Cultural Humility and Hospital Safety Culture

Joshua N. Hook, David Boan, Don E. Davis, Jamie D. Aten, John M. Ruiz & Thomas Maryon

Journal of Clinical Psychology in Medical Settings

ISSN 1068-9583

J Clin Psychol Med Settings DOI 10.1007/s10880-016-9471-x

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1 23 Author's personal copy

J Clin Psychol Med Settings DOI 10.1007/s10880-016-9471-x

Cultural Humility and Hospital Safety Culture

1 2 3 2 Joshua N. Hook • David Boan • Don E. Davis • Jamie D. Aten • 4 5 John M. Ruiz • Thomas Maryon

Ó Springer Science+Business Media New York 2016

Abstract Hospital safety culture is an integral part of error (i.e., mistakes of staff are not held against them), providing high quality care for patients, as well as pro- handoffs and transitions, and organizational learning. The moting a safe and healthy environment for healthcare cultural humility of one’s organization may be an impor- workers. In this article, we explore the extent to which tant factor to help improve hospital safety culture. We cultural humility, which involves openness to cultural conclude by discussing potential directions for future diverse individuals and groups, is related to hospital safety research. culture. A sample of 2011 hospital employees from four hospitals completed measures of organizational cultural Keywords Culture Humility Safety Hospital humility and hospital safety culture. Higher perceptions of Organization Á Á Á Á organizational cultural humility were associated with higher levels of general perceptions of hospital safety, as well as more positive ratings on non-punitive response to Introduction

Patient safety, which refers to the avoidance and prevention & Joshua N. Hook of patient injuries or adverse events resulting from the [email protected] processes of health care delivery, is a critical component of David Boan health care quality. Organizational processes such as safety [email protected] exist within the social context of an organization. This Don E. Davis social context is known as the culture of the organization, [email protected] and hospital safety culture supports or constrains processes Jamie D. Aten that provide for the safety of patients and staff. For [email protected] example, a culture that supports non-punitive error Thomas Maryon reporting is likely to positively affect the safety of patients [email protected] and staff; however, a culture in which staff feel as if their

1 mistakes are held against them may negatively affect Department of Psychology, University of North Texas, 1155 Union Circle #311280, Denton, TX 7520, USA safety. As a result, there has been increased focus among hospitals and health care providers to promote a culture and 2 Department of Psychology, Wheaton College, 501 College Ave., Wheaton, IL 60187, USA environment that prioritizes and values patient safety. This increased focus has led to efforts to assess and measure 3 Department of Counseling and Psychological Services, Georgia State University, 33 Gilmer St. SE, Atlanta, hospital safety culture, such as the Agency for Healthcare GA 30303, USA Research and Quality (AHRQ) Hospital Survey of Patient 4 Department of Psychology, University of Arizona, 1503 E. Safety Culture (Sorra, Famolaro, Yount et al., 2014). University Blvd., Tuscon, AZ 85721, USA Although there have been important advances in regard to 5 Blue Cross/Blue Shield, 1001 E. Lookout Dr., Richardson, the assessment and measurement of hospital safety culture, TX 75082, USA more work is needed to identify characteristics of hospitals

