Assessment of Safety Attitudes in a Skilled Nursing Facility

Assessment of Safety Attitudes in a Skilled Nursing Facility

Assessment of Safety Attitudes in a Skilled Nursing Facility Angela M. Wisniewski, PharmD, William S. Erdley, RN, DNS, Ranjit Singh, MD, MBA, Timothy ...

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Assessment of Safety Attitudes in a Skilled Nursing Facility Angela M. Wisniewski, PharmD, William S. Erdley, RN, DNS, Ranjit Singh, MD, MBA, Timothy J. Servoss, MA, Bruce J. Naughton, MD, and Gurdev Singh, PhD Safety has not been well studied in the longterm care setting. This pilot study assesses staff attitudes regarding safety culture at one 250-bed skilled nursing facility. A valid and reliable Safety Attitudes Questionnaire (SAQ) was administered once to a sample of 51 employees. Nursing staff and other health care staff were generally satisfied with their jobs (42% and 67% had a positive attitude, respectively) but gave low scores to Management (22% and 13%, respectively) and Safety Climate (28% and 33%, respectively). Registered nurses, licensed practical nurses, and nurse management/supervisors received the highest ratings for quality of collaboration and communication (range: 3.6 – 4.1 on a 5-point Likert scale with 1 ⫽ very low, 5 ⫽ very high), whereas nurse practitioners and physician assistants received the lowest (range: 2.5–2.9). The SAQ provided insight into employees’ safety attitudes and can be used to identify opportunities for improvements in safety. (Geriatr Nurs 2007;28: 126-136) s the nursing home population grows in both size and complexity, an associated increase in the absolute number of medical errors is likely, with the resultant undesirable effects on quality of life, morbidity, and mortality. In 1999, it was estimated that more than 1.6 million elderly (ⱖ65 years old) people resided in nursing homes; this population represents approximately 90% of nursing home bed occupancy in 18,000 facilities.1 The facilities are currently staffed by more than 1.5 million full-time equivalent (FTE) employees who have direct and indirect patient care responsibilities, the largest percentage (41%) being nurse’s aides and orderlies.1 The proportion of the nursing home population in the oldest age category (ⱖ85 years old) has increased by approximately one third.2 If nursing home residency trends continue, it is



estimated that occupancy will double by 2030 to more than 3 million.3 On admission, more than half of all nursing home residents have at least 3 diagnoses.3 Throughout the course of their stay, more than 90% of the residents require care from nursing staff, receive over-the-counter (OTC) or prescription medications (mean 7.3 scheduled drug mentions per month for Medicare beneficiaries4), and are the recipients of medical and personal care services.1 Even if there is no increase in the percentage of residents with disabilities, there will be an increase in the absolute number of these residents.2,5,6 With the publication of the Institute of Medicine (IOM)7 report To Err Is Human: Building a Safer Health System, attention was focused on the morbidity, mortality, and costs associated with medical errors. Although the IOM report principally dealt with data based on medical errors in the inpatient setting, studies published before8-12 and after13-16 the report have examined various facets of medication safety in the context of long-term care facilities. One study using retrospective, systematic chart review combined with computer-generated signals and reporting from nursing staff found the rate of actual and potential adverse drug events (ADEs) among nursing home residents to be 9.8 per 100 resident-months.14 In extrapolating their findings to the U.S. nursing home population, the authors of this study estimated that on an annual basis, residents would experience more than 1.9 million ADEs, of which more than 86,000 would be life-threatening or fatal. Resident factors that have been associated with a greater likelihood of experiencing an ADE include being a new resident of a facility,13 having a higher level of comorbidity,13 having more scheduled medications,10,13,14 and being prescribed certain classes of medication.13,14 As stated by Gurwitz and colleagues,14 “Current efforts relating to identifying and analyzing adverse events in the long-term care setting are

