Accepted: 11 December 2017 DOI: 10.1111/jonm.12615
ORIGINAL ARTICLE
Interpersonal relationships and safety culture in Brazilian health care organisations Eliana R. Migowski BNurs, PhD Candidate (Student), Assistant Professor1 | Nery Oliveira Júnior BNurs, MNurs, Assistant Professor1 | Fernando Riegel BNurs, PhD Candidate (Student), Assistant Professor1 | Sérgio A. Migowski Doctor of Business Administration, Associate Professor2 1 Department of Health School, Faculdade de Desenvolvimento do Rio Grande do Sul (FADERGS), Porto Alegre, Rio Grande do Sul, Brazil 2
Instituto Federal do Rio Grande do Sul (IFRS), Canoas, Rio Grande do Sul, Brazil Correspondence Sérgio Almeida Migowski, Instituto Federal do Rio Grande do Sul (IFRS), Novo Hamburgo, RS, Brazil. Email:
[email protected] Funding information This article was reviewed as part of our work in the affiliated institutions and is not financed by any other form of external funding
Aim: To examine the association between interpersonal relationships, nursing leadership and patient safety culture and the impact on the efficiency of hospitals. Background: Hospitals are still affected by the increased complexity of the treatments offered and by the diverse knowledge of professionals involved, which has made this assistance model ineffective, expensive and unsustainable over time. Method: A qualitative study of 32 professionals from three large hospitals in Southern Brazil was made. Semi-structured interviews, document analysis and analysis of electronic records were used. Results: All the hospitals had infection rates and an average stay higher than their goal. Lack of interpersonal relationships and physicians failing to commit to organisational objectives were demonstrated. Conclusion: Nursing leadership styles are not definitive factors to improving patient safety and efficiency. The flaws in consolidating interpersonal relationships seem to be related to difficulties in consolidating patient safety culture, which prevented hospitals reaching their efficiency indicators. Implications for Nursing Management: Professionals who work at the patients’ bedside should be involved in the development of strategies, in order to commit them to the organisational objectives. The consolidation of interpersonal relationships of nursing professionals can lead to improvements with medical professionals, with positive impacts on patient safety and efficiency. KEYWORDS
efficiency, interpersonal relationships, nursing leadership, patient safety
1 | INTRODUCTION
identified (Abdi, Delgoshaei, Ravaghi, Abbasi, & Heyrani, 2015; Rafter et al., 2015). Bae et al. (2017) argued for mutual support between
Some studies suggest that some leadership styles in nursing can
nursing professionals as a way to improve quality and patient safety.
lead to a greater involvement of other professionals (Bishop, 2013;
Weng, Huang, Chen, and Chang (2015) suggested that transforma-
Kaiser, 2017), which may result in improved communication, more
tional leadership is important in creating innovative behaviour and in
notifications of errors and, consequently, learning from the mistakes
establishing a transformational culture. Regan, Laschinger, and Wong
J Nurs Manag. 2018;1–7.
wileyonlinelibrary.com/journal/jonm © 2018 John Wiley & Sons Ltd | 1
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(2016) reported that structural empowerment, authentic leadership
Communication is defined as a shared understanding process, which
and a professional nursing practice environment may enhance inter-
establishes and keeps the relationship between the parts when it emerges
professional collaboration that impacts on patient safety issues.
(Manojlovich, Squires, Davies, & Graham, 2015). It plays such an essential
On the other hand, leadership is part of an assistance model affected
role in hospital organisations that it accounts for the main cause of human
by the increased complexity of the treatments offered and the extremely
errors in surgical centres along with teamwork (Tibbs & Moss, 2014),
diverse knowledge of professionals, which leads to fragmentation of ser-
70% of the damage caused to patients during hospitalization (Leonard,
vices. Such fragmentation is due to each sector or professional being
Graham, & Bonacum, 2004), and the satisfaction and commitment of the
responsible for one of the activities in the hospital process (Drupsteen,
nursing team (Galletta, Portoghese, Coppola, Finco, & Campagna, 2014).
