Patient Safety Culture in Neonatal Intensive Care Units (NICUs): What Is the Evidence?

The patient safety culture of a unit and/or organization plays an important role in patient safety. Patient safety issues were brought to the forefront of health care by the Institute of Medicine report, and it has been defined as “freedom from accidental injury” (Kohn, Corrigan, & Donaldson, 2000, p. 4). Preventable harm and error continues to have an impact on patients in intensive care units, and particularly on vulnerable infants in Neonatal Intensive Care Units (NICUs). It can also impact families and caregivers. Understanding the current evidence on safety culture within NICUs can inform nurses, and facilitate research and training to improve evidence-based patient safety practices in this vulnerable population.

Purpose: Perform a literature review to explore the current evidence on patient safety culture in NICUs and implications for future research and practice.

Method: The following databases were searched: PubMed, CINAHL, Cochrane Database of Systematic Reviews, Web of Science Core Collection, Google Scholar, Scopus and Dissertation Abstracts International. The search was limited to peer-reviewed research in English from 2011 to 2016 to obtain current evidence. The following search terms used were used: “patient safety culture” OR “safety culture” AND “NICU” OR the MESH term “Intensive Care Unit, Neonatal “

Findings: Although a great deal of research on safety culture can be found in intensive care units there is minimal research being done in NICUs. Research in NICUs in the past five years involves survey, cross-sectional and descriptive studies which is categorized as level II for evidence (Polit & Beck, 2014). An awareness of safety culture is necessary to improve the quality of healthcare in an organization. Safety culture awareness helps us receive as well as interpret the stimuli from the environment and select and organize it (Hemmat, Atashzadeh-Shoorideh, Mehrabi, & Zayeri, 2015). A positive patient safety culture encompasses good communication, attitudes, perceptions, values and mutual trust shared by individuals and groups within an organization or unit. Management of resources and awareness of inappropriate or unacceptable dimensions of safety culture are important. Expectations and actions of management/supervisors in promoting safety were the most important dimension in safety culture surveys making management involvement absolutely necessary. Frequency of error reporting had the lowest positive responses indicating that nurses tend to not report errors for fear of reprisal (Hemmat, Atashzadeh-Shoorideh, Mehrabi, & Zayeri, 2015). A reporting culture that is non-punitive is needed to improve the frequency of error reporting (Reason, 1998). Profit, et al., (2014) found that caregiver burnout is prevalent in NICU’s and is associated with lower perceptions of patient safety. It was also found to be less prevalent among physicians compared to non-physicians, and more burnout contributed to a lower teamwork climate in the NICU. Reducing burnout therefore improves teamwork and leads to reductions in medical error (Sexton, et al., 2014). It is important to determine if caregiver burnout affects patient outcomes (Profit, et al., 2014). Structured teamwork and training initiatives can positively impact staff safety attitudes and these improvements in safety attitudes could be sustained over a one-year period (Murphy, Laptook, & Bender, 2015). Tools such as the Safety Attitudes Questionnaire have been used to measure safety culture among hospitals and units but more evidence on its use in the NICU setting is needed (Profit, et al., 2012).

Conclusion: Safety culture questionnaires need more validation in the NICU setting. Current evidence shows that patient safety culture varies a great deal among NICU’s with physicians rating it more positively than nurses. Management involvement and support, allocation of resources, structured teamwork training and communication, a non-punitive approach or “just” culture, and positive overall perceptions of patient safety are characteristics that impact patient safety culture in NICU’s. More research is needed on caregiver (especially nursing) burnout and patient safety culture in NICUs. Future studies should also examine how the safety culture within NICUs impacts patient and nursing outcomes. These findings on the current evidence (2011-2016) on patient safety culture in NICU’s could be used to promote evidence-based teaching and learning for NICU nurses, staff and management. It can also be used to develop nursing research to promote the transformation of nursing knowledge and practice, and for the implementation of training programs to improve the safety culture within NICUs thereby reducing preventable harm in this vulnerable population and promoting health.