Original Article

Patient Safety Culture in Two FinnishState-Run Forensic Psychiatric Hospitals

AuthorUniversiClinical3ResearHelsinki5DepartKuopio,The studFinancinHealth afrom theThe authReceive

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DOI: 10

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Anssi Kuosmanen, RN, MSc1,5, Jari Tiihonen, MD, PhD1,2,3, Eila Repo-Tiihonen, MD, PhD1,Markku Eronen, MD, PhD4, and Hannele Turunen, PhD, RN5,6

ABSTRACTSafety culture refers to the way patient safety is regarded and implemented within an organization and the struc-tures and procedures in place to support this. The aim of this study was to evaluate patient safety culture, identifyareas for improvement, and establish a baseline for improving state hospitals in Finland. Cross-sectional designdata were collected from two state-run forensic hospitals in Finland using an anonymous, Web-based survey tar-geted to hospital staff based on the Hospital Survey on Patient Safety Culture questionnaire. The response ratewas 43% (n = 283). The overall patient safety level was rated as excellent or very good by 58% of respondents.The highest positive grade was for “teamwork within units” (72%). The lowest rating was for “nonpunitive re-sponse to errors” (26% positive). Good opportunities for supplementary education had a statistically significant(p � 0.05) effect on 9 of 12 Hospital Survey on Patient Safety Culture dimensions. Statistically significant (p �0.05) differences in patient safety culture were also found in the staff’s educational background, manager status,and between the two hospitals. These findings suggest there are a number of patient safety problems related tocultural dimensions. Supplementary education was shown to be a highly significant factor in transforming patientsafety culture and should therefore be taken into account alongside sufficient resources.

KEY WORDS:forensic nursing; forensic psychiatry; patient safety; patient safety culture

Organizational culture is an essential factor for im-proving patient safety in healthcare facilities (De-partment of Health, 2000; Hoffman & Mark,

2006; Kohn, Corrigan, & Donaldson, 2000; Neal &Griffin, 2006; Provonost et al., 2009; Scott, Mannion,Marshall, & Davies, 2003). The Institute of Medicine(2001) has recommended that healthcare organizations

Affiliations: 1Department of Forensic Psychiatry,ty of Eastern Finland, Kuopio, Finland; 2Department ofNeuroscience, Karolinska Institute, Stockholm, Sweden;ch Professor, National Institute of Health and Welfare,, Finland; 4Vanha Vaasa Hospital, Vaasa, Finland;ment of Nursing Science, University of Eastern Finland,Finland; 6Kuopio University Hospital, Kuopio, Finland.y was supported by funding from the Annual EVOg (special government subsidies from the Ministry ofnd Welfare, Finland). The researchers were independentfunder.ors have disclosed no conflict of interest.d July 9, 2012; accepted for publication November 19, 2012

ht © 2013 International Association of Forensic Nurses

.1097/JFN.0b013e318281068c

l of Forensic Nursing

Copyright © 2013 International Association of Forensic N

.

urse

view safety culture as a major leadership-driven organi-zational goal.

Many definitions of safety culture have been proposed(Glendon & McKenna, 1995; Hale, 2000; Provonostet al., 2009). In this study, we used the following defini-tion from the Health and Safety Commission (1993) wasadopted:

s. Un

The safety culture of an organization is the prod-uct of individual and group values, attitudes,perceptions, competencies, and patterns of be-haviour that determine the commitment to, andthe style and proficiency of, an organization’shealth and safetymanagement.Organizationswitha positive safety culture are characterized by com-munications founded on mutual trust, by sharedperceptions of the importance of safety and byconfidence in the efficacy of preventive measures(p. 23).

The purpose of this article is to report the findingsfrom a study that assessed the patient safety culture intwo forensic psychiatry hospitals located in Finland. The

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Original Article

ultimate objectives of the studywere to evaluate safety cul-ture and professional identity deficiencies of the staff sur-veyed as well as to establish a baseline for assessing futureimprovements.

