Volume 19, Issue 2 (9-2022)
J Res Dev Nurs Midw 2022, 19(2): 41-44 |
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Nooriani S, Oveisi S, Alizadeh A, Olfati F. Effect of Virtual Collaborative Learning with Mobile Devices on Patient Safety Culture among the Staff of a Maternity Center. J Res Dev Nurs Midw 2022; 19 (2) :41-44
URL: http://nmj.goums.ac.ir/article-1-1299-en.html
URL: http://nmj.goums.ac.ir/article-1-1299-en.html
1- Midwifery Counseling, Student Research Committee Qazvin University of Medical Sciences, Qazvin, Iran
2- Metabolic Diseases Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
3- Medical Microbiology Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
4- 4. Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran, and , papoy6olfati@yahoo.com
2- Metabolic Diseases Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
3- Medical Microbiology Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
4- 4. Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran, and , papoy6olfati@yahoo.com
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Introduction
Improving patient safety is a common international priority because errors and other forms of unnecessary damage to the process of patient care and treatment are global problems. Patient safety includes all measures that are planned and implemented to prevent damage to patients due to medical care (1).
Nearly 10% of hospital admissions lead to adverse events, and about half of them are preventable. About 1 out of every 3 adverse events causes actual damage to patients (2, 3). In a systematic review study in Iran, nearly 1,455 complaints (36%) of the total number of 3,977 complaints were proved to be medical malpractice, and physicians were acquitted in 2,542 (64%) cases. Most complaints were related to gynecologists, accounting for 43% of all complaints (4).
Obstetrics is the leading cause of admissions, triage, and hospital discharge. Appropriately, safety initiatives and the use of quality measures particularly relevant to obstetrics and gynecology are essential for patient satisfaction as well as safe and efficient evidence-based care (5). Three reasons for patient safety in obstetrics; 1. Obstetric admissions are considered a huge part of all patients' hospitalization. 2. The obstetric setting is unique with high families' and patients' expectations and failure to meet these expectations would be a disappointment for healthcare providers. 3. The high economic and emotional cost of the adverse outcomes that occur in obstetric settings (6).
A maternity center is a specialized hospital that provides healthcare for women during pregnancy, delivery, and postpartum periods (7). The existence of a patient safety culture among the staff of an organization significantly affects patient safety. Patient safety culture was introduced by the European Foundation for Quality Management in medical care. It is an integrated model of individual and organizational behavior based on shared beliefs and values that consistently seek to minimize damage to patients (8).
Patient safety culture has been considered an important factor in improving the quality of patient health and safety services (9). Surveys in some regions of Iran and other countries indicate that the culture of safety is currently low and moderate, and efforts should be made to promote it (2, 10, 11). The creation of a safety culture takes a long time and does not happen automatically (12). Patient safety culture training programs are useful for improving patient safety quality (13). There are still few safety culture training programs for midwifery training institutions (14). For improving safety, health systems should have easy access to information (15). A kind of classification divides training into two classes, classical and web-based. Web-based training is a new and active training method to improve the training quality, especially if it is applied as a complement to traditional training to establish the continuity of traditional training. Its benefits include easy access at any time and place, learners' limitless, great participation, and flexibility (16). The presence of educational proposals that are more distant from traditional approaches is an increasingly clear trend (17). One of the educational practices that have been gaining the most recognition in recent times is what is known as collaborative learning (18). The approach is based on the work of two or more people (19). The elements that make up this methodology are diverse. The didactic elements acquire a greater dimension, since they do not correspond to an individual mechanical task, but have to be one of the bases of the symbiosis between the members of the group (20). This pedagogical practice, whose presence in higher education has increased significantly, reinforces human characteristics, to benefits in the state of mind during the process (21). One of the strategies that has been most reinforced or that has accompanied the approaches to collaborative learning is what is known as mobile learning. Information and communication technologies are means associated with new pedagogical approaches, which is classified as an educational innovation. In this case, mobile learning and collaborative learning are closely linked. In recent years, the so-called Mobile Computer-Supported Collaborative Learning has emerged (22). Mobile learning is one of the major evidences that expose the :union: of information and communication technologies and education. Its conception is based on technological devices whose presence in daily life is already natural, and promotes the emergence of a great literary interest in its didactic applications (23).
