Table 2.

Definitions and Representative Quotes for Protective Factors in Inpatient Psychiatry (Domain 2)

Domain 2. Protective factors	Definition	Quotes
Engaging stakeholders in maintaining a culture of safety	Taking steps to ensure all of those with an interest in patient safety—leadership, frontline staff, patients—are meaningfully engaged in efforts to identify, report, and address risks to patient safety; includes creating an environment where people feel safe to express concerns	“Staff engagement is number one for making a safe environment, whether is it being observant of the environment, reporting things that could be a risk…[and] engage patients-- have a committee meet consistently that asks the patients ‘how are you doing, are you concerned about anything in your environment?’ Make safety a concern for the patients as well.” (Nurse, Site 1)
		“I think we are most successful when we engage the frontline staff in all of these things [safety initiatives]. Because they are the boots on the ground. They are the ones who see things, they are the ones who know what’s going on and how it can be working better. And a big mistake that we make sometimes is not engaging them.” (Nurse, Site 4)
		“…having managerial staff promote a culture of safety and a culture where things are open and transparent. We cannot deal with these [safety] issues until we know that they exist. Staff is not going to get into trouble whenever they put in [a report] because something is broken… staff needs to hear from the top that ‘we want to know what is going on on your floor.” (Nurse, Site 2)
Ensuring team members are interacting with patients and with each other	Supervisors and frontline staff are circulating through the mental health unit, interacting with patients and each other; supervisors and more experienced staff model best practices in inpatient psychiatric care for benefit of less experienced staff; staff get to know patients and the general environment on the unit	“…I have not had a staff member that has been out of tune with this {how to care for psychiatric inpatients], they usually get it. Because you use these examples and you [ask], ‘in this situation, how did you feel about this?’ or ‘did you like the way that happened?’ and if not, let’s talk about how this could have been better. And encouraging them to watch someone else interact with a patient and understand what they’re doing. Someone who is a little bit more experienced. They learn.” (Nurse, Site 7)
		“We are seeing fewer [nurses] skilled in psychiatric care…keeping them circulating in the milieu and keeping them interacting with the patients through the course of the day… is really the key. The more isolated a nurse becomes from the milieu, the more likely something will erupt… until that event happens, that nurse will not be aware that maybe something is getting ready to happen… having a good nurse flow through the milieu is vital.” (Medical Director, Site 3)
		“I am a very hands-on manager. I do not rely on reports. I want to see it myself… I like to participate. To me, that is part of role-modeling with my staff. It is also a way of empowering my staff to establish teamwork. That starts from the frontline supervisor and not just among themselves.”(Nurse, Site 6)
Promoting responsibility and accountability in work roles	Individual staff take responsibility for promoting patient safety through attitudes and behaviors; supervisors have the ability to hold individual staff accountable for failures resulting in patient safety events, and when necessary, to discipline or remove individual staff	“…continuous training and supervision, because the more you train your staff, the more outcomes you will be getting performance-wise. And this is very important to me; I always make sure my staff are accountable for their actions.” (Nurse, Site 6)
		“There was human error involved and human opportunities for doing the right thing…. No blame is one thing. But guess what, accountability is another. So I have taken a position where, when something is a problem with patient safety, someone gets a disciplinary action.” (Nurse, Site 1)
		“If I could wave a magic wand, I would change the hiring and firing practices in the VA…. allowing us to fire people who do not pull their own weight easier. And then you can bring in good people.” (Medical Director, Site 1)
Embracing patient-centeredness throughout the organization	Organization and staff understand and promote a recovery-oriented model of care; environment of care is non-stigmatizing; policies and practices focus on needs of patients (rather than on those of organization or staff); to the extent possible, patients are empowered and have a voice in their care	“So these are the things that as a psych staff you really have to embrace the totality of what you do. You do not just say ‘oh, this patient is this’ or ‘this patient is that.’ To me, if we drop a lot of the labeling in what we do, then we can really avoid some of these patient safety events. Because our patients… you respect them and they will respect you. But if they feel there is some degree of labeling or not responding to their needs, they will… start acting out. Then it becomes a safety event.” (Nurse, Site 6)
		“We did a lot of training with meeting Veterans where they are….It’s about really looking at respect and integrity and looking at the patient’s needs. It’s not so much about controlling every little thing, it’s really about helping people get better.” (Nurse, Site 5)
		“Our approach has completely changed to not micromanaging everything that the patients are doing. As long as they’re safe and it’s going to help them, is this okay? We really went through and looked at every rule, every policy, everything that we were doing and said ‘is that patient-centered, or is that what we want in a hospital setting for our Veterans?’” (Medical Director, Site 7)