A positive patient safety culture encourages healthcareprofessionals to make patient safety one of their highestpriorities (Sorra & Nieva, 2004). Forensic psychiatry ser-vices are safety-oriented, where the safety culture concernsall involved. However, to date, no evaluation of forensicpsychiatry patient safety culture has been reported. Thereare few studies that have focused on medication errors inpsychiatric care (Grasso et al., 2007; Shore, 2003), whereasmost previous studies of patient safety culture have beenconducted in somatic care.

In this study, we used the Hospital Survey on PatientSafety Culture (HSOPSC) questionnaire to measure safetyculture. The HSOPSC was developed from literature re-views, examination of existing published and unpublishedsafety culture instruments, and psychometric analyses (Sorra& Nieva, 2004).

Forensic Psychiatry in FinlandThere are two state-run mental hospitals in Finland (hence-forth referred to asHospitals 1 and 2),which are responsiblefor providing high-quality, specialized forensic psychiatricservices and mental examinations for the whole country,in addition to personnel training and development. Finnishstate-run mental hospitals are safety-oriented in accor-dance with the first Finnish Patient Safety Strategy (Minis-try of Social Affairs and Health, 2009) and the FinnishHealth Care Act (2010), which aim to improve the qualityof care and patient safety.

The two hospitals that were studied can accommo-date a total of 448 patients, who are all under involuntarycare, usually for several years. Over 90% of these patientshave schizophrenia (Niuvanniemi Hospital, 2010; VanhaVaasa, 2011) and have either been found not guilty byreason of insanity or are considered too dangerous or dif-ficult to treat in other (municipal) hospitals. In 2010, over750 threatening/violent events were reported in the twohospitals, and over 40% of patients were subjects of suchviolence (Niuvanniemi Hospital, 2010; Vanha Vaasa, 2011).Thus, patients’ violent behavior, lack of criminal responsi-bility, and involuntary (i.e., forced) treatment require forthe patient safety culture to be considered as a critical com-ponent in forensic psychiatry.

MethodsInstrumentThe primary instrument used in this study was theHSOPSC, which has been established as a valid and reli-able test of patient safety culture in hospitals (Sorra &Nieva, 2004). The instrument measures group values as

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well as individual attitudes of culture (Smits, Christiaans-Dingelhoff, Wagner, Wal, & Groenewegen, 2008).

Although the HSOPSC has been used within otherEuropean countries (Olsen, 2008; Pfeiffer & Manser, 2010;Smits et al., 2008), this is the first application of theHSOPSC in Finnish forensic psychiatric hospitals. A vali-dated translation of theHSOPSC fromEnglish into Finnishhas been reported (Turunen, Partanen, Kvist, Miettinen, &Vehviläinen-Julkunen, 2013). The resulting HSOPSC in-cluded background variables and 42 Likert-type items(scale: 1 = strongly disagree/never, 2 = disagree/rarely, 3 =neither/sometimes, 4 = agree/most of the time, 5 = stronglyagree/always).

Study Setting and Data CollectionThe survey was targeted to social and healthcare staff, in-cluding medical doctors (MDs), registered nurses (RNs),practical mental nurses (PMNs), pharmacy and laboratorystaff, social workers, psychologists, occupational therapists,and directors of MDs and nursing. For statistical reasons,staff categories were grouped according to backgroundeducation (see Table 1).

Hospital 1 is located in eastern Finland and has 13wards for adults and 1 ward for adolescents, which canaccommodate a total of 296 patients. In contrast, Hospital2 has facilities for 152 patients in eight wards and is locatedin western Finland. Both hospitals perform the same pro-fessional functions and treat similar patient groups (withthe exception of the adolescent ward). The Finnish qualifi-cation education of RNs takes place at universities of ap-plied sciences and lasts for 3.5 years. PMNs undergoqualification training for 3 years at a vocational college.The vocational qualification gives general eligibility forapplied sciences or university studies. TheNational Super-visory Authority for Welfare and Health grants RNs a li-cense to practice their profession, whereas PMNs arepermitted to use their protected occupational title. PMNsare not allowed to be recruited in an RN’s occupationalposition. RNs are responsible for implementing and devel-oping theoretical and practical nursing processes. Pharma-cotherapy belongs primarily to the activities of theRNs. Thework of PMNs includes psychiatric, aswell as primary nurseactivities, and also social and somatic basic care (Tenkanen,Tiihonen, Repo-Tiihonen, & Kinnunen, 2011). In Finland,there is no longer specialization in RN studies.