van der Vaart, & Van Donk, 2016), making it an ineffective, expensive
In turn, leadership is regarded as the ability to inspire individual and
and unsustainable assistance model over time (Smith et al., 2013).
organisational excellence, thus creating a shared view for the achieve-
These losses may be related to the behavioural standards set in
ment of organisational objectives (Cliff, 2012). Some studies associate the
the interpersonal relationships affected by variables such as com-
existence of a reliable leadership that supports the team with a smaller
petitiveness among colleagues; lack of honesty in relationships;
number of patient falls, pressure ulcers and associated infections (Vogus
abuse of power of formal leaders; and miscommunication that can
& Sutcliffe, 2007). It is because of the division of responsibilities within a
lead to errors and the professionals who are part of it being unin-
team that the commitment is enhanced and trust between members is
terested (Maggioni, Amaral, Santos, & Carvalho, 2015). In order to
improved (Huesch, 2013).
avoid these variables, the constructs of communication, leadership
The concept of trust in hospital organisations involves delegation that
and mutual trust must be developed (Vincent, 2009) to create con-
is effective and increases job satisfaction, productivity and cooperation
ditions so that professionals provide a higher quality service when-
among team members (Yoon, Kim, & Shin, 2016). Trust is closely linked
ever they are interacting with patients (Dobrzykowski, McFadden, &
to patient safety, because this is how the professionals are encouraged
Vonderembse, 2016). In fact, Kaynak and Hartley (2008) confirmed
to notify their own mistakes, allowing an identification of the causes, so
a strong relationship between employee relations and improving
reducing adverse events with patients and costs (Haw, Stubbs, & Dickens,
quality management through training and customer focus.
2014).
Besides, as quality management and efficiency are mutually de-
Based on the studies submitted, the patient safety culture seems
pendent on each other (Orvik, Vågen, Axelsson, & Axelsson, 2015),
to be supported by the interpersonal relationships through leadership,
quality management incorporated into the patient safety culture en-
communication and trust. Efficiency improvements, as proposed in the
hances the involvement of all professionals in order to prevent med-
theoretical framework (Figure 1), derive from this relationship.
ical errors and other adverse events with patients (Morello et al.,
With interpersonal relationships being encouraged by the top man-
2013), which may cause infections and higher average stay rates
agement and by other formal leaders, safety culture can be implemented
(McFadden, Lee, Gowen, & Sharp, 2014). The patient safety culture
because all those who understand the importance of their work commit
can be defined as a set of behavioural patterns of individuals and
to it (Morello et al., 2013). In order for all to be committed to it, the pro-
groups who, based on their values and attitudes, determine their
fessionals who effectively make daily decisions and operationalize care
work (Morello et al., 2013). According to Sammer, Lykens, Singh,
must be integrated into building and improving the processes (Yee et al.,
Mains, and Lackan (2010), it is a complex phenomenon, difficult to
2015).
operationalize by hospital managers. Thus, improvements in lead-
Moreover, as mistakes start to be notified, it is possible to adopt
ership styles seem not to be enough for nursing staff. This study
corrective actions in time to reverse any damage caused to the patient
aimed to examine the association between interpersonal relation-
(Haw et al., 2014). When the interpersonal relationship is perceived by
ships, nursing leadership and patient safety culture and the impact
all, physicians will feel encouraged to contribute, as they will understand
on the efficiency of hospital organisations.
that the other professionals will stop acting reactively, while adopting a proactive position. Otherwise, physicians will contribute only when it is of interest to them (Rafter et al., 2015). As a main result of the inter-
2 | BACKGRO UND AND THEORETICAL FRAMEWORK
personal relationships between all nursing professionals and physicians, efficiency gains are becoming a challenge for all, and not just isolated or disconnected actions (Haw et al., 2014). The maturity of these constructs occurs when a leader accepts having efficiency losses in their own sector
The conditions for patient safety culture include developing a lead-
for the benefit of others, whose superior gains will bring benefits to the
ership style both in top and in intermediate management (Oakland,
organisation as a whole (Yee et al., 2015).
