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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 14  |  Issue : 2  |  Page : 152-167

Hospital magnet designation attributes for nursing excellence that promotes patient safety culture: certified versus noncertified hospitals


1 Department of Nursing Administration, Faculty of Nursing, Cairo University, Cairo, Egypt
2 Department of Occupational and Environmental Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt

Date of Submission10-Apr-2017
Date of Acceptance30-May-2017
Date of Web Publication12-Jan-2018

Correspondence Address:
Magda Abd El Hamed Abd El Fattah
Department of Nursing Administration, Faculty of Nursing, Cairo University
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_18_17

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  Abstract 

Background Magnet designation gives a valuable mechanism for evaluating and transforming nursing practice environments that can be attributed to nursing excellence and patient safety culture.
Aim The aim of this study was to compare between ISO 9001-certified and noncertified hospitals regarding hospital magnet designation attributes for nursing excellence and patient safety culture.
Design A descriptive, comparative, correlational study design was used.
Setting This study was conducted at nine critical care units in an ISO 9001-2008-certified hospital and six critical care units in a non-ISO 9001-2008-certified hospital in Cairo, Egypt.
Sample A total of 180 critical care nurses who were working in an ISO 9001-2008-certified hospital and 90 critical care nurses working in a noncertified hospital were included in the study.
Tools Data were collected by the modified Essentials of Magnetism and patient safety culture questionnaires.
Results A significant correlation existed between the overall patient safety culture and hospital magnet designation dimensions in the ISO 9001-certified hospital. In the meantime, insignificant correlations were found between total patient hospital magnet designation and safety culture dimensions in the ISO 9001-noncertified hospital.
Conclusion The results concluded that hospital magnet designation attributes in the ISO 9001-certified hospital and the non-ISO 9001-certified hospital are necessary to encourage the critical care nurses to promote patient safety culture.
Recommendations Hospital management should conduct educational training programs regarding multidisciplinary teamwork building, communication behaviors during hospital handoffs, and risk management for critical care nurses working in both ISO 9001-certified and noncertified hospitals.

Keywords: critical care nurses, international standardization for organizations, magnet designation, patient safety culture


How to cite this article:
Abd El Fattah MA, Abo El Ata GA, Morsy FA. Hospital magnet designation attributes for nursing excellence that promotes patient safety culture: certified versus noncertified hospitals. Egypt Nurs J 2017;14:152-67

How to cite this URL:
Abd El Fattah MA, Abo El Ata GA, Morsy FA. Hospital magnet designation attributes for nursing excellence that promotes patient safety culture: certified versus noncertified hospitals. Egypt Nurs J [serial online] 2017 [cited 2018 Nov 18];14:152-67. Available from: http://www.enj.eg.net/text.asp?2017/14/2/152/223095


  Introduction Top


It is noteworthy that nurses are known to provide superior quality of patient care and make a transformation every day, not only to their patients but also to their relatives, colleagues, and the public. Therefore, nurses pride themselves on delivering the best care for their patients and being recognized as leaders in their field, and magnet-recognized organizations pride themselves on nursing excellence (Sulkowski, 2015). In a critical care work environment, all over the world, there is a consistent requirement for new nursing workforce (Lakanmaa et al., 2014), which is considered the main professional group working in the hospitals (European Federation of Critical Care Nursing Associations (EfCCNa), 2013).

The nursing workplace is a combination of different features that directly or indirectly influence the patient care system (Kelly et al., 2011). Enhancing the nursing workplace is a focal point and challenge for nursing administrators. In this way, hospitals are looking for identification as a magnet environment to build up its components that meet excellent nursing standards in giving quality and safe patient care. To achieve magnet status, hospitals ought to have a band of organizational elements such as professional practice model, structural empowerment, developments, knowledge and innovation, and transformational leadership. These elements interrelate to shape a positive work environment that should provoke better outcomes (Mills and Gillespie, 2013).

A magnet hospital is defined as an organization that is capable of attracting and retaining well-qualified nurses and then continually preparing them to deliver quality care. It has been shown to exhibit organizational features that permit nurses to practice their knowledge and expertise entirely to deliver patient care (Scott, 2010). Magnet recognition program is grounded on a model of excellence in leadership, clinical practice, innovations, structural empowerment, and positive outcomes. The model originates from the forces of magnetism that were identified more than 25 years ago (American Nurses Credentialing Center, 2008).

In the early 1980s, magnet designation, or recognition of the ‘best’ hospitals, was conceived when the American Academy of Nursing conducted a study to recognize which hospitals attracted and retained nurses and which organizational features were shared by these successful hospitals, referred to as magnet hospitals. The magnet hospitals had in common organizational features that stimulated and sustained professional nursing practice (Aiken et al., 2009).

Distinction among hospitals is based on particular leadership and organizational structures that support high-quality nursing care, which is foundational to the American Nurse Credentialing Center’s Magnet Recognition Program. The program identifies healthcare organizations that exhibit excellence in nursing care, an environment that maintains professional nursing practice, and an organizational structure that stimulates the leadership capabilities and nurses’ professional development (American Nurses Credentialing Center, 2013).

Magnet program for nursing excellence affects all levels, and the organization aspects contain clinical, administrative, technical, and philosophical features. The program standards identified the magnet recognition program incorporated under the dimensions identified as magnetism forces (American Nurses Credentialing Center, 2010). The crucial components of the fourteen magnetism forces were as follows: working with other competent nurses, respectable nurse–physician interactions, nurse autonomy and accountability, supportive nurse managers and supervisors, control over nursing practice and work environment, support for education, research and evidence-based practice, sufficient nurse staffing, and high-quality patient care (Floyd and Mulvey, 2011). Moreover, working for a magnet-recognized hospital has been shown to improve nursing standards and practice (Sulkowski, 2015). Magnet designation is an extensively appropriate indicator of a hospital’s investment in nursing (Olmsted et al., 2016), which provides a valuable tool for appraising and altering nursing workplaces that can be attributed to upgrade the professional practice environments (Stimpfel et al., 2014).

