………………………………………………. agree to participate in Cliff Asher’s research study. The purpose and nature of the study has been explained to me in writing and I am participating voluntarily. I give permission for my participation to fill the questionnaire. I understand that I can withdraw from the study, without repercussions, at any time, whether before it starts or while I am participating. I understand that anonymity will be ensured in the write-up by disguising my identity. I understand that disguised extracts from my participation may be quoted in the thesis and any subsequent publications if I give permission below: (Please tick one:
I agree to quotation/publication of extracts from my participation I do not agree to quotation / publication of extracts from my participation
Signed……………………………………. Date………………………………
(Respondent)
Signed: …………………………………. Date: …………………………….
(Researcher)
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Appendix 3c: Final SAQ Portuguese Version
Questionário de Atitudes de Segurança Para Enfermeiros Em UCI
Categoria Profissional na UCI (marque apenas uma resposta): (√) Tipo de UCI (marque apenas uma resposta):
____ Enfermeiro Supervisor/Enfermeiro-Chefe ____ Enfermeiro Responsável ____ Enfermeira de Cuidados Intensivos ____ Assistente Operacional ____ Administrativo da Unidade
___UCI Mista Medico - cirurgica ___ UCI Cirurgica ___ UCI Medica ___ UCI Pediatrica ___ Outra UCI (especifique) ............................................
A B C D E
DISCORDO TOTALMENTE DISCORDO PARCIALMENTE SEM OPINIAO CONCORDO PARCIALMENTE CONCORDO TOTALMENTE
POR FAVOR, RESPONDA ÀS SEGUINTES PERGUNTAS RELATIVAMENTE À SUA UCI (UNIDADE DE CUIDADOS INTENSIVOS). SELECIONE A SUA RESPOSTA UTILIZANDO A ESCALA ACIMA APRESENTADA.
98. Nesta UCI são comuns cargas horárias elevadas. A B C D E
99. Gosto do meu trabalho. A B C D E
100. O contributo dos enfermeiros é bem recebido nesta UCI. A B C D E
101. Eu sentir-me-ia seguro (a) como doente nesta UCI. A B C D E
102. Os erros clínicos são encarados apropriadamente nesta UCI. A B C D E
103. Este hospital faz um bom trabalho na formação de novos enfermeiros. A B C D E
104. Toda a informação necessária para as decisões de diagnóstico ou terapêuticas está disponível. A B C D E
105. Trabalhar neste hospital é como fazer parte de uma grande família. A B C D E
106. A administração deste hospital faz um bom trabalho. A B C D E
107. A administração do hospital apoia o meu empenho diário. A B C D E
108. Eu recebo feedback apropriado acerca do trabalho que realizo. A B C D E
109. Nesta UCI, é difícil discutir erros. A B C D E
110. Informações breves (por ex: na passagem de turno) são importantes para a segurança do doente. A B C D E
111. Informações detalhadas são comuns nesta UCI. A B C D E
112. Este hospital é um bom local de trabalho A B C D E
113. Quando sou interrompido (a) a segurança dos meus doentes não é afetada. A B C D E
114. Todos os enfermeiros na minha UCI são responsáveis pela segurança dos doentes. A B C D E
115. A administração do hospital não compromete a segurança dos doentes. A B C D E
116. O número de enfermeiros nesta UCI é suficiente para assegurar os cuidados ao número de doentes. A B C D E
117. A tomada de decisão neste UCI faz uso de contribuição de profissionais competentes. A B C D E
118. Este hospital incentiva o trabalho de equipa e a cooperação entre os seus enfermeiros. A B C D E
119. Sou incentivado (a) pelos meus colegas a dar a conhecer quaisquer preocupações que eu possa ter relativamente à segurança dos doentes.
A B C D E
120. A cultura nesta UCI facilita a aprendizagem através dos erros dos outros. A B C D E
121. Este hospital trata de forma construtiva com os enfermeiros problemáticos. A B C D E
122. O equipamento médico é adequada nesta UCI. A B C D E
123. Nesta UCI, é difícil expor algum problema que surja relativamente aos cuidados aos doentes A B C D E
124. Quando o volume de trabalho é excessivo, a minha prestação é prejudicada. A B C D E
125. É-me providenciada, atempadamente, informação sobre situações no hospital que possam afetar o meu trabalho. A B C D E
126. Tenho visto outras pessoas cometerem erros que tinham o potencial de prejudicar os doentes. A B C D E
127. Eu conheço os meios adequados para colocar questões referentes à segurança dos doentes nesta UCI A B C D E
128. Tenho orgulho de trabalhar neste hospital. A B C D E
129. As divergências nesta UCI são resolvidas apropriadamente A B C D E
130. Estou menos eficaz no trabalho quando estou estressado. A B C D E
131. Eu sou mais propensos a cometer erros em situações tensas ou hostis. A B C D E
132. Estresse de problema pessoal afetar adversamente o meu desempenho. A B C D E
133. Tenho o apoio que necessito de outros colaboradores para cuidar dos doentes. A B C D E
134. É fácil para as enfermeiras nesta UCI questionar quando há algo que não entendem. A B C D E
135. Interrupção na continuidade de cuidados (ex:, mão-over, transferências de pacientes), pode comprometer a segurança do doente.