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J Clin Psychol Med Settings that contribute to hospital safety culture. The present in recent years, parallel gains in access and quality across investigation targets cultural humility as one potential groups resulted in continued disparities. People who were characteristic that may be important to hospital safety poor experienced the largest number of disparities, fol- culture. lowed by Blacks and Hispanics (AHRQ, 2015). Brach and Fraserirector (2000) proposed a model that theoretically linked nine aspects of cultural competency to Hospital Safety Culture reduced health disparities for racial/ethnic minority patients: interpreter services, recruitment and retention, Hospital safety culture has received extensive coverage in training, coordinating with traditional healers, use of the professional literature and among healthcare organi- community health workers, culturally competent health zations attempting to improve their performance related to promotion, including family and/or community members, patient and staff safety. Hospital safety culture refers to immersion into another culture, and administrative and ‘‘management and staff values, beliefs, and norms about organizational accommodations. Unfortunately, with the what is important in a health care organization, how exception of interpreter services, which has evidence sup- organization members are expected to behave, what atti- porting its effectiveness in reducing health disparities, tudes and actions are appropriate and inappropriate, and Brach and Fraserirector (2000) concluded ‘‘there is little by what processes and procedures are rewarded and punished way of rigorous research evaluating the impact of partic- with regard to patient safety’’ (Sorra & Dyer, 2010). ular cultural competency techniques on any outcome, Hospital safety culture is characterized by (a) a foundation including the reduction of racial and ethnic disparities… of mutual trust, (b) a shared view that patient safety is Most linkages among cultural competency techniques, the important, and (c) a belief that preventative measures are processes of health care service delivery, and patient out- effective (Groves, 2014). comes have yet to be empirically tested’’ (p. 203). In recent The connection between organizational safety culture years, there have been several studies that have explored and performance has some limited evidence across indus- the effectiveness of interventions designed to improve tries (Molenar, Park, & Washington, 2009), but has largely cultural competency in health care workers (see Beach been challenging to quantify, and has been criticized for et al., 2005 for a review). However, there have been rela- focusing too narrowly on social interactions within the tively few studies that have linked cultural competency organization and ignoring larger contextual factors training to actual patient outcomes (Lie, Lee-Rey, Gomez, (Guldenmund, 2010; Naevestaad, 2009). Despite these Bereknyei, & Braddock, 2011). It is clear that more challenges, there is some evidence that hospital safety research linking aspects of cultural competence to patient culture is associated with actual hospital performance. For care is needed. example, perceptions of hospital safety culture are related One characteristic of hospitals that may be especially to the injuries experienced by staff (Grytdal, Kobeski, important for promoting hospital safety culture with racial/ Kaplan, Flanagan, & Cousin, 2006). Specifically, hospital- ethnic minority patients is cultural humility. Humility based healthcare personnel who had more positive per- includes both intrapersonal and interpersonal components ceptions of hospital safety culture were less likely to have (Davis et al., 2011, 2013). On the intrapersonal level, had a sharp injury in the past 12 months (Grytdal et al., humility involves an accurate view of self, including an 2006). Also, hospital safety culture has been linked to awareness and acknowledgement of one’s limitations. On patient safety outcomes such as lower rates of in-hospital the interpersonal level, humility involves an interpersonal complications and adverse events (Mardon, Khanna, Sorra, stance that is other-oriented rather than self-focused. Dyer, & Famolaro, 2010). Cultural humility is a subdomain of humility that focuses specifically on cultural differences (Hook, Davis, Owen, Worthington, & Utsey, 2013). On the intrapersonal Hospital Safety Culture and Cultural Differences level, cultural humility involves an accurate view of one- self culturally, including awareness of the limitations of Patient care and safety may be compromised if health care one’s own cultural perspective and one’s ability to under- workers fail to appreciate and understand patients who stand another person’s cultural background and experience. identify as racial/ethnic minorities. Indeed, disparities in On the interpersonal level, humility involves openness to quality of care and health status are persistent problems in the other person’s cultural background, characterized by the United States. The 2014 National Healthcare Quality respect and lack of superiority. Individuals with high levels and Disparities Report (Agency for Healthcare Research of cultural humility are open to the idea that other indi- and Quality [AHRQ], 2015) stated that although healthcare viduals and groups may differ in their beliefs, values, and access and quality (including patient safety) have improved attitudes, and seek to respect and perhaps even celebrate

