The effect of the SAFE or SORRY? programme on patient safety knowledge of nurses in hospitals and nursing homes: A cluster randomised trial

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Abstract

Background

Patients in hospitals and nursing homes are at risk for the development of often preventable adverse events. Guidelines for the prevention of many types of adverse events are available, however compliance with these guidelines appears to be lacking. As a result many patients do not receive appropriate care. We developed a patient safety program that allows organisations to implement multiple guidelines simultaneously and therefore facilitates guideline use to improve patient safety. This program was developed for three frequently occurring nursing care related adverse events: pressure ulcers, urinary tract infections and falls. For the implementation of this program we developed educational activities for nurses as a main implementation strategy.

Objectives

The aim of this study is to describe the effect of interactive and tailored education on the knowledge levels of nurses.

Design

A cluster randomised trial was conducted between September 2006 and July 2008.

Settings

Ten hospital wards and ten nursing home wards participated in this study. Prior to baseline, randomisation of the wards to an intervention or control group was stratified for centre and type of ward.

Participants

All nurses from participating wards.

Methods

A knowledge test measured nurses’ knowledge on the prevention of pressure ulcers, urinary tract infections and falls, during baseline en follow-up. The results were analysed for hospitals and nursing homes separately.

Results

After correction for baseline, the mean difference between the intervention and the control group on hospital nurses’ knowledge on the prevention of the three adverse events was 0.19 points on a zero to ten scale (95% CI: −0.03 to 0.42), in favour of the intervention group. There was a statistically significant effect on knowledge of pressure ulcers, with an improved mean mark of 0.45 points (95% CI: 0.10–0.81). For the other two topics there was no statistically significant effect. Nursing home nurses’ knowledge did neither improve (0 points, CI: −0.35 to 0.35) overall, nor for the separate subjects.

Conclusion

The educational intervention improved hospital nurses’ knowledge on the prevention of pressure ulcers only. More research on long term improvement of knowledge is needed.

Trial registration

ClinicalTrials.gov ID [NCT00365430].

Introduction

Recent studies showed that patients in hospitals and nursing homes are at risk for the development of, often preventable, adverse events (Thomas et al., 2000) (Table 1). An adverse event is defined as “an unintended injury that results in prolonged stay, disability at the time of discharge, or death and is caused by health care management rather than by the patient's underlying disease process” (Thomas et al., 2000).

Although many guidelines are available, compliance with these guidelines appears to be lacking (Grol, 2001, Schuster et al., 1998, Halfens and Eggink, 1995). As a result, many patients receive inappropriate care (Grol and Grimshaw, 2003). Generally, many factors or barriers may influence compliance – or noncompliance – with a guideline (Grol and Grimshaw, 2003). These general barriers may be related to the individual (e.g. knowledge, skills, attitudes, motivation) or the individual's social context (e.g. patients, colleagues, culture), and the organisational setting (e.g. financial, equipment) (Grol and Wensing, 2004). Moreover, the large number of guidelines competing for attention makes it difficult to keep track of all of them. In addition organisations must translate each guideline to their own target group, and develop and organise their own information and education, which is a time-consuming process. All this combined makes it difficult for organisations to implement all relevant guidelines. This situation is at odds with the responsibility of professionals to ensure patient safety. To facilitate hospital and nursing home organisations in guideline implementation, we developed a patient safety program (SAFE or SORRY?) that allows organisations to implement multiple guidelines simultaneously (Van Gaal et al., 2009). We developed this program for three frequently occurring nursing care related adverse events, for which guidelines on preventive care are available: pressure ulcers, urinary tract infections and falls. For the implementation of this patient safety program we developed educational activities as a main implementation strategy.

Education is a necessary component of any implementation strategy (Wensing and Grol, 2005) and can lead to changes in professional behaviour (Grol and Grimshaw, 2003), although the effects of most types of education are small (Grol and Grimshaw, 2003). In general, passive approaches (written material and large-scale educational meetings) are ineffective and unlikely to result in behaviour change (Grimshaw et al., 2001). To improve the effectiveness of an educational strategy, the activities should have specific characteristics (Grimshaw et al., 2001). Education that is interactive and personal, such as small-scale educational meetings and educational outreach visits, is more effective (Grol and Grimshaw, 2003). Therefore we developed interactive and personal educational activities which were tailored to the needs of the nursing ward. Subsequently, we assessed the effect of this educational implementation strategy on nurses’ knowledge.

In this article we will describe the effect of interactive and tailored education on the knowledge levels of the nurses.

Section snippets

Design and settings

The study was embedded in the SAFE or SORRY? study, which is a cluster randomised trial (Van Gaal et al., 2009) The effectiveness of our educational intervention was tested within this trial. In a cluster randomised trial, groups of individuals rather than individuals are randomised (Campbell and Grimshaw, 1998). In our study the intervention involved the entire team of nurses and not individual nurses on nursing wards. Therefore nurses within the same ward were considered to be a cluster (

Hospitals

In hospitals, 503 nurses (72%) returned the knowledge test. The response rate in all groups was high (>70%) with the exception of the intervention group at follow-up (49%) (Table 2), yet in each group every ward had an equal percentage of nurses who returned the questionnaire. The mean age of the nurses was 38 years (SD = 10.7) and 411 (89%) were females. There were no differences in hospital nurses’ characteristics between the intervention and the control group at baseline or follow-up (Table 2).

Discussion en conclusion

This study showed that the educational intervention of the patient safety program did not improve nurses’ knowledge on the three adverse events in hospitals and nursing homes. There was a small positive overall effect on hospital nurses’ knowledge, but this effect was statistically non-significant and too small to be relevant for daily practice. Of the three topics, only the knowledge on pressure ulcers showed a statistically significant improvement that is also relevant for daily practice. For

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