A B C D E
V.S.F.F
SN
……………
______
___
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136. Durante as urgências, consigo prever o que os outros professionais irão fazer de seguida A B C D E
137. Aqui, os médicos e enfermeiros trabalham em conjunto como um grupo bem coordenado. A B C D E
138. Sou frequentemente incapaz de expressar desacordo com os médicos “intensivistas” nesta UCI. A B C D E
139. Níveis muito elevados de volume de trabalho estimulam e melhoram o meu desempenho. A B C D E
140. Os verdadeiros profissionais, conseguem colocar de parte os seus problemas pessoais quando se encontram em serviço.
A B C D E
141. A moral nesta UCI é elevada. A B C D E
142. Os estagiários de enfermagem são adequadamente supervisionados. A B C D E
POR FAVOR, RESPONDA ÀS SEGUINTES PERGUNTAS RELATIVAMENTE À SUA UCI (UNIDADE DE CUIDADOS INTENSIVOS). SELECIONE A SUA RESPOSTA UTILIZANDO A ESCALA ACIMA APRESENTADA.
A B C D E
143. Conheço os primeiros e últimos nomes de todos os colaboradores com quem trabalhei no meu último turno. A B C D E
144. Eu cometi erros que tinham o potencial de prejudicar doentes. A B C D E
145. Uma equipe de médicos especialistas desta UCI estão fazendo um bom trabalho.
146. Cansaço prejudica o meu desempenho durante situações de urgência (ex.: reanimação, convulsões). A B C D E
147. O cansaço prejudica o meu desempenho durante o serviço de cuidados de rotina A B C D E
148. Se necessário, eu sei como relatar erros que possam ocorrer neste UCI. A B C D E
149. A segurança do doiente é constantemente reforçada como a prioridade desta UCI. A B C D E
150. As interações nesta UCI são colegiais e não hierárquicas. A B C D E
151. Os assuntos importantes são bem comunicados aquando da mudança de turno. A B C D E
152. Nesta UCI, há uma elevada aderência às guidelines clinicas e a critérios baseados na evidência. A B C D E
153. Os profissionais não são punidos por erros comunicados através de relatórios de incidentes. A B C D E
154. Relatório de erros recompensado nesta UCI. A B C D E
155. A informação obtida através da comunicação de incidentes é usada para tornar mais seguros os cuidados a ter com o doente.
A B C D E
156. Durante situações de urgência (ex.: reanimação), o meu desempenho não é afetado por trabalhar com profissionais inexperientes ou menos experientes.
A B C D E
157. Os profissionais, frequentemente, desrespeitam as regras ou guidelines que estão estabelecidas nesta UCI. A B C D E
158. Falhas de comunicação que levam a atrasos na prestação de cuidados, são comuns. A B C D E
159. Falhas de comunicação que afetam negativamente o atendimento ao doente, são comuns. A B C D E
160. Um sistema de comunicação confidencial que permita registar incidentes clínicos é útil para melhorar a segurança do doente.
A B C D E
161. Posso hesitar em comunicar incidentes clínicos porque tenho receio de vir a ser identificado(a). A B C D E
162. Já alguma vez respondeu a este questionário? sim não não sei
Utilize as escalas para descrever a qualidade de colaboração e comunicação de que tem tido experiência com:
Muito baixo Baixo Adequado Elevado Muito elevado Não aplicável
163. Enfermeiro(a) Chefe
164. Farmacêutico(a)
165. Enfermeiro(a) responsável
166. Fisioterapeuta
167. Enfermeiro especialista em Cuidados Intensivos
168. Assistente Operacional
169. Administrativo(a) / Secretária(o) de unidade
170. Médico Especialista em Cuidados Intensivos
171. Interno (Medicina)
172. Médico Interno dos Cuidados Intensivos
173. Interno (Cirurgia)
174. Médico Chefe de equipa (Medicina)
175. Médico Chefe de equipa (Cirurgia)
176. Outro (especifique)
DADOS PESSOAIS
Sexo: ____ masculino ____ feminino
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177. Tipo de vínculo de trabalho na UCI: ____ Tempo inteiro ____ Tempo parcial ____ Contrato a termo certo ____ Contrato a termo incerto ____ Contrato de trabalho em funções públicas
