Developing a safety culture : the unintended consequence of a 'one size fits all' policy

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Developing a safety culture: The unintended consequence of a ‘one size fits all’ policy. Background Adverse events in maternity care are relatively common but often avoidable. Evidence suggests it is necessary to understand the safety culture of an organisation to make improvements to patient safety. The safety domains that are thought to influence safety culture in health care include: Safety Climate; Teamwork; Working Conditions; Perceptions of Management; Job Satisfaction; and Stress Recognition. Little is known about the safety culture in the Australian maternity setting, which was the impetus for this Study. This thesis reports an examination of the safety culture in a maternity service in New South Wales (NSW). Setting The Study took place in one maternity service located in two public hospitals in NSW, Australia. Concurrently, both hospitals were undergoing an organisational restructure. Design This mixed method research study used a concurrent triangulation design and included two Studies. The Policy Study explored the policy context in which the maternity service was situated; and, the Service Study examined the safety culture within the maternity service. Data collection included: • A policy audit and chronological mapping of the key policies influencing safety culture within the maternity service. • Safety culture surveys, the Safety Attitudes Questionnaire and Safety Climate Scale (59/210, 28% response rate) that measured the following six safety culture domains; Safety climate; Teamwork climate; Job Satisfaction; Perceptions of management; Stress recognition and Working conditions (Sexton et al., 2004). • Semi-structured interviews (15) with key maternity, clinical governance and policy stakeholders. Results The safety culture was found to be lacking across all six safety domains. The key finding was that the overarching policy context created unintended consequences for the maternity service and adversely influenced their capacity to have a positive safety culture. These unintended consequences reduced their available infrastructure and capacity to respond to adverse events; and created a lack of leadership at all levels to drive the safety and quality agenda. The safety culture was also influenced by inadequate communication during the escalation of care; inadequate supervision of junior medical staff; difficulty ensuring the right staffing and skill mix, and low staff morale. Conclusion The safety culture in this maternity setting was complex, context-specific but importantly, influenced by the broader policy context in which it was situated. This Study provides evidence that the policy context needs to be included as a seventh safety culture domain in health care. This Study has demonstrated the importance of policy on the capacity to ensure patient safety. Implications The policy context has not been previously identified as being important when addressing the safety culture in health care. Considering the influence of the policy context in relation to safety culture is an important step to develop strategies to improve patient safety in other settings. This is an area for future research.
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