Análisis del mercado

Using codified knowledge laid down in protocols relies on the individual making sense of the information in the context in which it is applied (Li et al., 2009). Kitsonet al. (1998) defined context as the environment or setting in which people receive healthcare services. The importance of context has been recognised as an important factor that needs to be considered when putting evidence-based protocols and guidelines into practice (Greenhalgh et al., 2004; Grol and Grimshaw, 2003).

Context takes into account organisational culture, which is defined simply as‘‘the way things are done around here’’ (Drennan, 1992). Organisational culture can affect efforts to implement change (Ferlie and Shortell, 2001) and implementation strategies that work in one context may not work in a different setting with a different context (Schultz and Kitson, 2010). Several tools have been developed to measure the safety culture within an organisation through workforce perceptions.

Colla et al. (2005) carried out a systematic review of the quantitative tools available to measure an organisation’s safety culture in healthcare. The authors identified five domains (safety dimensions) common to each tool. This included leadership, policies and procedures, staffing, communication and reporting. Management was missing as a domain, yet this has been identified as a vital element of a positive health and safety culture within the organisational management literature (Guldenmund, 2000). A later systematic review of healthcare studies by Flin et al. (2006) identified important domains as management/supervisors, safety systems, risk perception, job demands, reporting/speaking up, safety attitudes/behaviours, communication and feedback, teamwork, personal resources and organisational factors. Their review identified a much broader number of dimensions than the review by Collaet al.(2005). It is unclear whether the domain of management/supervisors covers aspects such as commitment and leadership.

Some of the domains identified from the organisational literature as being important determinants of a positive safety culture were missing from the systematic reviews discussed above. Competence was not identified as a domain, yet this was identified as an important influence in a review by Flin et al. (2000) and relates to knowledge, skills and training. Priority of safety was not identified as a domain in the healthcare reviews by Collaet al. (2005) or Flin et al.(2006). Within the organisational literature, pressure to achieve a high work load has been implicated in accident causation and dangerous practices may be encouraged by management even though they contradict formal safety policies (Flinet al., 2000).

In a climate of cost reduction and organisational restructuring, work pressure is likely to impact on the safety culture as time and resources become stretched. Employees may then take short-cuts due to time pressure (Flin et al., 2000). Neither of the two reviews within the healthcare literature (Collaet al., 2005; Flin et al., 2006) identified roles and responsibilities, yet uncertainties in roles and responsibilities can lead to accidents and accountability is considered important (Gadd and Collins, 2002). Risk perception was not mentioned by Colla et al. (2005), whilst Flin et al. (2006) acknowledge that their review did not include attitudes to risk. Risk perception has been identified as an important factor in decision making (Guldenmund, 2000). Compliance with procedures/rules did not emerge as a domain in either review, although Flin et al. (2006) identified two studies which measured whether unsafe practices were corrected by supervisors and/or workmates. Lack of compliance with procedures can give insight to the lack of management commitment given to safety (Flin et al., 2000). Lastly, workforce participation or involvement in safety was not identified in either review. This is the process whereby employees are involved in decision making, such as the development of protocols or monitoring compliance with them. Participation or involvement allows workers to take ownership and responsibility for safety and is a key motivational tool used in organisational studies (Shearn, 2004).

Verhoeven et al. (2010) reported their findings from a multi-phase study which used healthcare professionals to adapt expert-driven paper based MRSA guidelines in the design of a website for the communication of the existing

guidelines. The study was part of a wider Dutch-German study for the prevention and control ofmethicillin-resistantStaphylococcus aureus(Friedrichet al., 2008). In the development phase of the study, 28 healthcare workers (doctors, nurses and nursing assistants) were asked to ‘think aloud’ about MRSA tasks, before and after the development of the web-based guidelines. The tacit assumptions of healthcare professionals were taken into account during the design of the web- based MRSA guidelines (See p.71 for explanation of tacit knowledge). The authors reported that the findings not only provided improved means of communicating the guidelines, but also developed a sense of ownership of the guidelines and a willingness to integrate the guidelines into routine infection control practice (Verhoevenet al., 2009, 2010).

The Department of Health (2008a) recognise the importance of organisational culture in their document Board to Ward: how to embed a culture of HCAI prevention in acute trusts. They suggest six key areas which Trusts should focus on to embed a culture of safety. This includes establishing a clear vision, providing leadership, ensuring staff competence and measuring compliance, communicating accountability and escalation of policies, putting in place an assurance framework, and learning from others. The next section discusses organisation learning and how this can influence the use of infection control protocols and guidelines in practice.