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J Clin Psychol Med Settings these differences rather than trying to force culturally dif- understanding and improving a hospital organization’s ferent individuals and groups to conform to one particular safety culture. We hypothesized that perceptions of orga- worldview. nizational cultural humility would be positively related to Most of the empirical research on cultural humility has general perceptions of safety, as well as ratings of occurred in the context of psychotherapy (Hook et al., important hospital safety culture variables. Specifically, 2013, 2016; Owen et al., 2014). For example, in a series of we focused on two hospital safety culture variables that four studies, Hook et al. (2013) found that (a) psychother- were deemed areas for improvement based on low average apy clients viewed cultural humility as an important aspect positive responses (i.e., non-punitive response to error and of their therapist and (b) client perceptions of therapist transitions; Agency for Healthcare Research and Quality cultural humility were positively related to having a strong [AHRQ], 2014), as well as one hospital safety culture working alliance and ultimately client improvement. Sec- variable that was theoretically linked to the concept of ond, Owen et al. (2014) replicated the findings of Hook cultural humility (i.e., organizational learning—continuous et al. (2013), and also found that cultural humility may be improvement). especially important for aspects of the client’s cultural background that are very important. Specifically, they found that therapist cultural humility toward a client’s Method religious worldview was positively related to client out- comes, but this relation was stronger for clients with high Participants and Procedure levels of religious commitment. Finally, Hook et al. (2016) examined the relation between cultural humility and racial Participants were 2011 hospital employees recruited from microaggressions (i.e., subtle type of covert racism con- four large hospitals in the Midwest United States. In regard sisting of brief, everyday exchanges that send denigrating to job role, 78.6 % of participants were front-line messages to racial/ethnic minorities, Sue et al., 2007). employees (e.g., nurses, technicians, clerical staff). The Therapists who were perceived to be high in cultural rest of the same was comprised of mid-managers (14.1 %), humility committed fewer racial microaggressions than did senior executives (1.2 %), and physicians (6.2 %). Partic- therapists who were perceived to be low in cultural ipants worked in a variety of units (15.8 % no specific unit, humility. 8.0 % surgery, 6.3 % non-surgical medicine, 5.6 % emer- Although the empirical research thus far on cultural gency department, 4.9 % obstetrics, 4.9 % psychia- humility has occurred in the context of psychotherapy, try/mental health, 4.5 % laboratory, 4.1 % radiology, researchers have begun to theorize that cultural humility 3.2 % pharmacy, 2.9 % rehabilitation, 2.7 % intensive care may be important in medical settings as well. For unit, 1.6 % pediatrics, 1.1 % anesthesiology, and 34.2 % example, Tervalon and Murray-Garcia (1998) proposed other). that cultural humility was a key goal in multicultural The hospitals in the present study were participants in a medical education. In this context, cultural humility is national project to improve hospital healthcare perfor- less focused on one’s cultural knowledge, and more mance called the Partners for Performance (PFP). Mem- focused on developing a ‘way of being’ with patients that bers of the project who were planning to complete the values, honors, and respects the patient’s cultural back- AHRQ Hospital Survey of Patient Safety Culture were ground and experiences. They defined cultural humility as invited to also complete the cultural humility survey. involving a lifelong commitment to: (1) self-evaluation Recruitment started with presenting the cultural humility and critique, (2) redressing the power imbalances in the instrument as part of a webinar on culture and health physician-patient dynamic, and (3) developing mutually disparities. PFP staff then received and responded to beneficial and non-paternalistic partnerships with inquiries about the instrument and invited interested hos- communities. pitals to participate in the survey process. The survey was The purpose of the present study is to investigate the completed online and included informed consent and a relation between organizational cultural humility and discussion of how the confidentiality of survey results hospital safety culture. Prior research on cultural humility would be protected. Participants received their individual has focused on the context of psychotherapy (Hook et al., (i.e. hospital level) results of the cultural humility survey 2013); in this study, we extended this research to the along with other survey results, copies of the literature hospital setting. Based on previous theory that has pro- supporting the instrument, and suggestions on how to posed cultural humility to be an important aspect of follow up on the survey results. Additionally and as part of medical training and education (Chang, Simon, & Dong, the PFP program, all participants received a phone 2012; Tervalon & Murray-Garcia, 1998), we propose that debriefing on the survey results. No individual results were cultural humility may be an important concept for reported.