2011). The quality of interaction between leaders and operational professionals has a positive relationship with the commitment of these professionals (Yee, Guo, & Yeung, 2015). Through an effective
3 | METHODOLOGY
communication, those being led are able to understand how important it is to perform each task requested and to perform it in the best way
The research method consisted of a multiple case study. The quali-
possible (Bisel, Messersmith, & Kelley, 2012).
tative research enables the researchers to go beyond their initial
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MIGOWSKI et al.
Interpersonal Relationships Trust Systemic Leadership
Patient Safety Culture
Efficiency
Communication
F I G U R E 1 Theoretical framework – relationship among the central concepts
concepts and to review their theoretical frameworks, as it is con-
Moreover, some processes were selected for this comparison. Given
ducted through an intense and/or prolonged contact with the object
the complexity and volume of existing processes in both units, we ana-
(Miles & Huberman, 1994).
lysed processes involving integration between assistance professionals, of sanitization, and processes related to three situations: hygiene of the
3.1 | Population and sample
bed during and after the hospitalization; medical discharge from the unit; and separation of clothes according to the degree of dirtiness.
Limitation of the number of interviews followed theoretical saturation cri-
Therefore, a triangulation through semi- structured interviews,
terion. Creswell (2010) suggested using 20–30 interviews. In this study,
document analysis and analysis of electronic records was made (Yin,
32 interviews in three large hospitals in Southern Brazil were carried out.
2010). The three data sources were compared in order to find conver-
Despite theoretical saturation being obtained at interview 30, two final
gences and divergences and to establish the influence of interpersonal
interviews were maintained. However, new data were not added.
relationships on efficiency rates (average stay rate; separation of the
The questions developed were validated by two researchers be-
clothes according to the degree of dirtiness; sanitization of hospital
fore being used in the interviews. They were carried out along with
beds); and quality rates (incidence of primary bloodstream infection
professionals from each of the three selected hospital organisations, in
associated with the central venous catheter (CVC), reporting of errors
order to identify their perceptions of the relationship between the con-
and indicator of hand hygiene).
structs of interpersonal relationships, safety culture and its efficiency. The interviews were conducted between August and December 2016, lasting 30–40 min with the following employees: administrative man-
3.3 | Data treatment and analysis
ager; nursing manager; clinical director; intensivist physician; surgeon;
Cluster analysis techniques were used to group expressions found in
nurse leader of the adult ICU; nurse leader of the adult hospitaliza-
the reports of external and internal interviewees with a similar mean-
tion unit; infection control coordination; hospitality coordination; hy-
ing. NVivo software 11 was used for decoding. All interviews were
giene sector supervision; and supervision of the hospital bed centre.
read by two researchers making it possible to classify the answers in
Interviewees were named as AA, AB, …, BA, BB, (…) and CA, CB, (…),
one of the constructs. Two external researchers assisted in the discus-
according to the hospital to which the interviewees belonged. In order
sion on how data should be classified.
to respect their confidentiality, the second letter of the classification is related to interview order.
After they were inserted into one of the constructs, the selected parts were again read within the NVivo software to check if they were compatible with their meaning, which would mean that they had been
3.2 | Procedures and data collection
allocated correctly. Each construct (safety culture, interpersonal relationships, leadership, communication and trust) was analysed sep-
The units analysed in the three hospitals were an adult intensive
arately, based on the excerpts of the interviews that were related to
care unit (AICU) and an adult hospitalization unit (HU). Despite their
each of these concepts. After this, we presented the excerpts for each
similar size, the epidemiological profile of each hospital makes it
respondent to validate them (Miles & Huberman, 1994). At the end of
difficult to compare their economic results. Therefore, for safety
each case study, these concepts were analysed and compared with the
culture, analysis of the rate related to the incidence of primary
indicators obtained from document analysis, in order to show if there
bloodstream infection, associated with a central venous catheter
was consistency or discrepancy between the interviews and between
(CVC) and an indicator of hand hygiene were selected. As an ef-
these and the documented data.
ficiency indicator, the average stay rate was used. Only the rates regarding the AICUs were used because HUs had a high demand from clinical and surgical patients being hospitalized simultaneously. As
4 | RESULTS
they receive diverse assistance, there are significant differences in the average stay and consequently infections with CVC. Both fac-
Data were categorized into four constructs: interpersonal relation-
tors could create a different bias.
ships, communication, leadership and trust.
