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Hospital unit safety climate: Relationship with nurses' adherence to recommended use of facial protective equipment

  • Michael Diamant Rozenbojm
    Correspondence
    Address correspondence to Michael Diamant Rozenbojm, MPH, Toronto General Hospital, 200 Elizabeth St, Eaton N, 1st Fl-812, Toronto, ON, Canada.
    Affiliations
    Department of Occupational and Environmental Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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  • Kathryn Nichol
    Affiliations
    Department of Occupational and Environmental Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada

    Collaborative Academic Practice, University Health Network, Toronto, Ontario, Canada

    Centre for Research Expertise in Occupational Disease, Toronto, Ontario, Canada
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  • Stephanie Spielmann
    Affiliations
    Department of Psychology, Wayne State University, Detroit, MI
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  • D. Linn Holness
    Affiliations
    Centre for Research Expertise in Occupational Disease, Toronto, Ontario, Canada

    Department of Medicine, University of Toronto, Toronto, Ontario, Canada

    Department of Occupational and Environmental Health, St Michael Hospital, Toronto, Ontario, Canada

    Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
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Published:December 16, 2014DOI:https://doi.org/10.1016/j.ajic.2014.10.027

      Background

      Despite the existence of formal guidelines for the acute health care sector, nurses' adherence to recommended use of facial protective equipment (FPE) to prevent occupational transmission of communicable respiratory disease remains suboptimal. In addition to individual factors such as knowledge and education, group factors such as shared perceptions of organizational support for safety may influence adherence. These group safety climate perceptions can differ depending on the pace and type of work, local leadership, and organizational structure of each unit.

      Methods

      An analysis of a data set from a cross-sectional survey of 1,074 nurses in 45 units of 6 acute care hospitals was conducted. Variance components analysis was performed to examine the variance in perceptions of safety climate and adherence between units. Hierarchical linear modeling using unit-level safety climate dimensions was conducted to determine if unit-level safety climate dimensions were predictors of nurses' adherence to FPE.

      Results

      Findings revealed statistically significant unit variances in adherence and 5 of the 6 unit-level safety climate dimensions (P < .05). Furthermore, a hierarchical model suggested that tenure and unit-level communication were significantly associated with increased adherence to FPE (P < .05).

      Conclusion

      Unit-level safety climate measures varied significantly between units. Strategies to improve unit-level communication regarding safety should assist in improving adherence to FPE.