The data covered two forensic hospitals in Finlandduring a 1-month period in April 2010. Data were col-lected in a cross-sectional design by an anonymous, Web-based questionnaire (see Table 2). Participation in the surveywas voluntary. The response rate in Hospital 1 was 44%compared with 40% in Hospital 2. Further details of thedemographic characteristics and total numbers of poten-tial respondents are shown in Table 1.

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TABLE 1. Demographic Characteristics of Respondents

Overall (100%) Hospital 1 (70.3%) Hospital 2 (29.7%)

n % n % n %

Gender

Female 144 50.9 99 49.7 45 53.6

Male 139 49.1 100 50.3 39 46.4

Basic education*

Medical doctors 18 (39) 6.4 10 (25) 5.1 8 (14) 9.5

Registered nurses 114 (215) 40.4 68 (127) 34.3 46 (88) 54.8

Practical mental nurses 118 (366) 41.8 95 (269) 48.0 23 (97) 27.4

Other 32 (43) 11.3 25 (31) 12.6 7 (12) 8.3

Years employed in the hospital

Less than 6 years 66 23.5 51 25.9 15 17.9

6–10 years 77 27.4 55 27.9 22 26.3

11–15 years 49 17.4 29 14.7 20 23.8

16 or more years 89 31.7 62 31.5 27 32.1

Interaction with patients

Yes 271 96.1 192 97 79 94

No 11 3.9 6 3 5 6

Manager status

Yes 29 10.2 18 9 11 13.1

No 254 89.8 181 91 73 86.9

Time worked in current unit**

Less than 6 years 212 74.9 162 82.2 50 59.5

6–10 years 37 13.2 22 11.2 15 17.9

11–15 years 19 6.8 4 2.0 15 17.9

16 or more years 13 4.6 9 4.6 4 4.8

Time worked in current specialty

Less than 6 years 58 20.5 43 21.7 15 17.9

6–10 years 61 21.6 40 20.2 21 25.0

11–15 years 59 20.8 41 20.7 18 21.4

16 or more years 104 36,7 74 37.4 39 35.7

Working hours per week

Less than 31 23 8.2 17 8.6 6 7.1

31–40 225 80.1 162 82.2 63 75.0

41 or more 33 11.7 18 9.0 15 17.9

Opportunities to supplement education

Very good/good 247 87.6 173 87.4 74 88.1

Very poor/poor 35 12.4 25 12.6 10 11.9

( ) = total potential respondents.*p = 0.002. **p = 0.000.

Original Article

We conducted one renewal questionnaire to increasethe total response rate. The total number of potentialrespondents was 663, and the overall response rate was43% (283 respondents). The research ethics committeeof the Hospital District of Northern Savo reviewed theethical issues and approved the study.

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Data AnalysisThe HSOPSC included 42 items covering 12 dimensions.We used Cronbach’s alpha scores to test the internal con-sistency and reliability of each of the 12 dimension com-posites. The Cronbach’s alpha scores varied from 0.81to 0.52 (see Table 2). “Teamwork within units” had the

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TABLE 2. Average Positive Response Rates for the HSOPSC Results of Hospital Data

Patient safety culture dimension (Cronbach’s alpha in parentheses) Average response (%) Mean

Positive Neutral Negative (SD)

Teamwork within units (0.81) 72 3.77 (0.72)

People support one another in this unit. 80 12 8

When a lot of work needs to be done quickly, we work together as a team to getthe work done.

70 19 11

In this unit, people treat each other with respect. 69 18 13

When one area in this unit gets really busy, others help out. 70 18 12

Supervisor/manager expectations and actions promoting patient safety (0.78) 68 3.78 (0.77)

My supervisor/manager says a good word when he/she sees a job doneaccording to established patient safety procedures.

59 21 20

My supervisor/manager seriously considers staff suggestions for improvingpatient safety.

74 15 11

Whenever pressure builds up, my supervisor/manager wants us to workfaster, even if it means taking shortcuts (R).

63 23 14

My supervisor/manager overlooks patient safety problems that happen overand over (R).

