Efforts to Improve the Safety Culture of the Elderly in Nursing Homes: A Qualitative Study

Introduction

Attention to building a safety culture in nursing homes is relatively less when compared to hospitals. Managers, health service providers, health insurance providers, patients, families, and communities constantly expect patient safety and the highest caliber of healthcare services.¹ The idea of “first no harm”, however, is insufficient to halt the rise of patient safety issues including prescription errors and the risk of falling.² By developing a safer care system that includes risk assessment, patient risk identification, and management, incident reporting, and analysis, the capacity to learn from incidents and their aftermath, as well as the implementation of solutions to minimize risks and prevent future injuries, nursing homes can increase the safety of the elderly caused by mistakes made during performing an action or failing to take an action that should have been taken.³

The values, beliefs, and actions employees adopt within an organization that emphasizes and promote the enhancement of safety is known as the safety culture.⁴ Components of safety culture include a culture of openness (informed culture), fairness (just culture), learning (learning culture), and reporting (reports culture). Safety culture is used as a space for discussion about adverse events and strategies to prevent them from happening again. Safety culture includes an open atmosphere to discuss mistakes, and improve processes and systems without fear of repercussions. Safety culture is fundamental in the implementation of health services. Good patient safety will improve the quality of health services, especially nursing care. A strong patient safety culture helps reduce patient safety-related occurrences.⁵

Nursing homes’ safety culture settings prioritize adhering to legal requirements and care coordination.⁶ Nursing homes are places that are prone to mistakes and adverse events. Elderly people’s declining physical and cognitive abilities lead to a reduction in their social roles, which increases their dependence on others.⁷ The use of several is also necessary for aged care in nursing homes since the elderly often experience a variety of health issues, including cognitive and sensory impairments that can raise the risk of medical errors.⁸ Treatment in nursing homes is frequently characterized by a high staff turnover rate, challenges finding qualified new hires, and inadequate care quality.^5,9 Additionally, unlicensed certified nursing assistants typically offer care in nursing homes.¹ Most caregivers in nursing homes are social workers, followed by nurses and doctors.¹⁰ Taken together, these factors have serious implications for the health and safety of older adults in nursing homes. Leadership and all staff members must be aware of the values, tenets, and organizational standards around what is significant, attitudes, and appropriate behavior to create a positive safety culture in nursing homes.⁸

Building an elderly safety culture allows all staff to minimize injuries and improve the quality of care in nursing homes. Efforts made by an institution in carrying out an effective role can affect the culture of patient safety. The purpose of this research is to find out the efforts to increase safety culture among the elderly in nursing homes.

Method

Research Design

This study uses a phenomenological qualitative design to explore efforts to improve the safety culture of the elderly in nursing home research. The design is considered appropriate because it involves meaningful and specific experiential investigations, exploring significant themes that characterize phenomena in efforts to improve safety culture in institutions.¹¹ In addition, this design is commonly used in the fields of nursing and health.

Data collection was carried out within 3 months, namely months June to August. Data collection was carried out in 4 government and private institutions in East Java Province.

Participant

This study used a purposive sampling method. Participants recruited in this study were managers and staff in nursing homes, including nurses, kitchen staff, administrative support staff, drivers, and security social workers. The criteria for this study were: (1) service providers at the orphanage; (2) have worked in an orphanage for at least 1 year; (3) able to communicate using Indonesian. There were 29 participants in this study, and sociodemographic information such as job category and length of service were also collected. This is further explained in Table 1.

Table 1 Participants in the Study

Data Collection

Before making contact with the participants, 4 government and private institutions in East Java province were contacted to recommend participants. Furthermore, the scheduling of Focus Group Discussions (FGD) was carried out in each orphanage. Participants who agreed to participate in the study filled out informed consent and were then asked to fill out demographic data.

The interview guide has been used by the researcher as a reference to ensure all important subjects are covered and serves as a reminder of the topics to be covered. The researchers have created an open-ended thematic interview guide, which includes open-ended questions such as, “How are efforts being made to improve safety culture in nursing homes?”