Magnet designation is required in many hospitals with the faith that excellence in the workplace would prompt nurses’ workplaces and better patient outcomes. It concentrated deeply on the structural components of the hospital and the work environment to improve nursing performance (Goode et al., 2011). Currently, the program of magnet acknowledgment does not highlight what hospitals perform or how they perform it but instead on what improvements have been done in enhancing results (Needleman et al., 2011).

Former studies have compared the differences between magnet hospitals and nonmagnet hospitals, and have shown the dominance of magnet hospitals with respect to job satisfaction of nurses, intention to leave, nurses’ perceptions of care quality or safety, and patient satisfaction (Ulrich et al., 2007). Furthermore, numerous studies demonstrate associations between hospital magnet designation and better outcomes for patients containing lesser central line-associated bloodstream infection rates (Barnes et al., 2016), lesser probabilities of in-hospital and 30-day mortality, and diminished odds of failure-to-rescue (Friese et al., 2015; Kutney-Lee et al., 2015).

Patient safety is one of the crucial elements in healthcare systems, which has turned into a significant urgency for most of such organizations all over the world through the recent decades. Patient safety means avoiding unwanted events or accidents that might happen while providing healthcare services for patients (Alahmadi, 2010).

Assessing a healthcare organization’s patient safety culture is the first step for developing a positive safety culture. Reflecting that, various international accreditation organizations currently necessitate patient safety culture assessment to assess the awareness of the healthcare staff on concerns such as teamwork, actions taken by management and leadership to support and stimulate patient safety, staffing problems, rate of incident reporting, and other patient safety culture concerns. Such assessments permit healthcare organizations to obtain a clear view concerning areas that require attention to support their patient safety culture and identify particular challenges relating to patient safety within hospital units (El-jardali et al., 2014).

The concept of patient safety culture (PSC) has been gradually used for improving safety and quality of healthcare. PSC is defined as the product of individuals’ values, attitudes, opinions, capabilities, and patterns of behavior, which determine the commitment to organization’s health and safety management (Robida, 2013). Achieving a culture of patient safety needs an understanding of the morals, beliefs, and standards about what is important in an organization and what attitudes and behaviors are related to patient safety. The assessment of the prevalent culture is a first step that should precede designing patient safety programs in hospitals (Alahmadi, 2010).

There is a recent emphasis on assessing and improving PSC to improve patient safety in hospitals. This is reflected in the increasing number of literature reports on PSC performance (Morello et al., 2013). For improving patient safety culture, healthcare staff in recent years have adopted and implemented quality management methods to improve patient services. One approach is to comply with the framework defined by the international quality standard, ISO 9001. The ISO 9001 standard is broad-based, which means that the similar standards are applied to any institute, huge or small, regardless of the product or service, in any division or activity. This standard exemplifies an international agreement on worthy management performance, which aims to guarantee that staff can constantly deliver the product or service that meets client quality demands; enhances client satisfaction; and always develops its performance as it follows these goals (Vitner et al., 2011; Psomas et al., 2013; Pop and Marian, 2014).


  Significance Top


Nowadays, building a safer healthcare system and excellent work environment has come to be the main concern to the world. Nursing care excellence starts by advancing and promoting patient safety culture in magnet designation work environment to retain the qualified nursing staff. Over the most recent 6 years, studies have demonstrated that noteworthy amounts of care are missed in acute care hospitals. To overcome missed nursing care, nursing staff needs to work together to create an environment for nursing excellence (Gelinas, 2015). Certainly, patient safety culture ought to be preserved in all hospitals either certified or not certified. In this manner, patient safety culture assessment in ISO 9001-certified and noncertified hospitals are necessary to conclude the causal attributes that hamper or support the positive patient safety cultures in these work environments. Therefore, the findings of this study will increase nursing’s body of knowledge with respect to hospital magnet designation attributes for nursing excellence that supports positive patient safety culture.


  Aim of the study Top


The present study was designed to compare between ISO 9001-certified and noncertified hospitals regarding hospital magnet designation attributes for nursing excellence and patient safety culture.

Research question

What is the difference between ISO 9001-certified and noncertified hospitals regarding hospital magnet designation attributes for nursing excellence and patient safety culture?

Study design

A descriptive comparative correlational study design was used to achieve the aim of the present study.

Setting

This study was conducted at nine critical care units (CCUs) that were affiliated to an ISO 9001-2008-certified hospital and six CCUs that were affiliated to a noncertified hospital. The two hospitals had the same predetermined inclusion criteria as follows: CCUs gave paid services, had the highest number of staff nurses, had the same authoritative and administration system, partnered to the similar healthcare sector, had a similar scheduling system, had the same supportive healthcare facilities, and similar functional classes and financial ranks.

Sample

A convenience sampling method was used to gather the data from (n=270) the studied sample, which was divided into two samples as follows: (i) a convenient sample of 180 nurses working at the CCUs in the ISO 9001-2008-certified hospital, and (ii) a convenient sample of 90 nurses working at CCUs in the non-ISO 9001-2008-certified hospital.

Inclusion criteria

Critical care nurses who accepted to participate in the study and had more than 1 year of experience at the hospital were included in the sample.