76 17 7

Organizational learning—continuous improvement (0.60) 50 3.36 (0.64)

We are actively doing things to improve patient safety. 74 20 6

Mistakes have led to positive changes here. 20 48 32

After we make changes to improve patient safety, we evaluate their effectiveness. 56 26 18

Management support for patient safety (0.79) 30 2.85 (0.91)

Hospital management provides a work climate that promotes patient safety. 32 28 40

The actions of hospital management show that patient safety is a top priority. 32 31 37

Hospital management seems interested in patient safety only after anadverse event happens (R).

27 28 45

Overall perceptions of patient safety (0.66) 43 3.23 (0.72)

Patient safety is never sacrificed to get more work done. 55 23 22

Our procedures and systems are good at preventing errors from happening. 27 53 20

It is just by chance that more serious mistakes dont happen around here (R). 47 28 25

We have patient safety problems in this unit (R). 43 21 35

Feedback and communication about errors (0.67) 50 3.32 (0.76)

We are given feedback about changes put into place based on event reports. 20 37 43

We are informed about errors that happen in this unit. 59 22 19

In this unit, we discuss ways to prevent errors from happening again. 72 20 8

Communication openness (0.52) 52 3.33 (0.74)

Staff will freely speak up if they see something that may negatively affectpatient care

76 20 4

Staff feel free to question the decisions or actions of those with more authority. 28 23 49

Staff are afraid to ask questions when something does not seem right (R). 53 25 22

Frequency of events reported (0.67) 62 3.79 (0.85)

When a mistake is made, but caught and corrected before affecting thepatient, how often is this reported?

63 19 18

When a mistake is made, but has no potential to harm the patient, how often isthis reported?

35 33 32

When a mistake is made that could harm the patient, but does not, how oftenis this reported?

88 8 4

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TABLE 2. ContinuedPatient safety culture dimension (Cronbach’s alpha in parentheses) Average response (%) Mean

Positive Neutral Negative (SD)

Teamwork across units (0.72) 59 3.58 (0.66)

There is good cooperation among hospital units that need to work together. 67 24 9

Hospital units work well together to provide the best care for patients. 51 36 13

Hospital units do not coordinate well with each other (R). 37 32 31

It is often unpleasant to work with staff from other hospital units (R). 82 13 5

Staffing (0.62) 44 3.22 (0.77)

We have enough staff to handle the workload. 32 16 52

Staff in this unit work longer hours than is best for patient care (R). 52 33 15

We use more agency/temporary staff than is best for patient care (R). 44 29 27

We work in crisis mode, trying to do too much, too quickly (R). 50 27 23

Handovers and transitions (0.71) 38 3.08 (0.73)

Things fall between the cracks when transferring patients from one unit toanother (R).

25 29 46

Important patient care information is often lost during shift changes (R). 59 25 16

Problems often occur in the exchange of information across hospital units (R). 22 30 48

Shift changes are problematic for patients in this hospital (R). 48 31 21

Nonpunitive response to errors (0.72) 26 2.76 (0.87)

Staff feel like their mistakes are held against them (R). 20 29 51

When an event is reported, it feels like the person is being written up, not theproblem (R).

32 33 35

Staff worry that mistakes they make are kept in their personnel file (R). 25 35 40

(R) = negatively worded item, reverse-coded.

Original Article

highest alpha values, whereas “communication openness”had the lowest alpha values.

There were five possible responses to each item, scored1–5 asmentioned above. The percentages of positive (scoresof 4–5) and negative (scores of 1–2) responses for eachitem are presented in Table 2. We also examined neutralresponses (scores of 3), as these might also imply lack ofsafety culture (Alahmadi, 2010). If the responses were un-certain, that is, neutral responses, this could signal that theresponse does not support a good patient safety culture.We defined areas of strength as items where more than75% of respondents answered positively and areas need-ing improvement where 50%or fewer did not answer pos-itively (Sorra&Nieva, 2004). We also calculated the meanand standard deviation (SD) for every dimension by aver-aging over the subitems, where a higher mean score indi-cated a more positive response for that dimension.

