|Year : 2020 | Volume
| Issue : 2 | Page : 54-59
Practice gaps and challenges to effective patient safety culture in a tertiary hospital in Nigeria
Amaka Y Ezeuko1, Chinomnso C Nnebue2, Raymond C Okechukwu3, Chigozie O Ifeadike4
1 Department of Public Health Pharmacy, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
2 Department of Community Medicine; Department of HIV Care, Nnamdi Azikiwe University Teaching Hospital, Nnewi; Department of Community Medicine, Nnamdi Azikiwe University Awka, Nigeria
3 Department of Pharmacy, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
4 Department of Community Medicine, Nnamdi Azikiwe University Teaching Hospital, Nnewi; Department of Community Medicine, Nnamdi Azikiwe University Awka, Nigeria
|Date of Submission||31-Jul-2020|
|Date of Decision||20-Aug-2020|
|Date of Acceptance||11-Sep-2020|
|Date of Web Publication||21-Dec-2020|
Dr. Chinomnso C Nnebue
Department of Community Medicine, Nnamdi Azikiwe University, PMB 5025, Awka, Anambra
Source of Support: None, Conflict of Interest: None
Background: Knowledge and experiences of inefficiencies, odds and difficulties in patient safety culture (PSC) maintenance in health-care systems can facilitate the development and implementation of better strategies.
Objective: The aim is to determine the practice gaps and challenges to effective PSC in Nnamdi Azikiwe University Teaching Hospital, (NAUTH) Nnewi, Nigeria.
Materials and Methods: This was a cross-sectional survey conducted from June to November 2016 in NAUTH Nnewi, Nigeria. Data were collected through mixed methods:-self-administered structured questionnaire survey (QS), focus group discussions (FGD) and key informant interviews (KII). Stratified sampling technique was used for the QS, while the convenience sampling technique. was employed in the FGD and KII. Data were analysed using the Statistical Package for the Social Sciences version 22.
Results: Challenges to the effective promotion of PSC each relate to gaps in either poor staff strength or punitive response to the error report. The challenges reported from the FGD are lack of training and re-training programmes (61%), poor team spirit and low staff capacity (56%). From the KII >80% reported non-availability of PSC unit, patient safety committee, patient safety guideline/policy, nor standard operation procedure while (61%) reported that management effort to provide enabling patient safety environment was adequate.
Conclusions: This study found challenges to effective PSCsuch as poor training, staff strength, team spirit cum communication, excessive work hours and fear of punitive response to the error report. This buttresses the need for urgent attention to these areas of weakness through awareness and educational programmes on PSC, adequate staffing and prompt information dissemination.
Keywords: Challenges, Nigeria, patient safety culture, practice gaps, teaching hospital
|How to cite this article:|
Ezeuko AY, Nnebue CC, Okechukwu RC, Ifeadike CO. Practice gaps and challenges to effective patient safety culture in a tertiary hospital in Nigeria. J Patient Saf Infect Control 2020;8:54-9
|How to cite this URL:|
Ezeuko AY, Nnebue CC, Okechukwu RC, Ifeadike CO. Practice gaps and challenges to effective patient safety culture in a tertiary hospital in Nigeria. J Patient Saf Infect Control [serial online] 2020 [cited 2021 Jan 27];8:54-9. Available from: https://www.jpsiconline.com/text.asp?2020/8/2/54/304215
| Introduction|| |
Patient safety culture (PSC) refers to a holistic snapshot of enacted norms, policies and procedures related to patient safety that guides the behaviours, attitudes and cognitions of care providers. Safety concerns spring up from practice gaps and challenges such as poor communication intra- and inter-specific units of the health-care delivery system.,
Developing a PSC was one of the recommendations made by the Institute of Medicine to assist hospitals in improving patient safety. Furthermore, the World Health Assembly in the adoption of its resolution WHA55.18, urged member states to pay attention to the problem of patient safety and to establish and strengthen evidence-based mechanism necessary for improving PSC.
Thus to maintain patient safety, the emphasis is placed on the system of care delivery that prevents errors; learns from occurred errors and is built on a culture of safety that involves health-care professionals, organisations, and patients. The Agency for Healthcare Research and Quality (AHRQ), therefore, recommends annual assessment of safety culture. This is to help unravel odds and inefficiencies inherent in the system.
While much emphasis is laid on the epidemiology of errors and adverse events, a little had been directed to practices that reduce such errors and events. Furthemore, literature regarding practice gaps and challenges to PSC in Nigeria and sub-saharan Africa remains scanty. The findings of this study can bridge knowledge and practice gaps, guide and inform country-level strategies to further improve the systems governing PSC practices that tackle these issues. It can help identify areas of strength and those that require improvement. In view of this, there is a need to assess the existing PSC in the study setting. This study was designed to determine practice gaps and challenges to effective PSC practice in Nnamdi Azikiwe University Teaching Hospital (NAUTH) Nnewi. Nigeria
| Materials and Methods|| |
A cross-sectional descriptive study on the practice gaps and challenges to effective PSC in a tertiary hospital in Nigeria.