To collect comprehensive information regarding efforts to improve safety culture in nursing homes, in-depth and semi-structured interviews were conducted with participants through FGDs.

Individual interviews were recorded by the researcher using a voice recorder, the results of which were then transcribed, exposed to nonverbal responses via field notes for data analysis, checked to improve data accuracy and then collected as verbatim data. Field notes and audio-visual recordings are used to facilitate recall and for further exploration of non-verbal language.

Data Analysis

Colaizzi’s approach was used to analyze and sensitize the audio recordings of the interviews. Participants may clarify data using this strategy, which might influence the results. Colaizzi’s first step was to write the interview verbatim, followed by three readings of the transcript to understand the participants’ feelings and mental processes. In the second step, the researcher examines each transcript to select a specific section. Each participant’s comments were transcribed separately and coded with a line and page number of the transcript.

In the third step, the researcher makes broad interpretations of each major textual statement. Significant statements are used to construct meaning, which is then discussed. The peer expert is then coded and broadly defined to verify that the procedure was followed correctly and consistently. Step 4 constructs interpretive meanings of events and circumstances and organizes them into themes and sub-themes. In Step 5, each theme is combined to create an overall picture of improving a culture of safety in nursing homes. Experts were then consulted to ensure they accurately described their phenomena. Verify results and findings with participants in the last step by emailing them “findings and transcripts” and then calling by phone after they have read. All participants expressed agreement and satisfaction with the features and interpretation.

Rigor

The researchers conducted the interview and got consent from the subjects to record the conversation using audio files. After the interview, the researcher transcribed the conversation. To guarantee that the data had a high degree of confidence and uniformity, the transcripts were examined and compared with the audio recordings. Researchers have also compared field notes from interviews with pre-existing data to better analyze interactions. To establish credibility, researchers ask outsiders to analyze and comment on their findings to come to a consensus, particularly to assess coding, consistency, and new findings.

Ethical Consideration

The Faculty of Nursing, Universitas Airlangga, Surabaya Indonesia Research Ethics Committee accepted the study’s protocol in conformity with the Declaration of Helsinki and assigned it approval number 2007-KEPK. Every participant were given free reign to leave the study at any moment, and informed consent was obtained from them. Each study participant gave informed consent to publish their comments while still being anonymous, and the location and timing of the interview were set up to maintain privacy and confidentiality. To protect participants’ privacy, the identities of the participants are made anonymous.

Results

Participant Characteristics

Table 1 shows the characteristics of the demos of the 29 participants who participated in the study based on the information they provided during the interviews. Participants are employees of 4 government and private nursing homes in East Java, Indonesia.

Themes and Sub-Themes

There are four themes that can be obtained from research regarding efforts to improve the safety of the elderly, namely the provision of new staff orientation, training, improving infrastructure, procurement of security staff. Further themes and sub-themes are described in Table 2.

Table 2 Theme and Subthemes

New Staff Orientation

The informant said that currently the orientation for new staff only focuses on introducing nursing homes and homesteads, while there is no specific safety for the elderly, only as an adjunct. The following is the statement of the informant below:

…This means that when (orientation) concerns specifically, it hasn’t been yet but it’s been rushing, yes, for example, yes, it must be related to the safety of the elderly, right? (UPT GWJ, Informant 3)

…for orientation, there are nurses who have been here for a long time, well, maybe the orientation is just an introduction to the grandparents and the room (Panti AI, Informant 2)

Help from Senior Staff

Some participants were helped by the orientation of senior staff. They said:

…As best as I can recall, the nurse or other staff members on duty welcomed and orientated me when I initially arrived. I recall that we were then accompanied for two weeks during the early morning shift. We will therefore choose the senior nurse. (Panti PNG, informan 1)

…The social service used to issue a decree to the nurse, ma’am. After that, we were often shown around the workplace and presented to the assistants. then engage in this activity now. If we have questions, we can ask the service provider, another nurse or assistant: (Panti PND, informan 5)

…New hires are typically followed until they are able to do alone (Panti PNG, informan 2)

