Traditional Lectures Actually Improve the Body of Knowledge, Skills, and Attitudes of Health Care Professional for Health Incident Reporting System

Abstract

Introduction: A solid patient safety culture lies at the core of an effective event reporting system in a health care setting requiring a professional commitment for event reporting identification. Therefore, health care settings should provide strategies in which continuous health care education comes up as a good alternative. Traditional lectures are usually more convenient in terms of costs, and they allow us to disseminate data, information, and knowledge through a large number of people in the same room. Taking in consideration the tight money budgets in Brazil and other countries, it is relevant to investigate the impact of traditional lectures on the knowledge, skills, and attitudes to incident reporting system and patient safety culture. Objective: The study aim was to assess the traditional lecture impact on the improvement of health care professional competency dimensions (knowledge, skills, and attitudes) and on the number of health care incident reports for better patient safety culture. Participants and Methods: An open-label, nonrandomized trial was conducted in ninety-nine health care professionals who were assessed in terms of their competencies (knowledge, skills, and attitudes) related to the health incident reporting system, before and after education intervention (traditional lectures given over 3 months). Results: All dimensions of professional competencies were improved after traditional lectures (P < .05, 95% confidence interval). Conclusions: traditional lectures are helpful strategy for the improvement of the competencies for health care incident reporting system and patient safety.

Introduction

A solid patient safety culture lies at the core of an effective health incident reporting system in a health care setting ¹ requiring an organizational commitment for health incident reporting assessment. ² Therefore, it is imperative to consolidate the report system within health care settings.

According to the World Health Organization, some health incidents need to be monitored to improve patient safety such as pressure ulcer, dispositive loss (DL), incorrect patient identification (PI), medication error (ME), drug quality deviation (DQD), adverse drug reactions (ADRs), falls, phlebitis, and surgery events.^3,4 Consequently, an effective reporting system must be sensitive enough to identify these incidents.^3,4

To consolidate the health incident reporting system as a patient safety pillar, health care settings should provide strategies and continuous health care education comes up as a good alternative. ⁵

There are many ways by which continuous education can be provided. Traditional lectures, role-playing, and problem-based learning are some of the ways.^{6 -8}

Traditional lectures are usually more convenient in terms of costs, and they allow the data to be disseminated, information and knowledge through a large number of people in the same room. Therefore, class rooms seem to be ideal environments for traditional lectures in health care settings which need to save money and time in the public health system. On the other hand, traditional lectures are questionable because they may seem to have a little impact on crucial dimensions of professional competencies such as skills and attitudes.^{9 -12} Considering that there is no money to profligate in health institutions, it is important to double-check whether traditional lectures are really cost-effective for improvement of professional competencies related to health incident reporting system.

In this context, the grade use for measuring knowledge and skills seems to be a good strategy because it is an objective measure for the impact of traditional lectures.^13,14 In addition, lecture impact on health care professional attitude can be studied by measuring the incident reporting frequency. In the end, this study strategy becomes comprehensive.^13,14

Taking in consideration the thight money budgets in Brazil and other countries, it is relevant to investigate the impact of traditional lectures on the knowledge, skills, and attitudes to health incident reporting system and patient safety culture.

Objective

The study objective was to assess the traditional lecture impact on the improvement of health care professional competency dimensions (knowledge, skills, and attitudes) and number of health incident reports for better patient safety culture.

Participants and Methods

Study Design

An open-label, nonrandomized trial, approved by the ethics committee and registered at the Brazilian Registration of Clinical Trials (REBEC) website with number RBR-6bxq36 (Brazilian equivalent of ClinicalTrials.gov) was conducted in a group of 356 eligible health care professionals of a public hospital in São Paulo state, Brazil.