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In the interpersonal relationships, the following barriers were found: lack of informal interaction, excessive autonomy of the physician, difficulties in information sharing, organisational culture, formal and informal profile of leadership. These barriers are summarized in
these professionals, top management hinders a sense of belonging and the importance of the work the operational professionals do. In leadership, the barriers identified are the lack of participation of the informal leaders and low commitment from formal leaders:
various excerpts of the interviews. Some of them are presented below: ‘[…] we need them to buy the idea, and to support it, be‘The physician has no corporate relationship with the in-
cause if the leadership does not support anything, nothing
stitution […].’ (AI);
moves forward […]’ (CH);
‘[…] we stay in the field of creation and it does not get there, where it matters, which is at the patient’s bedside
Notably, in Hospital C, formal leaders do not create conditions for
[…].’ (CF);
the other members to be autonomous enough to make decisions about
‘[…] For them not to feel embarrassed, as they are techni-
the processes in which they are involved. Although passages from other
cians, we tried not to put the nurses together.’ (CH);
hospitals are not described here, the other categories indicate that the
‘[…] when you give autonomy to the decision-making pro-
same situation occurs in both of them. Formal leaders seem to act much
cess, it is destabilized. The profiles of the leader and the
more because they feel pressured to do so since they know they will be
one being led influence this.’ (CF).
asked, rather than because they feel motivated to cooperate. In trust, the barriers identified were the punitive treatment given
Interpersonal relationships seemed to be absent at all levels in Hospitals A and B. In fact, in all the hospitals, the physicians seem to be
as a result of mistakes and the difficulty in granting autonomy. They can be identified in some of the following sections:
part of all assistance processes, which includes the discharge plan that impacts on average stay, but in Hospitals A and B, formal leaders do not
‘[…] If the mistake was severe or has caused harm to the
create solutions together. In Hospital C, the interpersonal relationships
patient, then I need to be punished and so does the educa-
seem to be stronger at the formal leadership level by the use of two
tional process as well.’ (CB);
rounds per day. They make the common definition of the priorities and
‘[…] institutionally, there is no punishment, but then you sur-
checking what was planned. However, in all hospitals, the operational
reptitiously see the comments, people judging you […]’ (BA).
level, called by many interviewees as the ‘bedside’ professional, is excluded from creating the processes, so that much of what is planned is
In all hospitals, mistakes were used as sources of punishment, al-
not performed. Nursing technicians prefer to meet only with their peers
though, institutionally, this was not the intention of the managers of
because they are not comfortable giving their opinion in the presence
Hospital B. The result was a low notification index because of fearing the
of nurses and the nurses do not share knowledge that makes assistance
consequences for the professional involved.
better.
In the construct safety culture, the following barriers were iden-
In communication, the barriers identified are the profile of formal
tified: work overload, excessive autonomy of the physician, fragmen-
leaders, the distance between hierarchical levels, the organisational
tation of assistance, turnover, lack of customization of services and
culture, the fragile sharing, and the development of leaders, as shown
lack of hand hygiene. In the following, there are some excerpts that
below:
exemplify the barriers found: ‘[…] some nurses are more resistant to passing it forward
‘[…] when your unit is over 90%, 95% occupied, you notice
[…].’ (CF);
a great fall in the care indicators.’ (AC);
‘[…] the employee feels a certain detachment from the
‘[…] the physicians are not part of a process of healing this
board directors […].’ (BA);
patient, they put themselves aside and start making the
‘[…] when the board members walk in, they don’t greet the
entire process. […]’ (BA);
employees. It makes us look transparent […].’ (AA);
‘[…] it is a very high turnover level. Around 7%, but our goal
‘[…] other nursing technicians accept better when it comes
is 2.5%’ (CF);
from their peers […] because they think […] the nurse is not
‘[…] I don’t see people washing their hands as often as they
in their shoes.’ (CH);
should’ (CK).
