Associations between safety outcomes and communication practices among pediatric nurses in the United States

Highlights

What is already known about the topic?

• Hospitalized children in the United States suffer preventable harm with efforts to reduce iatrogenic injury in children's care not effective.

• Nurses fear retaliation when reporting patient safety events in the pediatric care setting.

What this paper adds:

• Open communication within health care teams did not improve RNs’ reporting of incidents that cause children harm.

• Feedback from hospital leadership about reported safety events improves RN’s perceptions of children’s safety and encourages reporting.

• RNs will not report safety events unless they feel psychologically safe to report them. Until this happens, children will continue to be harmed.

Abstract

Purpose

To gain a deeper understanding of RNs communication related to patient safety.

Research aims

To determine: (1) the associations between the communication of registered nurses (RNs) within their health care teams and the frequency that they reported safety events; (2) the associations between RNs' communication within their health care teams and their perceptions of safety within the hospital unit; and (3) whether RNs' communication had improved from 2016 to 2018.

Theoretical framework and methods

We used the United Kingdom's Safety Culture model as the theoretical framework for this study. Our secondary data analysis from the Agency for Healthcare Research and Quality's Hospital Survey on Patient Safety Culture included 2016 (n = 5298) and 2018 (n = 3476) using multiple regression models to determine associations between responses for Communication Openness and Feedback & Communication About Error, and outcome responses for Frequency of Events Reported and Overall Perceptions of Safety.

Results

Our findings were: 1). In both 2016 and 2018 datasets, Feedback About Error had a greater impact on Reporting Frequency than Open Communication; 2). Feedback About Error had a greater impact on Safety Perceptions than Open Communication; 3). Open Communication and Feedback About Error and their associations with Reporting Frequency and Safety Perceptions showed little change; and, 4). The proportion of variance was low, indicating factors other than Open Communication and Feedback About Error were involved with Reporting Frequency and Safety Perceptions.

Conclusion

Pediatric RNs' communication, reporting, and perceptions of patient safety have not improved. (245 words).

Introduction

In the United States, children account for over 5 million hospital admissions annually (Healthcare Cost and Utilization Project (HCUP), 2021). The longer children are hospitalized, the greater their chance of experiencing a safety incident (Kirkendall et al., 2012). With an estimated 36.7% of hospitalized children experiencing a safety incident during their hospital stay (Kirkendall et al., 2012), up to 1,835,000 children may experience safety incidents annually, with many of these events leading to permanent injury or death.

A patient safety incident is any unintended or unexpected event that may result in patient harm (National Patient Safety Agency, 2003). Safety incidents include near misses, adverse events, and medical errors (National Patient Safety Agency, 2003). An adverse event is an injury caused by medical care. Adverse events do not imply error, negligence, or poor quality of care, but rather that an undesirable clinical outcome occurred as a result of some aspect of diagnosis or therapy and was not due to an underlying disease process (National Patient Safety Foundation, 2015). A medical error is an act of commission (doing something wrong) or omission (failing to do the right thing) that leads to or has the potential for an undesirable outcome (National Patient Safety Foundation, 2015). Over 400,000 hospitalized individuals die each year from medical errors (James, 2013; Makary & Daniel, 2016).

Pediatric health care providers work in complex settings where there are many opportunities to cause unintended harm (Mueller et al., 2019). Children are at higher risk than adults for safety incidents due to maturational differences related to their anatomy, physiology, and medical conditions (Ahuja et al., 2012; Gampetro et al., 2021; Leonard, 2010; Peterson et al., 2012; Rosenthal et al., 2017; Walsh et al., 2014). Examples of such incidents include infiltration of an intravenous infusion that causes cellulitis and necrosis of surrounding tissue, post-operative infection, or ventilator-associated pneumonia (Unbeck et al., 2014). Equipment and medications used in pediatric care can contribute to harm, such as drugs, biologic agents, and medical devices that have not been specifically tested for use in pediatric care (Clancy et al., 2013). Thus, it is difficult to ensure that these therapeutics and devices have the same safety profile in children as in adults (Clancy et al., 2013; Gonzales, 2010).

Medication errors are of particular concern in pediatric care due to the small size of children and the need for individualized dosing through weight-based calculations (Gampetro et al., 2021; Leonard, 2010; Peterson et al., 2012; The Joint Commission, 2021a; Unbeck et al., 2014; Walsh et al., 2014). Medication errors from a miscalculated dose are three times higher among children than adults, placing children at risk of serious or lethal injury (Brennan-Bourdon et al., 2020; Kaushal et al., 2001).