Data collection tool

Data collection tool consisted of three parts as follows:
  1. Part I − Demographic data questionnaire: items included on the questionnaire were gender, educational level, and years of experience in the current place.
  2. Part II − Essentials of Magnetism (EOM) instrument: it was developed by Kramer and Schmalenberg (2004). The EOM contains 53 items and seven dimensions as follows: (i) Collegial/collaborative nurse–physician (five items); (ii) support for education (four items); (iii) autonomous nursing practice (16 items); (iv) perceived staffing and resource adequacy (four items); (v) working with clinically competent nursing staff (four items); (six) nurse manager support (eight items); and (vii) culture in which concern for nurse on the patient is paramount (12 items). As for the scoring system, the EOM uses a five-point Likert scale, with responses ranging from strongly agree (5 points) to strongly disagree (1 point).
    • As regards the total mean percentage of agreement formula, total mean percentage of agreement of the studied sample was as follows: (total mean percentages of agree+strongly agree responses)/total sample size. As regards the scoring system of magnet and nonmagnet designation attributes, the magnetic designation attributes are calculated as follows: the total mean percentages of agree and strongly agree responses/total sample size; this value was at least 50% of total mean percentages of agreement. Meanwhile, nonmagnetic designation attributes were calculated as follows: total mean percentages of disagree pluses undecided and strongly disagree responses/total sample size; this value was at least 50% of total mean percentages of disagreement.
  3. Part III: PSC questionnaire: it was developed by the Agency for Healthcare Research and Quality of the Department of Health and Human Services in the USA (Sorra and Nieva, 2004). PSC Questionnaire consists of 45 questions designed to measure 12 dimensions of patient safety culture, seven of which are at the unit level and three at the hospital level.
    • The seven dimensions that are at the unit level are as follows: feedback and communication about error (three items); frequency of adverse events reported (five items); teamwork within units (four items); nonpunitive response to error (three items); supervisor/manager expectations and actions promoting patient safety (four items), adequate staffing (four items), and communication openness regarding patients’ risk exposures (three items). The three dimensions that are at the hospital level are as follows: management support for patient safety (three items); organizational learning–continuous improvement (four items); teamwork across units (four items); handoffs and transition across hospital units and during shift changes (four items); and overall perception of safety (four items).
    • As for the scoring system, the PSC uses a five-point Likert scale, with responses ranging from strongly agree (5 points) to strongly disagree (1 point). The results of the 12 dimensions of PSC are expressed as a percentage of positive and negative responses on the Likert scale. Responses ‘agree’ and ‘strongly agree’ are considered as positive, whereas ‘undecided’, ‘disagree’, and ‘strongly disagree’ are considered as negative responses. As regards the total mean percentage of agreement formula, total mean percentage of agreement of the studied sample is as follows: total mean percentages of agree plus strongly agree responses/total sample size. As regards the scoring system of positive and negative patient culture scoring systems, the positive PSC is as follows: the total mean percentages of agree and strongly agree responses/total sample size; this value was at least 50% of total mean percentages of agreement. Meanwhile, the negative PSC is equal to total mean percentages of disagree plus undecided and strongly disagree responses/total sample size, which was at least 50% of total mean percentages of disagreement.


Tools validity

Study tool validity was established by five professors who were expert in nursing administration to test content validity. Each of the experts were asked to examine the instrument for content coverage, clarity, wording, length, format, and overall appearance.

Pilot study

Once the permission was granted from the pertinent authorities, the pilot questionnaire was randomly distributed to a sample of 27 nurses, who constitute 10% from the total sample; they were further divided into nine from the noncertified hospital and 18 from the certified hospital to test the clarity of the questions of the study tools, estimate the time needed to complete the questionnaire, and to add or omit questions.

Reliability test

The reliability test was done to determine how strongly the attributes were related to each other and to the composite score. The EOM questionnaire demonstrated internal reliability with Cronbach’s α (0.91) and the PSC questionnaire demonstrated internal reliability with Cronbach’s α (0.89).

Ethical consideration

As for the ethics clearance, approval was gained to conduct the research at each hospital. At the interview with the study participants, oral informed consents were secured from each participant. The participants were informed about the purpose and benefits of the study and they were informed that their participation is voluntary and were assured complete confidentiality of the obtained data and that the study would not affect their work in any way.

Procedure

Upon receiving the formal approval from the authorities, and agreement from the medical directors board of the two hospitals, the researchers received a list of all studied sample numbers from all the CCUs in the two hospitals from the nursing directors, at which point the researchers approached the unit nurse managers of the 15 units to clarify the aim of the study and to get their agreement to approach the participants at the two shifts. The researchers started to invite each participant separately according to their shift to participate in the study to provide an oral clarification; the questionnaire was circulated to all participants. Data collection started in March 2015 until August 2015.

Statistical design

Data were analyzed using the Statistical Package for the Social Sciences, version 20.0 (SPSS Inc., Chicago, Illinois, USA). Data were presented using descriptive statistics in the form of frequency distribution, percentages, mean, and SD. T-test was used to test the difference between the two hospitals. The significance level of all statistical analysis was at P value above 0.05.


  Results Top


Regarding the ISO-certified hospital, among the 180 participants, 86.1% of the participants in this study were female and the remaining were male. An examination of the participants’ educational preparedness showed that 43.3% held a diploma degree in nursing and 38.9% held an associate degree in nursing. In all, 24.4% of the studied sample had less than 5 years of experience in the current work setting in the ISO 9001-2008-certified hospital. With respect to the noncertified hospital, out of 90 participants, in terms of sex 83.3% of the studied participants were female and the remaining were male. In terms of nursing education, 47.8% of the studied sample held a diploma degree in nursing and 31.1% held an associate degree in nursing. In addition, slightly more than half of the studied sample (52.2%) had 5–10 years of experience in the current work setting in the noncertified hospital.

[Table 1] demonstrates the perceived hospital magnet designation attributes for nursing excellence. With respect to the collegial/collaborative nurse–physician, a statistically significant difference existed between critical care nurses in ISO 9001-2008-certified and noncertified hospitals (t=3.05, significance=0.002), where critical care nurses working in the noncertified hospital agreed, somewhat, that their relations with physicians were collaborative (=2.26±0.58), when compared with their counterparts (=2.07±0.45).
Table 1 Mean value of hospital magnet designation attributes for critical care nursing excellence dimensions as perceived by the studied sample in ISO 9001-certified and noncertified hospitals (N=270)

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Regarding hospital support for education as a magnet designation attribute for nursing excellence, a statistically significant difference was observed between critical care nurses in ISO 9001-2008-certified and noncertified hospitals (t=3.5, significance=0.000), where critical care nurses working in ISO 9001-2008-certified hospitals had a higher agreement mean score (=2.78±0.55) when compared with their counterparts (=2.50±0.69).