      Key Words

      In recent years, highly infectious diseases such as severe acute respiratory syndrome and influenza A have escalated concern for the well-being of health care workers.
      • Lowe A.
      • Wilder-Smith A.
      Infectious respiratory illnesses and their impact on healthcare workers: a review.
      This has led to the development of multiple guidelines for the use of facial protective equipment (FPE) as an important strategy to prevent transmission of occupational respiratory disease.
      Public Health Agency of Canada
      Routine practices and additional precautions for preventing the transmission of personal protective equipment: revision of isolation and precaution techniques.
      Despite the existence of these guidelines, the literature shows adherence to such precautions remains suboptimal. A review of the evidence on compliance of health care practitioners to standard precautions before the 2009 influenza A epidemic found that, on average, adherence to FPE was 30% (range, 4%-55%).
      • Gammon J.
      • Morgan-Samuel H.
      • Gould D.
      A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions.
      More recently, a study of 21 intensive care units in China found that 55% of health care workers complied with the proper use of FPE.
      • Hu X.
      • Zhang Z.
      • Li N.
      • Liu D.
      • Zhang L.
      • He W.
      • et al.
      Self-reported use of personal protective equipment among Chinese critical care clinicians during 2009 H1N1 influenza pandemic.
      Two studies from Canada found 44% of nurses in 6 hospitals
      • Nichol K.
      • McGeer A.
      • Bigelow P.
      • O'Brien-Pallas L.
      • Scott J.
      • Holness L.
      Behind the mask: Determinants of nurse's adherence to facial protective equipment.
      and 11% of doctors in 14 hospitals reported they properly adhered to FPE.
      • Reid S.M.
      • Farion K.J.
      • Suh K.N.
      • Audcent T.
      • Barrowman N.J.
      • Plint A.C.
      Use of personal protective equipment in Canadian pediatric emergency departments.
      Such suboptimal adherence rates are of great concern because it is estimated that 1 in 4 health care workers contract a communicable respiratory illness through work.
      • Mitchell R.
      • Ogunremi T.
      • Astrakianakis G.
      • Bryce E.
      • Gervais R.
      • Gravel D.
      • et al.
      Impact of the 2009 Influenza A (H1N1) pandemic on Canadian healthcare workers: a survey on vaccination, illness, absenteeism, and personal protective equipment.
      Furthermore, FPE has been cited as the most uncomfortable and problematic of all types of personal protective equipment, and is often more poorly adhered to than other components of standard precautions such as hand washing and glove use.
      • Gammon J.
      • Morgan-Samuel H.
      • Gould D.
      A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions.
      • Yassi A.
      • Moore D.
      • Fitzgerald J.
      • Bigelow P.
      • Hon C.
      • Bryce E.
      Research gaps in protective healthcare workers from SARS and other respiratory pathogens: an interdisciplinary, multi-stakeholder, evidence-based approach.
      Together, these findings highlight the need to develop strategies to improve adherence to FPE, especially among nurses, who represent the largest occupational workgroup in the health sector and have the most patient interactions.
      Registered Nurses Association of Ontario
      SARS unmasked: final report on the nursing experience with SARS in Ontario registered nurses association of Ontario.
      A review of the literature showed that the majority of interventions to improve adherence focused on individual factors such as education and training; however, many of these studies report no or minimal improvements in adherence.
      • Gershon R.
      • Stone P.W.
      • Zelster M.
      • Faucet J.
      • Macdavitt K.
      • Chou S.
      Organizational climate and nurse health outcomes in the United States: a systematic review.
      Such findings have raised concerns about the key assumption in the literature that safe work behaviors are predominantly determined by individuals' knowledge and beliefs.
      • Neal A.
      • Griffin M.A.
      A study of the lagged relationships among safety climate, safety motivation, safety behaviour, and accidents at the individual levels and group levels.
      In response, a growing body of literature has demonstrated that organizational and psychosocial aspects of the workplace may play a significant role in determining safety behaviors and outcomes,
      • Gershon R.
      • Stone P.W.
      • Bakken S.
      • Larson E.
      Measurement of organizational culture and climate in healthcare.
      • Zohar D.
      Safety climate and beyond: a multi-level multi-climate framework.
      and the product of individual and group attitudes, perceptions, and patterns—also described as safety climate—may determine an individual's, team's, or organization's commitment to safety.
      • DeJoy D.M.
      • Murphy L.R.
      • Gershon R.M.
      The influence of employee, job/task, and organizational factors on adherence to universal precautions among nurses.
      • Hofmann D.
      • Stetzer A.
      A cross-level investigation of factors influencing unsafe behaviours and accidents.
      • Zohar D.
      Safety climate in industrial organizations: theoretical and applied implications.
      Using a 6-dimension safety climate scale model, researchers have shown an association between individuals' safety climate perceptions and their compliance with standard precautions in hospitals.
      • DeJoy D.M.
      • Murphy L.R.
      • Gershon R.M.
      The influence of employee, job/task, and organizational factors on adherence to universal precautions among nurses.
      Furthermore, studies have identified particular dimensions of safety climate that are most influential in predicting behavior.
      • Yassi A.
      • Moore D.
      • Fitzgerald J.
      • Bigelow P.
      • Hon C.
      • Bryce E.
      Research gaps in protective healthcare workers from SARS and other respiratory pathogens: an interdisciplinary, multi-stakeholder, evidence-based approach.
      • DeJoy D.M.
      • Murphy L.R.
      • Gershon R.M.
      The influence of employee, job/task, and organizational factors on adherence to universal precautions among nurses.
      However, these studies did not examine group-level differences within hospitals, such as specific nursing units. In hospitals, “units differ by type of patients, acuity, pace of clinical care activities, workload, as well as by staff composition, local leadership, and organizational structure.”
      • Campbell E.G.
      • Singer S.
      • Kitch B.T.
      • Iezzoni L.I.
      • Meyer G.S.
      Patient safety climate in hospitals: act locally on variation across units.
      These factors create discrete microsystems that develop their own interpretation of the global or hospital organizational climate.
      • Zohar D.
      • Livne Y.
      • Tenne-Gazit O.
      • Admi H.
      • Donchin Y.
      Healthcare climate: a framework for measuring and improving patient safety.
      As a result, heterogeneity exists between units, and this phenomenon has been recently demonstrated across intensive care units of a single hospital, as well as across different types of units in multiple hospitals.
      • Campbell E.G.
      • Singer S.
      • Kitch B.T.
      • Iezzoni L.I.
      • Meyer G.S.
      Patient safety climate in hospitals: act locally on variation across units.
      • Schwendimann R.
      • Zimmermann N.
      • Küng K.
      • Ausserhofer D.
      • Sexton B.
      Variation in safety culture dimensions within and between US and Swiss hospital units: an exploratory study.
      Despite such findings, no research has been conducted to examined the effect of unit-level perceptions of safety climate on adherence to FPE. We examined 6 dimensions of unit-level safety climate in 45 hospital units, and their relationship with nurses' self-reported adherence to recommended use of FPE.

      Methods

      Setting, subjects, and study design

      This study was a secondary analysis of data collected by Nichol et al.
      • Nichol K.
      • McGeer A.
      • Bigelow P.
      • O'Brien-Pallas L.
      • Scott J.
      • Holness L.
      Behind the mask: Determinants of nurse's adherence to facial protective equipment.
      The group conducted a cross-sectional study to describe nurses' adherence to recommended use of FPE to prevent occupational transmission of communicable respiratory illness, and to determine specific factors that influence adherence.
      • Nichol K.
      • McGeer A.
      • Bigelow P.
      • O'Brien-Pallas L.
      • Scott J.
      • Holness L.
      Behind the mask: Determinants of nurse's adherence to facial protective equipment.
      A total of 1,074 registered nurses and registered practical nurses in 45 distinct units located in 6 different hospitals in Toronto, Canada, completed a questionnaire (response rate 82%).
      • Nichol K.
      • McGeer A.
      • Bigelow P.
      • O'Brien-Pallas L.
      • Scott J.
      • Holness L.
      Behind the mask: Determinants of nurse's adherence to facial protective equipment.
      The questionnaire was derived from Moore's framework, which divides factors associated with self-protective behavior at work into 3 categories: organizational, environmental, and individual factors.
      • Moore D.M.
      • Gilbert M.
      • Saunders S.
      • Bryce E.
      • Yassi A.
      Occupational health and infection control practices related to Severe Acute Respiratory Syndrome.
      The questionnaire consisted of 84 items, primarily based on a 5-point Likert response scale that ranged from strongly agree to strongly disagree. Scales to measure organization and environmental factors were tested for reliability using Cronbach's α raw scores, and all had reliability scores of 0.7 and above.
      • Nichol K.
      • McGeer A.
      • Bigelow P.
      • O'Brien-Pallas L.
      • Scott J.
      • Holness L.
      Behind the mask: Determinants of nurse's adherence to facial protective equipment.
      Ethics approval for the initial study was obtained from the administering organization, the partner academic institution, and all 6 participating hospitals. Ethics approval for this secondary analysis was obtained from the administering hospital's Research Ethics Board.
      This secondary analysis focused on 42 of the 84 items to identify and define demographic variables, safety climate dimensions, and adherence. Safety climate was measured using a combination of 3 environmental and 3 organizational factors. These 6 factors, or dimensions, were based on a revised version of a tool developed by Gershon et al
      • Gershon R.
      • Karkashian C.D.
      • Grosch J.W.
      • Murphy L.R.
      • Escamilla-Cejudo A.
      • Flanagan P.
      • et al.
      Hospital safety climate and its relationship with safe work practices and workplace exposure incidents.
      to examine safety climate in health care settings. Scales in the original tool were tested for reliability and all had Cronbach's α scores of 0.7 and above.
      • Gershon R.
      • Karkashian C.D.
      • Grosch J.W.
      • Murphy L.R.
      • Escamilla-Cejudo A.
      • Flanagan P.
      • et al.
      Hospital safety climate and its relationship with safe work practices and workplace exposure incidents.