Inclusion Criteria

Health care professionals hired by the hospital and who freely consent to participate in this trial were enrolled. Because the hospital is a public health care setting in which a large number of health care professionals do many activities, we decided to invite only health care professionals who had job stability due to their job trades with the hospital. This selection criterion helped to avoid group changes and low participant adherence due to class missing related to job trade ending. If we trained health care professionals who would end the job trade in a near future, we made the study intervention invalid because a significant part of the trained staff would be out of the hospital invalidating the postintervention analysis because we were evaluating a different health care professional group. Once group composition was changed, it would be impossible to identify whether our results were due to group composition or the intervention effect. Based upon this condition, it was possible to evaluate the trained group performance in terms of knowledge, skills, and attitudes. The free consent term was given all participants and carefully read with them, It was explained the study relevance and objective, complete intervention duration, the intervention characteristics as well as the duration of classes. It was also explained the sensitive data protection. Professionals who demonstrated their initial willingness to complete the 4-module course and to do the 2 tests were enrolled in this trial. Restricting the participation in this study to health care professionals with job stability, we could evaluate the effects of our intervention because the health care professional performance could be accurately assessed before and after intervention.

Exclusion Criteria

Health care professionals who missed the classes not completing the modules were excluded from the trial. Professionals who were near their vacation or underwent health problems missing the classes were also excluded from the trial. Missing classes was a criterion for participant exclusion because we could not assess their knowledge fully. Professionals who were not hired by the hospital such as residents and interns were excluded from the trial. Professionals who did not complete the intervention (4-module course + final test) were excluded from the trial. Therefore, participants who did the 4-module course but did not do the final test were excluded from the trial.

Intervention

Over 3 months, 60-minute lectures were given to health care professionals weekly in 4 modules according to their work shifts. The concepts of health incident, adverse event, pressure ulcer (pressure injury), DQD, ADR, falls, drug-induced phlebitis, PI, ME, DL, and surgery event were taught, and health care professionals were told about the importance of reporting these incidents as well the importance of their prevention using some examples of health incidents and how to deal with them.

Health care professional performance assessment

A written test was applied to assess the knowledge, skills, and attitudes associated with health incident reporting. Afterward, an education intervention was conducted via 60-minute lectures weekly given in 4 modules over 3 months, followed by the application of a second written test.

A grade was associated with each dimension of competency (knowledge or skill). For assessment of knowledge, a 10-question written test was given to health care professional. Definition of adverse event, What is notifiable?, Who must notify?, Why notify?, Have you ever notified a health incident?, Who must receive your notification?, recognition of health incidents, recognition of possible causes for health incidents, recognition of actions to take to solve health incidents, and recognition of encouraging and discouraging factors for reporting health incidents were the knowledge concepts explored in the knowledge test. A grade was associated with the test depending on the participant performance. If the participant answered all questions correctly, then a maximum grade equals 10 was associated with its test. Other grades were associated with the test in a proportional basis. No correct answers were associated with grade 0 (zero).

For assessing skills, an example of incident form was given to health care professional whose task was to complete it to report a health incident. Participants had the task of recognition of 15 items as mandatory, needed, and informative. A 15-item checklist was used as an answer sheet to correct the test. If the participant completed all items correctly, then the maximum grade was associated with the test. Otherwise, a proportional grade was associated with it.

The global grade was calculated using the mean between the knowledge grade and skill grade.

The global grades, preeducation and posteducation intervention, were analyzed and compared to identify the impact of the lectures on the participant knowledge and skill improvements.^13,14

The impact of lectures on the participant attitude was assessed through the health care incident report numbers before and after education intervention. The absolute number of reports was accounted 3 months before and 3 months after education intervention.

Health Incident Monitoring

Falls, phlebitis, acquired pressure injury (API), origin pressure injury (OPI), invasive dispositive loss, (IDL), surgical event (SE), ADR, DQD, incorrect PI, and ME were the health incidents monitored in this trial. Also, the hospitalization number, surgery number, and the health professional adherence were monitored.

The absolute number and incidence rate of health incident reports were compared over the time to identify the impact of lectures on the participant skills and attitudes.

