Differences in Perceptions of Patient Safety Culture between Charge and Noncharge Nurses: Implications for Effectiveness Outcomes Research
Deleise Wilson, Richard W. Redman, AkkeNeel Talsma, and Michelle Aebersold
University of Michigan School of Nursing, Ann Arbor, 48109 MI, USA
Correspondence should be addressed to Deleise Wilson, email@example.com
Received 4 October 2011; Revised 15 January 2012; Accepted 15 January 2012
Academic Editor: John Daly
Copyright © 2012 Deleise Wilson et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
The implementation of evidence-based practice guidelines can be influenced by nurses’ perceptions of the organizational safety culture. Shift-by-shift management of each nursing unit is designated to a subset of staff nurses (charge nurses), whom are often recruited as champions for change. The findings indicate that compared to charge nurses, noncharge nurses were more positive about overall perceptions of safety (P = .05) and teamwork (P < .05). Among charge nurses, significant differences were observed based on the number of years’ experience in charge: perception of teamwork within units [F(3, 365) = 3.52, P < .01]; overall perceptions of safety, [F(3, 365) = 4.20, P < .05]; safety grade for work area [F(3, 360) = 2.61, P < .05]; number of events reported within the last month [F(3, 362) = 3.49, P < .05]. These findings provide important insights to organizational contextual factors that may impact effectiveness outcomes research in the future.
With the increasing emphasis in the efficient delivery of healthcare, healthcare organizations are investing in effec- tiveness outcomes research to improve patient outcomes. However, the uptake and implementation of evidence-based clinical practice guidelines are influenced by contextual fac- tors such as leadership support and use of change champions [1–3] and personnel perceptions of patient safety . Within acute care settings, nurses’ perceptions of patient safety cul- tures and attitudes towards new practice guidelines are very critical for predicting the use of research evidence and new guidelines [5, 6]. What is known about nurses’ perceptions of patient safety culture has been reviewed in comparison with interdisciplinary team members [7–9] and across ranks such as staff nurses versus nurse managers . Yet, staff nurses are not a homogenous group. In most acute care settings for each nursing unit, the management of each shift is designated to a nurse who then leads other staff nurses on that shift. The shift-by-shift leaders may be known as charge nurses, or assistant nurse managers [11, 12] and are often used as champions for change [13, 14]. Since nurses are very pivotal
to the implementation of safety guidelines, it is critical to have a deeper understanding of how these two groups of nurses, charge and noncharge nurses, perceive patient safety cultures. The purpose of this paper was to compare the perceptions of nursing units’ safety culture between charge nurses and staff nurses. For this study, the charge nurse is defined as a frontline nursing unit leader who makes shift- by-shift decisions about staffing, personnel and unexpected events that impact patient care . In contrast, the non- charge nurse is defined as a staff nurse who is a direct patient care provider and has never had charge nurse experience.
The creation of reliable healthcare organizations is funda- mental for the process of improving patient care [16, 17]. The use of evidence-based practice guidelines has become widespread as one of several methods healthcare organiza- tions seek to establish safe and reliable practice environments [18, 19]. Notwithstanding, there are many organizational barriers that limit the implementation of practice guidelines [20, 21]. Ricart et al.  found that nurses’ fear of potential
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harm to patients contributed to nonadherence to evidence- based guidelines for the prevention of ventilator-associated pneumonia. Doherty  found that the lack of regular nursing staff educational meetings was a barrier to the implementation of adult asthma guidelines in the emergency room. Similarly, in the examination of the use of research in nursing organizations, Estabrooks et al.  stated that work and communication patterns characteristic of the nurses and the types of decision making processes predicted variability across organizations. Likewise, the positive perceptions of patient safety culture were associated with greater use of research findings and lower in adverse patient outcomes [2, 3, 24].
However, perceptions of patient safety culture vary across disciplines, healthcare settings, and professional ranks [25, 26]. Notably, leaders are often associated with having more positive perceptions of the safety culture than frontline workers, and managers and physicians generally reported higher levels of positive perceptions of safety as compared to staff nurses . Singer et al.  found that among nurses, work experience and work position were significantly associated with perceptions of the patient safety culture. There were more positive reports from nurses who worked on a unit or hospital for more than 10 years, while Kim et al.  also found distinctions in perceptions of patient safety culture between staff nurses and managers among healthcare workers, but we would propose that this does not go far enough to examine potential differences between staff nurses and charge nurses.
At the nursing unit-level staff nurses function as either charge or noncharge nurses. Charge nurses generally func- tion as shift-by-shift leaders of nursing units whose duties may vary within and across organizations [29, 30]. Staff nurses tend to be recently hired, mainly provide direct patient care and are supervised by charge nurses [15, 31]. In the implementation of evidence-based practice initiatives, the nurses recruited as change champions can be either charge or noncharge nurses [32, 33].