      Demographic variables

      Eight demographic variables were included in this analysis. These included age, education, gender, nurse type (registered nurse or registered practical nurse), supervisory status, tenure as a nurse, tenure on the unit, and work status (full-time or part-time).

      Safety climate dimensions

      Safety climate was characterized using 6 dimensions: availability of FPE, absence of job hindrances, cleanliness and orderliness of unit, minimal conflict and good communication practices, organizational support for health and safety, and safety-related training and fit testing. Availability of FPE, absence of job hindrances, and cleanliness were measured with 3-item scales. Communication was measured using an 8-item scale, whereas organizational support and training and fit testing used 6-item scales. Examples of items include “my work area is kept clean” (cleanliness) or “there is open communication between supervisors and staff” (communication). For the first 5 dimensions, a participant received a score of 1 for a safety climate dimension if they answered “strongly agree” or “agree” to all items within the scale. For training and fit testing, a score of 1 was given when a participant was fit tested within the past 2 years and answered “strongly agree” or “agree” to 5 out of the 6 items within the scale.

      Adherence

      Individual adherence was defined as a participant responding always or mostly to at least 7 of the 8 items within the adherence scale.

      Statistical analyses

      SPSS version 21.0.0.0 software (IBM-SPSS Inc, Armonk, NY) was used to perform descriptive statistics and to aggregate individual perceptions of the 6 safety climate dimensions to the unit level.
      Before aggregation, the 1,074 participants were sorted according to their unit of work. Individual safety-climate dimension scores were summed, averaged by the number of participants in the unit, and multiplied by 100% to generate a positive percentage score for each unit. To remain consistent with the primary study published, where individuals received a 0 or a 1 for each safety climate dimension,
      • Nichol K.
      • McGeer A.
      • Bigelow P.
      • O'Brien-Pallas L.
      • Scott J.
      • Holness L.
      Behind the mask: Determinants of nurse's adherence to facial protective equipment.
      all unit-level safety climate scores were analyzed as dichotomous variables. Due to the low percentage of positive responses observed in this dataset, a cutoff of 50% was chosen instead of the 60% recommended in the literature. Therefore, if a unit had >50% of individuals reporting a positively for a safety climate dimension, the unit received a score of 1.
      Hierarchical linear modeling was used as participating nurses were nested within units, and units were nested within hospitals.
      • Ausserhofer D.
      • Schubert M.
      • Desmedt M.
      • Blegen M.A.
      • De Geest S.
      • Schwendimann R.
      The association of patient safety climate and nurse-related organizational factors with selected patient outcomes: a cross-sectional survey.
      HLM software version 7.01 (Scientific Software International, Skokie, Ill) was used to perform variance component analysis,
      and R software version 3.1.0 (R Foundation for Statistical Computing, Vienna, Austria) was used to compute bivariate analyses and logistic hierarchical model using individual factors and unit-level safety climate dimensions.
      P < .2 cutoff was used as the inclusion criterion for a generalized logistic mixed model consisting of 3 levels: individual, unit, and hospital.
      • Ausserhofer D.
      • Schubert M.
      • Desmedt M.
      • Blegen M.A.
      • De Geest S.
      • Schwendimann R.
      The association of patient safety climate and nurse-related organizational factors with selected patient outcomes: a cross-sectional survey.
      • Hosmer D.
      • Lemeshow S.
      Applied logistic regression.
      This model was then simplified using backward selection and a cutoff of P < .2 to yield a final model that predicted nurses' adherence to FPE.
      • Hosmer D.
      • Lemeshow S.
      Applied logistic regression.

      Results

      Demographics

      Most respondents were female registered nurses working full-time. Individual adherence to FPE was reported at 44% (Table 1). These results are identical to those obtained in the primary study.
      • Nichol K.
      • McGeer A.
      • Bigelow P.
      • O'Brien-Pallas L.
      • Scott J.
      • Holness L.
      Behind the mask: Determinants of nurse's adherence to facial protective equipment.
      Table 1Descriptive statistics
      VariableMean (range)n (%)
      Individual level (N = 1,074)
       Education
      Diploma538 (51)
      Degree525 (49)
       Nurse type
      Registered nurse1018 (95)
      Registered practical nurse54 (5)
       Sex, female976 (91)
       Supervisor status, yes502 (47)
       Work status, full-time816 (77)
       Age (y)38.8 (20-67)
       Tenure as nurse (y)14.4 (0-49)
       Tenure on unit (y)6.5 (0-36)
       Adherence, yes456 (44)

      Six dimensions of unit-level safety climate

      Training and fit testing was the best performing dimension, with 38 of the 45 units reporting positive responses. Communication was the dimension with the lowest score, with only 4 units reporting positive responses (Table 2).
      Table 2Unit-level safety climate variables
      Unit level (n = 45)
      Safety climate dimensionNumber of units (%)
      Absence of job hindrances, yes31 (69)
      Availability of facial protective equipment, yes29 (64)
      Cleanliness/orderliness of unit, yes8 (18)
      Communication, yes4 (9)
      Organizational support, yes7 (16)
      Training and fit testing, yes38 (84)
      NOTE. Yes indicates units where ≥50% of individuals reported “yes” for the dimension.