Given the importance of maternal health according to the Millennium Development Goals, it is essential to address safety and create or maintain a maternal safety culture among maternity center staff. Educational intervention could be an effective strategy to create a patient safety culture. This study was carried out to evaluate the impact of virtual collaborative learning with mobile devices on patient safety culture among the staff in the maternity center.
Methods
This study was conducted on staff working in Kowsar Hospital of Qazvin in 2019 with a pretest-posttest design. Sixty-three eligible participants were recruited using convenience sampling. Inclusion criteria included willingness to participate in the study, employment in a maternity center, access to the internet, ability to use the internet, having an email address or an account in WhatsApp to share learning, and at least a year of work experience as a nurse or midwife. Exclusion criteria were previous participation in similar training sessions and staff transfer.
According to Pakzad et al. (11), at the level of type I error α=0.05, type II error β=0.1, and error d=1.1, the sample size was calculated as 50. Considering 30% dropout, the sample size was calculated 65.
The Hospital Survey on Patient Safety Culture (HSOPSC) was used to estimate the status quo. The HSOPSC was designed by the Agency for Healthcare Research and Quality in 2004 (24) and was translated into Persian by Rahimi et al. (2020) (25). Internal consistency and reliability were evaluated by Cronbach's alpha. The tool consists of 42 items that measure 12 dimensions of patient safety culture. The dimensions of the HSOPSC are as follows: 1) communication openness, 2) feedback and communication about errors, 3) teamwork within units, 4) non-punitive response to error, 5) organizational learning–continuous improvement, 6) supervisor/manager expectations and actions promoting patient safety, 7) staffing, 8) handoffs and transitions, 9) management support for patient safety, 10) frequency of events reported, 11) overall perceptions of patient safety, and 12) teamwork across hospital units (26). The respondents' views using the 5-point Likert scale of agreement from 1 to 5 ("strongly disagree" to "strongly agree") or frequency ranged from 1 to 5 ("never" to "always"). The Cronbach’s alpha coefficient was between 0.57 and 0.8. In the present study, the internal reliability ranged from 0.78 to 0.87.
For educational intervention, the contents of the patient safety booklet available in hospitals (written by the Office of Hospital Management and Clinical Services Excellence of the Ministry of Health) and the book entitled Understanding and managing patient safety risk were used (27). This textbook was approved by five experts in midwifery.
A website with the following details was created for teaching. A domain was purchased with the address pcealborz.ir hosted by Mihan Web Host, the provider of Data Gostar Alborz Service, with the following specifications: 300 MB of space and 20 GB of bandwidth; Linux operating system with Iran hosting location; and 4,096 MB of RAM for visiting and content volume. The Persian web-based WordPress Software ver. 4.9.8 was installed on the main domain and then run. Among default themes, the Hueman theme was selected and installed. The next step was to install the necessary plugins on the counter. Participants registered on the website and completed informed consent and the HSOPSC survey. Participants created an account on WhatsApp. Next, training sessions were held online, a session per week for 8 weeks. A week after the final training session, the educational text was no longer available to participants and those participants completed the questionnaire 2 months later.
At the same time, new content was uploaded to the website, a WhatsApp message was sent to the members. This message contained only the session number and the session link. No content was uploaded on the WhatsApp channel. By clicking on the link, the members could directly link to the relevant training session and read it. The second reminder message was also sent at the end of the week for those who have not yet read the present week's training material. Those members who had read the sessions had to log in on the website at the end of each session, enter their email addresses, and click on the button "I’ve read" at the bottom of the page. A message confirming the attendance of the participants was then sent to the site management. One month later, participants entered the WhatsApp channel and shared/discussed what they had learned on the website (Table 1).
Data were analyzed using SPSS software (version 16) and R (version 4.0.4). Descriptive statistics including mean, standard deviation, median, interquartile range (IQR), frequency, and percentage were used to describe the collected data. According to the type and distribution of variables, paired t-test or Wilcoxon signed-rank test was applied to compare the pre and posttest data. The significance level of the tests was set to less than 0.05.