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inadequate and rarely lead to sustainable changes that result in improvements in medication safety.” In addition to a reduction in the absolute number of actual and potential medical errors, IOM reports call for systemic change to develop a “culture of safety” within health care.7,17 Many health care organizations employ a punitive approach to medical errors, fixing blame on workers. This approach ignores the weaknesses within the system that contributed to the error and does little, if anything, to prevent recurrence. Formation of a culture of safety is the most effective and enduring strategy for initiating and continuing improvements in patient safety. Sustaining a culture of safety within an organization requires time, commitment, and effort on the part of all employees, from senior management to front-line workers. As a start toward this end, Helmreich and colleagues at the University of Texas adapted their Crew Resource Management (CRM) experience in aviation safety to the field of medicine. Both are safety-critical industries in which the vast majority of errors are the result of human error. They advocated obtaining a “detailed knowledge of the organization, its norms, and its staff.”18 One component of this approach is utilization of the Safety Attitudes Questionnaire (SAQ). The SAQ permits inferences regarding an organization’s safety culture by assessing the attitudes of health care team members regarding factors affecting clinical practice. These factors (safety constructs) include Stress Recognition, Safety, Team, and Organizational (Perceptions of Management, Working Conditions, Job Satisfaction) Climates.19,20 The SAQ has now been used in a variety of health care settings and has proved to be valuable in identifying areas of strength and opportunity within an institution. In addition to eliciting employees’ safety attitudes,21,22 it serves as a starting point for system-based change23 and for assessing the impact of measures implemented to improve patient safety.24 A literature search yielded no evidence that this tool had been applied in long-term care. The purpose of this article is to address this gap by examining the utility of the SAQ in a skilled nursing facility (SNF). Because it is predominantly the nursing staff within the institution that submit error reports, a secondary aim is to determine whether a difference in the perception of safety exists between nursing staff (registered nurses [RNs],

licensed practical nurses [LPNs], certified nursing assistants [CNAs], and nurse management/ supervisors) with direct, daily, and ongoing patient care responsibilities and other health care staff (unit clerk/secretaries, administrators, counselors/social workers, physical [PTs]/occupational therapists [OTs], and others) with supportive or indirect patient care roles.

Methods Setting and Study Design This one-time study using a convenience sample was undertaken at a 250-bed skilled nursing facility located on the campus of a suburban community hospital in western New York State. This not-for-profit facility is maintained by a religious organization. It does not serve as a teaching site for any health profession schools. This study received institutional review board approval. Sample All nursing and allied health care staff with direct or indirect patient care responsibilities were eligible to participate. Physicians and midlevel providers (nurse practitioners [NPs] and physician assistants [PAs]) were not included as study participants. Four informational sessions were held at the site for employees. The sessions included a brief presentation (background, rationale for the study, and instructions for filling out the questionnaire) and enough time for employees to complete the survey. For those employees unable to attend an informational session, surveys were distributed via the internal mail system. Questionnaires were completed voluntarily and anonymously, with participants requested to refrain from placing any identifying information on the survey. A secure drop box was provided for completed questionnaires. Employees were allowed a 4-week time period during which surveys could be returned. At the time of survey administration in June 2005, there were 290 employees at the facility. Fifty-three surveys were returned within the specified time frame. Two surveys were excluded from analysis because respondents did not indicate a job category, leaving 51 surveys available for analysis. This resulted in an overall response rate of 18%. Although CNAs contrib-

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Table 1. SNF Job Categories and Response Rate

Job Category Nursing staff Registered nurse (RN) Licensed practical nurse (LPN) Certified nursing assistant (CNA) Nurse management/supervisor Other health care staff Administrator Unit clerk/secretary Counselor/social worker Physical/occupational therapist Other

No. of Staff (N ⴝ 290)

No. of Respondents (N ⴝ 51)

Staff Response Rate (%)

Percent of Total Respondents

7 47 145 12

1 9 19 7

14 19 13 58

2 18 37 14





SNF ⫽ skilled nursing facility.

uted the largest number of respondents, they also had the lowest response rate (13%) (Table 1). The response rate for nurse management/ supervisors was considerably higher than any other staff group, 58% versus 13%–19%. Data Collection The SNF version of the SAQ was adapted, with permission, from the SAQ (Intensive Care Unit [ICU] version) of the University of Texas Center of Excellence for Patient Safety Research and Practice. The original SAQ (ICU version) may be found in The Safety Attitudes Questionnaire Guidelines for Administration.25 Only minor changes were made to the questionnaire. These included the conversion of “ICU” to “SNF” and “hospital” to “SNF” in the phrasing of the survey statements. This adaptation is possible because the general context of the survey statements is not unit- or environment-specific. The composite scale reliability of the SAQ is good with a Raykov’s ␳ coefficient of 0.90.19,*


Parameter estimates of the final model: “The fit of the final model containing the 30 remaining items was generally satisfactory: ␹2(784) ⫽ 10,311.27, P ⬍ 0.0001; CFI ⫽ 0.90, RMSEA ⫽ 0.03, SRMR (between clinical areas) ⫽ 0.17, and SRMR (within clinical areas) ⫽ 0.04.”19 CFI ⫽ comparative fit index; RMSEA ⫽ root mean square error of approximation; SRMR ⫽ standardized root mean residual.