As regards autonomous nursing practice as a magnet designation attribute for nursing excellence, the observed difference between critical care nurses working in ISO 9001-2008-certified and noncertified hospitals was not significant (t=1.8, significance=0.06), where critical care nurses working in ISO 9001-2008-certified hospitals agreed, somewhat, that they had autonomous nursing practice (mean=2.65±0.29), when compared with their counterparts (=2.57±0.37).

Concerning perceived adequacy of staffing as a magnet designation attribute for nursing excellence, there was a statistically significant difference between critical care nurses in ISO 9001-2008-certified and noncertified hospitals (t=16.7, significance=0.000), where critical care nurses working in the ISO 9001-2008-certified hospital agreed that staffing for patient care was adequate (=3.01±0.44), when compared with their counterparts (=1.88±0.65).

Regarding working with clinically competent nursing staff as a magnet designation attribute for nursing excellence, a statistically significant difference was observed between critical care nurses working in ISO 9001-2008-certified and noncertified hospitals (t=14.6, significance=0.000), where critical care nurses working in the ISO 9001-2008-certified hospital agreed that they were working with clinically competent nursing staff (=3.51±0.44), when compared with their counterparts (=2.46±0.75).

In terms of nursing manager support as a magnet designation attribute for nursing excellence, a marked statistically significant difference was documented between critical care nurses in ISO 9001-2008-certified and noncertified hospitals (t=5.4, significance=0.000), where critical care nurses working in the ISO 9001-2008-certified hospital agreed, somewhat, that the nursing manager supported them (=2.51±0.49), when compared with their counterparts (=2.17±0.44).

Concerning culture in which concern for nurse on the patient is paramount as a magnet designation attribute for nursing excellence, a statistically significant difference was detected between critical care nurses working in ISO 9001-2008-certified and noncertified hospitals (t=2.5, significance=0.013), where critical care nurses working in the noncertified hospital agreed, somewhat, that the hospital had a paramount culture in which concern for nurse on the patient (=2.22±0.55), when compared with their counterparts (=2.12±0.30).

As for the perceived differences in magnet and nonmagnet designation attributes for nursing excellence in ISO 9001-certified and noncertified hospitals, [Table 2] shows that the most crucial attributes of magnet designation for nursing excellence in the ISO 9001-certified hospital was working with clinically competent nursing staff (68.06%), perceived adequacy of staffing (59%), and hospital support for education (42.78%), whereas nonmagnet designation attributes for nursing excellence in the ISO 9001-certified hospital were culture in which concern for nurse on the patient is paramount (80.97%), perceived nurse manager support (63.89%), and collegial/collaborative nurse–physician (66%). With respect to the perceived magnet designation attributes for excellence in the noncertified hospital, the results displayed that perceived hospital support for education (39.45%), nursing competence (38.34%), and nurse–physician collaboration (36%), respectively. However, the nonmagnet designation attributes for nursing excellence in the ISO 9001-certified hospital were the perceived clinical autonomy (78%), nurse manager support (73.61%), adequacy of staffing (72.5%), and nurse–physician collaboration (64%). In addition, a highly statistically significant difference was found between critical care nurses working in certified and noncertified hospitals regarding magnet and nonmagnet designation attributes for nursing excellence (t=2.964, significance=0.010).
Table 2 Total mean percentage regarding magnet and nonmagnet designation attributes for nursing excellence in ISO 9001-certified and noncertified hospitals (N=270)

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[Table 3] shows the perceived patient safety culture dimension difference in ISO 9001-certified and noncertified hospitals. Regarding the overall perception of safety culture dimension, a statistically significant difference was observed between critical care nurses working in ISO 9001-2008-certified and noncertified hospitals (t=11.9, significance=0.000), where critical care nurses working in the certified hospital had a higher mean score (=3.51±0.46) when compared with their counterparts (=2.80±0.44).
Table 3 Patient safety culture dimensions difference in ISO 9001-certified (N=180) and noncertified (N=90) hospitals (N=270)

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As regards supervisor/manager expectations and actions promoting patient safety culture, a statistically significant difference was found between critical care nurses working in ISO 9001-2008-certified and noncertified hospitals (t=8.5, significance=0.000), where critical care nurses working in the ISO 9001-2008-certified hospital had a slightly a higher mean score (=3.20±0.47), when compared with their counterparts (=2.65±0.54). With respect to continuous improvement activity, a statistically significant difference was observed between critical care nurses working in ISO 9001-2008-certified and noncertified hospitals (t=7.02, significance=0.000), where critical care nurses working in the ISO 9001-2008-certified hospital had a slightly a higher mean score (=2.82±0.53), when compared with their counterparts (=2.31±0.62).

Concerning teamwork across units, a non-statistically significant difference was detected between critical care nurses working in ISO 9001-2008-certified and noncertified hospitals (t=1.8, significance=0.06), where the critical care nurses working in the ISO 9001-2008-certified hospital had a slightly a higher mean score (=3.48±0.47) when compared with their counterparts (=3.38±0.42).

Regarding communication openness within the hospital, the result revealed that there was a statistically significant difference between critical care nurses working in ISO 9001-2008-certified and noncertified hospitals (t=2.3, significance=0.019), where critical care nurses working in the noncertified hospital had a higher mean score (=2.17±1.03) when compared with their counterparts (=1.90±0.83).

With regard to feedback and communication about error, a statistically significant difference was detected between critical care nurses working in ISO 9001-2008-certified and noncertified hospitals (t=10.5, significance=0.000), where critical care nurses working in the ISO 9001-2008-certified hospital had a slightly a higher mean score (=3.09±0.53) when compared with their counterparts (=2.35±0.56). With reference to nonpunitive response to error within the hospital, a non statistically significant difference was found between critical care nurses working in ISO 9001-2008-certified and noncertified hospitals (t=1.1, significance=0.26), where critical care nurses working in the noncertified hospital had a slightly higher mean score (=4.16±1.58) when compared with their counterparts (=3.99±0.82).

