Assessing safety climate in prehospital settings: testing psychometric properties of a common structural model in a cross-sectional and prospective study

It is well known that leadership has a strong cultural influence on an organization through its beliefs and values [39] and that effective leadership promotes better patient outcomes [1]. Top management’s safety-related attitudes and behaviors will form the basis for healthcare providers’ safety behavior and hence the organization’s safety performance [1]. Middle management, i.e. unit management, is responsible for transforming priorities and values into operating procedures and action guidelines [40] and the view that top management’s influence on unit management supervisory practices is aligned with a multilevel perspective on safety climate [41, 42]. Supervisors achieve higher levels of safety compliance from their subordinates if the subordinates perceive that the supervisors prioritize safety [43]. The decentralized nature of the prehospital setting, relative to the hospital setting, is an important aspect in this matter. One might speculate that prehospital unit management might have a more important role, compared to that of their hospital peers, in their influence on the integration of systems, patient safety interventions and staff performance. With the help of coaching, mentoring and the fostering of mutual respect, staff may incorporate management’s priorities and values into their daily work, helping them to develop their own leadership potential [7].

Different leadership styles seem to influence safety-relevant behavior [41]. Several studies suggest that there is a correlation between transformational leadership and organizational outcomes [43‐45]. Transformational leadership can also function as an antecedent of climate strength [46]. Transformational leadership is conducted on organizational workers to raise their awareness of the importance of task outcomes, to meet the team members’ needs, and to induce them to prioritize the organizational goals [47]. Effective leadership promotes a setting in which healthcare providers are treated respectfully, consequently improving their performance [1]. It is also essential that unit leadership behavior creates an atmosphere in which team members feel they can communicate openly and participate in decision-making [48] and speak up if they have safety concerns [49]. In addition, the prehospital unit management conducts leadership in the local unit by assigning teams to the different unit transport vehicles, from which the emergency dispatcher allocates the designated teams’ medical emergencies, transport assignments or similar. In the prehospital environment, critical tasks are performed in teams without direct supervision from the unit management, which implies that the leadership task of putting together teams influences team outcomes.

For different high-stake contexts, a close relationship between teamwork and performance has been identified [50‐55]. Teamwork is generally considered to be the basis for good patient care [56], and it is also valuable within fast-paced unpredictable environments [57]. Teamwork is also regarded as of critical importance in assuring patient safety [49, 58]. Poor teamwork and communication have emerged as contributions to medical errors [50, 51]; in particular, a lack of cross-monitoring of the actions of team members has been identified as a significant contributor to teamwork failure [54].

In acute healthcare settings, teams are hierarchical [1], and team leaders are responsible for executing operational procedures and action guidelines given by the unit management [42]. On one side, the positive attribute of hierarchy is the clear path of information and decision-making in critical situations. On the other side, hierarchy may hinder problem-solving, e.g. if team members leave everything to the team leader and do not contribute to collecting data or finding the best treatment option [1]. Although hierarchy, formal or informal, applies in the majority of the prehospital setting, HEMS is an exception to this, as the team members are responsible for different domains and tasks, according to their profession.

In addition to effective leadership and teamwork, key elements of a safety culture also include learning from errors and developing an open environment based on trust [7]. A recent study identified two effective interventions improving the governance of patient safety within organizations: simulation-based training is increasingly valued as an effective method to enhance safety knowledge and behavior, and, secondly, the use of well-designed incident reporting leads to increased learning, feedback and improvement within units [59]. Both are among many activities that could be undertaken to create organizational learning.

It is common to define organizational learning as change in the organization’s knowledge that occurs as a function of experience [60]. Organizational learning is a dynamic process [61], meaning that, in addition to occurring over time and between organizational, unit and individual levels, learning creates a tension between assimilating new learning (feed forward) and using what is already learned (feedback). For the purpose of assimilating new learning in the prehospital setting, it is important that sufficient resources for effective and efficient reporting are available [59]. It is also important to strive for an open and fair culture to achieve open discussions about things that went wrong and when, how, and in what context they occurred [62]. In addition, such a culture should encourage healthcare providers to report patient safety incidents [7].

The degree of risk for the patient in a decision-making situation depends on the healthcare providers’ (a) awareness and knowledge of threats, (b) experience and practice with similar situations, and (c) actual clinical competence [1]. Individual team members’ behavior is influenced by the team they work in, i.e. how they communicate, support and supervise each other [37]. Learning is also dependent on other individuals; e.g., inexperienced workers learn by observing more experienced colleagues’ actions and related consequences [1].

Patient transitions and handoffs in hospitals have the potential for errors [24, 63], and, recently, transitions and handoffs have gained greater attention, also in the prehospital domain [5, 23, 64‐67]. Due to the characteristics of the prehospital context, transitions and handoffs are both challenging and complex as they involve a number of different people, such as both hospital and prehospital staff, patients, the public, and a range of communication technologies and formats [5]. Several factors could prevent effective and high-quality transitions and handoffs, e.g. lack of understanding between health care disciplines, inattention, variable quality and quantity of information exchanged, and busy and complex situations [68]. Some poor communication practices are rooted in individual behavior, such as not listening, relational issues, or misunderstandings [5]. Heavy workload in the emergency department may induce reduced “active listening” [64, 69‐71]. Errors also tend to follow unsafe behavior, e.g. when workers do not follow procedures or rush to finish tasks [18]. A recent study found it disturbing that they observed no effective interventions to monitor or improve patient safety in the prehospital chain, considering the high number of patient transitions and handoffs between EMS organizations [59].