Additional psychometric properties of the questionnaire are reported elsewhere.19 The SAQ–SNF version has 3 sections. The first section obtains participant background information for basic demographics. The second is the 64-item SAQ, 30 items of which are used to calculate the 6 safety constructs: Teamwork Climate, Safety Climate, Perceptions of Management, Job Satisfaction, Working Conditions, and Stress Recognition. Teamwork Climate deals with how people work together, how they communicate with each other, and the extent to which there exists a climate of mutual trust, respect, and cooperation. Safety Climate addresses employees’ perceptions of and assessment of safety risks as well as colleague and management response to these safety risks. Job Satisfaction primarily speaks to how employees perceive the value of their work and the intangible (i.e., emotional) attributes associated with it. Stress Recognition assesses employees’ selfawareness of stress and fatigue and their ability to acknowledge the potential for impaired job performance under these conditions. Perceptions of Management gauges employees’ observations regarding management’s support for and provision of adequate resources for creating a culture of safety. Working Conditions determines whether employees perceive that they receive adequate training and support for maintaining job accountability. Participants use a

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5-point Likert scale to complete the SAQ, where 1 ⫽ disagree strongly, 2 ⫽ disagree slightly, 3 ⫽ neutral, 4 ⫽ agree slightly, and 5 ⫽ agree strongly. Lastly, the third section is a scale to evaluate the quality of communication and collaboration between employee groups. When rating the quality of collaboration and communication among team members, respondents use a 5-point Likert scale, where 1 ⫽ very low, 2 ⫽ low, 3 ⫽ adequate, 4 ⫽ high, and 5 ⫽ very high. The survey takes approximately 15 minutes to complete. Statistical Analysis Survey results were entered into an Access 2000 database (Microsoft Corporation, Redmond, WA) and analyzed using SAS, version 9.1 (SAS Institute, Cary, NC). A P value ⬍.05 was considered to be statistically significant. Means and standard deviations were calculated where indicated in the tables. The Fisher exact test was used to test for differences in categorical responses between Nursing and Other Health Care Staff, and the t test was used for continuous variables. In keeping with the analytic technique of the originators of the SAQ, safety attitudes for each of the 6 safety constructs (Teamwork Climate, Safety Climate, Perceptions of Management, Job Satisfaction, Working Conditions, and Stress Recognition) were calculated.26 This was done by converting results from categorical (Likertscale) to continuous variables, such that 1 (disagree strongly) ⫽ 0; 2 (disagree slightly) ⫽ 25; 3 (neutral) ⫽ 50; 4 (agree slightly) ⫽ 75, and 5 (agree strongly) ⫽ 100. For each construct, the responses were summed and then divided by the number of statements within that construct. A scale with a range of 0 –100 was formed, on which a mean score of ⱖ75 was considered to denote a positive safety attitude.

Results The majority of respondents identified themselves as female (94%), non-Hispanic White (70%), and working full-time (80%) on the day shift (76%). Demographic characteristics of nonrespondents were not available for comparison. Although a greater number of nursing staff than other health care staff self-identified as nonHispanic Black (28% vs. 14%) and working on the evening shift (28% vs. 7%), respectively,

there were no statistically significant differences between the 2 groups (Table 2). Members of the nursing staff had worked in this specific SNF significantly longer than Other Health Care Staff members (6.1 vs. 3.2 years, respectively, P ⬍ .0001). There were no significant differences between the 2 groups in terms of how many years they had worked in their current capacity nor in how many years they had worked in a SNF. When asked to rate the quality of collaboration and communication among team members, nursing staff gave the highest rating to LPNs (mean score 4.1 on a 5-point Likert scale, from 1 ⫽ very low to 5 ⫽ very high) and the lowest rating to PAs (mean score 2.5). Members of the nursing staff group tended to rate the quality of communication and collaboration among themselves higher (mean score range 3.6 – 4.1) than with members of other job categories (mean score range 2.5–3.4) with the exception of unit clerk/secretary (mean score 3.7). Nurse management/supervisors received the highest rating from other health care staff (mean score 3.9) and physicians received the lowest score (mean score 2.6). Between them, nursing staff and other health care staff consistently gave the lowest ratings to PAs and NPs. There were no statistically significant differences in the ratings given by the Nursing Staff and Other Health Care Staff (Table 3). Table 3 also provides the percentage of staff with positive safety attitudes and mean scale scores by staff type. Overall, the mean attitude scores for the 6 safety constructs ranged from a low of 57 (Perceptions of Management among the Nursing Staff) to a high of 80 (Job Satisfaction among Other Health Care Staff). Percent of staff with a positive attitude (score ⱖ75) ranged from a low of 13 (Perceptions of Management among Other Health Care Staff) to a high of 67 (Job Satisfaction among Other Health Care Staff). There were no statistically significant differences, based on mean scores, between the Nursing and Other Health Care Staff for any of the 6 safety constructs. Less than 40% of respondents had a positive attitude for 5 of the safety constructs (Teamwork Climate, Safety Climate, Perception of Management, Working Conditions, and Stress Recognition). The Perceptions of Management construct had the lowest percent of staff with a positive attitude, 22% for Nursing and 13% for Other Health Care Staff.