178. Turno Habitual: ____ Dias ____ Turnos variáveis ____ Turnos variáveis ____ Tardes ____ Noites
179. Idade atual? Responder: …………………………............ anos
180. Quantos anos de experiência tem nesta especialidade? Responder: ………………………………… anos.
181. Quantos anos trabalhou neste UCI? Responder: ……………................................. anos
182. Comentários: Quais são as três principais recomendações para melhorar a segurança do doente nesta UCI? 1. .................................................................................................................................................................. 2. .................................................................................................................................................................. 3. ..................................................................................................................................................................
Muito obrigado por responder a este questionário – O seu tempo e participação são extremamente valorizados
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Appendix 3 (d): Table 4.2 Communalities Kaiser-Meyer-Olking (KMO)
Communalities
Initial Extraction
Nurse input is well received in this ICU 1.000 .600
I would feel safe being treated here as a patient 1.000 .636
This hospital does a good job of training new personnel 1.000 .597
The administration of this hospital is doing a good job 1.000 .669
Hospital administration supports my daily efforts 1.000 .615
I receive a appropriate feedback about my performance 1.000 .645
Briefings are important for patient safety 1.000 .526
This hospital is a good place to work 1.000 .625
All the personnel in ICU take responsibility for patient safety 1.000 .654
Hospital management does not knowingly compromise the safety of patients 1.000 .634
Decision making in this ICU utilizes input from relevant personnel 1.000 .441
This hospital encourages teamwork and cooperation among personnel 1.000 .595
The culture in this ICU makes it easy to learn from errors of others 1.000 .458
This hospital deals constructively with problem personnel 1.000 .624
The medical equipment in this ICU is adequate 1.000 .436
When my workload becomes excessive, my performance is impaired 1.000 .658
I am provided with adequate, timely information about events in the hospital that might
affect my work
1.000 .474
I know the proper channel to direct questions regarding patient safety 1.000 .550
I am proud to work at this hospital 1.000 .548
Disagreements in this ICU are resolved appropriately 1.000 .581
I am less effective at work when fatigued 1.000 .512
I am more likely to make errors in tense or hostile situations 1.000 .552
Stress from personal problems adversely affect my performance 1.000 .498
I have the support I need from other personnel to care for patients 1.000 .531
It is easy for personnel in ICU to ask questions 1.000 .647
Disruptions in continuity of care can be detrimental to patient safety 1.000 .554
The physicians and nurses here work together as a coordinated team 1.000 .601
Very high level of workload stimulate and improve my performance 1.000 .599
Truly professional personnel can leave personal problems behind when working 1.000 .482
Trainees in my discipline are adequately supervised 1.000 .426
I know the first and last name of all the personnel I work with during my last shift 1.000 .445
Staff physician/ intensivist in this ICU are doing a good job 1.000 .622
Fatigue impairs my performance during emergency situation 1.000 .662
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Fatigue impairs my performance during routine care 1.000 .676
If necessary, I know how to report errors that happen in this ICU 1.000 .436
Interactions in this ICU are collegial, rather than hierarchical 1.000 .477
Important issues are well communicated at shift changes 1.000 .652
There is widespread adherence to clinical guidelines and EB criteria in this ICU 1.000 .516
Information obtained through incident reports is used to make patient care safer in this
ICU
1.000 .485
Extraction Method: Principal Component Analysis.
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Appendix 3 (e): Chi-Square test statistic for the 6-factor model
The
administrati
on of this
hospital is
doing a good
job
Hospital
administrati
on supports
my daily
efforts
I receive
appropriate
feedback
about my
performanc
e
This
hospital
is a good
place to
work
18 Hospital
management
does not
knowingly
compromise the
safety of
patients
This hospital
encourages
teamwork and
cooperation
among
personnel
This
hospital
deals
constructiv
ely with
problem
personnel
I am provided
with adequate,
timely
information
about events in
the hospital
that might
affect my work
I am
proud
to work
at this
hospita
l
Chi-Square 18.986a 26.932a 22.959a 33.027b 3.918a 22.548a 37.479a 23.370a 38.575a
df 4 4 4 3 4 4 4 4 4
Asymp. Sig. .001 .000 .000 .000 .417 .000 .000 .000 .000
a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 14.6.
b. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 18.3.