Statistical Analyses

The answers of the tests and the quantity and quality of the items filled in the repot form were evaluated by means of a comparison before and after the education intervention, according to the established standard answer.^12,13 Concepts and grades were assigned from 0 to 10 points based on the answers obtained in the test and the completion of the items in the report form.^12,13

Descriptive analysis

Categorical variables were described in terms of their absolute number and percentage, and continuous variables were described in terms of their mean and standard deviation. Also, Shapiro’s normality test was performed. Comparative analysis: Categorical variables were compared using chi-square and Fisher’s test when needed. Continuous variables were compared using paired t student and Wilcoxon tests for paired samples (the evaluation of knowledge in the report), and the analysis of variance (ANOVA) test for repeated samples was performed for the evaluation of skills and attitudes.

Results

Health Care Professional Profile and Training

Analyzing the participation by professional category, it was identified that physicians were the health care professionals who had the lowest trial participation percentage (3.48%) followed by health care assistance managers (20%), nurses (31.48%), and nursing technicians (26.76%). High trial participation was identified among pharmacists (75%), social assistants (75%), phonoaudiologists (75%), and nutritionists (100%) accounting 99 participants enrolled in this trial who did the 4-module course and the final test. For this reason, they were qualified for the postintervention analysis, considering a total of 356 eligible participants and a universe of 391 health care professionals.

Two hundred eleven health professionals did not do any of the 4 course modules. Fifty participants started the course but missed at least 1 of the 4 modules being excluded from the trial. One hundred thirty participants completed all 4 course modules (36.5%, 130/356) with P = 4.77 × 10⁻⁷ (95% confidence interval [CI]). However, from these 130, 31 participants did not do the final test. The 31 participants who completed the 4 modules of training but did not do the final test, not completing the trial, were excluded from the statistical analysis. Consequently, 99 participants completed the trial (4-module course + final test) showing a withdrawal percentage equals to 27.8% (P = 2.2 × 10⁻¹⁶, 95% CI). Table 1 shows trial participants by profession. Figure 1 shows the participant flow in this trial.

Table 1.

Participant Profile by Professional Category.

Professional	Trial universe (n = 391)	Trial completion a (%)
Physician	86	03 (3.48)
Nurse	54	17 (31.48)
Nursing technician	213	57 (26.76)
Pharmacist	04	03 (75)
Nutritionist	03	03 (100)
Psychologist	04	02 (50)
Social assistant	04	03 (75)
Phonoaudiologist	04	03 (75)
Respiratory therapist	12	07 (58.33)
Occupational therapist	02	0 (0)
Health assistance manager	05	01 (20)
Total	391	99 (25.31)

^aParticipants complete the trial, comprising 4-module course and final test. (%) shows the percentage of trial completion based upon the professional category.

Figure 1.

Flow diagram of participants.

Health Care Professional Performance Assessment

All knowledge concepts explored in the knowledge test were improved showing a P < .002 (95% CI). Skill analysis shows that recognition of mandatory items to inform was improved (P < .001, 95% CI), recognition of needed items was not improved (P = .2586, 95% CI), and recognition of informative items was improved (P = .0446).

Global grades analysis shows that preintervention global grade was 5.3 + 1.68 and postintervention grade was 6.36 + 1.53, being statistically significant (P = .0001; 95% CI). Boxplots for preintervention and postintervention global grades are shown in Figure 2.

Figure 2.

Evolution of global grades related to knowledge and skills about health care incident report system over time (preeducation and posteducation intervention).

Paired t student test considering P < .05 and 95% confidence interval.

Hospitalization Number Over Time

The number of hospitalizations before and after intervention was monitored over the trial to identify its impact on the event rates. It was identified that the numbers of hospitalizations were 2346 and 1804, respectively, before and after the education intervention. Comparing the periods preintervention and postintervention, a reduction of 23.11% was identified.

Health Incident Reports

Based upon the influence of the hospitalization number, health incident reports were organized into 2 groups: decreased number over time (DNOT) and increased number of time (INOT). DNOT comprised the following events: falls, phlebitis, API, OPI, SE, DL, ADR, and ME. INOT comprised DQD and PI.