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Table 2. Demographic Characteristics of SNF Staff Nursing Staff (n ⴝ 36)

Characteristic Gender (number, %) Female Male Race/ethnicity (number, %) Black (not Hispanic) White (not Hispanic) Other Job status (number, %) Full-time Part-time Usual shift (number, %) Days Evenings Nights Years in current capacity (mean, SD, range) Years in a SNF (mean, SD, range) Years in this SNF* (mean, SD, range)

Other Health Care Staff (n ⴝ 15)

35 (97) 1 (3)

13 (87) 2 (13)

10 (28) 23 (64) 3 (8)

2 (14) 12 (86) 0 (0)

27 (77) 8 (23)

13 (87) 2 (13)

25 10 1 11.43 11.74 6.13

(69) (28) (3) (10.46, 1-44) (9.78, 1-35) (6.98, 1-30)

14 1 0 10.36 7.64 3.21

(93) (7) (0) (7.78, 2-27) (6.96, 2-23) (2.23, 1-8)

The only statistically significant difference between the nursing staff and other health care staff for any of the demographic variables presented in this table was for years worked in this SNF. SNF ⫽ skilled nursing facility. *P ⬍ 0.0001.

Job Satisfaction was the only safety construct for which more than 40% of members of each staff group had a positive attitude. A detailed view of overall responses for the individual SAQ statements comprising the 6 safety constructs is provided in Table 4. The mean score for the majority of statements (70%) ranged between 3 (neutral on the 5-point Likert scale) and 4 (agree slightly). Ninety percent of respondents indicated they knew the proper channels for directing questions related to patient safety in the SNF, and 80% agreed they were encouraged by colleagues to report safety concerns. Eighty percent agreed with the statement, “I like my job.” Only slightly more than half of respondents indicated that a good working relationship existed between physicians and nursing staff. Potential areas for improvement, based on less than 50% respondent agreement, included morale, recognition of the impact of fatigue on performance during emergency situations, administrative support of staff, adequacy of staffing levels, availability of information for diagnostic and therapeutic decision making, and dealing constructively with problem personnel.


Discussion Summary and Key Findings The SAQ was successfully adapted for and administered in the long-term care setting. Despite a low response rate, it provided a preliminary overview of the safety culture in the institution in which it was piloted. No statistically significant differences were found between Nursing and Other Health Care Staff in ratings of the 6 safety constructs or the quality of collaboration and communication between staff members. It is encouraging that overall a majority of respondents had a positive attitude in regard to Job Satisfaction, even though morale was comparatively lower. The reason(s) for the disparity between the relatively higher Job Satisfaction and lower Teamwork Climate scores for Other Health Care Staff is not known but warrants further investigation. A higher response rate would have been informative in determining whether the majority of the staff shared these attitudes. The safety construct “Perceptions of Management” received the lowest overall mean score

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Table 3. Quality of Collaboration and Communication Among Team Members, Percentage of Staff with Positive Safety Attitudes and Mean Scale Scores by Staff Type Nursing staff (n ⴝ 36) Collaboration and Communication* Nursing staff (mean, SD) Registered Nurse (RN) Licensed Practical nurse (LPN) Certified Nursing assistant (CNA) Nurse management/supervisor Other Health Care Staff (mean, SD) Administrator Unit clerk/secretary Counselor/social worker Physical/occupational therapy Physicians and mid-level providers (mean, SD) Physician Physician assistant (PA) Nurse practitioner (NP) Safety Attitudes† Teamwork Climate Number (%) with positive attitude Mean score (SD) Safety Climate Number (%) with positive attitude Mean score (SD) Perception of Management Number (%) with positive attitude Mean score (SD) Job Satisfaction Number (%) with positive attitude Mean score (SD) Working Conditions Number (%) with positive attitude Mean score (SD) Stress Recognition Number (%) with positive attitude Mean score (SD)

Other Health Care Staff (n ⴝ 15)