We applied the t test and ANOVA to compare com-posite scores across different hospitals, staff positions, andlevels of opportunity for supplementary education and basiceducational factors for all 12 safety culture dimensions.Post hoc (Bonferroni) tests on the basic educational

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variable were used when the ANOVA showed significantdifferences. The Mann–Whitney U and Kruskal–Wallistests were used for composites (i.e., “feedback and commu-nication about errors” and “frequency of events reported”)that did not follow a normal distribution. Statistical differ-ences between hospitals and demographic backgroundvariables were evaluated with the chi-square test. Dataanalyses were performed using SPSS 17.0 for Windows,assuming p < 0.05 indicated statistical significance.

ResultsSampleDemographic characteristics of the respondents are shownin Table 1. In total, 283 hospital staff members completedthe survey, of which slightly more were women (51%) thanmen (49%). Most respondents were PMNs (41.8%) orRNs (40.4%). Many respondents (31.7%) had workedin their current hospital for over 16 years, and slightlymore (36.7%) had worked in their current special fieldfor over 16 years. Respondents reported having good op-portunities to supplement their education (87.6%), and

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Original Article

almost all (96.1%) reported that they had direct interac-tion with patients.

Cross-tables were generated to evaluate respondents’differences between the two hospitals. Statistical differ-ences (p< 0.05) were found for two variables (see Table 1):There were more nurses with a higher basic educationallevel (RN) in Hospital 2 (54.8%) than in Hospital 1(34.3%), and more respondents in Hospital 1 (82.2%)had worked in their current unit for less than 6 years thanin Hospital 2 (59.5%).

▪

Patient Safety CultureOverall patient safety was rated positively (excellent orvery good) by 58%, acceptable by 39%, and poor or failingby 3% of respondents.

Positive responses to patient safety dimensions rangedfrom 26% to 72% (see Table 2). Perceptions were mostpositive for “teamwork within units” (72%), “supervisor/manager expectations and actions promoting patient safety”(68%), and “frequency of events reported” (62%). Thelowest positive responses were for “nonpunitive responseto errors” (26%), “management support for patient safety”(30%), and“handovers and transitions” (38%; see Table 2).

Areas of Strength or Needing ImprovementPositive responses to individual items ranged from 20% to88% (see Table 2). Areas of strength included reporting“a mistake made that could harm the patient, but did not”(88%), “it is often unpleasant to work with staff fromother hospital units” (82%; reverse-coded), “people sup-port one another in this unit” (80%), “my supervisor/manager overlooks patient safety problems that happenover and over” (76%; reverse-coded), “staff will freelyspeak up if they see something that may negatively affectpatient care” (76%). All items within the “managementsupport for patient safety,” “staffing,” and “nonpunitiveresponse to errors” dimensions were identified as areas re-quiring improvement in addition to several other items(see Table 2), that is, procedures and systems for prevent-ing errors (27% positive, 53% neutral), feedback aboutchanges based on event reports (20% positive, 43% nega-tive), mistakes leading to positive changes (20% positive,48% neutral), sense of freedom to question the decisionsor actions of those with more authority (28%), and ex-change of information across hospitals units (22%).Over-all, there were more positive than negative responses toindividual survey items, and the overall mean was >3.00(see Table 2).

Further analyseswere conducted using the t test,Mann–Whitney U test, and ANOVA. The highest mean safetyscores were observed for a positive manager status. Statis-tical analyses also indicated that several dimensions con-tributed to opportunities for supplementary education.

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At the hospital level, statistical differences were found innine dimensions (see Table 3).

Comparison of scores for dimensions of safety culturerevealed statistically significant lower results for nurses(RNs and PMNs) than for MDs and other staff in “man-agement support,” “overall patient safety,” “teamworkacross units,” and “nonpunitive response to errors.”Nursegroups evaluated “handovers and transitions” more posi-tively than didMDs or other staff. Detailed results are pre-sented in Table 4.

DiscussionThis represents the first study of Finnish patient safety cul-ture in forensic psychiatry. Although HSOPSC was devel-oped for hospitals in general (Sorra & Nieva, 2004), theresults suggest that it can also be applied to forensic psy-chiatry hospitals.