When considering the proportions of incident reports, we identified an increase from 37.29% (before) to 42.84% in the number of reports after education intervention (P =.003, 95% CI). Even considering reduction of hospitalizations, there was a higher percentage of incident reports

Table 2 shows these groups and the event incidence per 1 000 hospitalizations covered in this trial.

Table 2.

Incidence of Reported Health Incidents.

Event	B	A
Fall	7.7	9.4
Phlebitis	22.2	16.6
API	7.2	6.7
OPI	11.1	12.2
SE*	20.5	10.5
PI*	9.8	15.0
DL	37.9	37.7
ADR*	12.4	5.0
DQD*	3.8	7.8
ME	240.4	307.6
Total	373	428.5

Note. Statistical test: ANOVA (confidence interval = 95%). (n) = number per 1 000 hospitalizations over time. B = before intervention; A = after intervention; API = acquired pressure injury; OPI = origin pressure injury; SE = surgical event; PI = patient identification; DL = dispositive loss; ADR = adverse drug reaction; DQD = drug quality deviation; ME = medication error; ANOVA = analysis of variance.

^*P < .05.

Discouraging Reasons for Reporting

The questionnaire related to discouraging reason for reports shows that time, punishment fear, and accusation fear were the mostly cited reasons for not reporting health incidents. Before the education intervention, time was cited by 63 health care professionals, while punishment fear was cited by 40 and accusation fear was cited by 22 participants. After intervention, time was cited by 33 participants, while punishment fear was also cited by 33 and accusation fear was cited by 3 participants. Comparative analysis shows that education intervention reduced time reason as contributing factor (P < .0001, 95% CI) and accusation reason as contributing factor (P = .0019, 95% CI) for not reporting health incidents.

Identification of Possible Contributing Factors for Health Incidents

The above analysis was followed by the identification of some possible contributing factors for health incidents. Time and accusation fear identified in the previous analysis were also considered the contributing factors for health incidents in the hospital because they can be associated with stressing factors and then rising the error probability. The causal relationship analysis was not deployed.

Then, we limited the analysis to the impact of traditional lectures on reducing the report of these 2 contributing factors among health care professional. This analysis shows that there was a 42.35% reduction of reports by health care professionals, from 85 (63 + 22 reports) to 36 (33 + 3) reports of contributing factors for not reporting health incidents (P < .0001, 95% CI).

Another contributing factor came up: the administrative nature of reporting task. However, it was not studied because it was not proposed in the original project.

Discussion

This trial shows relevant findings regarding the type of education intervention, health care professional adherence, and their impacts on the health care incident reporting and patient safety culture. Our study also shows that traditional lectures may still be helpful to promotion of health incident reporting culture. In addition, our findings show that health care professionals have a key role in this scenario. The more the health care professionals are encouraged and actively involved, the better the incident reporting system may be.

Critical Points in Continuous Medical Education

Initially, we thought that the critical points in improving competencies could be trial participant adherence and type of education (traditional lectures). These 2 aspects could strongly interfere with the improvement of competencies and consequently with the effectiveness of education intervention, according to some studies.^{9 -12}

It is important to bear in mind that patient safety culture is an institutional commitment as advocated by the World Health Organization,^3,4 Joint Commission on Accreditation of Healthcare Organizations (JCAHO), ¹⁵ Organização Nacional de Acreditação (ONA)”, ¹⁶ and Brazilian Program for Patient Safety. ¹⁷ In this context, health care professional understand clearly that each education intervention is related to patient safety including trials conducted in their institutions. In contrast to this culture, we identified a poor participant adherence among health care professionals directly involved in patient care (physicians, nursing technicians, and nurses) who have a key role in health incident identification and reporting. Based upon the poor adherence, we could predict a feeble impact of education on health incident report numbers. Furthermore, we have to bear in mind that physicians, nursing technicians, and nurses provide patient care in the front line and, therefore, directly related to health incident identification and reporting.