3.61 4.06 3.97 3.74

(1.02) (0.95) (1.03) (0.86)

3.86 3.57 3.14 3.93

(1.03) (1.02) (1.03) (1.14)

3.16 3.71 3.27 3.42

(1.14) (1.07) (1.17) (1.08)

3.36 3.42 3.69 3.50

(1.28) (0.90) (1.18) (1.00)

3.17 (1.47) 2.50 (1.21) 2.94 (1.26)

2.63 (0.74) 2.67 (0.58) 2.67 (0.58)

13 (36) 69.3 (19.8)

4 (27) 69.3 (14.8)

10 (28) 68.8 (16.5)

5 (33) 66.8 (15.7)

8 (22) 57.0 (19.8)

2 (13) 61.5 (14.2)

15 (42) 65.3 (25.2)

10 (67) 80.4 (18.9)

13 (36) 63.4 (22.3)

5 (33) 70.5 (15.8)

14 (39) 64.8 (26.4)

3 (20) 69.4 (11.6)

There were no statistically significant differences between the nursing staff and other health care staff for any of the 6 safety constructs or in their ratings of the quality of collaboration and communication with other staff groups. *Respondents were asked to use a 5-point Likert scale where 1 ⫽ very low, 2 ⫽ low, 3 ⫽ adequate, 4 ⫽ high, and 5 ⫽ very high. † Positive attitudes were defined as having scale scores ⱖ75, the equivalent of agree or strongly agree on the Likert scale used for response options.

and had the lowest proportion of respondents with a positive attitude. Based on an evaluation of the individual statements contained within this construct, this likely could be most improved through an increase in staffing levels. Attempts on the part of management to be overtly supportive of the staff’s daily efforts

would appear to be warranted. A management team that fosters a more open, nonpunitive discussion about safety among team members could also improve the staff’s perception of management. The unease of both staff groups with regard to discussion of errors and their hesitation to

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Table 4.

SAQ Item Descriptives (n ⴝ 51) Safety Construct

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Teamwork Climate Nurse input is well received in this SNF. In this SNF, it is difficult to speak up if I perceive a problem with patient care. (R) Disagreements in this SNF are resolved appropriately (i.e., not who is right but what is best for the patient). I have the support I need from other personnel to care for patients. It is easy for personnel in this SNF to ask questions when there is something that they do not understand. The physicians and nurses here work together as a well-coordinated team. Safety Climate I would feel safe being treated here as a patient. Medical errors are handled appropriately in this SNF. I receive appropriate feedback about my performance. In this SNF, it is difficult to discuss errors. (R) I am encouraged by my colleagues to report any patient safety concerns I may have. The culture in this SNF makes it easy to learn from the errors of others. I know the proper channels to direct questions regarding patient safety in this SNF. Job Satisfaction I like my job. Working in this SNF is like being part of a large family. This SNF is a good place to work. I am proud to work at this SNF. Morale in this SNF area is high. Stress Recognition When my workload becomes excessive, my performance is impaired. I am less effective at work when fatigued. I am more likely to make errors in tense or hostile situations. Fatigue impairs my performance during emergency situations (e.g., resuscitation, seizure). Perceptions of Management SNF administration supports my daily efforts. SNF management does not knowingly compromise the safety of patients. The levels of staffing in this SNF are sufficient to handle the number of patients. I am provided with adequate, timely information about events in the SNF that might affect my work.

Mean (SD)

Agree* (%)

Disagree† n (%)

0 (0) 1 (2) 0 (0)

3.69 (1.10) 2.58 (1.36) 3.51 (1.25)

29 (57) 12 (24) 26 (51)

8 (16) 30 (60) 12 (24)

0 (0) 0 (0)

3.82 (1.18) 4.04 (1.06)

32 (63) 37 (73)

6 (12) 5 (10)

1 (2)

3.72 (1.31)

26 (52)

9 (18)

0 0 1 1 0 1 1

(0) (0) (2) (2) (0) (2) (2)

3.92 3.92 3.56 2.98 4.27 3.54 4.46

(1.16) (1.16) (1.23) (1.36) (0.98) (1.07) (0.81)

30 28 31 18 41 27 45

(59) (55) (62) (36) (80) (54) (90)

6 5 11 22 3 8 1

(12) (10) (22) (44) (6) (16) (2)

0 0 1 0 0

(0) (0) (2) (0) (0)

4.35 3.55 3.84 4.08 3.12

(1.04) (1.42) (1.32) (1.20) (1.37)

41 32 29 40 17

(80) (63) (58) (78) (33)