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45 Very high level of workload stimulate and improve my performance
Truly professional personnel can leave personal problems behind when working
Interactions in this ICU are collegial, rather than hierarchical
Information obtained through incident reports is used to make patient care safer in this ICU
This hospital does a good job of training new personnel
The culture in this ICU makes it easy to learn from errors of others
I have the support I need from other personnel to care for patients
Trainees in my discipline are adequately supervised
Important issues are well communicated at shift changes
There is widespread adherence to clinical guidelines and EB criteria in this ICU
6.836b 18.164a 19.671a 69.123a 29.808a 30.219a 86.247a 29.521b 66.384a 64.740a
3 4 4 4 4 4 4 3 4 4
.077 .001 .001 .000 .000 .000 .000 .000 .000 .000
Nurse imput is well received in this ICU
I would feel safe being treated here as a patient
Decision making in this ICU utilizes input from relevant personnel
Disagreements in this ICU are resolved appropriately
It is easy for personnel in ICU to ask questions
The physicians and nurses here work together as a coordinated team
Briefings are important for patient safety
All the personnel in ICU take responsibility for patient safety
The medical equipment in this ICU is adequate
When my workload becomes excessive, my performance is impaired
I know the proper channel to direct questions regarding patient safety
I am less effective at work when fatigued
38Disruptions in continuity of care can be detrimental to patient safety
I am more likely to make errors in tense or hostile situations
58.342b
61.192b
39.534a 35.288a 47.205a 54.466a 106.890b 70.945b 70.767a 47.342a 53.370a 61.315a
21.452a 36.932a
3 3 4 4 4 4 3 3 4 4 4 4 4 4
.000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000
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Erasmus Mundus Master Course in Emergency and Critical Care Nursing
Stress from personal
problems adversely affect
my performance
Fatigue impairs my
performance during
emergency
situation
Fatigue impairs my
performance during
routine care
I know the first and last
name of all the personnel
I work with during my
last shift
Staff
physician/intensivist
in this ICU are doing
a good job
If necessary, I
know how to report
errors that happen
in this ICU
46.658a 41.726a 63.233a 88.589b 45.562a 70.219a
4 4 4 3 4 4
.000 .000 .000 .000 .000 .000 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 14.6. b. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 18.3.
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Erasmus Mundus Master Course in Emergency and Critical Care Nursing
Appendix 3 (f): Table 4.4b Rotated Component Matrix Rotated Component Matrix a
Component (Factor)
1 2 3 4 5 6
Nurse input is well received in this ICU .746
I would feel safe being treated here as a patient .692
This hospital does a good job of training new personnel .524
The administration of this hospital is doing a good job .751
Hospital administration supports my daily efforts .743
I receive a appropriate feedback about my performance .592
Briefings are important for patient safety .680
This hospital is a good place to work .692
All the personnel in ICU take responsibility for patient safety .742
Hospital management does not knowingly compromise the safety of patients
.748
Decision making in this ICU utilizes input from relevant personnel .459
This hospital encourages teamwork and cooperation among personnel
.683
The culture in this ICU makes it easy to learn from errors of others .485
This hospital deals constructively with problem personnel .713
The medical equipment in this ICU is adequate .568
When my workload becomes excessive, my performance is impaired
.501
I am provided with adequate, timely information about events in the hospital that might affect my work
.544
I know the proper channel to direct questions regarding patient safety
.541
I am proud to work at this hospital .665
Disagreements in this ICU are resolved appropriately .564
I am less effective at work when fatigued .511
I am more likely to make errors in tense or hostile situations .662
Stress from personal problems adversely affect my performance .353
I have the support I need from other personnel to care for patients .536
It is easy for personnel in ICU to ask questions .627
Disruptions in continuity of care can be detrimental to patient safety .379
The physicians and nurses here work together as a coordinated team
.515
Very high level of workload stimulate and improve my performance .479
Truly professional personnel can leave personal problems behind when working
.426
Trainees in my discipline are adequately supervised .605
46I know the first and last name of all the personnel I work with during my last shift
.653
48Staff physician/intensivist in this ICU are doing a good job .684
49Fatigue impairs my performance during emergency situation .802
50Fatigue impairs my performance during routine care .768
51If necessary, i know how to report errors that happen in ICU .531
53Interactions in this ICU are collegial, rather than hierarchical .403
54Important issues are well communicated at shift changes .760
55There is widespread adherence to clinical guidelines and EB criteria in this ICU
.552
58Information obtained through incident reports is used to make patient care safer in this ICU
.446
Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization.
a. Rotation converged in 8 iterations.
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