Sharing with Colleagues

Sharing makes new staff know how co-workers handle the elderly. They said:

…We therefore see how seniors interact with elderly, learn from the seniors present, share experiences with them, participate in the activities here. (Panti PND, Informan 2)

Studying the SOP Book

Reading SOP book helps understand elderly safety procedure and priorities. The following participant statements:

…However, there is an SOP book that prioritizes the security and safety of the elderly and provides nursing interventions (Panti PNG, Informan 7)

Training

The informant said that during training for staff at nursing homes or homes for the elderly, there was nothing specifically about the safety of the elderly. The following is the statement of the informant below:

…regarding the training, we usually have some sort of SK, ……no specific material but delivered, ma’am. (Panti PND, Informant 9)

Regarding the Implementation of Health Protocols

Participants said there was counseling on the implementation of health protocols in the orphanage. The following is the statement of the informant below:

…Regarding the application of the Health protocol at the nursing home, there was counseling. From the public health center, if I’m not mistaken. the same instruction in prior wound care. (Panti PND, Informant 2)

Injury Cure

Participant said there is injury cure training. The following is the statement of the informant below:

…Additionally, the service sector occasionally offers training in injury cure (Panti, PND 10)

Training Organized by the Provincial Social Services

Participant said there are training from provincial social service. The following is the statement of the informant below:

…In terms of training, we typically have some sort of SK; the letter for education comes from the provincial social service and points directly to the relevant fields. As an example, there is a culinary training program for which the SK is typically written directly on behalf of the cooking department. For instance, when I administer items, it is typically done so with such mind training. (Panti PND, Informat 9)

Improvement of Infrastructure

The informant said that several safety equipment facilities and infrastructure had been provided by the nursing home. The following is the statement of the informant below:

……if you get the gown from the Ministry of Social Affairs, then the mask, gloves, hand sanitizer, disinfectant, then equipment for clients who complain of coughing or shortness of breath, the nebulizer device can also be (Panti Pnd, Informant 5)

APAR

Participants said fire extinguishers had been provided at the nursing homes. Here the statement:

…We have prepared one of them—gas cylinders for fires—but at this time there is only one (Panti PND, Informant 9)

Safety

Including the security carried out at the nursing homes mentioned by the participants, viz:

…along with providing grip handles. (Panti PNG, Informat 5)

…Considering the supervision and security measures in place, in my opinion (Panti PND, Informat 3)

Missing Labels/Marks

Participants said they needed to label the room.

…The wording on the dining area for the elderly has vanished a lot, perhaps due to poor facility upkeep. So perhaps it needs to be changed (Panti PNG, informant 1)

Reduce Stairs

Stairs can cause elderly, easy to fall.

…For instance, there are quite a few stairs to the pantry, it’s currently raining, and (older adults) are more prone to injury (Panti PNG, Informant 1)

Procurement of Security Officers

The informant said that security officers, especially night guards, are needed to keep the elderly in nursing homes safe. The following is the statement of the informant below:

…guard for the night during the day, there’s a nurse on guard here, if it’s in front, we don’t know (Panti AI, Informant 2)

Prevent Unwanted Event

Security can prevent unwanted events such as the elderly fighting, the elderly running away from the nursing homes. The following is the statement of the informant below:

…The issue or event involving the older started when I was notified of an older fight while working in security (Panti PND, Informant 1)

…When we report a fight issue, security arrives right away (Panti PND, Informant 4)

Second, some older people jumped the fence to escape. (Panti PND, Informant 1)

Discussion

Researchers agree that this research will help understand efforts to improve the safety culture of the elderly in nursing homes. The concept of patient safety is fundamentally defined as “freedom from accidental injury” by the Institute of Medicine (IOM).¹² The Hospital Patient Safety Committee (KKP-RS) defines patient safety by these restrictions as being free from harm that should not have occurred or potential injury resulting from health services caused by errors, which include failure of a plan or using the incorrect plan to achieve goals.¹³ According to Minister of Health Regulation No. 11 of 2017 concerning Patient Safety, patient safety is a system that makes patient care safer. The system includes risk assessment, identification, and management of patient risks, reporting and analysis of incidents, the ability to learn from incidents and their follow-up, as well as the implementation of solutions to minimize risks and prevent injuries caused by mistakes due to acting or not taking the action that should be taken.¹³ Safety culture is an important factor in understanding efforts to promote safe elderly care. Efforts to improve service quality and improve safety culture are not only within the scope of hospitals and companies but safety culture is also very important in the scope of nursing homes.¹⁵

