Abby Fayen^1*, M Aamer Sarfraz²

¹Foundation year 2 doctor, South East London, Oxleas NHS organisation

²Institute of Medical Studies, Rowan Williams Court, 30 Pembroke Court, Chatham Maritime, Kent, ME4 4UF

*Corresponding Author: Abby Fayen, Foundation year 2 doctor, South East London, Oxleas NHS organisation

Abstract
Background: There is a growing focus on patient safety in hospital settings. Improving patient safety culture is a vital part of improving patient safety. The aim of this study is to evaluate and determine ways to adopt patient safety culture in an NHS mental health organisation.

Methods: A survey was designed based on The Safety Attitudes Questionnaire (SAQ). All staff members working in the organisation were asked to complete the anonymous survey. The results of the survey were then analysed.

Results: Staff scored the highest (>80%) in sections relating to Teamwork and Psychological Safety and (79%) in relation to the organisation respecting individuals differences. Low scoring areas include the fair resolution of disputes and conflicts (52%) and trust leaders ensuring that patient safety culture is promoted, maintained (63%) and evaluated (50%).

Conclusion: There are areas for improvement within all aspects of patient safety culture in this NHS mental health organisation.

Keywords: patient safety culture, patient safety, safety culture, mental health

Introduction
The World health organisation defines patient safety as “the absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with health care to an acceptable minimum” [1].

There is a growing focus on the improvement of patient safety in hospitals [2]. One of the most important strategies for determining and improving patient safety in healthcare institutions is to create and improve on patient safety culture [3].

The term “safety culture” was first used by the International Consultative Group on Nuclear Safety on its report in the Chernobyl accident that occurred in 1986 [4]. Safety culture is defined as the product of individual and group attitudes, values, perceptions and skills, determining a pattern of behaviour and commitment to safety management [4].

In healthcare settings, safety culture is defined as the association of individuals and groups with the aim of reducing patient harm because of interactions, attitudes and perceptions of safety issues [5]. There is direct association between patient safety culture and reduction in adverse events [5].

Effective hospitals are grounded by a robust patient safety culture [6]. Patient safety culture promotion is best rooted in leadership, behaviour change and teamwork [7].

The vision of the NHS (National Health Service) in terms of patient safety is to continuously improve patient safety [8]. The NHS patient safety strategy is built on insight, involvement and improvement. Insight is defined by improving the understanding of safety, involving patients and staff with the skills and opportunities to improve patient safety and the support and design of programmes delivering sustainable and effective change [8]. The 2023/2024 priority for NHS patient safety in to improve incident reporting, to ensure learning and improvement from these incidences [2].

Table 1: Team work

Table 1 regarding teamwork shows how well team members understand each other’s roles (83%) and listen and care about each other (81%).

Positive feedback about teamwork from staff members includes “Great place to work in,” “I love my job and the team i work in” and “I am happy at where I work. The staff are so lovely that I cannot ask for another team”.

Table 2: Communication

Table 2 shows that only (60%) of staff feel that information is easily accessible and (66%) feel it could be more clear, accurate and timely.

Specific feedback from a member of staff regarding communication included “There is a lack of communication and not being responsive to questions or requests verbally or via email”.

Table 3: Just culture

Table 3 shows that regarding just culture only (52%) of staff feel that disputes or conflicts are raised fairly but (78%) feel safe to speak up about their concerns.

One member of staff mentioned in feedback that they felt that “when staff raise concerns about staff members, & request support to improve areas, the information is often breached, portrayed negatively, or deliberately misinterpreted. Which in turns 'gets someone's back up' creates barriers to productive working relationships, prevents transparency, and ultimately effects patient care”.

Table 4: Psychological safety

Table 4 shows that for psychological safety, staff feel able to ask members of the team for help (85%) but there is room for improvement regarding concerns of retaliation and criticism over admitting to making an error or mistake (64%).

In the additional information feedback one member of staff felt “unhappy” that they did not have a” well-being champion for nurse and HCA to express their concerns” and another felt that staff were “afraid to put in official complaints”. Positive feedback from staff regarding psychological safety was that staff felt that they could “contribute ideas” and that everyone had be “kind and offered me a place to speak”.

Table 5: Diversity and inclusive behaviour

Table 5 shows (68%) of staff feel that there are equal opportunities for people of different backgrounds and abilities, but these results also need to take into account that 74% of the people carrying out this questionnaire are white.

One member of staff with neurodiversity felt that “neurodiversity is not considered or actively included in the way training is structured or delivered”. However another member of staff felt that there was an “inclusive culture”.

Table 6: Civility

Table 6 shows that staff feel that team members are polite (76%) and understanding (75%) with positive feedback including that it is “a good service to be working in” but there remains room for improvement with dealing with disagreements in a constructive manner as staff feel that “disagreements are not dealt with fairly”.

Table 7: Leadership

Table 7 regarding leadership shows that only (66%) think that trust leaders demonstrate commitment to safety with their decisions and behaviours and only (63%) thinking that management creates a safety of culture in the organisation. Only (50%) feel that the trust leaders evaluate the culture of safety using valid and reliable tools.

