Background
Globally, more than 10% of hospitalised patients experience adverse events.1 Some of the most common types of adverse events are related to surgery.1 Adverse events are unintended injuries caused by medical management rather than the underlying disease that prolong hospitalisation and cause disability or even death.1 This is an immense burden on individuals and consumes resources in health systems and societies that could be used productively elsewhere.2 About half of the adverse events can be prevented through a strategic and coordinated approach.1 3 One approach is to monitor incidents, including harmful events and near-misses, with the emphasis on making future care safer.3 4 It is imperative for healthcare professionals to get an overview of incidents to be able to prevent future harm. However, not all complications can be prevented; patients get older and frailer and react differently to medical treatment. By monitoring incidents, healthcare professionals can anticipate complications and respond more effectively when they occur, thereby contributing to resilience.3 5 6
To get a comprehensive review of the types of events that occur, complex adaptive systems should use multiple monitoring methods.3 7 The most widespread methods are incident reporting systems where healthcare professionals record incidents.4 8 However, incident reporting systems are not effective for double loop-learning, that is, cultural change.8 9 Under-reporting is common and linked to a lack of feedback and learning.10 Other barriers are non-consensus on what to report, complicated systems and fear of shame and blame.11 To make incident reporting systems more effective, it is advocated to decentralise their management from centralised hospital departments to clinical teams, make reporting easier, give timely feedback and focus more on learning.4 8 12–14 To promote learning it is imperative to develop a culture of respect, openness and transparency.3
The Green Cross (GC) method is a simple visual method for healthcare professionals to recognise incidents in real time.15 Contrary to traditional incident reporting systems, the GC method is based on teamwork where incidents are discussed in daily safety briefings and weekly quality improvement meetings, thus decentralising its management and providing daily feedback. The non-anonymous reporting requires psychological safety to dare to speak up about errors, thus facilitating openness and transparency.3 16 Moreover, it requires that everyone involved avoids blaming and shaming and supports a restorative and just culture.16 17 Templates and the use of incident definition facilitate clarity and promote learning.16 The GC method was invented in Sweden in 2011 and has since spread internationally.18 It consists of seven steps: (steps 1–3) daily interprofessional safety briefings in which incidents are collected, assessed and visualised, and (steps 4–7) the recording of adverse events in the hospital incident reporting systems, involvement of patient and relatives, and working on improvements.15
A culture of openness and learning is closely linked to the safety culture. The term was first used in 1986 to describe the cause of the nuclear power plant disaster in Chernobyl, which was attributed to a breakdown in the safety culture of the organisation.19 The aspects of safety culture that relate to patient safety are termed patient safety culture (PSC).20 PSC is the cornerstone of the safety movement21 22 and is perceived as an indirect measure of quality of care.23 24 A PSC can be defined as ‘an integrated pattern of individual and organisational behaviour, based on shared beliefs and values that continuously seeks to minimise patient harm, which may result from the processes of care delivery’ (EUNetPaS, p4).25 This definition implies active involvement in reducing patient harm, which is the crux of the GC method.
Positive PSC is statistically associated with reduced adverse events.26 It plays an essential role in the effective recognition and response to surgical complications and may be the main driver of the variation in failure to rescue.27–29 PSC as a part of safety culture can be measured and improved.30 Since PSC is a group-level property that emerges and lives in work units,31 32 initiatives to improve PSC at the unit level are necessary.27 Thus, the GC method was implemented in a Norwegian postanaesthesia care unit (PACU) in 2019, which is the context of this study.33 Questionnaires, such as the Safety Attitudes Questionnaire (SAQ),34 can effectively capture tangible themes of PSC, such as teamwork, error notification and learning, and staff well-being.35–37 Since 2018, Norwegian hospitals have used an annual hospital staff survey (staff survey) to assess the safety culture.38 This study explores the Staff Survey factors ‘work engagement’, ‘teamwork climate’ and ‘safety climate’. The factors were chosen because they play an important role in providing safe patient care.26
Related reporting methods like safety briefings have significantly improved PSC.39 The GC method has also significantly improved PSC in nursing units in a Swedish hospital.15 However, the longitudinal effects of these methods are not studied. Longitudinal studies are useful in evaluating the sustainability of interventions.40 This study fills the gap of longitudinal, controlled studies on the effect of the GC method and safety briefings on PSC,41 specifically in relation to teamwork, job satisfaction and work engagement.39 42 This may be useful to present and future users of the GC method and similar methods.
This study aimed to explore whether the implementation of the GC method in a PACU changed nurses’ perceptions of different factors associated with PSC over 4 years. The research question was How does the implementation of the GC method in a PACU change the nurses’ perceptions of ‘work engagement’, ‘teamwork climate’ and ‘safety climate’ over 4 years.
Conceptual framework
The conceptual framework for this study builds on the Systems Engineering Initiative for Patient Safety (SEIPS) model.43 SEIPS depicts how the GC method (input) shapes nurses’ work systems independently and collaboratively by providing a reporting tool that is simple to use and by attempting to improve PSC. In turn, work processes influence organisational, group-level outcomes (‘teamwork climate’, ‘safety climate’) and professional, individual-level outcomes (‘work engagement’). The inter-relatedness within and between each component illustrates the complexity of the system43 (see online supplemental file 1).