Results
The mean age of maternity ward staff was 31.9±6.4 years. The mean employment history was 6.8±5.2 years. The mean employment duration in the current ward was 2.5±1.56 years.
At first, the normality of the scores obtained from the studied units was confirmed using the Kolmogorov-Smirnov and Shapiro tests (P>0.05). Of 65 participants, 63 (88%) completed the study. Of all participants, 21 (33.3%) were working in the emergency ward, 18 (28.7%) in the delivery ward, 12 (19%) in the prenatal ward, and 12 (19%) in the postpartum ward.
The results showed that the mean scores of safety culture increased significantly after the intervention (t= -4.46, df=62, P<0.001). Moreover, there were significant differences between mean scores of reporting frequency, organizational learning, intra-organizational teamwork, non-punitive response to errors, teamwork between organizational units, and information exchange and transfer (P<0.05). However, the differences in mean scores of general understanding of patient safety, inferential channel openness, communication, feedback on errors, staff issues, and patient safety management support were not statistically significant (P>0.05) (Table 2).
The intervention significantly increased the error reporting at the center (median of error reporting at pretest = 1, IQR: [1, 2] and at posttest = 2, IQR: [2, 3], P<0.001) (Figure 1).
Discussion
Results of the present study indicated that collaborative learning with mobile devices could improve patient safety culture in maternity center staff. In particular, mean scores of reporting frequency, organizational learning, intra-organizational teamwork, non-punitive response to errors, teamwork between organizational units, and information exchange and transfer changed significantly following the intervention. Costa et al. (2020) concluded that the collaborative learning method associated with mobile learning is more effective for learning didactic programming than the traditional method (28). Some good practices that educational institutions have started to promote are based on the creation of useful methodological principles that converge in a quality, current, and innovative education (29, 30). Pakzad et al. (2016) reported that virtual education could significantly improve the patient safety culture of nurses in educational and medical centers (11). Although the mentioned study and the present study differed in the methods used, both virtual methods could improve the patient safety culture.
In a multicenter interventional study, the improvement of patient safety scores was closely associated with the personnel's behavior. The study concluded that a healthy immune culture could improve patient safety (31).
Mostafaei et al. (2018) stated that improving patient safety should be a major priority for hospital managers and the staff should be encouraged to report errors without fear of punishment and blame. The institutionalization of this issue requires the strong support of senior managers in organizations. The results indicated that teamwork within hospital units (62%) and frequency of adverse event reporting (62%) had the highest scores among safety culture dimensions, while the overall understanding of patient safety (56%) and non-punitive response to errors (58%) received the lowest scores among different aspects of patient safety culture (32). These results are consistent with the present study in terms of error reporting and teamwork but inconsistent in other dimensions.
In a study by Akbari et al. (2017), it was also concluded that labor block personnel were the strongest in teamwork and weakest in error reporting. It was also stated that despite implementing the safety culture protocol in the labor block, there is still a great distance to reach a high level of patient safety. They also recommended that non-midwives working in the labor block should be more involved in this issue, but non-midwives were reluctant to participate in the study in the present research (33).
In our study, only one maternity center was investigated, which is a limitation of the present study. Also, due to the participatory nature of the intervention, we did not have a suitable control group. It is suggested to compare this method with another learning method and a control group in future studies.
Conclusion
Comprehensive programs for patient safety culture improvement can affect the maternity center staff behavior and lead to the promotion of patient safety levels to the highest standard. Given the availability of mobile phones and the Internet, it is suggested to utilize this method in comprehensive programs for patient safety culture improvement. This teaching method could be applied in confinement, allowing the staff to adequately follow the teaching-learning process by utilizing available resources.
Acknowledgements
The present study was extracted from a Master's thesis on midwifery counseling. We are grateful to Qazvin University of Medical Sciences and the maternity center staff in Kowsar Hospital for helping us conduct this research.
Fnding source
The project was supported by the Student Research Committee of Qazvin University of Medical Sciences.