Good transitions and handoffs are associated with improved patient safety, continuity of patient care and improved decision-making [64, 71‐73] and are clearly more than an exchange of information [65]. Quality of care is dependent on the transfer of patient information, and, since verbal transfer is often only 50% accurate, a technical solution is likely to improve patients’ outcome [67]. Nevertheless, due to the inherent complexity found in healthcare settings and communication tasks, this indicates that communication issues may not be solved by technical solutions alone [5]. The quality and quantity of information has been found to correlate with the ambulance personnel’s level of formal training and experience [71, 74]. To provide quality patient transitions and handoffs from prehospital to in-hospital, it is imperative to have ongoing formal learning in interdisciplinary teamwork, communication and a structured flexible framework in a supportive work environment [68]. Four potential improvements have been identified for transitions and handoffs from prehospital to in-hospital: direct communication between the EMS provider and the physician responsible for the patient’s care; interdisciplinary communication between hospital and prehospital staff; standardization of many of the aspects of transitions and handoffs; and improved information technology [23]. There seems to be a need for a broader conceptualization of patient transitions and handoffs, including social and organizational factors, some of which are embedded in the organization’s safety culture.

A recent study was performed on whether an organization’s safety culture factors influence effective handoffs within hospitals [24], especially the effect from an organization’s communication, teamwork, reporting and management cultures. They found that these safety culture composites influence different aspects of transitions and handoffs, i.e. information, responsibility and accountability. Viewing transitions of care as a more specific variant of patient safety culture attenuates ambiguity so that the stakeholders may more easily identify and align with the goals and processes of patient safety improvement programs [24]. Based on this, we made a major adjustment to the theoretical framework that constitutes the HSOPSC-S. The safety climate dimension “transitions and teamwork across units” was replaced with the safety climate dimension “transitions and handoffs” from the original HSOPSC, and, moreover, it was treated as an outcome dimension in our model.

The direct path from the top management level dimension “management support to patient safety” on the outcome dimension “transitions and handoffs” may be related to the EMS providers’ perception of the overall healthcare system. This implies that top management has an important direct role in patient safety in transitions and handoffs, through the quality of internal work processes, procedures and routines for patient transitions and handoffs in the prehospital domain. Patient transitions and handoffs are also organizational interfaces [91]. When commencing transitions and handoffs between the prehospital and hospital domains, EMS workers may perceive this as an interface, where both these cultural domains influence the outcome of patient transitions and handoffs. This may be seen in light of patient transitions and handoffs being considered an important area of contact between employees and the hospital [23]. An implication of this is that the better the EMS providers perceive the management support to patient safety, the better they perceive the hospital management effort to provide and maintain effective and safe systems for transitions and handoffs. In essence, top management’s expressed values and priorities are important for obtaining improved outcomes.

The lack of a direct path from the outcome dimension “transitions and handoffs” to both of the unit levels “teamwork within units” and “learning, feedback and improvement within units”, demonstrates a full mediation by individual safety behavior. An implication of this finding is that workers’ perception of the safety climate within the unit differs from their perception of the safety climate in transition and handoff situations. This observation was surprising, as safe transitions and handoffs have been linked to interdisciplinary team effort and team communication skills [69]. The explanation may be that transitions and handoffs often involve collaboration across units in the prehospital chain, which implies that the safety climate in this broader domain is different from the safety climate related to teamwork within the unit.

Another explanation may be related to the fact that two of the three samples applied in this study are retrieved from HEMS workers. In the ground ambulance, tasks related to patient diagnostics, treatment, transitions and handoffs are often shared by the team. The composition of a HEMS team has a higher degree of individual professionalism than that of other prehospital team compositions, with each professional having their defined set of tasks and areas for which they are responsible [30]. The physician in HEMS is mainly responsible for patient diagnostics and treatment, in addition to transitions and handoffs, i.e. transfer of patient information, responsibility and accountability. However, patient safety processes and climate within the unit influence the individual behavior, hence having an indirect influence on the outcome of transitions and handoffs. This implies the importance of the continued focus on teamwork and the focus on learning, feedback and improvement within the unit.

The dimension “stop working in dangerous situations” is a particular type of safety behavior [29], and in practice such behavior is likely to be primarily related to high-risk tasks in the prehospital domain such as driving [92] or clinical judgement and decision-making [2, 93]. An example of “stop working” behavior is cross-monitoring, i.e. the possibility to ask critical questions or voice concerns if one believes that an action may harm the patient [56, 63]. The direct path from the safety behavior dimension “stop working in dangerous situations” to the outcome dimension “transitions and handoffs” implies that, if individuals perceive that they can “stop working” when performing safety-related tasks, it also increases quality and safety in the individual tasks related to patient transitions and handoffs. Implementing different “stop working” techniques in training programs, simultaneously with promoting and cultivating such behavior, is likely to improve both the outcome of transitions and handoffs, as well as overall patient safety.