      Unit-level variations in safety climate and adherence

      Results revealed significant unit-level contributions toward the variance in adherence to FPE, and toward 5 of the 6 safety climate dimensions (Availability of FPE, Cleanliness, Communication, Organizational Support, and Training) (Table 3). The sixth safety climate dimension, Job Hindrances, was not found to be significant (P = .24), and was excluded from further analysis.
      Table 3Unit variability in adherence and safety climate dimensions
      VariableSDVariance componentdfχ2P value
      Adherence0.3950.1563974.91<.001
      Availability of facial protective equipment0.5600.31439116.32<.001
      Cleanliness/orderliness of unit0.6820.46539127.28<.001
      Communication0.5040.2543988.29<.001
      Job hindrances0.1830.0333944.77.24
      Organizational support0.4020.1623978.54<.001
      Training and fit testing0.2470.0613958.06.025
      NOTE. χ2 tests were used to determine whether nurses' self-reported adherence rates or perceptions of 6 safety climate dimensions varied by their unit of work. P < .05 suggests that the unit of work contributes significantly toward the variance in nurses' responses.

      Relationship between unit-level safety climate dimensions and adherence to FPE

      Thirteen variables were examined for their association with an individuals' adherence to FPE. Results revealed 3 individual demographic variables (age, education, and tenure) and 4 unit safety climate variables (availability of FPE, communication, organizational support, and training) that met the inclusion criterion (P < .2) for the final model (Table 4).
      Table 4Bivariate analysis of association between individual and unit-level factors and adherence to facial protective equipment (FPE) use
      VariableP valueOdds ratio (95% confidence interval)
      Individual level
       Education, degree.050.77 (0.60-1.00)
       Nurse type, registered nurse.671.14 (0.62-2.07)
       Sex, female.711.09 (0.70-1.70)
       Supervisor status, yes.271.15 (0.89-1.49)
       Work status, full-time.931.05 (0.32-3.49)
       Age (y).0051.02 (1.006-1.03)
       Tenure as nurse (y).011.02 (1.004-1.03)
       Tenure on unit (y).441.01 (0.99-1.03)
      Unit level
       Availability of FPE, yes.141.64 (0.76-1.86)
       Cleanliness/orderliness of unit, yes.931.02 (0.64-1.64)
       Communication, yes.031.64 (1.08-4.05)
       Organizational support, yes.081.64 (0.95-2.83)
       Training and fit testing, yes.191.37 (0.85-2.21)
      Note: Yes indicates units where ≥50% of individuals reported “yes” for the dimension.

      Hierarchical modeling

      Seven factors found to be significant through bivariate analysis were included in the model. Backward selection using a cutoff of P < .2 yielded a final model with 3 variables, including 1 individual demographic variable, tenure, and 2 unit safety climate dimensions: communication and availability of FPE. Two factors were significant predictors of adherence: unit-level communication (P = .03) and individual tenure as a nurse (P = .01) (Table 5).
      Table 5Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for adherence to facial protective equipment use
      Variable categoryVariableP valueOdds ratio (95% CI)
      IndividualTenure as nurse.011.02 (1.003-1.03)
      UnitAvailability of facial protective equipment.161.27 (0.91-1.78)
      Communication.032.04 (1.07-3.86)

      Discussion

      Results from this study revealed 3 major findings. First, safety climate dimensions varied significantly between units. Second, adherence to FPE also varied significantly among the 45 units. Last, individual tenure and unit-level communication were significant predictors of adherence to FPE. The implications of these findings are discussed in the next 3 sections.

      Variation of safety climate dimensions between units

      Results from our study showed that the unit of work significantly contributed to the variance in nurses' perspectives on 5 of 6 safety climate dimensions (P < .05). These findings are consistent with several studies, and support the notion that units develop their own interpretation of the global or hospital-level organizational climate.
      • Zohar D.
      Safety climate and beyond: a multi-level multi-climate framework.
      • Zohar D.
      • Livne Y.
      • Tenne-Gazit O.
      • Admi H.
      • Donchin Y.
      Healthcare climate: a framework for measuring and improving patient safety.
      Units may differ in various aspects, including patient factors such as severity, complexity, acuity of illness, and length of stay; workforce factors such as staffing levels, nurse type mix, average tenure, education, and training; and performance factors such as pace of work, technologic complexity, and communication and management style of frontline managers.
      • Neal A.
      • Griffin M.A.
      A study of the lagged relationships among safety climate, safety motivation, safety behaviour, and accidents at the individual levels and group levels.
      • Campbell E.G.
      • Singer S.
      • Kitch B.T.
      • Iezzoni L.I.
      • Meyer G.S.
      Patient safety climate in hospitals: act locally on variation across units.
      • Clarke S.P.
      • Sloane D.M.
      • Aiken L.H.
      Effects of hospital staffing and organizational climate on needlestick injuries to nurses.
      Together, unit differences in patient type, staffing composition, and performance expectations may influence nurses' perceptions of the organizations' commitment to safety. From a policy and practice perspective, these findings suggest initiatives tailored to the context of the unit will influence safe work perceptions and behaviors. For example, an organization may have an overarching policy on training and fit testing but require that each unit do a risk assessment and determine additional procedures or requirements needed to keep workers safe and healthy. In those units where the risk of transmission of occupational respiratory disease is low, training may need to be focused on general knowledge and skills with resources available (procedures and experts) for supervisors and workers to access in the event they have a patient with a communicable respiratory disease. In those units where the risk of transmission is high, training may be more frequent, more comprehensive, and may include competency testing. In these 2 scenarios the same overarching organizational policy is in place, but the context of the unit is taken into consideration.