Specific feedback regarding leadership includes that the management teams are "unapproachable", "not supportive", "conflict avoidant" and that leadership use "the word hierarchy too often". This leads to staff feeling that it "doesn't feel like a safe place to work and concern for patient safety seems to be lip service". Staff also feel that "trus leaders do not value safe staffing" and that "the organisation continue to turn a blind eye on because staff continue to turn up for work despite feeling burnout and loss of motivation".

Discussion
NHS England defines a positive patient safety culture as one where the environment is collaboratively crafted, created, and nurtured so that staff, patients, service users, families and carers can work together to ensure safe care [12].

There is a positive correlation between patient safety culture and patient experience, especially with regards to teamwork and Communication [13]. Camacho-Rodriguez et al. found when reviewing the patient safety culture in Latin America that nursing staff reported major concerns about inadequate staff levels negatively impacting patient safety and clinical outcomes [6]. However despite poor staffing, effective teamwork in these situations contributed to positive patient safety culture [6] This highlights the importance of good teamwork. In comparison our study found regarding teamwork that 81% on people felt the team listens and cares about each-others concerns and 64% felt the teams within the organisation work well together.

While the NHS 2023/2024 priority for patient safety is to improve incident reporting [2], it is important to acknowledge what prevents staff from incident reporting. In order to establish an effective incident reporting system and facilitate disclosure it is essential to establish open Communication and a nonpunitive culture [6]. Our study found that 78% felt safe to speak up about their concerns however only 52% felt that conflicts and disputes are resolved fairly. Azyabi et al found that reporting errors, safety awareness and staffing levels have been identified as essential factors in promoting patient safety culture [11].

Elmontsri et al found when reviewing patient safety culture in Arab countries it is important to include all stakeholders including leaders, policymakers, healthcare providers and those involved in medical education when reviewing patient safety culture. [14]. This study found that further commitment is also required by trust leaders to ensure that patient safety culture is created, maintained and evaluated withing the trust as currently only 63% feel that leaders create and maintain a safety culture in the organisation and 50% feel that trust leaders evaluate the culture of safety with valid and reliable tools.

Most of the research that has been done on patient safety culture in hospital settings is in relation to the experience of nurses [15]. Hamaideh surveyed nurses in a psychiatric inpatient setting in Saudi Arabia and of the 12 dimensions of patients' safety culture, only one was strong, six within acceptable range and five were weak and need improvement [16]. Our findings while similar were more in line with Lopes et al who showed that in their hospital, there was room for improvement in all areas of patient safety culture especially non punitive response to error and staffing [5].

There is not a lot of research done on patient safety culture in mental health settings. In comparison the inpatient mental health research mainly focuses on risk assessment, security, policies and processes [8]. Waddell and Gratzer found when assessing patient safety research in Canada it mainly focuses on suicide and violence risk [17]. Quinlivan et al. found that mental health patients have either the same or higher risks of adverse events in comparison to medical or surgical patients [18]. In England between 1 April 2014 and the 3 March 2019 out of the patients that received harm resulting in death because of their care, 57% of these were in mental health services [18].

While studies have also been conducted on the research methods used to evaluate patient safety culture in healthcare settings [11], including SAQ which was used for this study. It is clear that inpatient mental health settings demonstrate unique patient safety challenges so further research is needed to explore this further [18]. This is in line with the NHS Patient Safety Strategy which highlights the importance of measuring patient safety culture to improve patient safety in mental health settings [2].

We found in our study the highest selected response was "agree" in each statement of the survey, the second highest response was "not- sure", followed by "disagree" in third place and "don't know" in fourth place. There were only three exceptions to this where the second highest response was "disagree" followed by "not-sure" in third place, these were when asked if the people they work with are polite and treat each other with respect, that you feel safe to speak up about anything that concerns you and that you are involved in suggesting and deciding on changes that affect your work. The high selection of "not-sure" in comparison to "disagree" may indicate a lack of information available or a difficulty in sourcing this information. It may also be that "not-sure" is a less polarising response in comparison to "disagree" if they were not confident in their response to the question.

Limitations of this study include the poor response rate to the survey. Possible reasons for poor response may include patient safety culture measurement being a new concept, of limited interest to non-clinical and domestic staff, and survey fatigue as many other surveys are also taking place in the organisation. This study will also need to be completed on a wider multi-site level of the NHS to gain a more accurate depiction of patient safety culture in mental health organisations in England.

This pilot study is the first time that a patient safety culture survey has been conducted in a mental health organisation in the UK and useful results can still be obtained from it to improve the patient safety culture in NHS organisations.

Conclusion
This study identified that there is room for improvement in all aspects of patient safety culture. Specific areas of weakness it identified include the fair resolution of disputes and conflicts (52%) and trust leaders ensuring that patient safety culture is promoted, maintained (63%) and evaluated (50%) within the organisation. It did however also highlight positives with the organisation including scoring (>80%) in sections relating to Teamwork and Psychological Safety, (79%) in relation to the organisation respecting individuals differences and (>70%) in sections relating to Communication in patient safety culture. These higher scoring sections also indicate that improvement can be achieved in relation to patient safety culture in mental health organisations.

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