Regarding staffing within the hospital, a statistically significant difference was documented between critical care nurses in ISO 9001-2008-certified and noncertified hospitals (t=6.7, significance=0.000), where critical care nurses working in the noncertified hospital had a higher mean score (=3.24±0.44) when compared with their counterparts (=2.82±0.51). With reference to hospital management support for patient safety culture, a statistically significant difference was detected between critical care nurses working in ISO 9001-2008-certified and noncertified hospitals (t=7.4, significance=0.000), where critical care nurses working in the ISO 9001-2008-certified hospital had a higher mean score (=3.07±0.39) when compared with their counterparts (=2.55±0.75). As regards teamwork within units, a statistically significant difference was observed between critical care nurses working in ISO 9001-2008-certified and noncertified hospitals (t=4.2, significance=0.000), where the critical care nurses working in the ISO 9001-2008-certified hospital had a higher mean score (=3.28±0.79) when compared with their counterparts (=2.89±0.53).

Regarding hospital handoffs and transitions, a statistically significant difference was found between critical care nurses in ISO 9001-2008-certified and noncertified hospitals (t=2.6, significance=0.009), where critical care nurses working in the ISO 9001-2008-certified hospital had a higher mean score (=3.34±0.59) when compared with their counterparts (=3.34±0.59). Regarding adverse event reporting, a statistically significant difference was observed between critical care nurses working in ISO 9001-2008-certified and noncertified hospitals (t=15.5, significance=0.000), where critical care nurses working in the ISO 9001-2008-certified hospital had a higher mean score (=3.78±0.46) when compared with their counterparts (=2.89±0.40).

[Table 4] shows the total mean percentage regarding positive and negative patient safety culture dimensions as perceived by critical care nurses working in ISO 9001-certified and noncertified hospitals. With respect to the ISO 9001-certified hospital, the results showed that adverse event reporting (72.45%), teamwork within units (66.39%), and supervisor/manger expectations and actions promoting patient safety (57.5%) were perceived by critical care nurses as primary sources of positive patient safety culture. However, overall perception of safety (49%), feedback and communication about error (49%), teamwork within units (47.3%), organizational learning–continuous improvement (37.22%), hospital management support for patient safety (25.5%), staffing (21%), hospital handoffs and transitions (20.39%), nonpunitive response to error (17.8%), and communication openness (14.31%) were perceived by critical care nurses as the primary sources for negative patient safety culture dimensions by nursing staff in the ISO 9001-certified hospital.
Table 4 Total mean percentage regarding positive and negative patient safety culture dimensions as perceived by the nursing staff in ISO 9001-certified and noncertified hospitals (N=270)

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With respect to the noncertified hospital, ‘teamwork within units’ (65%), supervisor/manger expectations and actions promoting patient safety (57%), and adverse event reporting (52%) were perceived by critical care nurses as contributing factors for positive patient safety culture in the noncertified hospital, whereas overall perception of safety (40%), hospital handoffs and transitions (36%), continuous improvement (35%), feedback and communication about error (33.7%), teamwork within units (24%), hospital management support for patient safety (23.7%), communication, openness (17.04%), nonpunitive response to error (12.22%), and staffing (10%) were perceived as contributing factors for negative patient safety culture dimensions by nursing staff. In addition, a highly statistically significant difference was found between critical care nurses working in ISO 9001-certified and noncertified hospitals regarding positive and negative patient safety culture dimensions (t=3.759, significance=0.001).

As can be seen from the findings ([Table 5]), there were significant correlations among the overall patient safety culture and hospital magnet designation dimensions in the ISO 9001-certified hospital (P<0.01), where a significant correlation existed between hospital magnet designation dimensions and total dimensions of patient safety culture regarding ‘supervisor/manger expectations and actions promoting patient safety’ (P=0.00), ‘communication openness’ (P<0.01),‘nonpunitive response to error’ (P<0.01), ‘hospital management support for patient safety’ (P<0.01), ‘adverse event reporting’ (P<0.01), and total dimensions of patient safety culture.
Table 5 Pearson correlation between hospital magnet designation and patient safety culture dimensions in ISO 9001-certified (N=180) and noncertified (N=90) hospitals (N=270)

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As can be seen from the findings, there was a statistically significant correlation between the overall hospital magnet designation attributes for critical care nursing excellence and patient safety culture dimensions in ISO 9001-certified and noncertified hospitals (P<0.01), where a significant correlation existed between patient safety culture dimensions, ‘perceived support for education’ (P<0.01), ‘clinical autonomy’ (P<0.01), ‘perceived adequacy for staffing (P<0.01), ‘nursing competence’ (P<0.01), and ‘perceived nurse manager support’ (P<0.01). Meanwhile, nonsignificant correlations were found between total patient hospital magnet designation and safety culture dimensions in the ISO 9001-noncertified hospital (P<0.05).


  Discussion Top


Together, the safety and quality of patient care received depend upon the quality of the healthcare work environment where care is delivered (Shen et al., 2011). Thus, magnet work environment emphasizes intensely on improving nursing care excellence. The essential structures of nurses work environment magnetism comprise supportive nurse supervisors and managers, hospital support for education, sufficient nurse staffing, nurse–physician collaboration, working with other proficient nurses, high-quality patient care, nurse autonomy, and control over nursing practice (Floyd and Mulvey, 2011). Furthermore, nowadays, assessment of patient safety culture is most significant in creating such a culture within an organization (Nie et al., 2013). Consequently, the study sought to compare between ISO 9001-certified and noncertified hospitals regarding hospital magnet designation attributes for nursing excellence and patient safety culture.

It is acknowledged in the literature that collaboration between professionals is vital in health institutions where utmost actions are team-performed. Unsuccessful nurse–physician collaboration affects patient outcome, nurses’ job satisfaction, and organizational budget, and is challenged by personal, interpersonal, and organizational issues (Amsalu et al., 2014).

