Investigating the relationship between nurses' understanding of working environment conditions and safety outcomes in patients hospitalized in special care units of medical education centers in Gilan province in 2013

Dissertation to receive a master's degree in intensive care nursing

Introduction: Maintaining safety and preventing side effects, especially in patients hospitalized in wards, is a concern

It has become a global concern in the field of health and wellness and has led to the issue of the effectiveness of working environment conditions.

Objectives: This study was conducted with the aim of determining the relationship between the nurses' understanding of the working environment conditions and the safety outcomes of patients hospitalized in the special care units of Gilan province's medical education centers.

Methodology: This descriptive-analytical cross-sectional study was conducted on 101 nurses working in the special care units of Gilan province with specified characteristics.  The research samples were selected by census method. The data were collected by self-report method and using a 3-part tool, including a questionnaire made by the researcher in the field of individual information of the samples, a sheet for recording the frequency of 4 unwanted outcomes (medication errors, ventilator-associated pneumonia, pressure ulcers, and patient falls) in special care units and a standard scale of nurses' understanding of the working environment conditions and using descriptive statistics (mean, standard deviation, and frequency percentage) and inferential (chi-square tests, correlation coefficient) Spearman, independent t-test and Mann-Whitney test) were analyzed. 

Findings: The results of this research show that the doctor-nurse communication subscale had the highest percentage (72.5%) of favorable status. The score obtained in the standard scale of working environment conditions in nursing was in the optimal group in about half (50.5%) of the samples, which had a significant relationship with the type of departments (p<0.01).  This finding also showed that ventilator-dependent pneumonia had the highest mean and standard deviation of incidence (2.8±2.92) among the unwanted safety outcomes. All unwanted safety outcomes had a mean and standard deviation of incidence of 0.88±1.05. Finally, a significant relationship was observed between the marital status of the samples with medication errors (P<0.02) and the department of activity with the incidence of ventilator-dependent pneumonia (P<0.001), medication errors (P<0.001), the incidence of patient falls ((P<0.05 and all safety outcomes P<0.05)).  But the nurses' understanding of the overall conditions of the work environment did not have a statistically significant relationship with the perceived incidence of unwanted safety consequences by the nurses.

Final conclusion: The presence of a statistically significant difference between the workplace department with the percentage of occurrence of 3 of the outcomes and all of them indicates the need for special attention to improve the working environment conditions in a variety of special care departments.

Statement of the problem

Safety is a global concept that includes adequacy, security of care, appropriate response of caregivers and satisfaction of patients and relatives. Based on this, patient safety is considered as a main goal to improve health care (1) and after that the term patient outcomes [1] has been proposed (2). This term, which takes into account all the different functional, social, physical, psychological and physiological aspects of the patient's experience in the two perspectives of positive outcomes and adverse events[2], has received attention in numerous studies and researches(3).

Despite the great emphasis of experts on maintaining safety, reliable international evidence shows that the safety of patients in healthcare centers is not in a favorable condition (4). The results of various studies along with the reports of the World Health Organization have shown that between 3 and 16 percent of hospitalized patients are affected by adverse events such as medication errors, care-related infections, or falls (2). Mazieh[3] also reports the rate of occurrence of these events in one out of ten patients admitted to hospitals in the world and writes that developing countries have a higher proportion of these complications(3). The high prevalence of these side effects or side events has drawn researchers' attention to nurses and their performance. Because the role of nursing care in the outcomes of hospitalized patients is well known (5).In this regard, the American National Quality Council [4] has introduced certain clinical outcomes from the perspective of patient nursing, which include pressure ulcers [5], ventilator-dependent pneumonia [6], blood infection related to central catheters, failure to resuscitate the patient [7], patient falls, falls with injury, use of restraints, and medication errors (6). These consequences have a direct effect on the quality of care provided by nurses, and are of great importance in terms of pathogenicity and attenuation. Because these incidents can lead to temporary disabilities (34% of cases), permanent (6-9% of cases) or death (3% of cases) of patients (2). For example, falling, with a prevalence of 2 to 12% in hospitalized patients, can cause hip fracture, brain hemorrhage, and ultimately death of the affected(7). Statistics show that 48-98,000 deaths occur in the United States every year due to unwanted consequences and complications caused by them (8).

The costs associated with the treatment of these complications are also increasing and staggering, for example, the annual cost of treating pressure ulcers in the United States is nearly 11 billion dollars (9) and the cost associated with medication errors is estimated at 3.5 billion dollars (8). In addition to increasing the duration of each patient's stay in the hospital for an average of 25 days, the ventilator also increases the hospitalization costs of each patient to about 12,000 dollars (10). Because patients hospitalized in special care units often require special care with multiple organ failure and multiple abnormalities (11). Due to the need for respiratory support and mechanical ventilation, as well as access to central vessels to administer drugs, these patients are usually at high risk of unwanted consequences such as ventilator-associated pneumonia, blood infection related to central catheters, and pressure ulcers (12), which will lead to more complications and death (13).  On the other hand, the type and quality of nursing care provided in special care units [8] is different from normal units due to high levels of work-related stress. Naturally, the high level of work stress in intensive care units increases the risk of medical errors and will lead to more serious unwanted consequences in patients (12). Therefore, nurses in special care units, due to the unstable physiological conditions of patients and their greater dependence on caregivers, are faced with the challenge of providing optimal care and advanced services along with reducing costs and the length of the patient's stay in the hospital(13).

     The important point and agreed upon by the majority of experts is the preventability of safety consequences and their strong connection with the quality of nursing care provided to patients(14). Therefore, knowing the magnitude of these incidents and identifying solutions for them in complex health care environments will be a necessary step for planning strategies to promote positive patient outcomes and ensure safe and effective care provision (3). Garoust-Orgeas [9] and colleagues also emphasize the high prevalence of adverse events in special departments and the necessity of accurate reporting systems, and write that their prevention requires multifaceted changes in the organization of special care departments and the behavior of health care workers (1). In this way, the role of structural, organizational and management factors in the occurrence of such events should not be ignored. Because the structural components of the department, such as the work environment, and the characteristics of care workers play a vital role in providing quality care leading to patient safety and satisfaction (15). Meanwhile, the conditions of the work environment or organizational characteristics that facilitate professional activities in the work environment are among the concepts that have received special attention today (14). The components related to the conditions of the professional work environment in nursing, according to the definition of the Association of American Colleges of Nursing [10], include conditions that improve the quality of patient care, which, with multi-system cooperation, will be the basis for the improvement of nurses' knowledge and professional progress. In fact, the conditions of the working environment are a combination of the characteristics of organizations, departments and units, nurses and patients