‘[…] one day I found out that everybody was using this new syringe, and I had never heard of that.’ (BG);
The difficulties in achieving the safety culture and the commitment
‘[…] there is a cleaning system for the surgical room that is
of all professionals have different characteristics, including autonomy of
a communication through screaming […].’ (CK).
the physicians who are unaware of the processes developed by other professionals, because of the work overload or the lack of perception of
In all hospitals, four interviewers in Hospital A and another three in
the importance that the work itself has in the care process. As a result,
Hospitals B and C mentioned the distance between top management
simple processes such as hand hygiene end up not taking place, along
and operational professionals. Because they rarely pass by or meet with
with negative results in associated infection rates.
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MIGOWSKI et al.
In all hospitals, difficulties in consolidating interpersonal relationships have consequences for loss of efficiency, which is represented more strongly in the improper use of surgical rooms and in their hospital beds.
those of ANVISA, but higher than those of ANAHP (ANAHP, 2017; Brasil, 2015). Regarding the average length of stay in the AICUs, Hospital A had an annual average of 10 days compared with a goal of 6 days. Hospital
Time measurements for bed cleaning after the hospitalization
B had 11.2 days with a goal of 9 days, and Hospital C had 7.6 days
were not known and the discharge was more linked to the commit-
with a goal of 6 days. In the hospitalization units of Hospital C, the
ment of each professional than to well-defined processes. In Hospital
average length of stay ranged from 11 to 12 days, while in Hospital B,
A, the board of supervisors was expanded, as there was no trust in the
the average length was 6.8 days, and in the Hospital, it was 6.3 days.
operational professionals of this sector, which only raised costs with-
In safety culture, the losses of all hospitals are shown by the diffi-
out creating a continuous improvement in efficiency. Moreover, none
culty in making the professionals adhere to hand hygiene, by the under-
of the hospitals separated clothes according to the degree of dirtiness.
reporting of errors, and by the infection rate always being higher than
Several professionals from all hospitals mentioned being un-
the goal they established. Regarding efficiency, losses are reflected
aware of innovations in the processes implemented in other sectors
in the high average stay rate, poor utilization of rooms in the surgical
that ended up generating efficiency gains. Process improvements are
block, lack of separation of clothes according to the degree of dirtiness,
treated as a secret of a particular sector and competition for results
inability to manage the time needed for hygiene and bed release, lack of
takes place. In addition to not being involved in improving and devel-
discharge planning, and the need to create jobs to supervise the work
oping processes, they fear making a mistake and consequently being
performed by sanitizers in the three hospitals. Table 1 summarizes the
punished.
obstacles found in the interviews carried out in the three hospitals:
The infection indicator of CVC in the ICU of Hospital A, was 4.02 infections per 1000 CVC/day, while its goal in 2016 was 3.5. In Hospital B, the rate was 4.76 infections per 1000 CVC/day, against the goal of 3.74. In Hospital A, the rate was 3.8 infections per 1000
5 | DISCUSSION AND IMPLIC ATIONS FOR NURSING MANAGEMENT
CVC/day for a goal of 2.2. All three hospitals had rates lower than Given the reports, it is seen that interpersonal relationships take place only formally in the three hospitals, which does not corroborate the T A B L E 1 Constructs and barriers Category Interpersonal Relationship – Barriers Organisational culture Physician autonomy
theoretical framework proposed here, although it is not invalidated. The existing failures in communication, leadership and trust evidenced in the three hospitals are the possible causes to not consolidate the inter-professional relationships that reflects on their capacity to provide a service with a higher quality (Kaynak & Hartley, 2008) represented here by higher infection and average stay rates. Several sectors of all hospitals seem to work as hermetic silos that
Work overload
become barriers to building trust and interaction (Haw et al., 2014), mak-
Turnover
ing each individual seek only what is good for the sector in which they
Formal leadership style
are working. The main obstacle to building interpersonal relationships
Patient Safety Culture– Barriers
seems to be derived from the profile of some formal leaders who do not
Work overload
understand the importance of a systemic view. It means that all actions
Physician autonomy
developed in one sector should be also examined based on the influence
Turnover
caused in other sectors before being implemented (Yee et al., 2015).