Ethical statement
The present study was conducted after receiving approval from the Ethics Committee of Qazvin University of Medical Sciences (code: IR.QUMS.REC.1396.496). Informed consent was also from participants after ensuring the confidentiality of their information.Conflict of interest
Improving patient safety is a common international priority because errors and other forms of unnecessary damage to the process of patient care and treatment are global problems. Patient safety includes all measures that are planned and implemented to prevent damage to patients due to medical care (1).
Nearly 10% of hospital admissions lead to adverse events, and about half of them are preventable. About 1 out of every 3 adverse events causes actual damage to patients (2, 3). In a systematic review study in Iran, nearly 1,455 complaints (36%) of the total number of 3,977 complaints were proved to be medical malpractice, and physicians were acquitted in 2,542 (64%) cases. Most complaints were related to gynecologists, accounting for 43% of all complaints (4).
Obstetrics is the leading cause of admissions, triage, and hospital discharge. Appropriately, safety initiatives and the use of quality measures particularly relevant to obstetrics and gynecology are essential for patient satisfaction as well as safe and efficient evidence-based care (5). Three reasons for patient safety in obstetrics; 1. Obstetric admissions are considered a huge part of all patients' hospitalization. 2. The obstetric setting is unique with high families' and patients' expectations and failure to meet these expectations would be a disappointment for healthcare providers. 3. The high economic and emotional cost of the adverse outcomes that occur in obstetric settings (6).
A maternity center is a specialized hospital that provides healthcare for women during pregnancy, delivery, and postpartum periods (7). The existence of a patient safety culture among the staff of an organization significantly affects patient safety. Patient safety culture was introduced by the European Foundation for Quality Management in medical care. It is an integrated model of individual and organizational behavior based on shared beliefs and values that consistently seek to minimize damage to patients (8).
Patient safety culture has been considered an important factor in improving the quality of patient health and safety services (9). Surveys in some regions of Iran and other countries indicate that the culture of safety is currently low and moderate, and efforts should be made to promote it (2, 10, 11). The creation of a safety culture takes a long time and does not happen automatically (12). Patient safety culture training programs are useful for improving patient safety quality (13). There are still few safety culture training programs for midwifery training institutions (14). For improving safety, health systems should have easy access to information (15). A kind of classification divides training into two classes, classical and web-based. Web-based training is a new and active training method to improve the training quality, especially if it is applied as a complement to traditional training to establish the continuity of traditional training. Its benefits include easy access at any time and place, learners' limitless, great participation, and flexibility (16). The presence of educational proposals that are more distant from traditional approaches is an increasingly clear trend (17). One of the educational practices that have been gaining the most recognition in recent times is what is known as collaborative learning (18). The approach is based on the work of two or more people (19). The elements that make up this methodology are diverse. The didactic elements acquire a greater dimension, since they do not correspond to an individual mechanical task, but have to be one of the bases of the symbiosis between the members of the group (20). This pedagogical practice, whose presence in higher education has increased significantly, reinforces human characteristics, to benefits in the state of mind during the process (21). One of the strategies that has been most reinforced or that has accompanied the approaches to collaborative learning is what is known as mobile learning. Information and communication technologies are means associated with new pedagogical approaches, which is classified as an educational innovation. In this case, mobile learning and collaborative learning are closely linked. In recent years, the so-called Mobile Computer-Supported Collaborative Learning has emerged (22). Mobile learning is one of the major evidences that expose the :union: of information and communication technologies and education. Its conception is based on technological devices whose presence in daily life is already natural, and promotes the emergence of a great literary interest in its didactic applications (23).
Given the importance of maternal health according to the Millennium Development Goals, it is essential to address safety and create or maintain a maternal safety culture among maternity center staff. Educational intervention could be an effective strategy to create a patient safety culture. This study was carried out to evaluate the impact of virtual collaborative learning with mobile devices on patient safety culture among the staff in the maternity center.