It has been postulated that those organizations with a constructive professional practice environment, characterized by healthy and respectful nurse–physician relationships, are better able to recruit and retain the best nurses, and that this, coupled with higher levels of communication, respect, and collaboration between nurses and physicians, contributes to a better environment for patients (Galletta et al., 2013).

In the current study, comparing ISO 9001-certified with noncertified hospitals regarding collegial/collaborative nurse–physician as a magnet designation attribute for nursing excellence, the results showed that critical care nurses working in the noncertified hospital had significantly higher mean score perceptions of collegial/collaborative nurse–physician, when compared with their counterparts. It seems possible that these results are due to the medical staff shortage, which leads to high workload and lack of sufficient time for communication between the medical team. Despite the existence of policies governing the cooperation process between the medical team members, but it need from the hospital management to build a culture of collaboration between the medical team members through the creation of projects in which everybody can shares in the development of the safe healthcare for patient’s needs. The present findings seem to be consistent with those of Amsalu et al., (2014), who identified that neither nurses nor physicians were satisfied with their current collaboration, and nurses demonstrated less satisfaction with the current nurse–physician collaboration.

As for hospital support for education as a magnet designation attribute for nursing excellence, the results indicated that ISO 9001-2008-certified hospitals supported the critical care nurses’ education to a greater extent when compared with their counterparts. A possible explanation for this might be that in ISO 9001-certified hospitals there was a training and continuing education department that conducted training programs for nursing staff. Meanwhile, in the non-ISO 9001-certified hospital, there was a lack of education support procedures that contain financial support, prizes for education, and time existing to join the educational activities or training programs to keep up with scientific development in the field of nursing.

When comparing ISO 9001-certified with noncertified hospitals regarding clinical autonomy as a magnet designation attribute for nursing excellence, the result explored that the critical care nurses working in the ISO 9001-2008-certified hospital were significantly more autonomous when compared with their counterparts. A possible explanation for this might be the decentralized structures of CCU in the ISO 9001-certified hospital, and the majority of critical care nurses have considerable experience in caring for critical conditions since the opening of the hospital, which creates a sense of control over their nursing practices. These results are in agreement with those of Papathanassoglou et al. (2012), who conducted a study to explore the levels of autonomy among European critical care nurses. They reported that European critical care nurses had lower autonomy and were associated with increased frequency and intensity of moral distress and lower levels of nurse–physician collaboration.

When comparing ISO 9001-certified with noncertified hospitals regarding the perceived adequacy of staffing as a magnet designation attribute for nursing excellence, the result revealed that the ISO 9001-2008-certified hospital have marked significantly adequate nursing staff when compared with their counterparts. It seems possible that these results are obtained because the certified hospital might have had the magnet designation attributes for retaining critical care nurses. According to Kramer and Schmalenberg (2008) adequate staffing provides the nurse the ability to deliver excellent care. Moreover, Ritter (2011) stated that appropriate staffing involved the effective match among patient needs, nurse competencies, and an equitable workload. The results are in agreement with those of Matlakala and Botha (2016), who conducted a qualitative study to explore the critical care nurse managers’ perspectives regarding nurse staffing in the large CCUs. One of the drawbacks that emerged from the data was the shortage of competent and trained nurses. Shortage of competent and trained nurses was associated with the global shortage of nurses and led to increased patient-to-nurse ratios and the use of other categories of nurses, other than professional nurses.

Regarding working with clinically competent nursing staff as magnet designation attribute for nursing excellence, the result showed that the critical care nurses working in ISO 9001-2008-certified had significantly higher perceptions of their nursing competence when compared with their counterparts. As documented in the literature, the competence concept is multidimensional (e.g. focusing on clinical practice, ethics, collaboration, leadership, education, and development work) and strongly related to, for example, work experience, and frequency of using specific competencies (Lakanmaa et al., 2015). Besides, the nurses’ competency has a close relationship with patient outcomes and safety issues such as medical mistakes, hospital infections, deaths, complications after surgery, and taking out the tracheal tube in an unplanned manner at the CCU (Penoyer, 2010). Perhaps the most likely explanation for this finding is the high technical and clinical skills in the CCUs maintained by the continuous staff development in the ISO 9001-2008-certified hospital. Meanwhile, in the noncertified hospital, it is possible that nurses lack experience and resources to continue their education and also to attend paid training program. The result in agreement with Lakanmaa et al. (2015), who reported that the studied sample rated themselves as good in clinical competence.

Concerning nursing manager support as a magnet designation attribute for nursing excellence, the result revealed that the critical care nurses working in the ISO 9001-2008-certified hospital were significantly more supported by their nurse managers when compared with their counterparts. Perhaps the most likely explanation for this finding in the noncertified hospital was that the nursing managers were powerless to advocate and to create opportunities for the development of staff nurses. It is encouraging to compare these findings with those of Buffington et al. (2012), who found that nurses reported feeling a lack of support and recognition from their managers. Meanwhile, the results of the current study are in contrast to those of Kramer et al. (2011), who stated that clinical units in 34 magnet hospitals were markedly skewed toward excellence.

Regarding culture in which concern for nurse on the patient is paramount as a magnet designation attribute for nursing excellence, the result showed that critical care nurses in the noncertified hospital had significantly higher perceptions mean score when compared with their counterparts. This result may be explained by the fact that critical care nurses working in the noncertified hospital had the same values and norms that shape their behaviors regarding patient safety. As documented in the literature, culture in which concern for patients is paramount meant that a nurses are shared considerations for satisfactory conduct in the work environment which create a culture of excellence that beliefs in and values the quality of patient care and the lives of the nurses who rendered care for them (Kramer and Schmalenberg, 2008).

Collectively, the results showed that the primary hospital magnet designation attributes for nursing excellence in the ISO 9001-certified hospital were hospital support for education, nursing competence, and adequacy of staffing, whereas the primary hospital magnet designation attributes in the noncertified hospital were hospital support for education, nursing competence, and nurse–physician collaboration.