The dimensions with the highest positive ratings re-vealed that the two hospitals have good teamwork skillswithin and across units, with managers actively promotingpatient safety. This is notable because previous studies havefound that poor teamwork is a common contributing fac-tor to adverse events (Manser, 2009; Woodward et al.,2010) and the working atmosphere has a large effect onhandover quality (Manser et al., 2010). Moreover, at thehospital level, differences in teamworkmay also be causedby hospital size. Hospital 1 has over 100 beds and 150staff more than Hospital 2, and this could directly affectthe sense of teamwork.

Only 30%of respondents gave positive scores forman-agement support for patient safety. However, it has beenshown that strong management and leadership strengthenthe safety culture in healthcare facilities (Perry, 2002). There-fore, it is important to emphasize patient safety at a strategiclevel and implement activities that support improvementof patient safety culture in patient care.

Our results show that 53% gave neutral responses tothe dimension of “our procedures and systems are good atpreventing errors from happening.” These results may in-dicate problems with the patient safety reporting systemand feedback on errors that are being worked on. Never-theless, our study shows that respondents discuss ways toprevent errors and have supporting supervision, and theseare related toworkplace safety (cf. Parker, Axtell,&Turner,2001).

In this study, lower scores were received for the dimen-sion of “nonpunitive response to errors.” According toprevious findings, the orientation of forensic psychiatricnursing in Finland still is largely custodial rather than ther-apeutic (Tenkanen et al., 2011), and inpatients are sub-jected to a high level of containment measures (Bowerset al., 2007), probably in favor of staff occupational safety.This, together with deep-rooted treatment traditions and

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TABLE3.ComparisonofMeansforCompositeScoresAcrossManagerStatus,Supplementary

Education,andHospitalLevel

Manager

status

Opportunities

for

supplementary

education

Hospital

Yes

(SD)

No(SD)

pYes

(SD)

No(SD)

p1(SD)

2(SD)

p

Tea

mworkwith

inun

its4.00(0.50)

3.74(0.74)

NS

3.82(0.69)3.38(0.84)0.001

3.68(0.77)

3.98(0.54)0.000

Supervisor/managerexpectations

andactions

prom

otingpatientsafety

3.96(0.75)

3.76(0.77)

NS

3.82(0.72)3.45(0.99)0.039

3.72(0.77)

3.90(0.75)

NS

Organ

izationa

llea

rningcontinuo

usimprovem

ent

3.67(0.50)

3.32(0.65)

0.006

3.42(0.60)2.88(0.73)0.000

3.34(0.67)

3.40(0.57)

NS

Man

agem

entsupp

ortforpa

tient

safety

3.37(1.06)

2.8

(0.88)

0.002

2.95(0.88)2.16(0.79)0.000

2.76(0.94)

3.06(0.79)0.007

Overallperceptions

ofpatient

safety

3.38(0.92)

3.21(0.70)

NS

3.29(0.77)2.79(0.66)0.000

3.22(0.77)

3.25(0.61)

NS

Fee

dbackandcommun

icationab

outerror

3.52(0.84)

3.29(0.75)

NSa

3.38(0.72)2.84(0.91)0.001a

3.42(0.75)

3.25(0.61)0.000a

Com

mun

icationop

enne

ss3.59(0.77)

3.31(0.74)

NS

3.40(0.73)2.85(0.64)0.000

3.27(0.75)

3.49(0.70)0.029

Frequ

ency

ofeven

tsrepo

rted

3.94(0.65)

3.77(0.87)

NSa

3.87(0.85)3.86(0.89)

NSa

3.96(0.79)

3.37(0.88)0.000a

Tea

mworkacross

units

3.87(0.58)

3.55(0.66)

0.019

3.62(0.65)3.29(0.66)0.006

3.68(0.77)

3.98(0.54)0.005

Staffing

3.61(0.95)

3.17(0.73)

0.003

3.25(0.77)2.98(0.72)

NS

3.32(0.738)2.97(0.79)0.000

Han

dovers

andtran

sitio

ns3.05(0.90)

3.08(0.71)

NS

3.10(0.74)2.94(0.66)

NS

2.99(0.71)

3.28(0.73)0.003

Non

punitiverespon

seto

errors

3.17(0.93)

2.71(0.85)

0.007

2.82(0.85)2.29(0.92)0.000

2.52(0.85)

3.33(0.62)0.000

Dataaremea

ns.S

Dsarein

parenthe

ses.NS=no

tsignifican

t.aMan

n–Whitney

Utest.

