Safety culture in residential aged care facilities: an integrative review

Objectives: Safety culture is studied frequently in hospitals, where measurement is used for regulatory and accreditation purposes, quality improvement, research and as a proxy to monitor patient safety. The concept of safety culture has relevance to aged care and focuses on organisational norms, values and behaviours that explicitly relate to clinical and patient safety within Residential
aged care facilities (RACFs). A synthesis of research on safety culture in RACFs provides a representation of how culture is related to care quality, including in outcomes for both residents and staff. In this study, we reviewed diverse studies of safety culture in RACFs. An integrative review design was used to comprehensively examine how safety culture is understood and studied in
RACFs, and the interventions used by RACFs to improve safety culture.
Methods: Five academic databases (Ovid Medline, Scopus, PsycInfo, CINAHL and Embase) were searched using keywords for safety culture and residential aged care facilities, in April 2022. Article information was extracted that was relevant to the review objectives including each study’s publication details; facet of culture being studied; context; design; determinants of culture; culture change intervention framework; and implementation determinants. Findings were inductively coded and classified into one of three categories: describing safety culture, exploring relationships with other variables, or an intervention to improve safety culture.
Results: A total of forty-one studies were included in the review. Most studies (n=34, 82.9%) exclusively used the term “culture” to distinguish the conceptual focus of the study, while five (12.2%) used the term “climate”, and two (4.9%) used both. “Safety culture” (n=32, 78.0%) was considerably the most frequent facet of culture studied, followed with far fewer studies focusing on “safety climate” (n=6) and “treatment culture” (n=3). The vast majority of studies (n=37, 90.2%) utilised a quantitative approach, while one (2.4%) study was qualitative, and three studies used mixed methods (7.3%). Surveys were the most common method of data collection (either quantitative or mixed methods), reported in thirty-nine (95.1%) studies. The primary purpose ofeach study was also classified: twelve (29.3%) studies aimed at describing the safety culture within RACFs, while twenty-seven (65.9) attempted to understand the relationship between culture and other variables, and only two (4.9%) evaluated an intervention to improve culture.
Conclusion: This review presented an integrative approach which allowed for the synthesis of findings from studies focused on understanding the relationship between the safety culture of RACFs and other factors (e.g. clinical care processes, person centred care, facility level characteristics). Although studies in this review overwhelmingly used surveys to assess safety culture, a range of different survey tools and conceptual frameworks were utilised to understand and assess the concept of safety culture in RACFs. Findings demonstrated safety culture in RACFs as less advanced than in other healthcare settings, and heterogeneity in how culture was demarcated, conceptualised, and operationalised throughout the included studies contributed to mixed findings. Implications for future research and evaluation on safety culture in RACFs will be discussed.