Patient safety standards must be implemented in hospitals and other healthcare facilities including nursing homes, there are patient safety standards consisting of seven standards, one of which is educating staff about patient safety through healthcare facilities having an education, training, and orientation process for each position includes a clear link between the position and patient safety and organizes continuous education and training to improve and maintain staff competence and support an interdisciplinary approach in patient care.¹⁴ After education and training and a long time in the orphanage, workers will then have Work experience. According to research results work experience and the direct provision of services to older adults have a significant relationship with safety culture. Work experience is the most dominant factor affecting safety culture.¹⁵

In addition, based on the Regulation of the Minister of Health no. 11 of 2017 concerning Patient Safety states that every health service facility, especially hospitals, must have an education, training, and orientation program for new staff that includes patient safety topics according to their respective duties, every health service facility, especially hospitals, must integrate the topic of patient safety. In every in-service training activity and provide clear guidelines on reporting incidents, and every health service facility must organize training on teamwork to support an interdisciplinary and collaborative approach in serving patients.¹³ Healthcare facilities can improve the implementation of patient or elderly safety standards, reduce risks and improve patient safety by providing adequate human resources, facilities, and infrastructure, increasing staff participation in service quality improvement programs, increasing staff training, communicating with patients and families, as well as overcoming challenges and obstacles.¹⁵

The need to implement a patient safety culture in healthcare facilities is one step toward patient or elderly safety. Eight steps to develop a patient safety culture are 1) set a focus on patient safety, patient safety must be a strategic priority for health care facilities; 2) Thinking simply and taking steps to improve services, providing safe health services for patients may require rather complex steps, but breaking down this complexity will provide more tangible improvements; 3) Encouraging an open reporting system, all staff must create a culture that encourages reporting, recording actions that harm patients is as important as recording actions that save patients. An open discussion of the incidents that occurred can be a lesson for all staff; 4) A better data recording system is required to periodically evaluate and follow quality advancements, making the recording system a top priority.¹³

Furthermore, 5) Use a holistic not individual system approach, development can only occur if there is an adequate support system. Staff must also be trained and encouraged to improve service quality and patient safety, if the patient safety approach is not fully integrated into the applicable system, then the improvements that occur will only be temporary; 6) Develop thinking systems and program implementation. Staff also need motivation and support to develop methodologies, thinking systems, and program implementation; 7) Involve patients in safety efforts. Patient involvement in the development of patient safety is proven to have a positive influence, and finally 8) Establishing a system for gathering high-quality data, encouraging a culture of not blaming one another, inspiring staff, and involving patients in the workplace all require prioritizing patient safety, which calls for strong leadership, a cohesive team, as well as high dedication and commitment to achieving the goal of developing a patient safety culture.¹³

In architectural design, physical comfort correlates with the psychological comfort of the occupants. Architecture can support a sense of comfort for its residents. If it is physically fulfilled, then more or less it will also have a positive impact on the psychology of its inhabitants. Comfort and safety for the elderly is a condition where it is easy to do activities independently and avoid the risk of minor accidents that may occur.

Conclusion

The findings from this study can identify efforts to improve the safety culture of the elderly in nursing homes. Safety culture plays an important role in improving the quality of care. Safety culture becomes a space for discussion about adverse events and strategies to prevent them from happening again. Efforts that can be made to improve the culture of safety in the orphanage include providing new staff orientation, and training, improving infrastructure, and procuring security staff. Furthermore, the government and institutions need to encourage steps to improve the safety culture in institutions. As well as policies related to improving safety culture need to be carried out thoroughly by the government.