Original Article

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attitudes, can have a negative effect on patient safety, con-travening rules and regulations or patients’ rights, for ex-ample, when coercive measures are used, which are oftenunder-reported (Keski-Valkama, 2010) and may reflecton whole organization culture. Therefore, it is importantto recognize the current organization culture when operat-ing “behind closed doors,” like in forensic psychiatry.

Many of the respondents reported problems with theexchange of information across units and when transfer-ring patients from one unit to another. This is significantbecause patients are regularly transferred between unitsin forensic psychiatry, and therefore, effective interunitreporting is essential. It has been show that communica-tion problems, inadequate information transfer, and sharedunderstanding are major contributors to adverse events(Beyer, Rohe, & Nicklin, 2007; Manser, 2009).

Statistical analysis revealed significant differences be-tween managers, opportunities for supplementary educa-tion, hospitals, and the educational status of staff. The resultsof this study show that, in general, hospital managers’ per-ceptions of the patient safety culture were better thanthose of frontline staff. Parand et al. (2010) and Abbas(2008) reported similar findings. This should be consid-ered when planning interventions or patient safety educa-tion as there are clearly discrepancies between managerialand frontline views on certain aspects of patient safety andquality improvement (Price, Fitzgerald, & Kinsman, 2007;Singer, Falwell, Gaba, & Baker, 2008). This may also re-flect a tendency for frontline workers andmanagers to mis-understand patient safety problems.

We evaluated a novel variable, that is, opportunitiesfor supplementary education, and found that it posi-tively enhanced the patient safety culture in almost alldimensions. This finding shows that education is an im-portant factor for developing and improving the patientsafety culture in such organizations. In fact, it has beenshown that health professionals should be educated insystems thinking to enable them to learn from adverseevents (Marck, 2006; Wakefield et al., 2005).

Moreover, the dimensions concerning feedback, “fre-quency of events reported,” and “nonpunitive responseto errors” might be interrelated. The reporting of adverseevents and feedback on errors appears to be higher inHospital 1 than in Hospital 2. Staff should be given feed-back in a way that does not leave them feeling guilty fortheir errors. However, this poses a considerable challenge(Institute ofMedicine, 2001). Nevertheless, it is importantto identify clearly negligent or nonethical actions and in-tervene at the individual level.

There were also significant differences in the educa-tional background of the nurses at the hospital level (i.e.,more nurses with a higher basic educational level in Hos-pital 2). In a previous study (Tenkanen et al., 2011), RNsshowed more mastery of the forensic psychiatry core

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TABLE 4. Descriptive Statistics of the Dimensions at Staff Group Level

MD RN PMN OtherSignificant (p < 0.5) post hoc(Bonferroni) group differences

Teamwork within units 3.65 3.88 3.74 3.53 NS

Supervisor/manager expectations and actionspromoting patient safety

3.67 3.86 3.73 3.73 NS

Organizational learning–continuous improvement 3.48 3.40 3.28 3.53 NS

Management support for patient safety 3.53 2.79 2.66 3.38 RN: MD, Other; PMN: MD, Other

Overall perceptions of patient safety 3.29 3.19 3.14 3.65 Other: RN, PMN

Feedback and communication about error 3.22 3.32 3.40 3.04 NSa

Communication openness 3.16 3.43 3.30 3.25 NS

Frequency of events reported 3.50 3.77 3.90 3.60 NSa

Teamwork across units 3.71 3.68 3.53 3.33 NS

Staffing 3.65 3.20 3.15 3.32 NS

Handovers and transitions 2.82 3.20 3.09 2.73 RN: Other

Nonpunitive response to errors 2.94 2.91 2.55 2.89 RN: PMN

MD = medical doctors; RN = registered nurses; PPN = practical psychiatric nurses; NS = not significant.aKruskal–Wallis test.

