Patient Safety Attitudes Among Respiratory Therapists in Taiwan

Discussion

Our results suggest that the safety attitudes of RTs in Taiwan vary by type of institution, education, experience, and age. The respondents had lower positive-attitude scores with respect to safety climate and work climate than RTs in the United States and other professions in Taiwan.^10,15 The patient safety issue appears to get more emphasis with work experience and age. The RTs working in the medical centers recognized their stress more, but responded low on safety attitude.

The positive-attitude scores on the Safety Attitude Questionnaire reflect how much the employers have emphasized patient safety issues. The questionnaire was originally designed by Sexton, and it is one of the most widely verified psychometric questionnaires on safety attitudes.^10–20 The primary factors associated with patient safety climate are employee attitude toward risks and safety, organizational commitment to safety systems, and managers' attitude toward patient safety.¹⁰ The Safety Attitude Questionnaire is divided into 6 domains to examine clinicians' patient safety attitudes in different dimensions. According to Saxon, the teamwork climate domain examines perceived quality of collaboration between personnel; the job satisfaction domain examines positivity about the work experience; the perception of hospital management domain measures employee approval of managerial action; the safety climate domain measures the employee's perception of a strong and proactive organizational commitment to safety; the work-conditions domain measures the perceived quality of the work environment and logistical support; and the stress-recognition domain examines acknowledgment of how performance is influenced by stressors.¹⁶

There is an association between higher morbidity and mortality and ICU employee work overload, and it has been shown to increase up to 50% in pediatric ICUs when the number of clinicians is reduced by half.^22,23 Therefore, a staff shortage might constitute a threat to patient safety, especially in ICUs. Our survey found that 80% of the RTs in the medical centers reported work overload, with a shortage in the respiratory therapy department. The Taiwan Joint Commission on Hospital Accreditation requires that the ratio of beds to RTs should be 10 to 1 in an ICU, and 30 to 1 in a long-term weaning center.²⁴ The requirement for total RT number is approximately 3,500. However, currently only 1,600 RTs are registered with the licensing board. Patients might not receive appropriate care at times when RTs have to cover many areas due to the shortage. With the combination of low patient safety attitudes and shortages, the quality of patient care might be insufficient.

Although RTs have an important role in critical care, the number of RTs working in the ICUs is small. Additionally, the respiratory care profession is still in the process of developing in Taiwan. Some RTs are managed under departments of pulmonary medicine, internal medicine, nursing, or intensive care. RTs work as floaters in the ICUs and on the floors, with heavy work load, and sometimes they work in multiple units. Under those circumstances, RTs have fewer resources and lack formal channels for problem-solving when patient safety issues occur. Not being taken into account as part of the critical care team might have contributed to the low perception-of-hospital-management scores, which were far lower than the responses by nurses and physicians.

A recent large survey by Lee et al¹⁵ with the Chinese version of the Safety Attitude Questionnaire collected responses from approximately 40,000 medical and administrative staff in Taiwan, and found a 30–50% positive response rate. In comparison to other professions in Taiwan, the RTs responded much lower on their perceptions of management (24% vs 42%), followed by safety climate (21% vs 37%). The low perception-of-hospital-management score might be attributable to the fact that RTs are managed under other professions.

Kaya et al studied clinicians' perceptions in a neonatal ICU and their implications for team training in that environment,¹⁹ and found that stability of the team members is considered necessary for patient care conditions. A respondent wrote that “when there was a problem with one member or one person in the system, teamwork suffered.” When RTs are not available for the critical care team in Taiwan, the safety and quality of patient care may be reduced.

Work overload might be a contributing factor to the low scores on job satisfaction and teamwork climate given by Taiwanese RTs. According to the American Association for Respiratory Care Uniform Reporting Manual, RTs in the United States are assigned approximately 40–50 procedures per 12-hour shift.²⁵ In comparison, RTs in Taiwan have more than 60 procedures per 8-hour shift, including aerosol therapy, bronchial hygiene, ventilation manipulation, weaning parameter check, lung expansion therapy, airway management, and care of tracheostomy. In general, a Taiwanese RT provides care for more than 13 ventilator-assisted patients in an ICU in a medical center, or 30 ventilated patients in a chronic respiratory weaning center.

RTs in the Huang et al study had much higher job satisfaction and much lower perception of management.⁹ The implementation of RT-driven protocols might have contributed to greater job satisfaction in their data. With the RT-driven protocol, RTs assess and treat according to the patient's needs, so care is more dynamic, with more adjustment of respiratory care services. On the other hand, without the RT-driven protocol, the RTs have to perform some unnecessary treatments, and job satisfaction is reduced by work-related physical exhaustion.

The healthcare system in Taiwan provides comprehensive healthcare services for ventilator-dependent patients. RTs in the 3 different types of hospitals responded differently about safety attitudes. Patients in the medical centers usually have acute severe illness, so the medical center RTs have higher stress. The medical center RTs had higher positive scores on stress recognition and lower scores on the other domains. On the other hand, the patients in the regional and district hospitals are in step-down units and have stable disease status. Furthermore, with smaller teams the communication is much easier, vertically and horizontally, so the RTs in the regional and district hospitals had higher positive-attitude scores on most domains.

In Taiwan the healthcare field is dominated mainly by women, who are thought to be more patient and detail-oriented in Chinese culture. RTs registered with the RT licensure board have an 18 to 1 female to male ratio. Male RTs who weren't satisfied with the work conditions or had higher stress might have left the field, so the male RTs remaining in the field responded with higher positive scores. Education level correlated with attitudes about stress response and perception of management. Another study found that higher-level employees have higher stress recognition.¹⁵ Patient safety issues might be managed better when the employees are better able to recognize their own stresses.