      Variation in self-reported adherence to FPE between units

      Findings from this study showed that the unit of work significantly contributed to the variance in nurses' self-reported adherence to recommended use of FPE (P < .001). Although similar studies have examined the variability in the incidence of medical errors, error reporting, and patient outcomes between units,
      • Clarke S.P.
      • Sloane D.M.
      • Aiken L.H.
      Effects of hospital staffing and organizational climate on needlestick injuries to nurses.
      • Taylor J.A.
      • Dominici F.
      • Agnew J.
      • Gerwin D.
      • Morlock L.
      • Miller M.R.
      Do nurse and patient injuries share common antecedents? an analysis of associations with safety climate and working conditions.
      ours is the first study to examine variability in adherence to FPE between units. Studies examining the incidence of medical errors found that units with a greater proportion of registered nurses or stronger perceptions of safety climate reported lower incidences of medical errors.
      • Clarke S.P.
      • Sloane D.M.
      • Aiken L.H.
      Effects of hospital staffing and organizational climate on needlestick injuries to nurses.
      • Hall M.L.
      • Doran D.
      • Pink G.H.
      Nurse staffing models, nursing hours, and patient safety outcomes.
      These studies suggest that policy makers focus their efforts on improving safety climates and introducing more registered nurses to reduce medical errors.
      • Clarke S.P.
      • Sloane D.M.
      • Aiken L.H.
      Effects of hospital staffing and organizational climate on needlestick injuries to nurses.
      • Hall M.L.
      • Doran D.
      • Pink G.H.
      Nurse staffing models, nursing hours, and patient safety outcomes.
      Therefore, understanding how unit-level factors affect adherence to FPE may have important implications for leaders and policymakers aiming to improve the health and wellness of health care workers.

      Determinants of adherence to FPE

      The 2 significant predictors of adherence to FPE were found to be individual-level tenure as a nurse and unit-level communication.
      The literature has largely shown demographic factors to have no significant association with adherence to FPE.
      • Zohar D.
      Safety climate in industrial organizations: theoretical and applied implications.
      • Gershon R.
      • Vlahov D.
      • Felknor S.
      • Velsey D.
      • Johnson P.
      • Delclos G.
      • et al.
      Compliance with universal precautions among healthcare workers at three regional hospitals.
      In our study, a relationship between education and adherence was demonstrated at the bivariate level but it was lost during multivariable analysis. The only demographic variable that remained a predictor of adherence was tenure as a nurse, and was associated with a 2% increase in adherence to FPE for every additional year of a nurse's tenure at a hospital. This finding differs from the primary study, which did not report a statistically significant relationship between any of the demographic variables and adherence to FPE use (P ≤ .05). Differences in the findings of this study and the primary study may be attributed to the nested or hierarchical methodology performed in this study.
      • Hofmann D.
      • Stetzer A.
      A cross-level investigation of factors influencing unsafe behaviours and accidents.
      No other studies were found linking tenure and adherence, but higher tenure has been associated with stronger safety climate perceptions.
      • Beus J.M.
      • Bergman M.E.
      • Payne S.C.
      The influence of organizational tenure on safety climate strength: a first look.
      • Abrahamson K.
      • Ramanujam R.
      • Anderson J.G.
      Co-worker characteristics and nurses' safety-climate perceptions.
      Because a strong safety climate influences safe behaviors,
      • Zohar D.
      • Luria G.
      A multilevel model of safety climate: cross-level relationships between organization and group-level climates.
      the role of tenure on safe behaviors might be implicated directly or indirectly through its mediation of safety climate. Therefore, the possibility of an association between tenure and safe behaviors is an important area for further research.