Methods
This study was conducted on staff working in Kowsar Hospital of Qazvin in 2019 with a pretest-posttest design. Sixty-three eligible participants were recruited using convenience sampling. Inclusion criteria included willingness to participate in the study, employment in a maternity center, access to the internet, ability to use the internet, having an email address or an account in WhatsApp to share learning, and at least a year of work experience as a nurse or midwife. Exclusion criteria were previous participation in similar training sessions and staff transfer.
According to Pakzad et al. (11), at the level of type I error α=0.05, type II error β=0.1, and error d=1.1, the sample size was calculated as 50. Considering 30% dropout, the sample size was calculated 65.
The Hospital Survey on Patient Safety Culture (HSOPSC) was used to estimate the status quo. The HSOPSC was designed by the Agency for Healthcare Research and Quality in 2004 (24) and was translated into Persian by Rahimi et al. (2020) (25). Internal consistency and reliability were evaluated by Cronbach's alpha. The tool consists of 42 items that measure 12 dimensions of patient safety culture. The dimensions of the HSOPSC are as follows: 1) communication openness, 2) feedback and communication about errors, 3) teamwork within units, 4) non-punitive response to error, 5) organizational learning–continuous improvement, 6) supervisor/manager expectations and actions promoting patient safety, 7) staffing, 8) handoffs and transitions, 9) management support for patient safety, 10) frequency of events reported, 11) overall perceptions of patient safety, and 12) teamwork across hospital units (26). The respondents' views using the 5-point Likert scale of agreement from 1 to 5 ("strongly disagree" to "strongly agree") or frequency ranged from 1 to 5 ("never" to "always"). The Cronbach’s alpha coefficient was between 0.57 and 0.8. In the present study, the internal reliability ranged from 0.78 to 0.87.
For educational intervention, the contents of the patient safety booklet available in hospitals (written by the Office of Hospital Management and Clinical Services Excellence of the Ministry of Health) and the book entitled Understanding and managing patient safety risk were used (27). This textbook was approved by five experts in midwifery.
A website with the following details was created for teaching. A domain was purchased with the address pcealborz.ir hosted by Mihan Web Host, the provider of Data Gostar Alborz Service, with the following specifications: 300 MB of space and 20 GB of bandwidth; Linux operating system with Iran hosting location; and 4,096 MB of RAM for visiting and content volume. The Persian web-based WordPress Software ver. 4.9.8 was installed on the main domain and then run. Among default themes, the Hueman theme was selected and installed. The next step was to install the necessary plugins on the counter. Participants registered on the website and completed informed consent and the HSOPSC survey. Participants created an account on WhatsApp. Next, training sessions were held online, a session per week for 8 weeks. A week after the final training session, the educational text was no longer available to participants and those participants completed the questionnaire 2 months later.
At the same time, new content was uploaded to the website, a WhatsApp message was sent to the members. This message contained only the session number and the session link. No content was uploaded on the WhatsApp channel. By clicking on the link, the members could directly link to the relevant training session and read it. The second reminder message was also sent at the end of the week for those who have not yet read the present week's training material. Those members who had read the sessions had to log in on the website at the end of each session, enter their email addresses, and click on the button "I’ve read" at the bottom of the page. A message confirming the attendance of the participants was then sent to the site management. One month later, participants entered the WhatsApp channel and shared/discussed what they had learned on the website (Table 1).
Data were analyzed using SPSS software (version 16) and R (version 4.0.4). Descriptive statistics including mean, standard deviation, median, interquartile range (IQR), frequency, and percentage were used to describe the collected data. According to the type and distribution of variables, paired t-test or Wilcoxon signed-rank test was applied to compare the pre and posttest data. The significance level of the tests was set to less than 0.05.
Results
The mean age of maternity ward staff was 31.9±6.4 years. The mean employment history was 6.8±5.2 years. The mean employment duration in the current ward was 2.5±1.56 years.
At first, the normality of the scores obtained from the studied units was confirmed using the Kolmogorov-Smirnov and Shapiro tests (P>0.05). Of 65 participants, 63 (88%) completed the study. Of all participants, 21 (33.3%) were working in the emergency ward, 18 (28.7%) in the delivery ward, 12 (19%) in the prenatal ward, and 12 (19%) in the postpartum ward.
