Antecedents and Consequences of Patient Safety Culture: Investigations in a Dynamic Clinical Setting

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Schleimer, Stephanie

Powell, Michael

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Rice, John

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Patient safety culture is one of the most intriguing and researched new phenomena to emerge in the health literature in the last two decades. One in ten patients will experience an adverse event during their hospital stay (Australian Commission on Safety and Quality in Health Care, 2014). Improving patient safety culture is seen as one way of enhancing patient safety outcomes in health services. Despite the enormous interest in this area, there remains much that is unknown. The literature is voluminous and diverse, and the term “culture” is often used to explain lapses in health care outcomes. Numerous enquiries into health system failings have unequivocally attributed causation to issues of patient safety culture. While recommendations have been made to improve safety culture there is little evidence on how this can be achieved. This thesis investigates patient safety culture by looking at the antecedents that contribute to this phenomena and consequent outcomes. Key points of differentiation from existing work in this area are that the method employs an interprofessional approach and a post positivist philosophy. This research occurs over a period that includes the relocation of a major tertiary hospital. A longitudinal case study contains data collected from a staff survey in 2013, with a follow up in 2015. The context of studying patient safety culture longitudinally and encapsulating a major hospital move is unique to this PhD. Additionally, a patient perspective is provided using qualitative and quantitative methodology. Triangulation of findings from a comprehensive review of the literature, and three data collections makes some new discoveries not previously reported. These findings are presented in one literature review, three empirical papers and one mixed method report. A summary of each chapter is provided below. Chapter 1, the Introduction, includes high level information regarding the Australian health care system, describes the research setting and lays out the research aims and an overview of the chapters. In Chapter 2, the philosophy and methodology used is described. Theoretical models are presented and a philosophical research paradigm discussed. The overall methods are outlined and a summary of each paper is provided. Chapter 3, paper 1 is a comprehensive review of the literature including a bibliometric analysis and a synthesis of findings. This chapter demonstrates what is known and what isn’t known on patient safety culture, and refines the research questions to be considered in this thesis. Chapter 4 includes paper 2, an empirical paper that explores workforce relationships finding a significant interaction between employee engagement, interprofessional collaboration and patient safety culture. Chapter 5 includes two papers (papers 3 and 4) providing different perspectives of changing the work environment and using different paradigms. Paper 3 is an empirical paper from the staff perspective and paper 4 is a report of the patient’s experience derived from a patient survey and interviews. The impact of moving hospitals on patient safety culture is explored. Differences in the patient safety perceptions of clinical and non-clinical staff are compared and considered. Chapter 6, paper 5 explores the theme of developing workforce capacity and tests the moderating effect of reflexivity on patient safety culture and quality patient care. The goal here is to gain a better understanding of patient safety culture and inform the development of strategies aimed at improving quality of patient care. Finally, Chapter 7 brings all the findings together with a discussion and conclusions. Particular emphasis is given to the implications for practice and the unique contribution that this thesis makes to understanding the research endeavour.

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Thesis (PhD Doctorate)

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Doctor of Philosophy (PhD)


Dept Intnl Bus&Asian Studies

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Patient safety culture

Dynamic clinical setting

Interprofessional approach

Post positivist philosophy

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