      Unit-level safety communication

      Our study showed that communication practices regarding safety were reported to be positive in 9% of units, and nurses on these units were 2.04 times more likely to report adherence to recommended use of FPE. Examples of good within-unit communication practices include regular opportunities for open communication between frontline managers and staff, positive expectations and actions on promoting safety by frontline managers, and nonpunitive feedback on errors related to safety. Such findings add to the safety climate literature by proposing that in addition to organization-level relationships,
      • Zohar D.
      Safety climate in industrial organizations: theoretical and applied implications.
      • Paine L.A.
      • Rosenstein B.J.
      • Sexton J.B.
      • Kent P.
      • Holzmueller C.G.
      • Pronovost P.J.
      Assessing and improving safety culture throughout an academic medical center: a prospective cohort study.
      unit-level safety climate relationships with safe behaviors also exist. These relationships support theories that propose that workers' safe behaviors vary within a hospital, and are in part influenced by different unit environments, as well as each unit's frontline managerial staff and their performance expectations.
      • Campbell E.G.
      • Singer S.
      • Kitch B.T.
      • Iezzoni L.I.
      • Meyer G.S.
      Patient safety climate in hospitals: act locally on variation across units.
      • Zohar D.
      • Livne Y.
      • Tenne-Gazit O.
      • Admi H.
      • Donchin Y.
      Healthcare climate: a framework for measuring and improving patient safety.
      Furthermore, these findings highlight the importance of good within-unit communication practices in fostering a strong safety climate and a positive commitment to safe behaviors.
      The association between unit-level communication perceptions and adherence to FPE has important implications for policy decisions and setting priorities for interventions targeted at improving adherence to FPE. Although some top-down, organization-wide interventions have been effective in improving communication,
      • Paine L.A.
      • Rosenstein B.J.
      • Sexton J.B.
      • Kent P.
      • Holzmueller C.G.
      • Pronovost P.J.
      Assessing and improving safety culture throughout an academic medical center: a prospective cohort study.
      research has found frontline managerial staff to be significant mediators in the implementation of such interventions.
      • Birken S.A.
      • Lee S.Y.D.
      • Weiner B.J.
      Uncovering middle managers' role in healthcare innovation implementation.
      • Zohar D.
      • Luria G.
      Group leaders as gatekeepers: testing safety climate variations across levels of analysis.
      For instance, a study comparing organization- to group-level managerial outcomes found frontline managerial staff to be more effective than organizational leaders in promoting safe behaviors.
      • Zohar D.
      • Luria G.
      A multilevel model of safety climate: cross-level relationships between organization and group-level climates.
      Within their own units, frontline managers have the opportunity to interact with their staff on a regular basis. Due to these close interactions, frontline managers have the ability to listen to workers' concerns, exchange information, offer feedback, and ultimately mitigate immediate consequences as part of their daily routine.
      • Neal A.
      • Griffin M.A.
      A study of the lagged relationships among safety climate, safety motivation, safety behaviour, and accidents at the individual levels and group levels.
      • Hofmann D.
      • Stetzer A.
      A cross-level investigation of factors influencing unsafe behaviours and accidents.
      • Birken S.A.
      • Lee S.Y.D.
      • Weiner B.J.
      Uncovering middle managers' role in healthcare innovation implementation.
      • Hofmann D.
      • Morgeson F.P.
      Safety-Related Behaviour as a Social Exchange: the role of perceived organizational support and leader-member exchange.
      In turn, actions mediated by frontline managers have been shown to produce more frequent and immediate positive outcomes when compared with those of top managerial staff.
      • Zohar D.
      • Luria G.
      Group leaders as gatekeepers: testing safety climate variations across levels of analysis.
      Frontline managers have also been found to be important mediators in the dissemination of information about policy and innovation implementation.
      • Birken S.A.
      • Lee S.Y.D.
      • Weiner B.J.
      Uncovering middle managers' role in healthcare innovation implementation.
      Often, managers translate organizational strategies into clinically relevant terms so they can be implemented by workers. Furthermore, each frontline manager may interpret safety policies and procedures differently depending on the job tasks, environments, and performance expectations within each unit.
      • Zohar D.
      • Luria G.
      A multilevel model of safety climate: cross-level relationships between organization and group-level climates.
      • Birken S.A.
      • Lee S.Y.D.
      • Weiner B.J.
      Uncovering middle managers' role in healthcare innovation implementation.
      • Hofmann D.
      • Morgeson F.P.
      Safety-Related Behaviour as a Social Exchange: the role of perceived organizational support and leader-member exchange.
      Differences in interpretation and dissemination of such strategies could therefore affect how a particular group of workers perceive a policy, and consequently, their decision to engage in safe work behaviors.
      • Campbell E.G.
      • Singer S.
      • Kitch B.T.
      • Iezzoni L.I.
      • Meyer G.S.
      Patient safety climate in hospitals: act locally on variation across units.
      • Zohar D.
      • Luria G.
      A multilevel model of safety climate: cross-level relationships between organization and group-level climates.
      • Birken S.A.
      • Lee S.Y.D.
      • Weiner B.J.
      Uncovering middle managers' role in healthcare innovation implementation.
      This creates a potential for discrepancy between formal and executed policy, and may result in workers of particular units becoming misinformed about the organization's priorities.
      • Zohar D.
      Safety climate and beyond: a multi-level multi-climate framework.
      The discrepancy between formal and executed policy has been observed in medium-sized manufacturing plants,
      • Zohar D.
      • Luria G.
      A multilevel model of safety climate: cross-level relationships between organization and group-level climates.
      and may be attributed to organization guidelines being vague in defining the roles, goals, and expectations of unit managers.
      • Hofmann D.
      • Morgeson F.P.
      Safety-Related Behaviour as a Social Exchange: the role of perceived organizational support and leader-member exchange.
      To align unit managers to the organizations' priorities, policies need to have flexibility. For example, a policy regarding training and fit testing could set frequency guidance but specify that unit managers can conduct training and fit testing more frequently according to the specific context of the unit. Policies should also include leadership training and development programs for unit managers to promote leadership styles that foster open and frequent communication.
      • Griffin M.A.
      • Hu X.
      How leaders differentially motivate safety compliance and safety participation: the role of monitoring, inspiring and learning.
      • Clarke S.
      Safety leadership: a meta-analytic review of transformational and transactional leadership styles as antecedents of safety behaviours.
      The role of open and frequent communication regarding the organizations' commitment to safety has been reported in the literature to be positively associated with safe work behaviors.
      • Griffin M.A.
      • Hu X.
      How leaders differentially motivate safety compliance and safety participation: the role of monitoring, inspiring and learning.
      Given the association between unit-level safety communication and adherence to FPE demonstrated in this study, interventions targeted at improving frontline managers' communication may be an effective way to address long-standing suboptimal adherence rates.