4 12 7 7 17

(8) (24) (14) (14) (33)

0 0 0 0

(0) (0) (0) (0)

3.82 3.96 3.78 3.41

(1.20) (1.26) (1.43) (1.70)

35 38 35 16

(69) (75) (69) (31)

8 8 12 17

(16) (16) (24) (33)

0 0 0 0

(0) (0) (0) (0)

3.35 3.72 2.65 3.71

(1.16) (1.31) (1.32) (1.06)

22 29 18 34

(43) (57) (35) (67)

13 9 28 6

(25) (18) (55) (12)

Missing n (%)

(R) denotes that the item was reverse scored. SAQ ⫽ safety attitudes questionnaire. Respondents used a 5-point Likert scale where 1 ⫽ disagree strongly, 2 ⫽ disagree slightly, 3 ⫽ neutral, 4 ⫽ agree slightly, and 5 ⫽ agree strongly. Participants who chose 3 (neutral) on the 5-point Likert scale are not represented in the Agree or Disagree columns. Number of participants who chose 3 ⫽ number of respondents – (Agree ⫹ Disagree). *Agree refers to the number and percent of participants who chose 4 (agree slightly) or 5 (agree strongly) on the 5-point Likert scale. † Disagree refers to the number and percent of participants who chose 1 (disagree strongly) or 2 (disagree slightly) on the 5-point Likert scale.

19 (37) 4 (8) 3.10 (1.47) 4.24 (1.09) 0 (0) 0 (0)

21 (41) 34 (67)

6 (12) 8 (16) 34 (68) 22 (43) 3.92 (1.14) 3.78 (1.33) 1 (2) 0 (0)

Mean (SD) Safety Construct

Working Conditions This SNF does a good job of training new personnel. All the necessary information for diagnostic and therapeutics decisions are routinely available to me. This SNF deals constructively with problem personnel. Trainees in my discipline are adequately supervised.

Disagree† n (%) Agree* (%) Missing n (%)

Table 4. Continued

speak up if they perceive a problem with patient care is potentially problematic. Impaired discussion about potential or perceived errors decreases the opportunity for team members to learn from one another. The finding also highlights the negative safety consequences of a culture that focuses on human causes of error instead of systems-based causes. Employee groups who have primary patient care responsibilities within the SNF indicated that they had at least adequate, if not high, quality of communication and collaboration among themselves. The generally lower quality of communication and collaboration that respondents accorded to physicians and midlevel providers could have important implications in regard to patient and medication safety, particularly if it is a manifestation of professional rivalry, and needs to be addressed. Although no previous reports have described use of the SAQ in the long-term care setting, comparisons can be made with other job satisfaction surveys, safety attitude surveys, and focus group sessions, as well as with SAQ administrations in the inpatient setting. SNFs may differ based on factors such as geographic location, size, affiliation, the number and discharge rate from short-stay beds, staff turnover, and sociodemographic characteristics of the patient population; nonetheless, our findings are consistent with those of previously reported studies. Despite possible perceptions to the contrary, this study and others have found that nursing staff are generally content with their jobs.23,27-29 The purpose of this was not to explore factors contributing to job satisfaction, but some findings may relate to the literature on this topic. For example, recurring themes associated with job satisfaction have included nurses having a sense of feeling valued by the residents with whom they work, recognition for and pride in one’s work, and a sense of collegiality and teamwork with coworkers.27,29,30 This study provides additional support for factors identified as contributing to decreased job satisfaction, including a lack of adequate staffing levels,22,23,29-31 a desire for improved teamwork with providers (including more input into decision making),21-23,30-32 and the working relationship with management.28,30,31 Improving job satisfaction can lead to increased job performance quality and improved patient safety.

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Similar to our findings, others have found nursing staff in both inpatient and long-term care settings rate the quality of their communication and collaboration with physicians lower than among themselves.21,22,31,32 This study demonstrates that the valid and reliable SAQ can be successfully adapted to and used in the long-term care setting. On the basis of the dimensions of safety culture that it assesses, the scope of the SAQ is more extensive than other previously reported studies in the long-term care setting, and thus it provides additional insight into the safety culture at a SNF. Strengths and Limitations To our knowledge, this is the first report of the use of the validated and reliable Safety Attitudes Questionnaire in the SNF setting. Of the job satisfaction and safety attitudinal literature available for the SNF setting, this is one of the few studies that has not focused exclusively on feedback of nursing staff. This study reflects real-world experience with the SAQ instrument in the SNF setting; the SNF where it was administered is not university-affiliated, and employees are unaccustomed to participating in research. Study limitations include the low response rate, potential Type II error and sampling bias, and potential nonresponse bias. The overall response rate for this study of 18% is lower than the overall response rate associated with administration of the SAQ (range: 40%–59%)21-23 or Safety Climate Survey (preintervention 67%, postintervention 55%)24 to health care professionals and staff in hospital-based practice environments as well as lower than the response rate reported for other job satisfaction and safety attitudinal surveys administered to nursing staff (range: 35%–56%).28,30,32 Response rate was not provided in one study.27 To maintain respondent anonymity, encourage participants to be candid in their responses, and avoid putting staff under pressure to answer potentially sensitive questions, a reminder system was not part of the study protocol. This approach likely contributed to the lower response rate. Other possible explanations include an inadequate understanding regarding the purpose of the questionnaire, competing demands, and lack of experience with participatory research. Although