Safety incidents occur when there are deficits or unclear exchanges in the understanding of verbal or written information that is transmitted between individuals or teams. Communication is a reciprocal process of sending and receiving information that forms and reforms a group or team's attitudes, behaviors, and thoughts (Gregory et al., 2021; Salas et al., 2018). Effective communication occurs when there are understandable exchanges of information, thoughts, and feelings among individuals through verbal speech, written reports, and other exchanges (Kourkouta & Papathanasiou, 2014; Ratna, 2019). Communication errors between health care providers may contribute to unanticipated risks, serious injuries, and deaths (Rosenthal et al., 2017; Starmer et al., 2017).

Effective team communication is critically important, between providers and a child's adult caregivers. For example, poor communication regarding a child's pain management can result in the administration of too little or too much medication. Lapses in effective communication have been found to increase the occurrence of patient safety incidents, driving up the duration and cost of hospital admissions (Rosenstein, 2011). The lack of effective communication increases family caregivers' anxieties about their child's care, and decreases their overall satisfaction (Cox et al., 2013; Khan et al., 2016; Tarini et al., 2009; Woods et al., 2008). Effective communications within the health care team regarding safety incidents are essential to creating system changes that prevent further harm (Gampetro et al., 2021; Kaushal et al., 2001; The Joint Commission, 2021 b).

A safety culture is defined as “the product of individual and group values, attitudes, competencies and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety programs” (Cooper, 2000, p. 114; National Patient Safety Foundation, 2015, p. xii; Health and Safety Executive, 2005, p. 4). An organization displaying a positive safety culture characteristically ensures that communications are founded on mutual trust and shared perceptions of the importance of safety. There is a group confidence in the efficacy of the preventive measures found within the organization (Health and Safety Executive, 2005).

Organizations with positive safety cultures support the communications of near misses and errors within just cultures (Reason, 1998). Just cultures reinforce the trust that reporting of safety incidents will be supported within the health care organization, and not met with punitive responses from management (Reason, 1998). Such reporting cultures occur in environments that prime employees to report safety lapses and potential safety hazards (Reason, 2000). Following reports, the health care system needs to collect, analyze, and disseminate the knowledge gained from the reported incidents in rapid, useful, and intelligent ways. Health care systems with just cultures value these reports and welcome the learning that occurs that will improve the organization's ability to function safely (Reason, 1998).

United States hospital systems indirectly discourage reporting of safety incidents (Burlison et al., 2020; Gampetro et al., 2021; Mitchell et al., 2016). Studies have found that health care providers do not speak up when they confront a safety incident because such reporting was perceived negatively by their team and unit managers (Ahlberg et al., 2020; Burlison et al., 2020; Gampetro et al., 2021). Since the publication of To Err is Human (1999), quality improvement initiatives in the United States have targeted hospital-acquired safety incidents that increase patient morbidity, mortality, and length of hospital stay. However, there is a gap in the patient safety literature that focuses on the institution and promotion of sustainable system changes for the prevention of these incidents (Kohn et al., 1999; Patterson et al., 2013; Schneider et al., 2021; The Joint Commission, 2018, The Joint Commission, 2021a). For instance, medication errors in neonatal care remain common, along with unsafe transfers of children between hospital units and specialties (Gampetro et al., 2021; Mueller et al., 2019).

Previous research has analyzed data on pediatric care extracted from the Agency for Healthcare Research and Quality's (AHRQ's) 2016 Hospital Survey on Patient Safety Culture (HSOPSC) dataset (Gampetro et al., 2021). This research determined that pediatric administrators and managers reported a more positive safety culture than pediatric frontline providers such RNs, physicians, nurse practitioners, and physician assistants (p < .001). Frontline health care providers did not perceive their settings as open to communicating safety events, nor did hospital administrators and managers (p < .001). This demonstrates a gap in perceptions about how safety events are identified and communicated within hospital units (Gampetro et al., 2021).

This follow-up study looks deeper into the communication gap uncovered within the pediatric care setting regarding patient safety incidents and reporting. This study explored differences in how pediatric RNs perceived and conceptualized team communication regarding safety incidents that could cause children harm. We analyzed pediatric RNs' responses from datasets from the national HSOPSC survey, from two separate cohorts at two points in time (2016, 2018), to determine communication regarding safety incidents. The communication dimensions in the survey examined the perceptions of reporting safety incidents from the perspective of RNs (see Table 1).

We chose a population of RNs because RNs are the largest group of health care providers in the workforce (Smiley et al., 2018). Our primary objective in this study was to gain a deeper understanding of RNs' perception of communication within the pediatric hospital setting. In addition, we wanted to establish whether the previously identified gap in communication and in the reporting of safety incidents persists (Gampetro et al., 2021).

Our study aims were to: (1) determine the associations between RNs' communication within their health care teams and the frequency that they reported safety events; (2) determine the associations between RNs' communication within their health care teams and their perceptions of safety within their hospital units; and (3) determine whether RNs' communication differed in the 2016 and 2018 datasets. We hypothesized that given the attention to quality improvement initiatives over the past decade, hospitals would develop safety cultures that would support reporting cultures and quality improvement.