With respect to the difference in patient safety culture dimensions in ISO 9001-certified and noncertified hospitals, it was detected that the critical care nurses working in the certified hospital had significantly higher perception of patient safety culture when compared with their counterparts. This result may be explained by the fact that ISO 9001-2008-certified hospitals have a safety manual that includes policies and procedures to control the occurrence of safety problems and to standardize the performance of studied sample toward patient safety culture. Nevertheless, in non-ISO 9001-2008-certified hospitals, unavailability of safety manual and procedures was effective at preventing errors, leading to the occurrence of safety problems at the hospital. The current study result was in agreement with a study that was done to assess the impact of this certification on patient safety before and after implementing ISO 9001. Their overall patient safety culture score showed an improvement of 80% compared with 50% for 10 hospitals with no quality management system, and their policy and management score showed an improvement of 58% compared with 5%. Moreover, document control system improved the perception of safety and increased the quality (Van den Heuvel et al., 2005). In addition, the result was in agreement with that of Khater et al. (2015), who conducted a study to assess patient safety culture in Jordanian hospitals from nurses’ perspective. Study results implied that improving patient safety culture requires a fundamental transformation of nurses’ work environment. In addition, new policies to improve collaboration between units of hospitals would improve patients’ safety.

Regarding supervisor/manager expectations and actions for promoting patient safety culture, the result showed that the critical care nurses working in ISO 9001-2008-certified hospitals had significantly slightly higher perceptions of supervisor/manager expectations and actions for promoting patient safety culture when compared with their counterparts. A possible explanation for this might be that the ISO-certified hospitals have top management that is committed to the development and implementation of the safety management, continually conducting management reviews and considering staff suggestions and appreciating good performance to keep up with patient safety culture. However, in non-ISO-certified hospitals there was inadequate training for supervisors and manager regarding how to handle patient safety issue, and the absence of safety policy made them ignore staff suggestions, in addition to focusing only on the achievement of the job and the need for taking shortcuts. The results were in line with those of the study by Šklebar et al. (2013), which reported that there was a statistically lower level of positive attitude toward supervisor/manager expectations and actions promoting patient safety, which required strengthening the role of healthcare management in improving patient safety culture.

Regarding teamwork within units, the result revealed that the critical care nurses working in the ISO 9001-2008-certified hospital had significantly slightly higher perceptions of teamwork within units when compared with their counterparts. It seems possible that these results were seen because of the use of conflict management resolution, the leadership democratic styles, and trust among colleagues. The result is in agreement with that of Costa et al. (2014), who concluded that hospital managers should not overlook the importance of cooperation within teams and should find ways to develop teamwork. For example, they should foster shared cognitions (e.g. team-shared mental models, team situation awareness), provide opportunities for team training (e.g. in explicit communication skills), and develop teamwork adjustment behaviors such as intrateam coaching or collaborative problem-solving and task-related collaborative behaviors (e.g. coordination, information exchange). This will affect quality of care indirectly in all of its dimensions.

Concerning communication openness within the hospital, the result revealed that the critical care nurses working in the ISO 9001-certified hospital had low communication openness within the hospital when compared with their counterparts. This result was because of nursing workload, which definitely affects the time that a nurse can allot to various tasks. Under a heavy workload, nurses may not have sufficient time to communicate with their managers or even with other nurses in the same unit. The result is in agreement with the findings of Mattson et al. (2015), who concluded that leader communication played a vital role in improving organizational and patient safety culture and that different communication approaches seem to positively affect different but equally essential employee safety behaviors. In addition the author highlighted the necessity for leaders to engage in one-way communication of safety values also, in more relational feedback communication with their subordinates in order to enhance patient safety.

Regarding, feedback and communication about error, the result revealed that critical care nurses working in the ISO 9001-2008-certified hospital had a slightly a higher mean score when compared with their counterparts. This result may be explained by the fact that in the ISO 9001-certified hospital there was a quality assurance unit that was concerned with the proactive planning to prevent errors from occurring, as well as reactive planning to eliminate duplication of error, but they did not know the importance of constructive feedback and dissemination of finding. Nevertheless, in the non-ISO 9001-certified hospital, there was no quality assurance unit concerned with that issue, leading to the absence of a system on how to deal with errors.

The result was in agreement with the study of Zhaleh et al. (2011), which was conducted to measure patient safety culture in three teaching hospitals. The finding revealed that ‘nonpunitive responses to error’, ‘teamwork across hospital units’, and ‘feedback and communication about error’ had the lower-most scores. In addition, the results were in agreement with the study by Vlayen et al. (2012), which was conducted to measure patient safety culture in Belgian hospitals and to examine the homogeneous grouping of underlying safety culture dimensions. The findings revealed that the overall dimensional scores were low. In addition, feedback and communication about error had the lowest scores.

Regarding nonpunitive response to error within the hospital, the result revealed a slightly higher mean score for critical care nurses working in the noncertified hospital when compared with their counterparts. It seems possible due not adopt blame-free culture as a pattern for internal behaving represented as a structured system for dealing with events reported. The result in agreement with the study by Barnsteiner and Disch (2012), which concluded that failure to track errors, and learning from them, actually increases the likelihood of other errors and near misses. A culture had to be created in clinical settings in which confidential reporting and trending of errors and near misses helps to identify problems and directs action to improve system issues. In addition, the result is in agreement with that of Moumtzoglou (2010), who concluded that nurses’ impeding factors for bringing up adverse events may be projected not only by cultural aspects such as professional, national, and organizational cultures, but also by healthcare practice structural issues such as safety systems, rules and procedures, and relevant acts and regulations. Moreover, nursing management should change management rules and establish systems so that nurses work in a blame-free culture, which examines system factors as causes of error rather than individuals.