This study was conducted from June to November, 2016 in NAUTH, Nnewi, Nigeria. Primary activities of the center include specialist health-care delivery, training of undergraduate and post-graduate medical, pharmacy and nursing students as well as research. This level of care requirement suffices that NAUTH has all cadres of health-care professionals and attend to a range of health conditions in patients and clients from the State and beyond.
Data were collected using (1) questionnaire adapted from a customised version of the hospital survey on PSC and the pharmacy survey on PSC, developed by the AHRQ,,,, which had been tested for validity and reliability. Furthermore, appropriate facilitator guides developed from the same sources,, were used for (2) focus group discussions (FGD) and (3) key informant interviews (KII), respectively.
Three categories of the population were involved in the study. (1) Calculated samples of professionals (Doctors, Pharmacists, Nurses, Laboratory scientists, Physiotherapists and Medical record officers), (2) FGD among representatives (focal persons) from the various professional groups and (3) KII of hospital management officers.
Health-care professionals on permanent appointment, with at least 1 year of experience and who gave consent.
Health-care professionals absent from work during the study period. Respondents for the FGD and KII.
These comprise: (a) Demographic variables of respondents, (b) practice gaps cum challenges to the effective promotion of PSC.
Frequencies of the variables were assessed using univariate analysis.
Reporting bias could result from the sensitive nature of the questions. This we overcame using anonymous questionnaires and ensuring the Health-care professionals that their answers are would be strictly confidential and specifically for research purposes.
Sample size determination
The sample size was determined based on the estimate population of 1200 health-care professionals in the employment of the teaching hospital using the sample size formula for cross-sectional studies in population >10,000 (Cochran) stated thus: N = z2 pq/d2, Where n = minimum sample size; z = Standard normal deviate set at 1.96 (95% confidence interval); p = PSC practice prevalence level in the study institution (Estimated at 0.5 since none was available); q = 1– p and d = Maximum allowable error (5% =0.05). Therefore, the estimated sample size n = 380. Since estimated sample size was >5% of the estimated population, the sample size was therefore adjusted using the formula: N1 = n/1+ (n/N), N1 = 288. Using 10% attrition rate, the actual sample size was made to be 315.
For the questionnaire survey (QS), stratified random sampling technique was employed. Convenient sampling technique was used to select participants for both FGD and KII. Participants of the QS were stratified in the ratio of 3:2:1:1:1:1 for nurses; doctors; pharmacists, laboratory scientists, physiotherapists and medical records professionals respectively (considering the population of the respective professional in the hospital). Following the above, therefore, a sample of 105 nurses, 70 doctors, 35 each of pharmacists, health records officers, laboratory scientists and physiotherapists were proportionately allocated and included in the survey. However, professionals like physiotherapists whom their population was below the calculated sample were made up from the more populated professionals. For the FGD, 22 respondents (2 from Physiotherapy and 4 each from the other five departments) were selected for the two sessions of the group discussion conducted (11 professionals per session). On the KII, five hospital management officers who included directors and assistant directors were interviewed.
For the QS, a structured questionnaire was self-administered. A facilitator was employed to moderate the FGD and KII after a written informed consent of each of the participants.
Data cleaning was done by carrying out range and consistency checks. Data generated were keyed into the excel spreadsheet for analysis. Descriptive and analytical statistics of the data were carried out using the International Business Machine/Statistical Package for the Social Sciences (IBM/SPSS) Windows version 22.0 IBM Corp. Armonk NY: United States 2013. Univariate analysis was utilised to obtain an overview of respondent demographics (gender, profession, work unit/area, year of experience, and work hours per week) of the respondents. Quantitative data were analysed by computing frequency tables.
| Results|| |
Results from the questionnaire survey
A total of 370 questionnaires were administered and 321 returned, giving a response rate of 87%. Forty questionnaires were rejected, while 281 were valid. [Table 1] shows some demographic variables of the respondents for the QS. About (35%) had close to 5 years working experience of service, while (8%) have worked for more than 20 years in the study institution. Almost half of them work between 40 and 59 h/week and about 30% work beyond this period per week. Challenges to the effective promotion of PSC in the study hospital are summarised in [Table 2]. Each of the challenges relates to gaps in either poor staff strength or punitive response to the error.
