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IIR 13-343 – HSR Study

IIR 13-343
Safety climate in CLCs: variation, predictors, and impact on resident outcomes
Christine W. Hartmann, PhD
VA Bedford HealthCare System, Bedford, MA
Bedford, MA
Funding Period: March 2016 - February 2019
Safety is a key component of care quality. A climate where safety is prioritized and employees feel comfortable questioning others and disclosing their own mistakes-that is, a strong safety climate-figures prominently in improving unacceptably high healthcare organization safety error rates. Nursing home staff must prioritize safety because they care for an inherently vulnerable population in which safety errors are already more likely to occur. Yet relatively little research has been done on nursing home safety climate, although studies suggest that nursing home safety climate varies considerably and that staff safety climate perceptions are related to some resident outcomes. Research also points to a possible perceived conflict for nursing home staff between safety and resident-centered care. To date, no nursing home safety climate interventions have been tested. This project builds on pilot work and incorporates feedback from VHA operations partners. It represents the first comprehensive study of Community Living Center (CLC) safety climate and the first usability study of a CLC safety climate toolkit.

The CLC Employee Survey of Attitudes about Resident Safety (CESARS) was developed to assess and help improve CLC safety climate. The CESARS consists of two parts: (1) a multi-domain CLC safety climate instrument (i.e., "CESARS Survey") and (2) a CLC safety climate toolkit (i.e., "CESARS Toolkit"). The current study builds on this prior work. The study has 3 aims. (1) Identify employee and organizational characteristics associated with safety climate variation across VHA and over time. (2) Examine the relationship of safety climate to both care processes and clinical outcomes across VHA and over time. (3) Pilot the use of the CESARS Toolkit.

The study uses a mixed-methods design. Aims 1 and 2 are achieved by administering the CESARS Survey and a measure of organizational readiness to change in a random national sample of 64 CLCs at two time points (organizational readiness to change only at Time 1) and conducting quantitative analyses. Aim 3 is achieved by conducting qualitative interviews with staff at 6 purposively sampled CLCs about safety climate and the usability of the CESARS Toolkit. These results will be used to refine the Toolkit. Quantitative and qualitative results will also be integrated to provide a comprehensive picture of safety climate nationally.

Using data from the Time 1 CESARS administration, we investigated the association of staff tenure in years with safety climate, to further understand the potential impacts of staff retention policies. 56 Veterans Affairs Community Living Centers (CLCs, i. e., nursing homes) were sampled nationally to participate; 1,396 staff participated. We used mixed random effect models with "individual attitudes towards safety" and "senior managers' commitment to safety" as the dependent variables and tenure in years as the key independent variable, controlling for VA facility complexity, staff occupation, shift, and full-time/part-time status, as well as clustering effects (by VA hospital, VA service network, and geographic region). Staff with longer tenure in the CLC showed more familiarity and felt more comfort and personal responsibility towards resident safety than staff with shorter tenure (p<0. 0001). Yet staff with longer tenure perceived their senior managers' role as less active (p<0. 01). Results indicate successful retention of staff may foster a higher personal commitment to resident safety, possibly by allowing staff to gain more learning opportunities, thus enriching their safety understanding. Although longer-tenured staff are more skeptical of senior managers' contributions to resident safety, when compared with their own, harnessing these staff's understanding of resident safety may be instrumental when designing nursing home safety interventions.

This project will generate new knowledge about CLC safety climate. It will provide a nuanced picture of safety climate nationally and the relationship between safety climate and outcomes, in addition to providing detailed information on the barriers to and facilitators of using the CESARS Toolkit. These findings will help enhance care for some of VHA's most vulnerable Veterans. The knowledge gained will be of immediate applicability to CLCs nationwide and will be help guide further improvements in safety climate. Additionally, the refined CESARS Toolkit will be immediately relevant. Results will also lead directly to subsequent implementation work.

External Links for this Project

NIH Reporter

Grant Number: I01HX001440-01A2

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Journal Articles

  1. Engle RL, Gillespie C, Clark VA, McDannold SE, Kazi LE, Hartmann CW. Factors Differentiating Nursing Homes With Strong Resident Safety Climate: A Qualitative Study of Leadership and Staff Perspectives. Journal of gerontological nursing. 2023 Feb 1; 49(2):13-17. [view]
  2. Quach ED, Kazis LE, Zhao S, McDannold S, Clark V, Hartmann CW. Nursing Home Senior Managers and Direct Care Staff: Are There Differences in Their Perceptions of Safety Climate? Journal of Patient Safety. 2021 Dec 1; 17(8):e1616-e1621. [view]
  3. Quach ED, Kazis LE, Zhao S, Ni P, Clark VA, McDannold SE, Hartmann CW. Organizational readiness to change as a leverage point for improving safety: a national nursing home survey. BMC health services research. 2021 Aug 20; 21(1):842. [view]
  4. Quach ED, Kazis LE, Zhao S, McDannold SE, Clark VA, Hartmann CW. Relationship Between Work Experience and Safety Climate in Veterans Affairs Nursing Homes Nationwide. Journal of Patient Safety. 2021 Dec 1; 17(8):e1609-e1615. [view]
  5. Quach ED, Kazis LE, Zhao S, Ni P, McDannold SE, Clark VA, Hartmann CW. Safety Climate Associated With Adverse Events in Nursing Homes: A National VA Study. Journal of The American Medical Directors Association. 2021 Feb 1; 22(2):388-392. [view]
  6. Lindsey Jacobs M, Lynn Snow A, Allen RS, Hartmann CW, Dautovich N, Parmelee PA. Supporting autonomy in long-term care: Lessons from nursing assistants. Geriatric nursing (New York, N.Y.). 2019 Mar 1; 40(2):129-137. [view]

DRA: Aging, Older Veterans' Health and Care, Health Systems
DRE: Prevention
Keywords: Outcomes - Patient
MeSH Terms: none

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