However, we identified a statistically significant increase in the number of health incident reports after education intervention showing that the traditional lectures were effective for the improvement of incident reporting system.

Type of Education Intervention

In some studies, traditional lectures have been shown as ineffective mainly in changing health care professional behaviors.^{9 -12} Even under these critics, traditional lectures were chosen in this study due to the limited investment budget of the public health system to payment of other types of interventions and also to payment of professional to do these tasks.

However, our findings show the traditional lectures were effective for the improvement of health care professional competencies. All competency dimensions were improved according to the results measured in our study showing that this intervention may still be cost-effective.

From the authors’ perspective, education intervention has to be adapted to professional routine suggesting hospital flexibility. In this scenario, problem-based learning could be the best strategy because it involves knowledge, skills, and attitudes in the same real-world situation.^{9 -12} However, our findings support the use of traditional lectures as good education strategy.

Sixty-minute traditional lectures were carried out in 4 modules over 3 months. Health care professionals were assessed before and after education intervention through written test. This type of intervention may be partially effective because it does not stimulate all cognitive dimensions of learning ¹⁸ being limited to stimulation of memory, knowledge, and skills, but it is not effective for attitude improvement, creation, and solving problems being therefore considered ineffective as shown by other authors.^{9 -12} Our findings also refute this argument because all competency dimensions were improved.

For this reason, we only recommend other type of education intervention such as role-play and problem-based learning to measure how much better they could be in comparison with traditional lectures because they require an active participation of health care professional.^{7 -10} In these types of education, the health care professionals participate actively in tasks related to patient safety and event reporting, and they can interact with each other in real-world situations.^{4 -6}

Health Incident Reports

This trial approach is relevant because it searched for health incidents related to patient safety according to the World Health Organization’s solutions,^3,4 strongly advocated by accreditation commissions (JCAHO ¹⁵ and ONA ¹⁶ ) and Brazilian National Programme for Patient Safety. ¹⁷ For this reason, our findings become professionally, clinically, and politically relevant in our and other hospitals which can identify the same problems.

The effectiveness of health care training could be associated with the number of incident reports (attitude dimensions: increase in the number of reported incidents), and the effectiveness of health care lectures could also be associated with knowledge and skill dimensions. These findings are relevant in terms of showing the impact of health care professional adherence to the report culture and patient safety culture. Furthermore, it suggests that patient safety awareness development is multifactorial and a daily, repetitive, and long-term process because it requires continuous safe attitudes.

Trials about knowledge, skill, and attitude and their relationships with education intervention and improvement of incident reporting in drug surveillance showed some benefits: improvement of the body of knowledge about incident reporting system,^19,20 improvement of skills in incident reporting leading to improvement of report quality,^21,22 and improvement of attitude leading to the increase in the incident report number.^23,24 Our findings corroborate the findings of these studies.

Education interventions may affect patient safety culture through reporting culture. ²⁵ Nevertheless, their effectiveness depends on the other factors requiring a set of interventions not only education interventions.

Our study explored only 1 factor (education intervention). But many other factors could be analyzed to improve incident reporting system.

Health Incident Analysis

It is well known that health incidents in hospitals have a multifactorial basis.^{26 -28} Time and fear are the contributing factors for rise of stress among health care professionals and stress levels are related to rise of adverse events.^29,30 We also identified time and fear as stressing factors that contribute not only for avoiding incident report but also for health incident occurrence decreasing the patient safety.

In addition, analysis of the reporting system shows that the number of items to be filled by health professional to report incidents is high becoming a time-demanding activity. Once more, time consumption is an obstacle for reporting health incidents. ²⁹ From the authors’ perspective, it is imperative to facilitate health care professional in the activity bringing sentinels to report health incidents. Furthermore, a time-consuming administrative task makes no sense when takes the time of all members of the health care team.

Conclusion

Our findings show that the traditional lectures are great and helpful strategy for the improvement of the body of knowledge, skills, and attitudes about health incident reporting system and patient safety. In addition, traditional lectures seem to be a high-impact intervention and cost-effective on incident report numbers.