Professional training Support from the High Management Leadership – Barriers Participation of the informal leaderships Lack of autonomy Profile of the formal leaderships Communication – Barriers
As communication is poor and the professionals who work at the patients’ bedside do not participate in the planning process, they may not understand how important it is to perform the task requested as well as to perform it in the best way possible (Bisel et al., 2012). The environment found in all hospitals does not seem to be that of cooperation or trust (Yoon et al., 2016). This context is reflected in the way the mistakes are handled, especially in Hospitals A and C. The reports show that they are handled both as a learning source and as a
Organisational culture
punishment and that is an institutional practice (Haw et al., 2014). In
Work overload
Hospital B, despite institutional encouragement to handle the mistake
Trust – Barriers Handling the mistake Lack of autonomy Source: Created by the authors.
as a learning source, mistakes are punished by the employees’ peers (Vogus & Sutcliffe, 2007). At the same time, as formal leaders do not cooperate with each other probably because of competitiveness among colleagues, or
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MIGOWSKI et al.
6
simply because they are uninterested (Maggioni et al., 2015), it is not
58900916.4.1001.5335; and by Hospital C, protocol no.
surprising that nursing technicians prefer separated meetings and
59471316.4.3002.5328.
have low adherence to hand hygiene or error reporting (Yoon et al., 2016). This suggests a distance between two professional categories that should work in an integrated way, which makes it difficult to improve routines that could mitigate the mistakes made (Vogus & Sutcliffe, 2007).
O RC I D Sérgio A. Migowski
http://orcid.org/0000-0002-8328-5368
This lack of inter-professional relationship between nursing staff reflects in losses for the patient safety culture (Morello et al., 2013) and it is evidenced by the infection rates and average stay that are always higher than the goal they have established, for which no one seems to be responsible. If interpersonal relationships do not occur even among the nursing staff, it can be expected that it will not happen between the physicians and nursing staff either. It is not by chance that, only in AICUs, the discharge planning occurs as there is a contractual relationship between the physicians and the hospital (Rafter et al., 2015). The physician’s autonomy, a barrier to the interpersonal relationships, is also related to the quality of the relationships among these physicians and the nursing staff, which reflects in a higher average stay rate as well as in poor utilization of surgical rooms. Physician’s autonomy seems to be related to the commitment and intention of the nursing professionals to leave the organisation. Some reports reveal a high turnover in the three hospitals and that physicians put themselves apart from the care processes or use communication by screaming in surgical rooms (Rafter et al., 2015).
6 | CONCLUSION Flaws in consolidating interpersonal relationships, trust, leadership and communication seem to be related to the difficulties in carrying out the patient safety culture, which has prevented all hospitals reaching the efficiency indicators. As several professionals could not be involved in simple actions, such as hand hygiene, the risk of associated infections is increased, which implies a failing of patient safety, leading to an increased average length of stay. These considerations suggest that changing only the profile of formal leaders does not guarantee a successful implementation of the patient safety culture. Regarding the limitations of this study and the lack of economic data that could not be accessed to assist in the comparison of the efficiency of the three hospital organisations, a replication of this study in other national and international units would be interesting.
ACKNOWLE DG E MEN TS Thanks to Dr Cláudia de Souza Libânio and Dr Iuri Gavronski for making substantial contributions to the research revision.
ET HI CAL APPROVAL The study was authorized by Hospital A, protocol no. 59471316.4.3001.5305;
by
Hospital
B,
protocol
no.
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How to cite this article: Migowski ER, Oliveira Júnior N, Riegel F, Migowski SA. Interpersonal relationships and safety culture in Brazilian health care organisations. J Nurs Manag. 2018;00:1–7. https://doi.org/10.1111/jonm.12615
