Stress, lack of time and unreported errors still problematic at health-care organizations
The quality of work life in health-care organizations has an overall effect on patient safety, but issues such as a stressful work environment, not having enough time to deliver high-quality care and unreported errors need to be improved, according to a report by Accreditation Canada.
Among workers who were satisfied with their organization or feel they can do their best quality work, 71 per cent gave their unit a positive overall grade on patient safety and 61 per cent gave their organization the same grade, found the 2010 Canadian Health Accreditation Report, which outlines the results of two surveys — Patient Safety Culture Tool and Worklife Pulse Tool — of 236 organizations.
There is definitely a link between the quality of life on the job and patient care, said Debbie Fischer, senior vice-president of organizational development and strategic projects at Mount Sinai Hospital in Toronto.
“That’s how we make a lot of business cases around investment for employee training and changes to how we do things,” she said.
With a workforce predominantly made up of women, at 80 per cent, and mental health a bigger issue for women, the hospital looks at programs to support staff even if it doesn’t have pure data to support it, she said. Measurement indicators include turnover, why people leave, incidents, workplace safety and insurance claims, reported injuries and the cost of health and dental programs.
“The better we get at analyzing the data, the better we’re able to target programs to specific needs,” said Fischer, adding the hospital has seen strong employee engagement scores.
Key problems need to be addressed: Union
But based on the most recent information, the Canadian Nurses Association (CNA) is not seeing improvements around sick time, which is one of the big indicators, said Judith Shamian, president of CNA, which has 140,000 members. Workload and overtime lead to a lot of the problems, she said.
“It is absolutely correct organizations are putting in a lot of effort but they are not dealing with a lot of the key issues and, until they remove some of the key problems, they’re not going to see change.”
Some organizations, however, are seeing improvements in turnover, well-being and productivity, said Shamian. These have been helped by changes such as looking at the ratio between full- and part-time workers. And some hospitals are providing educational support and engaging nurses, giving them the ability to have an impact on the change process, with greater buy-in, said Shamian
Progress hard to measure: Study authors
Despite an increased focus on improving work life in health care, it’s difficult to say if there are improvements as indicators are measured differently across the country and among organizations, said Wendy Nicklin, president and CEO of Accreditation Canada in Ottawa.
Figuring out how to improve overall stress levels is a very complex question, she said.
“If it was easily solved, it would have been solved years ago,” she said. “The good news is that there is increased sensitivity to the importance of the health-care work life and, depending on the leadership of the organization (board and CEO), some organizations have more deliberate steps in place to improve the quality of work life than other organizations.”
Sick Kids focuses on 4 elements
The Hospital for Sick Children has done a lot of work around the concept of a healthy organization, said Tracey Deline, director of organizational development at Sick Kids in Toronto, which has about 8,000 employees. It now focuses on four elements: employee health and well-being, supportive and respectful behaviour, safe work environment and shared responsibility for the organization.
While patient satisfaction scores at Sick Kids are high, the hospital recognizes the stress staff are under and has introduced staff-to-staff coaching to help people debrief in situations that might be specifically stressful.
“We are going to undergo more work to understand how to help (with) burnout,” said Deline.
Transparency encouraged among leaders
Strengths identified in Accreditation Canada’s Patient Safety Culture Tool survey (completed by 35,901 health care workers) show healthcare providers are taking responsibility and reporting mistakes and they feel comfortable asking for help.
There has been a major effort to encourage health-care leaders, whether managers of a ward or CEOs, to encourage transparency when an adverse event occurs, said Nicklin.
“There must be a no-blame environment,” she said. “Most adverse events (errors) are not due to the incompetency of the individual but are related to a number of factors in the system — such as heavy workload, very complex patients to care for, working overtime, fatigue, staff shortages, et cetera.”
Mount Sinai has worked to build a no-blame culture, with help from an incident-reporting system, said Fischer.
“We embrace incidents as a way to learn and to dissect a process and to understand what in the process can be improved,” she said. “It’s not a punitive environment. Obviously, it’s something we keep working at, so we do training around it and we want to make sure that is ingrained in our culture.”
Sick Kids has put a strong focus on the reporting of errors, said Deline. “We’ve actually done a great deal of work to make sure people do feel comfortable, and we track to make sure managers act on things on a timely basis.”
“Those organizations that walk the talk and really build a culture of safety, both safety of care providers and of patients, build an environment where there’s a relationship staff can trust to raise their ideas, concerns, and if an organization takes them seriously and looks at how they can improve the organization, they will reap the benefits,” said Shamian.
Room for improvement: Unreported errors, cutting corners
However, unreported errors and cutting corners in patient care are two of the areas in need of improvement, according to the survey. Health-care providers also feel they are not rewarded if they identify a serious mistake. The involvement of senior leadership is critical and all team partners must work together to identify risks and prevent errors from occurring, said the report.
But the strength of leadership depends on the organization, said Nicklin. Some provide strong professional development programs and support while others provide minimal leadership instruction.
“There is no question that the type of leader needed for today is quite different from the leader of five years ago. Leaders need to evolve with the changing reality to continue to be effective,” she said.
Six or seven years ago, Mount Sinai realized it was behind so it has invested extensively in training for leadership, said Fischer.
“We really ramped up investment to support the needs of the organization and to improve the overall culture, our leadership cadre and patient safety,” she said.
Strong scores on job clarity, satisfaction with supervisors
The Worklife Pulse Tool survey was completed by 35,594 respondents in health care. Work environment was evaluated on a number of aspects, including communication, learning, involvement in decision-making, safety and work-life balance. The areas with the most positive scores were job clarity, satisfaction with supervisors and a safe environment, found Accreditation Canada.
Sick Kids has seen consistently high scores on employee surveys when it comes job clarity and has spent a lot of time on this issue, said Deline.
“With clarity comes power, with power comes action, so if you start anywhere, you start with clarity.”
The three areas with the lowest ratings were the ability to do the job required in the time provided, communication within the organization and involvement in decision-making.
Over the last 15 to 20 years, the role of nursing leadership has been somewhat diluted, said Shamian. Whereas before there was chief of nursing, matron or head nurse who was very influential in managing health-care services and sitting at the decision-making table, that phenomenon has gradually eroded and often there isn’t a nursing voice at the executive table.
The issues of workload, staff shortages and feeling rushed are factors that health-care staff have mentioned for several years, said Nicklin.
“In addition, when the pace and workload are high, communication does deteriorate and involving staff in decision-making may be compromised,” she said, so the Work Life Pulse Tool takes a pulse of an organization and signals to leadership which areas should be reviewed so action can be taken.
A focus on wellness, work-life balance, stress release, supportive supervisors, culture and measurement are all combining to have an impact, said Nicklin, as are initiatives such as the Quality Worklife Quality Healthcare Collaborative by Accreditation Canada.