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Measures four subscales. For each subscale, the lowest possible mean score is 1, and the highest possible mean score is 5. Higher Cultural Background scores indicate higher levels of hospital safety culture. Responses ranged from 1 = strongly disagree to Participants completed a single-item measure that asked: 5 = strongly agree. What aspect of your cultural background is most central or First, we examined a subscale that assessed general important to you? Responses included race/ethnicity, gen- perceptions of safety. This subscale has 4 items. Typical der, religion, sexual orientation, age, disability, socioeco- items are ‘‘Patient safety is never sacrificed to get more nomic status, and other. work done’’ and ‘‘Our procedures and systems are good at preventing errors from happening’’. For the current sample, Organization Cultural Humility the Cronbach’s alpha coefficient was .74. Second, we examined two subscales that were deemed Participants completed a modified version of the cultural areas for improvement, based on their lowest average humility scale (Hook et al., 2013). The scale has 12 items. positive responses from over 6000 hospitals across the The lowest possible mean score is 1, and the highest pos- United States (AHRQ, 2014). The first ‘area for improve- sible mean score is 5. Higher scores indicate higher levels ment’ subscale was non-punitive response to error. This of perceived cultural humility. Typical items are ‘‘Asks subscale has 3 items. Typical items are ‘‘Staff feel like their questions when he/she is uncertain’’ and ‘‘Is open to mistakes are held against them’’ (reverse coded) and explore’’. Participants were given the following instruc- ‘‘When an event is reported, it feels like the person is being tions: ‘‘Please think about your organization. Think about written up, not the problem’’ (reverse coded). For the the culture of your organization generally, or how most current sample, the Cronbach’s alpha coefficient was .82. people from your organization act. Using the scale below, The second ‘area for improvement’ subscale was handoffs please indicate the extent to which you agree or disagree and transitions. This subscale has 4 items. Typical items with the following statements about individuals from your are ‘‘Things ‘fall between the cracks’ when transferring organization, regarding different aspects of culture.’’ patients from one unit to another’’ (reverse coded) and Responses ranged from 1 = strongly disagree to ‘‘Important patient care information is often lost during 5 = strongly agree. Scores on the CHS have shown evi- shift changes’’ (reverse coded). For the current sample, the dence for reliability and validity (Hook et al., 2013). For Cronbach’s alpha coefficient was .86. the current sample, the Cronbach’s alpha coefficient was Third, we examined the organizational learning—con- .91. tinuous improvement subscale, which was theoretically linked to our concept of cultural humility. This subscale Hospital Safety Culture has 3 items. Typical items are ‘‘We are actively doing things to improve patient safety’’ and ‘‘Mistakes have led Participants completed the Hospital Survey on Patient to positive changes here.’’ For the current sample, the Safety Culture (Sorra & Nieva, 2004). This survey was Cronbach’s alpha coefficient was .73. designed to assess hospital staff opinions about patient safety issues, medical errors, and event reporting. Partici- pants were given the following instructions: ‘‘Your hospital Statistical Analysis has arranged for you to complete the AHRQ Hospital Survey on Patient Safety Culture in order to measure and For our preliminary analyses, we reported descriptive improve your hospital’s safety culture. Your responses to statistics, including means, standard deviations, and inter- the survey are the only data collected and retained by this correlations among study variables. Our primary research form. The focus of the survey is the hospital where you are question was to investigate the extent to which ratings of employed or serve on medical staff. An ‘‘event’’ is defined organization cultural humility predicted ratings of hospital as any type of error, mistake, incident, accident, or devia- safety culture using hierarchical multiple regression. We tion, regardless of whether or not it results in patient harm. used four hierarchical multiple regression analyses, with ‘‘Patient safety’’ is defined as the avoidance and prevention general perceptions of safety and the three hospital safety of patient injuries or adverse events resulting from the culture subscales (i.e., non-punitive response to error, processes of health care delivery.’’ handoffs and transitions, and organizational learning— The survey has 42 items, which are separated into 12 continuous improvement) as dependent variables. Because subscales. Each subscale had acceptable levels of internal the data are grouped as individuals nested within hospitals, consistency, with the exception of the staffing subscale we included three dummy-coded hospital variables as (Sorra & Dyer, 2010). For the present study, we focused on covariates in Step 1 of all analyses. The hospital with the

