The Role of Safety Coaches in a Culture of Safety

Over the past two decades there has been much effort aimed at improving the quality and safety of our hospitals. Numerous patient safety organizations have developed blueprints that hospitals may use to build and sustain a culture of safety. The importance of such a culture has been consistently supported in the literature as the key factor related to positive patient outcomes. A culture represents the attitudes, values, and behaviors of a group of people. A hospital’s culture of safety reflects the way a staff approaches daily tasks related to patient care. Regardless of policy, a safety culture is the way things are done when no one is watching—it’s the accepted norm. Unfortunately, even where robust safety cultures are in place, humans are prone to errors and inconsistency which contribute to unreliable processes and poor outcomes.

Improving reliability in healthcare requires a systemic approach. Healthcare leaders have turned to other industries where safety is critical for guidance. Examples of “highly reliable” industries include commercial airlines, nuclear power, and naval aviation. Checklists and communication protocols are used to standardize procedures, thus improving the likelihood of consistent outcomes. Healthcare professionals have looked to these industries to find practices that might help improve the safety and reliability of hospitals. One proven method to reinforce safe practices is the use of behavior-based safety coaching. A review of the literature was conducted to learn how hospitals are using safety coaches to improve quality and promote positive patient outcomes.

Starting a safety coach program is an important step in creating a culture of safety. Peer coaching adds a layer of accountability for desired safety behaviors at the front line of patient care. When such a program is established there must be clear and consistent communication of safety coach expectations and responsibilities. Because programs tend to drift off course, intentional steps must be taken to keep everyone on track. The evidence related to safety coach programs establishes the need for coach mentoring, opportunities for coaches to share safety stories, and continuous training. These areas have been identified as a gap in practice for an existing safety coach program at a pediatric hospital in Southeast Tennessee. The translational project designs a quality improvement initiative to address this gap by providing mentoring, education, and opportunities to further develop coaching skills.

The purpose of this quality improvement translational project is to determine the degree to which adding a formalized structure affects the practice of safety coaches and improves a culture of safety in the Pediatric Acute Care Unit of a children’s hospital in Southeast Tennessee. A mixed-method design will provide quantitative data related to the unit’s culture of safety and a qualitative analysis of themes from safety coach focus groups before and after the interventions. The PICOT question serving as the basis for this project is “In those serving as safety coaches in the Pediatric Acute Care Unit how will the implementation of a formalized safety coach program affect safety coach self-efficacy, role-related practices, and unit culture of safety over a 6-month period versus current practice?”

The theory guiding this project is Barbara Resnick’s Nursing Theory of Self-Efficacy. The role of the safety coach is to reinforce safe behaviors, so a behavior-based theory is appropriate. The specific behaviors of a safety coach are influenced by many factors including an understanding of the role, a belief in one’s ability to coach effectively, other staff members’ perceptions of the role, time to perform in the role, and motivation to serve in the role. The theory describes the interaction of these influences, so the project will be designed around the concepts of this framework. Additionally, Resnick describes the sources of information for self-efficacy as enactive attainment, vicarious experience, verbal encouragement, and physiologic feedback which can be influenced by a variety of internal and external factors. Interventions to improve the self-efficacy of safety coaches will be based on these information sources. Also, many self-efficacy tools have been validated which can be used as models to create a safety coach self-efficacy tool. An advantage of this model is the ability to use a self-efficacy tool to learn the perceived challenges of effectiveness as a safety coach. With this knowledge, mentoring interventions can address the specific areas of concern.

Interventions will be aimed at improving the self-efficacy of safety coaches and the overall culture of safety within the Pediatric Acute Care Unit. A formalized Safety Coach program will be implemented to include Safety Coach mentoring, monthly education topics, and leadership safety rounds. Safety Coaches will be introduced to a new documentation system which will be used to measure the number and type of interactions coaches have with coworkers.

To measure the effectiveness of the project interventions, several tools will be used. The Safety Coach Self-Efficacy Tool will be used to assess the self-perceived effectiveness of those in the role of safety coach. The Safety Attitudes Questionnaire will be used to assess the overall safety culture of the Pediatric Acute Care Unit before and after the project. Additionally, focus groups will be used before and after interventions to elicit the opinions and feelings of Safety Coaches about the role, how others perceive the role, and challenges of the role.

Research indicates that teamwork among healthcare professionals is essential to providing safe care. Coaches have always played a vital role where teams are involved. The role of Safety Coach provides daily reinforcement of safe practices to those on the frontlines of patient care. Safety is the cornerstone of a healthy work environment for hospital workers and patients. This project aims to contribute to patient safety by providing the mentoring and training necessary to ensure coaches’ effectiveness.