Regarding hospital management support for patient safety culture, it was observed that the critical care nurses in the ISO 9001-2008-certified hospital had a higher mean score when compared with their counterparts. It seems possible that these results regarding the ISO 9001-certified hospital are because the top management is committed, and adheres, to the quality management system adopted by the hospital, which leads to promoting patient safety culture when compared to their counterparts. The findings of this study were in contrast to those reported by Abbas et al. (2008), which showed that respondents perceived a significantly stronger commitment to patient safety culture from hospital management. This study included 400 front-line clinical staff members working in general medical and surgical wards, CCUs, and paramedical departments at Alexandria Main University Hospital.

Regarding teamwork across units, it was observed that the critical care nurses in the ISO 9001-2008-certified hospital had a higher mean score when compared with their counterparts. As acknowledge by Alameddine et al. (2009) that within the context of challenges concisely touched on in CCUs, effective communication and group cohesion are crucial for critical care professionals to perform their works. Team building is complicated because CCU personnel must regularly interact with different kinds of healthcare providers, each with separate and important knowledge, technical skills, and perspectives; it is important to respect the contributions of different providers .The result is in agreement with that of O’Leary et al. (2012), who observed that there was a negative response toward teamwork across units during interdisciplinary rounds and suggested the need to improve consistency of teamwork and emphasized the importance of leadership.

Regarding hospital handoffs and transitions, the result revealed that the critical care nurses in the ISO 9001-2008-certified hospital had a higher mean score when compared with their counterparts. It seemed possible that in the ISO 9001-2008-certified hospital had hospital handoffs for endorsement, whereas in the noncertified hospital endorsement between hospital units was without a template and thus may lead to missing patient information while transferring between units. The result is in agreement with that of Rosenbluth et al. (2015), who conducted a study to determine whether variability exists in the content of printed handoff documents and to identify key data elements that should be uniformly included in these documents. The finding revealed that a wide variation existed in the content of printed handoff documents. Moreover, standardizing printed handoff documents has the potential to decrease omissions of key data during patient care transitions, which may decrease the risk of downstream medical errors.

Regarding adverse event reporting, it was observed that the critical care nurses in the ISO 9001-2008-certified hospital reported that the hospital had adverse event reporting system when compared with their counterparts. This result may be explained by the fact that hospital administration of the ISO 9001-2008-certified hospital had simple and applicable event reporting, which was clearly defined. Another possible explanation for this it might be related to the systematic and periodical reviews from the International Standardization for Organizations (ISO) Certification members to the hospital also may be due to the regular nurse supervisors’ rounds that may perhaps discover the adverse event on time. This result was in agreement with the study by Heavner and Siner (2015), which concluded that the voluntary reporting is the most frequently used tool to identify adverse events and errors. This reporting method is the most useful for promoting attitude and behavioral changes by allowing individuals to participate in the event recognition process, as well as engaging these individuals in process improvement and feedback mechanisms. This is the same view of Borowitz et al. (2008), who reported that handoffs and transitions have a significant effect on patient safety. In addition, Aboshaiqah et al. (2013) found that ineffective communication leads to unsafe actions that may affect patients’ health conditions. This probably led to some factors, such as fear of job loss, punishment or blame, and possibility for shame, which have been recognized in the literature related to reporting mistakes.

Finally, there was a significant correlation between the overall patient safety culture and hospital magnet designation dimensions in the ISO 9001-certified hospital. In the meantime, insignificant correlations were found between total patient hospital magnet designation and safety culture dimensions in the ISO 9001-noncertified hospital. This is a similar perspective of Elsayed and Mahmoud (2016), who announced that magnet workplaces are not just important to enhance nurses’ work environment and organizational outcomes but they also motivate the nurses to support patient safety. This study produced results that corroborate with the findings of Kutney-Lee et al. (2015), who found that magnet status had a significant improvement of nursing workplace and consequently patient safety. In addition, these findings of the current study are consistent with those of Kvist et al. (2013), who found that magnet work environment promotes patient safety.


  Conclusion Top


The results of the current study concluded that hospital magnet designation dimensions in the ISO 9001-certified hospital and non-ISO 9001-certified hospital are necessary to encourage the nurses to promote patient safety culture. In addition, the primary hospital magnet designation attributes for critical care nurses’ excellence in ISO 9001-certified hospitals were hospital support for education, nursing competences, and adequacy of staffing in CCUs. However, the primary hospital magnet designation attributes in the noncertified hospital were hospital support for education, nursing competence, and nurse–physician collaboration. Concerning nonmagnet designation attributes, the primary hospital nonmagnet designation attributes in the ISO 9001-certified hospital were nurse manager support and nurse–physician collaboration, whereas the primary hospital nonmagnet designation attributes in the ISO 9001-certified hospital were clinical autonomy, nurse manager support, adequacy of staffing, and nurse–physician collaboration. In ISO 9001-certified hospitals adverse event reporting, teamwork within units, and supervisor/manger expectations and actions promoting patient safety were perceived by critical care nurses as the primary source of positive patient safety culture.

Recommendations

  1. Establish a system for recruitment, selection of personnel, training, and organization of working hours in both hospitals.
  2. Develop effective mechanisms for communicating safety problems and solutions through representative members of safety committees in different units in the ISO 9001-2008-noncertified hospital. In addition, improve the performance of the previous concerned committee in the ISO 9001-2008-certified hospital.
  3. Provide training to staff nurses in the ISO 9001-2008-noncertified hospital regarding aspects of patient safety culture that includes teamwork across the units, continuous improvement, adverse events reporting, handoffs and transitions, and effective communication skills. In addition, retrain nursing staff in the ISO 9001-2008-certified hospital on the same subjects.
  4. Raise awareness of staff nurses about patient safety policies and procedures through conferences, seminars, and workshops in the ISO 9001-2008-certified hospital. In addition, establish patient safety policies and procedures in the ISO 9901-2008-noncertified hospital.
  5. Develop a well-established system for incident reporting, and all staff nurses should be informed in the ISO 9001-2008-noncertified hospital. In addition, provide feedback about area of improvement and actions be taken at reported events to nursing staff in both hospitals.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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Abstract
Introduction
Significance
Aim of the study
Results
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