      Limitations

      There are 3 main limitations to this study. First, the use of a cross-sectional study design precludes the determination of causality. Because this study used self-report data, subject recall and social desirability bias may have been a problem. Second, the study sample, consisting of nurses in acute care hospitals located in Toronto, Canada, may also limit the generalizability of the findings to all health professionals, other types of health care organizations, or different geographic locations. Third, dichotomization of unit-level data led to low event rates for certain unit-level safety climate dimensions. The low event rate required a cutoff of 50%, instead of 60%, which is recommended in the literature. Where response rates >60% are said to be representative of a unit's culture or climate,
      • Pronovost P.
      • Sexton B.
      Assessing safety culture: guidelines and recommendations.
      • Sexton K.B.
      • Berenholtz S.M.
      • Goeschel C.A.
      • Watson S.R.
      • Holzmueller C.G.
      • Thompson D.A.
      • et al.
      Assessing and improving safety climate in a large cohort of intensive care units.
      the range between 50% and 60% could be seen as important because it represents a transition zone where individual options begin to come together to create a climate of safety. Lastly, the low number of hospital units (6 hospitals) in this study limited the ability to calculate interclass correlation coefficients (ICCs).
      • Sherbaum C.A.
      • Ferreter J.M.
      Estimating statistical power and required sample sizes for organizational research using multilevel modeling.
      ICCs represent the percentage of total variance explained by individual, unit, and hospital levels, and help determine if a statistically significant variation has practical significance.
      • Hofmann D.
      • Stetzer A.
      A cross-level investigation of factors influencing unsafe behaviours and accidents.
      • Schwendimann R.
      • Zimmermann N.
      • Küng K.
      • Ausserhofer D.
      • Sexton B.
      Variation in safety culture dimensions within and between US and Swiss hospital units: an exploratory study.
      Future studies with larger sample sizes could use ICCs to examine both the significance and magnitude of the effect of unit variation on the adherence to FPE.

      Conclusions

      This study highlights the significance of the unit of work on nurses' perceptions of safety climate, and their self-reported adherence to recommended use of FPE. Findings demonstrate that units vary significantly in terms of adherence and safety climate dimensions and suggest that aggregated, unit-level perceptions of communication practices regarding safety and availability of FPE were associated with nurses' self-reported adherence to FPE. These results add to the safety climate literature by establishing an association between unit-level safety climate dimensions and adherence to safe work behaviors. This association supports unit-level interventions to be important; specifically, interventions led by frontline managers to improve unit communication practices regarding safety. These interventions could assist in improving safe work behaviors and practices, reduce occupational transmission of communicable respiratory illness, and better protect our health care workers.

      Acknowledgments

      The authors thank Helen Kelly, MScN, clinical research manager, Collaborative Academic Practice, at University Health Network for her assistance with ethics and administrative approvals. The authors also thank Lisa Wang, MSc, biostatistician, Ontario Cancer Institute, for statistical support and consultation.

