Exploring leadership perspectives on the dual responsibility of Health, Safety and Environment, and Quality and Patient Safety: A single embedded case study
Original version
Exploring leadership perspectives on the dual responsibility of Health, Safety and Environment, and Quality and Patient Safety: A single embedded case study by Malin Rosell Magerøy, Stavanger : University of Stavanger, 2024 (PhD thesis UiS, no. 811)Abstract
Introduction: Healthcare leaders play an important role in managing responsibilities and requirements for patients, employees and the quality and safety of the provided services. Different legislations regulate these responsibilities, and leaders play a significant role in managing the dual responsibility for health, safety, and environment (HSE), and quality and patient safety (QPS). HSE regulations encompass health, safety, and welfare for employees, while QPS includes patient safety, quality of service delivery, clinical effectiveness, and patient experience. Keeping both patients and employees safe in healthcare is crucial, but there are complex interactions we do not know enough about between these two arenas of safety management, and research and practical experience show that it is necessary to understand HSE and QPS in a holistic way, as they can affect each other and generate conflicts of interest. There is knowledge that leadership can have a significant effect on patient safety culture and work engagement, and hierarchical leadership levels and organizational factors can affect leadership approaches, and thus the outcome for HSE and QPS, but there is not a clear understanding of leaders’ perspectives and the strategies they enact regarding this duality.
Aim: The overall aim of this thesis was to explore how leaders at different system levels in primary healthcare interpret, negotiate, and manage the dual responsibility and possible tensions between HSE and QPS. The aim was to develop new knowledge about leaders’ experience of this dual responsibility in a nursing home setting, identifying the support available or needed by the leaders, and the enablers and barriers in the process of handling the dual responsibility of HSE and QPS. Additionally, a goal was to explore whether the different hierarchical leadership levels experience the same enablers and barriers, and whether policy plans and regulations made at the macro level are known, used, and understood by the lower leadership levels in the organization.
Methods: To examine the issues discussed above, a single embedded case study was conducted. The case was defined as the two perspectives of safety: HSE and QPS in nursing homes. The embedded units involve three levels of stakeholders. The macro level consisted of politicians and the municipality director, director of health and welfare, and head of health and care services (top-level leaders). The meso level consisted of head of nursing homes (mid-level leaders), and the micro level consisted of department leaders in nursing homes (frontline leaders). Five municipalities differing in size and type of location (urban/rural) participated in this study, and the case study was divided into three substudies. Data was consisted of 40 individual interviews with leaders, five focus group interviews with elected politicians, and collected policy documents and guidelines regarding HSE and QPS. Data was analyzed using thematic analysis and qualitative content analysis.
Results: Sub-study I (macro level) explored how healthcare leaders and elected politicians organize, control, and follow up the work of HSE and QPS. Five themes were identified as significant: 1. Establish frameworks and room for maneuver in the work with HSE and QPS, 2. Create good routines and channels for communication and collaboration, 3. Build a culture for a health-promoting work environment and patient safety, 4. Create systems to handle the possible tensions in the dual responsibility between caring for employees and quality and safety in service delivery, and 5. Define clear boundaries of responsibility between politics and administration. Sub-study II (meso level) explored how nursing home leaders manage the dual responsibility of HSE and QPS, the approaches they take and the dilemmas they face. Four themes emerged: 1. Establishing good systems and building a culture for a work environment that promotes health and patient safety, 2. Establish channels for internal and external collaboration and communication, 3. Establish room for maneuver to practice leadership, and 4. Recognizing and having the mandate to handle possible tensions in the dual responsibility of HSE and QPS. Sub-study III (micro level) explored the barriers and enablers that department leaders in nursing homes encounter when managing the dual responsibility of HSE and QPS. Four themes was identified: 1. Temporal capacity, 2. Relational capacity, 3. Professional competence, and 4 organizational structure.
Conclusion: The results identified several factors that affected leaders across system levels when enacting their dual responsibility of HSE and QPS. The data shows that both politicians and leaders at all system levels experience tensions in handling the dual responsibility, and that both contextual and internal factors influence their experience. Conflicting interests, such as legislation and economic factors, led to trade-offs at all system levels. Size, location, legislation, and economic situation were the external factors that had the greatest impact, while organization, system, competence, and relations were the internal factors that were most prominent. The findings indicates that relationships are important for leaders at all system levels to maintain HSE and QPS, and that changes in the work system may affect how the work is carried out, and thus affect the outcome. Adapting to changed conditions was a part of all leaders’ everyday life, and good relationships made the adaptations easier, which in turn could influence the outcome. The results indicate that relations are an additional and crucial process component when using a human systems approach, such as the SEIPS model, and that combining the process of relations with the human factors SEIPS model in a resilience perspective has the potential to provide a more holistic view of HSE and QPS.
Has parts
Paper 1: Magerøy, M. R., Braut, G. S., Macrae, C., & Wiig, S. (2023). Healthcare leaders’ and elected politicians’ approach to support-systems and requirements for complying with quality and safety regulation in nursing homes–a case study. BMC Health Services Research, 23(1), 880. https://doi.org/10.1186/s12913-023-09906-6Paper 2: Magerøy, M. R., Macrae, C., Braut, G. S., & Wiig, S. (2024). Managing patient safety and staff safety in nursing homes: exploring how leaders of nursing homes negotiate their dual responsibilities—a case study. Frontiers in Health Services, 4, 1275743. https://doi.org/10.3389/frhs.2024.1275743
Paper 3: Magerøy, M. R., Braut, G. S., Macrae, C., Clay-Williams, R., Braithwaite, J., & Wiig, S. (2024). Leading Quality and Safety on the Frontline – A Case Study of Department Leaders in Nursing Homes. Journal of Healthcare Leadership, 16, 193–208. https://doi.org/10.2147/JHL.S454109