Influence of Negative Behaviors on Patient Safety Culture and Mortality Within Acute Care

Behaviors that undermine a culture of safety pose a serious threat to the overall wellbeing of healthcare workers as well as to patient outcomes. Despite zero tolerance policies related to negative behaviors among healthcare professionals by the American Medical Association, American Nurses Association and the Joint Commission, incivility and other disruptive negative behavior persist. Published studies have focused on identifying prevalence of these behaviors within single disciplines such as nursing or physicians while limited evidence exists for interprofessional teams. This study is innovative, as it will establish the existence of a relationship between the prevalence of negative behaviors and the relationship of these behaviors to perceptions of hospital safety culture and publicly reported AHRQ patient safety outcomes related to mortality.

Understanding these relationships provides novel insights for healthcare leaders and researchers, guiding future studies exploring development and testing of potential interventions. These potential interventions may mitigate negative behaviors that undermine a culture of safety, improve perceptions of safety culture and/or improve outcomes for AHRQ publicly reported outcomes. A descriptive correlational cross-sectional design will be used to evaluate relationships between disruptive behaviors displayed by healthcare professionals across a healthcare system and hospital performance on Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI) related to mortality. Comparisons will be made across a healthcare system regarding self-reported perceptions of hospital staff on composite scores of the AHRQ Survey on Hospital Patient Safety Culture.

There are five specific innovations within this study. First, the study setting is in an academic health system that includes eight hospitals in the United States. A large portion of existing work within the field has occurred outside of the United States, thus adding to the innovation of the proposed study setting. A secondary innovation for this study includes the diverse sample of proposed participants. In lieu of a homogenous sample within a single discipline, this study aims to include a diverse sample of healthcare workers, as many of the published studies measuring negative behaviors include only a single discipline. Third, the Negative Behaviors in Healthcare Survey (NBHC) instrument is an innovative instrument designed to measure negative behaviors among the interprofessional team. The NBHC instrument evolved from a valid and reliable instrument the Lateral Violence in Nursing Survey (LVNS) Cronbach’s alpha of 0.74 LV by self and 0.86 for LV from others (3). To date, only two instruments have measured negative behaviors among interprofessional healthcare teams (4, 5). Moreover, majority of existing instruments measure negative behaviors designed for nurses (3, 6-18).

The NBHC measures negative behaviors using five sub scales identified through confirmatory factor analysis. These subscales include contributing factors, experiences with aggression, fear of retaliation, seriousness and use of negative behaviors. To date, no available studies have examined the fear of retaliation or the seriousness of negative behaviors. This instrument was developed to capture the negative behavior experiences of the interprofessional team in healthcare settings. Through measurement of the frequency, magnitude, and source of negative behaviors interventions can be designed and tested to improve relationships among the interprofessional team which is an existing gap. The fourth innovation includes the specific aim to understand the relationship between negative behaviors among healthcare workers and mortality outcomes measured by AHRQ PSIs. While evidence exists to support that negative behaviors increase the risk for poor patient outcomes, a link to AHRQ PSIs has yet to be published. Finally, Healthy People 2020 lists social and community context as one of five social determinants of health (19). The fifth innovation is the evaluation of specific aspects of a culture of safety within a healthcare system in the context of negative behaviors. Results from this study could inform additional research aimed at understanding the relationship between social determinants of health for healthcare workers and negative behaviors.

Understanding the prevalence of negative behaviors among members of the interprofessional team within hospitals is the critical first step in the development and testing of interventions to improve patient outcomes as well as employee engagement and experience. While existing instruments and studies address components of these issues, few studies have documented interprofessional prevalence of negative behaviors, and none to date have provided data related to the relationship of these behaviors to a culture of safety within hospitals. Understanding whether and how these concepts are related will aid healthcare leaders and researchers to develop and test improved interventions for patient and employee safety.