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J Clin Psychol Med Settings largest number of participants was used as the reference Table 2 Hierarchical regression analysis predicting general percep- group. Ratings of hospital cultural humility were included tions of safety as a predictor in Step 2. Predictor DR2 b sr2

Step 1 .03* Results D_Hospital 2 -.06 .00 D_Hospital 3 -.19* .03 Participants listed a range of cultural identities that were D_Hospital 4 -.06 .00 most central or important to them, including religion Step 2 .20* (35.3 %), race/ethnicity (20.9 %), age (17.6 %), gender D_Hospital 2 .00 .00 (15.0 %), socioeconomic status (8.0 %), disability (2.2 %), D_Hospital 3 -.13* .01 and sexual orientation (0.9 %). Means, standard deviations, D_Hospital 4 -.01 .00 and inter-correlations among study variables are in Cultural humility .45* .20 Table 1. * p \ .001 Cultural humility was a significant positive predictor of perceptions of safety. Table 2 summarizes this analysis. In Step 1, there were significant differences based on hospital, which accounted for about 3 % of the variance in overall Table 3 Hierarchical regression analysis predicting non-punitive perceptions of patient safety (R2 = .03, p \ .001). In Step response to error 2, controlling for overall hospital differences, perceptions Predictor DR2 b sr2 of organization cultural humility were positively associated Step 1 .01 with perceptions of patient safety, and accounted for an D_Hospital 2 .03 .00 additional 20 % of the variance (DR2 = .20, p \ .001). Cultural humility was also a significant positive pre- D_Hospital 3 -.06 .00 dictor of non-punitive response to error. Table 3 summa- D_Hospital 4 .04 .00 rizes this analysis. In Step 1, there were significant Step 2 .18* differences based on hospital, which accounted for about D_Hospital 2 .10* .01 1 % of the variance in non-punitive response to error D_Hospital 3 .01 .00 (R2 = .01, p = .004). In Step 2, controlling for overall D_Hospital 4 .08* .01 hospital differences, perceptions of organization cultural Cultural humility .43* .18 humility were positively associated with non-punitive * p \ .001 response to error, and accounted for an additional 18 % of the variance (DR2 = .18, p \ .001). Cultural humility was also a positive predictor of handoffs and transitions. Table 4 summarizes this analysis. Table 5 summarizes this analysis. In Step 1, there were In Step 1, there were no significant differences based on significant differences based on hospital, which accounted hospital (R2 = .00, p = .129). In Step 2, controlling for for about 2 % of the variance in organizational learning— 2 overall hospital differences, perceptions of organization continuous improvement (R = .02, p \ .001). In Step 2, cultural humility were positively associated with handoffs controlling for overall hospital differences, perceptions of and transitions, and accounted for an additional 15 % of the organization cultural humility were positively associated variance (DR2 = .15, p \ .001). with organizational learning—continuous improvement, Cultural humility was also a positive predictor of and accounted for an additional 21 % of the variance 2 organizational learning—continuous improvement. (DR = .21, p \ .001).

Table 1 Descriptive Variable M (SD) 1 2 3 4 5 information and incorrelations for all variables 1. Cultural humility 3.59 (.77) – 2. Overall perceptions of safety 3.71 (.79) .46* – 3. Nonpunitive response to error 3.04 (.97) .42* .51* – 4. Handoffs and transitions 3.26 (.83) .39* .47* .37* – 5. Organizational learning—continuous improvement 3.87 (.69) .47* .58* .41* .37* –