      References

        • Lowe A.
        • Wilder-Smith A.
        Infectious respiratory illnesses and their impact on healthcare workers: a review.
        Ann Acad Med. 2005; 31: 105-110
        • Public Health Agency of Canada
        Routine practices and additional precautions for preventing the transmission of personal protective equipment: revision of isolation and precaution techniques.
        Public Health Agency of Canada, Ottawa, Canada1999 (Available from:) (Accessed July, 2014)
        • Gammon J.
        • Morgan-Samuel H.
        • Gould D.
        A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions.
        J Clin Nurs. 2008; 17: 157-167
        • Hu X.
        • Zhang Z.
        • Li N.
        • Liu D.
        • Zhang L.
        • He W.
        • et al.
        Self-reported use of personal protective equipment among Chinese critical care clinicians during 2009 H1N1 influenza pandemic.
        PLoS One. 2012; 7: 1-7
        • Nichol K.
        • McGeer A.
        • Bigelow P.
        • O'Brien-Pallas L.
        • Scott J.
        • Holness L.
        Behind the mask: Determinants of nurse's adherence to facial protective equipment.
        Am J Infect Control. 2013; 41: 8-13
        • Reid S.M.
        • Farion K.J.
        • Suh K.N.
        • Audcent T.
        • Barrowman N.J.
        • Plint A.C.
        Use of personal protective equipment in Canadian pediatric emergency departments.
        Can J Emerg Physicians. 2011; 13: 71-78
        • Mitchell R.
        • Ogunremi T.
        • Astrakianakis G.
        • Bryce E.
        • Gervais R.
        • Gravel D.
        • et al.
        Impact of the 2009 Influenza A (H1N1) pandemic on Canadian healthcare workers: a survey on vaccination, illness, absenteeism, and personal protective equipment.
        Am J Infect Control. 2012; 40: 611-616
        • Yassi A.
        • Moore D.
        • Fitzgerald J.
        • Bigelow P.
        • Hon C.
        • Bryce E.
        Research gaps in protective healthcare workers from SARS and other respiratory pathogens: an interdisciplinary, multi-stakeholder, evidence-based approach.
        J Occup Environ Med. 2005; 47: 41-50
        • Registered Nurses Association of Ontario
        SARS unmasked: final report on the nursing experience with SARS in Ontario registered nurses association of Ontario.
        2004 (Available from:) (Accessed July 2014)
        • Gershon R.
        • Stone P.W.
        • Zelster M.
        • Faucet J.
        • Macdavitt K.
        • Chou S.
        Organizational climate and nurse health outcomes in the United States: a systematic review.
        Ind Health. 2007; 45: 622-636
        • Neal A.
        • Griffin M.A.
        A study of the lagged relationships among safety climate, safety motivation, safety behaviour, and accidents at the individual levels and group levels.
        J Appl Psychol. 2006; 91: 946-953
        • Gershon R.
        • Stone P.W.
        • Bakken S.
        • Larson E.
        Measurement of organizational culture and climate in healthcare.
        J Nurs Adm. 2004; 34: 33-40
        • Zohar D.
        Safety climate and beyond: a multi-level multi-climate framework.
        Safety Sci. 2008; 46: 376-387
        • DeJoy D.M.
        • Murphy L.R.
        • Gershon R.M.
        The influence of employee, job/task, and organizational factors on adherence to universal precautions among nurses.
        Int J Ind Ergonomics. 1995; 16: 43-55
        • Hofmann D.
        • Stetzer A.
        A cross-level investigation of factors influencing unsafe behaviours and accidents.
        Personnel Psychol. 1996; 49: 307-339
        • Zohar D.
        Safety climate in industrial organizations: theoretical and applied implications.
        J Appl Psychol. 1980; 65: 96-102
        • Campbell E.G.
        • Singer S.
        • Kitch B.T.
        • Iezzoni L.I.
        • Meyer G.S.
        Patient safety climate in hospitals: act locally on variation across units.
        Jt Comm J Qual Patient Safety. 2010; 36: 319-327
        • Zohar D.
        • Livne Y.
        • Tenne-Gazit O.
        • Admi H.
        • Donchin Y.
        Healthcare climate: a framework for measuring and improving patient safety.
        Crit Care Med. 2007; 35: 1312-1317
        • Schwendimann R.
        • Zimmermann N.
        • Küng K.
        • Ausserhofer D.
        • Sexton B.
        Variation in safety culture dimensions within and between US and Swiss hospital units: an exploratory study.
        BMJ Qual Saf. 2013; 22: 32-41
        • Moore D.M.
        • Gilbert M.
        • Saunders S.
        • Bryce E.
        • Yassi A.
        Occupational health and infection control practices related to Severe Acute Respiratory Syndrome.
        J Am Assoc Occup Nurs. 2005; 53: 257-266
        • Gershon R.
        • Karkashian C.D.
        • Grosch J.W.
        • Murphy L.R.
        • Escamilla-Cejudo A.
        • Flanagan P.
        • et al.
        Hospital safety climate and its relationship with safe work practices and workplace exposure incidents.
        Am J Infect Control. 2000; 28: 211-221
      1. SPSS. Version 21.0.0.0. International Business Machines Corporation, Armonk, NY2012
        • Ausserhofer D.
        • Schubert M.
        • Desmedt M.
        • Blegen M.A.
        • De Geest S.
        • Schwendimann R.
        The association of patient safety climate and nurse-related organizational factors with selected patient outcomes: a cross-sectional survey.
        Int J Nurs Stud. 2013; 50: 240-252
      2. HLM for Windows. Version 7.01. Scientific Software International, Stokie, IL2013
      3. R. Version 3.1.0. The R Foundation for Statistical Computing, Vienna, Austria2014
        • Hosmer D.
        • Lemeshow S.
        Applied logistic regression.
        2nd ed. John Wiley & Sons, Inc, New York [NY]2000
        • Clarke S.P.
        • Sloane D.M.
        • Aiken L.H.
        Effects of hospital staffing and organizational climate on needlestick injuries to nurses.
        Am J Public Health. 2002; 92: 1115-1119
        • Taylor J.A.
        • Dominici F.
        • Agnew J.
        • Gerwin D.
        • Morlock L.
        • Miller M.R.
        Do nurse and patient injuries share common antecedents? an analysis of associations with safety climate and working conditions.
        BMJ Qual Saf. 2012; 21: 101-111
        • Hall M.L.
        • Doran D.
        • Pink G.H.
        Nurse staffing models, nursing hours, and patient safety outcomes.
        J Nurs Adm. 2004; 34: 41-45
        • Gershon R.
        • Vlahov D.
        • Felknor S.
        • Velsey D.
        • Johnson P.
        • Delclos G.
        • et al.
        Compliance with universal precautions among healthcare workers at three regional hospitals.
        Am J Infect Control. 1995; 23: 225-236
        • Beus J.M.
        • Bergman M.E.
        • Payne S.C.
        The influence of organizational tenure on safety climate strength: a first look.
        Accid Anal Prev. 2010; 42: 1431-1437
        • Abrahamson K.
        • Ramanujam R.
        • Anderson J.G.
        Co-worker characteristics and nurses' safety-climate perceptions.
        Int J Healthcare Qual Assurance. 2013; 26: 447-454
        • Zohar D.
        • Luria G.
        A multilevel model of safety climate: cross-level relationships between organization and group-level climates.
        J Appl Psychol. 2005; 90: 616-628
        • Paine L.A.
        • Rosenstein B.J.
        • Sexton J.B.
        • Kent P.
        • Holzmueller C.G.
        • Pronovost P.J.
        Assessing and improving safety culture throughout an academic medical center: a prospective cohort study.
        Qual Saf Healthcare. 2010; 19: 547-554
        • Birken S.A.
        • Lee S.Y.D.
        • Weiner B.J.
        Uncovering middle managers' role in healthcare innovation implementation.
        Implement Sci. 2012; 7: 1-12
        • Zohar D.
        • Luria G.
        Group leaders as gatekeepers: testing safety climate variations across levels of analysis.
        Appl Psychol. 2010; 59: 647-673
        • Hofmann D.
        • Morgeson F.P.
        Safety-Related Behaviour as a Social Exchange: the role of perceived organizational support and leader-member exchange.
        J Appl Psychol. 1999; 84: 286-296
        • Griffin M.A.
        • Hu X.
        How leaders differentially motivate safety compliance and safety participation: the role of monitoring, inspiring and learning.
        Safety Sci. 2013; 60: 196-202
        • Clarke S.
        Safety leadership: a meta-analytic review of transformational and transactional leadership styles as antecedents of safety behaviours.
        J Occup Organizational Psychol. 2013; 86: 22-49
        • Pronovost P.
        • Sexton B.
        Assessing safety culture: guidelines and recommendations.
        Qual Saf Healthcare. 2005; 14: 231-233
        • Sexton K.B.
        • Berenholtz S.M.
        • Goeschel C.A.
        • Watson S.R.
        • Holzmueller C.G.
        • Thompson D.A.
        • et al.
        Assessing and improving safety climate in a large cohort of intensive care units.
        Crit Care Med. 2011; 39: 934-939
        • Sherbaum C.A.
        • Ferreter J.M.
        Estimating statistical power and required sample sizes for organizational research using multilevel modeling.
        Organ Res Met. 2009; 12: 347-367