The results showed that the mean scores of safety culture increased significantly after the intervention (t= -4.46, df=62, P<0.001). Moreover, there were significant differences between mean scores of reporting frequency, organizational learning, intra-organizational teamwork, non-punitive response to errors, teamwork between organizational units, and information exchange and transfer (P<0.05). However, the differences in mean scores of general understanding of patient safety, inferential channel openness, communication, feedback on errors, staff issues, and patient safety management support were not statistically significant (P>0.05) (Table 2).
The intervention significantly increased the error reporting at the center (median of error reporting at pretest = 1, IQR: [1, 2] and at posttest = 2, IQR: [2, 3], P<0.001) (Figure 1).
Discussion
Results of the present study indicated that collaborative learning with mobile devices could improve patient safety culture in maternity center staff. In particular, mean scores of reporting frequency, organizational learning, intra-organizational teamwork, non-punitive response to errors, teamwork between organizational units, and information exchange and transfer changed significantly following the intervention. Costa et al. (2020) concluded that the collaborative learning method associated with mobile learning is more effective for learning didactic programming than the traditional method (28). Some good practices that educational institutions have started to promote are based on the creation of useful methodological principles that converge in a quality, current, and innovative education (29, 30). Pakzad et al. (2016) reported that virtual education could significantly improve the patient safety culture of nurses in educational and medical centers (11). Although the mentioned study and the present study differed in the methods used, both virtual methods could improve the patient safety culture.
In a multicenter interventional study, the improvement of patient safety scores was closely associated with the personnel's behavior. The study concluded that a healthy immune culture could improve patient safety (31).
Mostafaei et al. (2018) stated that improving patient safety should be a major priority for hospital managers and the staff should be encouraged to report errors without fear of punishment and blame. The institutionalization of this issue requires the strong support of senior managers in organizations. The results indicated that teamwork within hospital units (62%) and frequency of adverse event reporting (62%) had the highest scores among safety culture dimensions, while the overall understanding of patient safety (56%) and non-punitive response to errors (58%) received the lowest scores among different aspects of patient safety culture (32). These results are consistent with the present study in terms of error reporting and teamwork but inconsistent in other dimensions.
In a study by Akbari et al. (2017), it was also concluded that labor block personnel were the strongest in teamwork and weakest in error reporting. It was also stated that despite implementing the safety culture protocol in the labor block, there is still a great distance to reach a high level of patient safety. They also recommended that non-midwives working in the labor block should be more involved in this issue, but non-midwives were reluctant to participate in the study in the present research (33).
In our study, only one maternity center was investigated, which is a limitation of the present study. Also, due to the participatory nature of the intervention, we did not have a suitable control group. It is suggested to compare this method with another learning method and a control group in future studies.
Conclusion
Comprehensive programs for patient safety culture improvement can affect the maternity center staff behavior and lead to the promotion of patient safety levels to the highest standard. Given the availability of mobile phones and the Internet, it is suggested to utilize this method in comprehensive programs for patient safety culture improvement. This teaching method could be applied in confinement, allowing the staff to adequately follow the teaching-learning process by utilizing available resources.
Acknowledgements
The present study was extracted from a Master's thesis on midwifery counseling. We are grateful to Qazvin University of Medical Sciences and the maternity center staff in Kowsar Hospital for helping us conduct this research.
Fnding source
The project was supported by the Student Research Committee of Qazvin University of Medical Sciences.
Ethical statement
The present study was conducted after receiving approval from the Ethics Committee of Qazvin University of Medical Sciences (code: IR.QUMS.REC.1396.496). Informed consent was also from participants after ensuring the confidentiality of their information.
Conflict of interest
The authors declare that there is no conflict of interest regarding the publication of this article.
Author contributions
Conceptualization: Forouzan olfati, Soheila Nooriani, Sonia Oveisi. Methodology, analysis, research a review: Forouzan olfati, Ahad Alizadeh, Sonia Oveisi.
Type of Study: Original Article |
Subject:
Midwifery
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