* p \ .001

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Table 4 Hierarchical regression analysis predicting handoffs and safety culture were moderate to large—cultural humility transitions predicted between 15 and 21 % of the variance in hospital Predictor DR2 b sr2 safety culture ratings. This is an important first step in exploring the possible Step 1 .00 role of cultural humility in hospital settings. Hospital D_Hospital 2 -.03 .00 employees who viewed the members of their organizations D_Hospital 3 -.06 .00 to be more culturally humble also reported better experi- D_Hospital 4 -.04 .00 ences with hospital safety, including general perceptions of Step 2 .15* safety, non-punitive response to error, handoffs and tran- D_Hospital 2 .02 .00 sitions, and organizational learning—continual improve- D_Hospital 3 .00 .00 ment. Thus, cultural humility practiced in the medical D_Hospital 4 .00 .00 context may contribute to (1) style of communicating, Cultural humility .39* .15 which affects rapport, accurate diagnosis, and facilitates a * p \ .001 non-paternalistic approach; (2) cooperation, which affects rapport, adherence, and partnership building; (3) health beliefs, especially those different from the provider’s, and those that emphasize self-evaluation; and (4) better iden- Table 5 Hierarchical regression analysis predicting organizational tifying and addressing psychosocial factors related to pain, learning—continuous improvement anxiety, and depression. These all contribute to patient Predictor DR2 b sr2 safety needs beyond traditional indicators such as medical errors, adverse events, and infection rates. Step 1 .02* Although this is the first study to our knowledge to D_Hospital 2 -.09 .01 examine the role of cultural humility in the context of D_Hospital 3 -.13* .01 hospital safety culture, our findings are consistent with past D_Hospital 4 .10* .01 theory and research on the role of cultural humility and Step 2 .21* healthcare (Chang et al., 2012; Tervalon & Murray-Garcia, D_Hospital 2 -.02 .00 1998). Furthermore, it supports a growing body of research D_Hospital 3 -.07 .00 showing that cultural humility plays an important role in D_Hospital 4 -.06 .00 the helping professions (Davis et al., 2016; Hook et al., Cultural humility .46* .21 2013, 2016; Owen et al., 2014). * p \ .001 There were several limitations to the present study. First, the data were cross-sectional, which precludes causal inferences. Although the data are consistent with our the- oretical model (i.e., cultural humility leading to better Discussion hospital safety culture), other causal models are possible (e.g., positive hospital safety culture leading to higher The purpose of this study was to examine the association ratings of cultural humility). Longitudinal and experimen- between perceptions of organization cultural humility and tal research is necessary to elucidate the causal connections perceptions of hospital safety culture. We examined gen- between these variables. Second, we used self-report eral perceptions of hospital safety, two aspects of hospital measures of cultural humility and hospital safety culture. safety culture that were deemed areas for improvement, Although both measures had high levels of internal con- based on having the lowest average positive responses from sistency and past evidence for validity, there are limitations over 6000 hospitals across the United States (i.e., non- to self-report measures, including social desirability bias punitive response to error and handoffs and transitions; and other types of response bias (e.g., yea-saying). Future AHRQ, 2014), and one aspect of hospital safety culture research should incorporate other types of measures, such that was theoretically linked with cultural humility (i.e., as other-report or behavioral measures (Dorn, Hook, Davis, organizational learning—continual improvement). Van Tongeren, & Worthington, 2014). Third, due to limi- Overall, our findings were consistent with our hypoth- tations in our data collection process, we did not gather esis that higher ratings of organization cultural humility demographic data such as race, gender, and socioeconomic would be positively associated with higher ratings of hos- status. Future research should gather these data to provide a pital safety culture. This association held even when con- clearer context to interpret the findings. Fourth, we utilized trolling for mean differences across hospitals. Effect sizes a limited number of hospitals, and thus were unable to for the relationship between cultural humility and hospital assess the effect of hospital characteristics (e.g., population

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J Clin Psychol Med Settings of city, % non-white, rural vs. urban, etc.) on perceptions of Beach, M. C., Price, E. G., Gary, T. L., Robinson, K. A., Gozu, A., cultural humility or hospital safety culture. Palacio, A., … Cooper, L. A. (2005). Cultural competency: A systematic review of health care provider educational interven- In addition to utilizing more intensive research designs tions. Medical Care, 43, 356–373. and measurement strategies, there are several exciting Brach, C., & Fraserirector, I. (2000). Can cultural competency reduce areas for future research. First, the current study examined racial and ethnic health disparities? A review and conceptual ratings of cultural humility of the organization as a whole. model. Medical Care Research and Review, 57, 181–217. Chang, E. S., Simon, M., & Dong, X. (2012). 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