this study did not detect any statistically significant differences in responses between the Nursing and Other Health Care Staff, the small number of respondents in each group (36 and 15, respectively) and low overall response rate (18%) could have contributed to a Type II error. An a priori power analysis was not performed to determine the number of nursing staff and other health care staff respondents needed to detect statistically significant differences in responses between the 2 employee groups. Sampling bias may have influenced the results obtained in this study. In particular, the response rate for nurse management/supervisors (58%) was much greater than that of other staff job classifications (range: 13% for CNAs, 19% for LPNs and other health care staff). Use of a systematic approach to improve overall response rate, such as a reminder system, would be expected to contribute to a more similar response rate among the various job classifications listed. It was impossible to know whether the survey respondents differed in meaningful ways from the nonresponders. Despite these limitations, the use of this survey may be helpful for individual institutions, because every institution is unique. Specifically, it is recommended that each institution survey team members to establish safety attitudes within their specific organization. This can serve as a starting point for devising site-specific solutions. In general, patient safety issues have been less well studied in the SNF setting compared with the inpatient and ambulatory care environments. With a projected doubling of the nursing home population over the next 2 decades (and these residents expected to have lower levels of functioning, more comorbidities, and be on more medications), it is important to begin focusing on this issue. One approach is to understand the safety attitudes of the health care staff that work in this setting and provide care to the residents. Administration of the SAQ begins the formative process of increasing the awareness of team members of the resources available within the organization. This can provide employees with the sense that they are involved in a bottom-up approach to improving patient safety and contribute to the formation of selfempowered, self-motivated teams. The SAQ permits management and staff to identify areas of strength and opportunities for improvement to-

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ward forming a culture of safety. Furthermore, it can be used to determine whether implemented system and culture changes produce measurable and meaningful changes in any of the 6 safety constructs over time. The usefulness of such measures depends in large part on achieving a meaningful response rate. The authors recommend that facilities attempt to maximize the response rate by clarifying for staff the goal of the survey. Specifically, it should be emphasized that the survey provides an opportunity for staff to express their views anonymously and that the information collected will be used constructively to improve their work environment.

References 1. Jones A. The National Nursing Home Survey: 1999 summary. Vol 13. Hyattsville, MD: National Center for Health Statistics; 2002. 2. Decker FH. Nursing homes, 1977–99: what has changed, what has not? Hyattsville, MD: National Center for Health Statistics; 2005. 3. Sahyoun NR, Pratt LA, Lentzner H, et al. The changing profile of nursing home residents: 1985–1997 [Aging Trends, No. 4]. Hyattsville, MD: National Center for Health Statistics; 2001. 4. Briesacher B, Stuart B, Doshi J. Medication use by Medicare beneficiaries living in nursing homes and assisted living facilities. Baltimore: University of Maryland, Peter Lamy Center; June 5, 2002. 5. Goulding MR, Rogers ME. Public Health and Aging: Trends in Aging—United States and Worldwide. MMWR 2003;52(6):101-6. 6. Adminstration on Aging. A profile of older Americans: 2005. Department of Health and Human Services. Available at: profile/2005/2005profile.pdf. Cited May 23, 2006. 7. Kohn LT, Corrigan J, Donaldson MS. To err is human: building a safer health system. Institute of Medicine, editors. Washington, DC: National Academy Press; 2000. 8. Gurwitz JH, Field TS, Avorn J, et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med 2000;109:87-94. 9. Gurwitz JH, Sanchez-Cross MT, Eckler MA, et al. The epidemiology of adverse and unexpected events in the long-term care setting. J Am Geriatr Soc 1994;42:33-8. 10. Cooper JW. Probable adverse drug reactions in a rural geriatric nursing home population: a four-year study. J Am Geriatr Soc 1996;44:194-7. 11. Cooper JW. Adverse drug reaction-related hospitalizations of nursing facility patients: a 4-year study. South Med J 1999;92:485-90. 12. Gerety MB, Cornell JE, Plichta DT, et al. Adverse events related to drugs and drug withdrawal in nursing home residents. J Am Geriatr Soc 1993;41: 1326-32.