|Table 2: Challenges to effective patient safety culture practice from the questionnaire survey|
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Results from the focus group discussions
The factors which the professionals reported as challenges to effective PSC practice are presented in [Figure 1]. Major challenges are lack of training and re-training programs (61%), poor team spirit and low staff capacity (56%), respectively). Other responses from the FGD are summarised in [Table 3]. All the respondents (100%) were of the view that PSC is not given optimal attention in the hospital. More than (80%) also reported that there are no PSC unit, no patient safety committee and no patient safety guidelines or operation procedure in the hospital. About (61%) reported that management effort to provide enabling patient safety environment in workplace is fair.
|Figure 1: Challenges to patient safety culture from the focus group discussions|
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Results from the key informant interviews
Findings from the KII are summarised in [Table 4]. Sixty percent of the informants reported non-availability of either patient safety guideline or hospital policy for ensuring safety and 80% reported unavailability of patient safety committee in the hospital. Though (20%) reported the existence of such committee, none of them was aware of the activity of the committee for the past 12 months. Staff strength was poor, according to (60%) of them. However, management support was reported as adequate by (60%) of the informants.
| Discussion|| |
This was a cross-sectional descriptive survey of the practice gaps and challenges to effective PSC in a tertiary hospital in Nigeria. The results summary shows that each of the challenges relates to gaps in either poor staff strength or punitive response to error reporting. Similar to these findings, several studies in different parts of the world have reported 'punitive response to error' reporting and 'staffing' as weak areas of their safety culture.,, Furthermore, studies in Nigeria reported inadequate staff strength.,
From the FGD reports, the major challenges are lack of training and re-training programs, poor team spirit, low staff capacity, poor communication, poor logistics, workspace constraints and excessive work hours. Also reported were fear of punitive measure on event report, poor staff strength and use of temporary staff. With these challenges in place, not much can be done to improve the patient safety practice of the study institution. This finding is in keeping with the findings in Lebanon, that effective PSC faces challenges such as punitive response to error, poor staffing and poor communication, in Kuwait, which reported barriers were related to support, staffing, resources and response to error, while Farokhzadian, et al., reported poor communication, teamwork, leadership support and reporting. The situation seems a general picture, as several other studies have reported similar challenges including a study in Bayelsa state tertiary hospital pharmacy section where poor staff strength, work pressure and workspace were reported; a study by the Nigerian Maternal, Neonatal and Child Health nurses which reported poor staffing as a challenge to patient safety and a Delta state hospital pharmacy facilities study where poor staff strength was also reported.
Findings from the key informant interview showed \non-availability of either patient safety guideline or hospital policy for ensuring safety and unavailability of patient safety committee in the hospital. In the absence of a unit or committee responsible for patient safety, then safety related issues cannot easily be reported, discussed and outcome feedback into the system. Guideline and standard operation procedure (SOP) is an essential instrument that should be made available to equip the health-care professionals in handling, resolving and preventing safety events. Majority of the key informants as well, reported non-availability of patient safety guidelines, hospital policy for ensuring safety and patient safety committee in the hospital. Unavailability of these is a serious handicap for health-care professionals in upholding safety practices. Though a few (20%) reported the existence of the patient safety committee in the hospital, none of the informants was aware of the activity of the committee for the past 12 months. In the environment of this nature, developing and maintaining a culture of safety may be hindered. If indeed, patient safety unit, committee, guideline or SOP is not in existence in the hospital according to majority of the professionals, then developing and maintaining a culture of safety in the institution is baseless.
However, if safety systems are in existence and professionals are unaware of either the existence or the activities of the committee, safety practice cannot be moved to the next level because the professionals are ignorant of its operation. Additional studies with improved methodology and a common protocol are required to accurately determine the practice gaps and challenges to effective PSC among countries. This will help accommodate this limitation and provide more evidence for policymaking.
Strengths and limitations to the study
The strengths include the use of a standardised instrument and that it employed a mixed-method survey to provide detailed information. The limitations include the use of cross-sectional design and that this survey failed to assess the representative public health actions, but rather concentrated on the tertiary level.
| Conclusions|| |
The study results suggest that the effective maintenance of culture of safety posed many challenges, including poor training and retraining programs, poor team spirit and communication among professionals, fear of punitive response to the error report, poor staff strength/excessive work hours among professional. The current study showed that urgent attention should be given to the areas of weakness, mainly in the dimension of training and retraining programmes, workshops and seminars on critical areas like teamwork and coordination among different professional groups to promote the team environment. Error report should be encouraged by motivational strategies and staff alerted on this to alleviate fear of punitive measures on reports among professionals. Staff strength in different hospital units should be assessed and reconsidered.
Ethics approval and consent to participate
This study has been examined and approved by the Nnamdi Azikiwe University Teaching Hospital Ethical Committee (NAUTHEC). A written informed consent was obtained from each participant for the conduct and publication of this research study and assurance of confidentiality given. Study participants were free to refuse or withdraw from the study at any time without any penalty. The objectives were explained to each participant prior to interview. All authors hereby declare that the study has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]