Similar to findings about other contextual factors influ- encing effective outcomes research, the impact of opinion leaders is also multifaceted [6, 34]. Curran’s  study of opinions leaders indicated that the success of an opinion leader in leading change was influenced by acceptance of the role, developmental level of the social networks within organizations clarity of role expectations and perceptions of organizational context. Although positive perceptions of patient safety culture have influenced increased use of practice guidelines as reported by Estabrooks et al.  and Cummings et al. , there may be challenges to smooth implementation when confronted with differences in perceptions of organizational context experienced by change champions [36, 37]. To disentangle the effects of nurses’ perceptions of patient safety culture on the use of evidence- based practice guidelines, it may be necessary to determine whether differences in perceptions do exist between charge and noncharge nurses. With this need, this paper was aimed at exploring the differences in perceptions of safety culture between charge and noncharge nurses.
3.1. Design and Participants. This study used a descriptive, correlational and cross-sectional design to examine the differences in the perceptions of patient safety culture among registered nurses working in 12 adult medical surgical units at a large academic medical center in the Midwest. There were 710 registered nurses working in the 12 units at the time of the study. To be included in this study, the nurses had to have at least six months experience on their current unit and were supervised by a charge nurse or worked as charge nurse. LPNs and nurse managers were excluded from the study.
3.2. Data Collection. Following the approval of the institu- tional review board (IRB) of the medical center, a modified Dillman method was used to recruit nurses . The design involved engaging the study participants in the following manner: (1) questionnaires in large manila envelopes were placed in staff nurses’ unit mailboxes; (2) 1-2 weeks after the study began, a thank you postcard was placed in the mailboxes to express appreciation for completion or as a reminder if the questionnaire had not been returned; (3) 3-4 weeks after, a thank you postcard was placed in mailboxes to express appreciation for completion of survey or as a gentle reminder if the questionnaire had not been returned. Completed surveys were placed in sealed drop boxes located within each nursing unit and sequentially numbered as they were returned. A total of 710 surveys were distributed. Over a 3-month period, 381 nurses returned completed questionnaires and signed consent forms, which yielded a response rate of 54%. Six of the 381 questionnaires were not used in the analyses on account of missing data that exceeded 10% of the total items in the study. The final sample, therefore, consisted of 375 respondents representing 53% of the total possible registered nurses who met the inclusion criteria.
3.3. Measures. The independent variables were charge nurse experience (no charge and some charge), percentage of shifts worked incharge in the past month (<25% and >25%), and number of years as charge nurse on current unit (none, less than 1 year, 1 to 5 years, and more than 5 years). Shift worked was a categorical variable with three options: permanent day, permanent night, and rotating shift. The demographic variables for the study were level of highest degree, length of time in current unit. The educational level options were (1) diploma and associate’s degrees; (2) baccalaureate degree; (3) master’s degree. Length of time in current unit response categories were (1) less than 1 year; (2) 1 to 5 years; (3) more than 5 years.
There were four dependent variables in the study, name- ly; overall perceptions of patient safety, number of events reported, teamwork within units, and safety grade. These dependent variables are four of the eleven subscales of the AHRQ Hospital Survey on Patient Safety Culture survey . Researchers have found the AHRQ Hospital Survey on Patient Survey Culture to be reliable ranging from .72 to .84 with the exception of the staffing dimension (.63) . In this
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study, the Cronbach alpha for overall perceptions of safety was .70, and teamwork within units was .80 . Safety grade and number of events reported were single items.
3.4. Data Analysis. The statistical package for the social sciences (SPSS) software version 18.0.3 was used for analyses of the data. At the completion of data entry, there were fewer than 5% of missing items. Following the guidelines of McKnight et al. , this is below the 10% threshold. Therefore, the items were not deleted and were included in data analysis. Mean substitution done to impute the values for the missing items. t-tests were conducted to test the hypothesis that there were differences in patient safety culture between nurses with no charge and some charge experience. Pearson’s chi-square test was utilized to test the relationship between percentages of shifts in charge during the past month. ANOVA technique was utilized to examine differences in the perceptions of patient safety among nurses with varying percentages of shifts in charge and number of years as charge nurse during the past month.
The descriptive characteristics of the study sample can be found in Tables 1 and 2. The sample of registered nurses consisted of 215 nurses with some charge experience and 159 without charge experience. Six out of ten of the nurses with no charge experience had a bachelor’s degree as compared to five out of ten of those with some charge experience. The nurses who were never in charge worked mainly during the rotating shifts (46%) with the least (17%) working the permanent day shift and 37% working the permanent night shift. A somewhat opposite pattern was noted in the nurses with some charge experience: 47% worked during the day; 31% at night; 22% percent worked as shift rotators. Of the nurses who were in charge, 47% worked on the current unit for more than six years compared to 12% of the staff nurses. Only 31% of the nurses functioned in the charge role for greater than twenty-five percent of shifts worked, while 25% were in charge for less than twenty-five percent of the shift worked, and the remaining 44% were never in charge. Interestedly, only 6% of the charge nurses self-identified as being permanent in the role in that they were in charge for 75% or greater of shifts worked. The educational preparation for those who were charge nurses was captured by number of shifts for shadow-charge orientation. Eight percent of the charge nurses stated they had no shadow-charge orientation. The majority (63%) of charge nurses had one to two shifts, while 29% had 3 or more shifts of shadow charge experience.