13. Field TS, Gurwitz JH, Avorn J, et al. Risk factors for adverse drug events among nursing home residents. Arch Intern Med 2001;161:1629-34. 14. Gurwitz JH, Field TS, Judge J, et al. The incidence of adverse drug events in two large academic long-term care facilities. Am J Med 2005;118:251-8. 15. Boockvar K, Fishman E, Kyriacou CK, et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med 2004;164: 545-50. 16. Barker KN, Flynn EA, Pepper GA, et al. Medication errors observed in 36 health care facilities. Arch Intern Med 2002;162:1897-903. 17. Aspden P, Wolcott JA, Bootman JL, et al., eds. Preventing medication errors. Prepublication copy ed. Quality Chasm series. Washington, DC: Institute of Medicine, National Academies Press; 2006. 18. Helmreich RL. On error management: lessons from aviation. BMJ 2000;320:781-5. 19. Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res 2006;6(44). 20. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ 1998;316:1154-7. 21. Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about teamwork among critical care nurses and physicians. Crit Care Med 2003;31:956-9. 22. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320:745-9. 23. Luther KM, Maguire L, Mazabob J, et al. Engaging nurses in patient safety. Crit Care Nurs Clin North Am 2002;14:341-6. 24. Thomas EJ, Sexton JB, Neilands TB, et al. The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units. BMC Health Serv Res 2005;5:28. 25. Sexton JB, Thomas EJ. The Safety Attitudes Questionnaire (SAQ) guidelines for administration. Houston: University of Texas; June 11, 2003. 26. Modak I, Sexton JB, Lux TR, et al. Measuring safety culture in the ambulatory setting: the Safety Attitudes Questionnaire–Ambulatory Version. J Gen Intern Med. In press, 2007. 27. Anderson MA, Aird TR, Haslam B. How satisfied are nursing home staff? Geriatr Nurs 1991;12:85-7. 28. Carr KK, Kazanowski MK. Factors affecting job satisfaction of nurses who work in long-term care. J Adv Nurs 1994;19:878-83. 29. Moyle W, Skinner J, Rowe G, et al. Views of job satisfaction and dissatisfaction in Australian long-term care. J Clin Nurs 2003;12:168-76. 30. Aiken LH, Clarke SP, Sloane DM, et al. Nurses’ report on hospital care in five countries. Health Aff 2001;20: 43-53. 31. Ponte PR, Kruger N, DeMarco R, et al. Reshaping the practice environment. JONA 2004;34:173-9. 32. Kaissi A, Johnson T, Kirschbaum MS. Measuring teamwork and patient safety attitudes of high-risk areas. Nurs Econ 2003;21:211-8.

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ANGELA M. WISNIEWSKI, PharmD, is a Clinical Assistant Professor, University at Buffalo, School of Medicine and Biomedic Sciences, Department of Family Medicine. WILLLIAM S. ERDLEY, RN, DNS, is a Clinical Associate Professor, University at Buffalo, School of Nursing. RANJIT SINGH, MD, MBA, is a Clinical Assistant Professor, Associate Director, Patient Safety Research Center, University at Buffalo, School of Medicine and Biomedical Sciences, Department of Family Medicine. TIMOTHY J. SERVOSS, MA, is an Interim Assistant Professor, Canisius College, Department of Psychology. BRUCE J. NAUGHTON, MD, is an Associate Professor, University at Buffalo, School of Medicine and Biomedical Sciences, Department of Medicine; Kaleida Health, Department of Medicine, Division of Geriatrics and Gerontology. GURDEV SINGH, PhD, is Director, Patient Safety Research Center, University at Buffalo, School of

Medicine and Biomedical Sciences, Department of Family Medicine. ACKNOWLEDGEMENTS Funding for this study was provided through a grant from the ASHP Foundation Pharmacy/Nursing Partnership for Medication Safety Grant Program. The authors thank Jim Smith for facilitating data collection, Letitia Cowens for data entry, and Andy Danzo for his critical review of the manuscript. We also thank Dr. Thomas Rosenthal and John Taylor for their continued support of our research endeavors. 0197-4572/07/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2007.01.001

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Geriatric Nursing, Volume 28, Number 2