Patient safety culture in the emergency medical services : the patients, students, and professionals' perspective

Patient safety culture (PSC) is a complex phenomenon, and it is important to understand, especially in prehospital settings where the working conditions are more unpredictable than in other healthcare settings. Knowledge and understanding of PSC can help enhance and develop patient safety in emergency medical services (EMS) at the organisational, team, and even individual levels. Therefore, this study aims to describe how PSC manifests in Finnish EMS from the patient, prehospital nursing students, EMS personnel, and EMS management perspective. The study consisted of four sub studies. All the data used in this study was collected between 2018 and 2021. EMS patients in study I were encountered and transported by the EMS after calling to the emergency medical communication centre (EMCC). EMS professionals in study II were recruited via social media aiming to achieve EMS personnel working full- or part-time in the EMS from different areas in Finland. Final year prehospital nursing students in study III were recruited from three different University of Applied Sciences. EMS managers and medical directors in study IV were recruited from five healthcare districts to participate the study. Participants job descriptions should include managerial/supervisor responsibilities. Results of this thesis were analysed using qualitative (I, III and IV) and statistical analysis methods (II). Interviews were analysed using inductive content analysis in study I while (reflexive) thematic analysis was used in studies III and IV. In study II, confirmatory factor analysis (CFA) was conducted to validate the EMS safety attitudes questionnaire (EMS-SAQ) in a Finnish setting. Connections between individual and organisation-based characteristics and six safety culture domains (safety climate, job satisfaction, perceptions of management, teamwork climate, working conditions, and stress recognition) were explored by using appropriate non-parametric tests. Altogether, 384 persons participated in the four studies conducted. Of those participants, 21 were patients (I), 327 were EMS professionals (II), 17 were prehospital nursing students (III), and were 19 EMS managers and medical directors (IV). According to the findings of qualitative studies (studies I, III, IV), PSC in EMS forms the operational environment, behaviour, attitudes, and feelings. The changing working and operational environment was highlighted when patients, prehospital nursing students, EMS managers, and medical directors described their experiences or views of patient safety issues in EMS. EMS managers and medical directors considered patient safety an organisational responsibility, but according to the students, there was lack of reporting patient safety events. The EMS personnel and EMS managers’ and medical directors’ interaction skills and behaviour were highlighted when EMS professionals and students described PSC in EMS. Also, patients highlighted the meaning of EMS personnel behaviour when patients described their experiences regarding safety in the EMS. Feelings and assumptions also have connection to experienced PSC in the EMS. According to the CFA results, the EMS-SAQ model fit was not totally optimal, and the correlations between five out of the six factors were high. The total mean scores for each safety culture domain were identified as non-positive. Within the individual characteristics, only education level was linked with significant variation in safety culture scores. All organisation-based characteristics were connected in significant variation in at least one safety culture domain scores. Changing working and operational environment in the EMS clearly manifests circumstances where EMS operates and is linked to the PSC in EMS. However, the nature of the EMS missions could affect the patient participation to develop patient safety in EMS. Attitudes and behaviour are seemingly in connection to PSC in EMS from the patients, students, and EMS professionals’ perspective. EMS does not always seem to be a psychologically safe environment for EMS patients, prehospital nursing students and EMS professionals. Overall, it looks like PSC in Finnish EMS is not optimal and needs development.