Original Article

interventions of their jobs than PMNs, which could alsohave a direct effect on the patient safety culture at hospi-tal level. Moreover, employers probably supervise PMNs’duties more closely than fully qualified RNs, which wouldincrease the punitive effect in the PMN group at hospitallevel. RNs were able to master forensic psychiatry coreinterventions in their jobs better than PMNs, which couldalso have a direct effect on the patient safety culture athospital level.

For four of the dimensions, scores of nurses (RNs andPMNs)were lower thanMDs or other specialists. A previousreport (Degeling, Maxwell, & Coyle, 2003) has suggestedthere may be cultural differences between professionalgroups, which should be taken into account when con-structing educational plans. Such differences may arise be-cause nurses spend more time with patients and are morecentral to the safety process in the ward, thus allowingthem to observe patient safetymore directly than other oc-cupational groups. Hence, lower scores for nurses in thesedimensions may need special consideration. Notwithstand-ing, RNs and PMNs achieved better scores (comparedwithMDs and other specialists) in “handovers and transi-tions,” which is directly related to patient care.

LimitationsThe response rate of the studywas relatively low (43%), thatis, such survey data are typically biased by nonresponses,and the results represent only a single point in time. The re-sponse rate in the subgroups varied from 74% (other) to34% (PMN). Despite these limitations, therewas a represen-tative sample for all subgroups. One of the dimensions (i.e.,“communication openness”) had an alpha score of lower

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than 0.6, which could indicate that the validity of the resultsin this dimension is low (Nunnally & Bernstein, 1994).

Individuals embedded in a culture are often unawareof its particularities, and quantitative culture data can of-ten provide more objective information (Nieva & Sorra,2003). A patient safety score is only an indirect indicatorof patient safety, and existing patient safety culture instru-ments may also have weaknesses (Colla, Bracken, Kinney,&Weekks, 2005; Singla et al., 2006). In addition, it is im-portant to take into account patients’ opinions on the pa-tient safety and care process, involving them as partnerswith professional staff (Kohn et al., 2000; Vincent &Coulter, 2002).

Conclusions and Clinical ImplicationsThe findings of this study provide useful informationabout the patient safety culture in forensic psychiatry. Aprevious study has shown that hospitals where staff hasmore positive perceptions of patient safety culture tendto receive more positive assessments of care from patients(Sorra, Khanna, Dyer,Mardon,& Famolaro, 2012). Over-all, the results of the study described in this article contrib-ute to the current debate over patient safety and ongoingimprovement efforts and help to reveal staff attitudes andexperiences about patient safety culture. Staff should beengaged in discussions about their responses to raise aware-ness of patient safety and provide opportunities to share con-cerns (Parker, 2009). Furthermore, these measures shouldbe used tomotivate staff to actively participate in safety ac-tivities to improve the work environment, rather than sim-ply blaming individuals who fail to comply with currentstandards.

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Original Article

These results also indicate that increased educationleads to a better patient safety culture, as mentioned byKontio (2011): “Continuing vocational education shouldbe amalgamated with written clinical guidelines, ethicaland legal issues and support frameworks (p. 4).” It is alsoclear that cultural differences between professional groupsshould be taken into account when constructing (patientsafety) educational plans and health professionals needto be educated in systems thinking if they are to effectivelylearn from adverse events (Marck, 2006; Wakefield et al.,2005). In addition, these results also imply that there is in-adequate communication between the frontline workers(e.g., nurses) of the management regarding patient safety.

The results highlight that the patient safety culture isyet to be fully developed. Our study suggests that patientsafety surveys are an effective means of assessing strengthsandweaknesses of existing safety cultures in hospitals, whichis particularly important in forensic hospitals. Managersplay a critical role in supporting and improving patientsafety in their organization, and there should be a proac-tive strategic planning process for patient safety. Furtherresearch is needed to understand how improvement strat-egies influence the patient safety culture and determinehow safety culture assessment can be related to outcomemeasurement. The study findings provide useful informa-tion for all staff involved in forensic psychiatry regardingshared values, beliefs, and attitudes toward patient safety.In particular, it demonstrates that the safety behaviors ofhospital staff are partly influenced by the prevailing cul-tural norms in their organizations and work groups.

AcknowledgmentsWe would like to thank everyone who contributed to the

study and Ms. Tarja Koskela for secretarial assistance.

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