A culture of patient safety is believed to exist when a common understanding regarding patient safety emerges among staff . The culture is constructed by a dynamic interaction within the organizational structure and formed through two intertwined procedures: 1) reinforcement of reciprocal, multi-professional interactions that include patients and leadership, and 2) a goal-directed facilitation to achieve an understanding of what should be changed and how to do it . The wards included in our study were in different phases of fall prevention implementation. The rehabilitation ward had successfully implemented a multi-factorial and multi-professional intervention program. The fall risk assessments were a task that engaged the whole team, communication was efficient, and leadership and ward infrastructure facilitated the work of preventing falls. Each of these are important parts of a patient safety culture . The acute ward used only a part of the reciprocal phase and had not managed to proceed to the next phase.
The LPN’s right to decide meant that many choices had to be made, often within moments. Previous studies have shown that licensed practical nurses feel a lack of professional status and that their competence is not utilized or adequately acknowledged, nor is the opportunity to express opinions facilitated . This contrasts with our study, where the LPNs expressed a strong professional pride and made it clear that speaking one’s mind was important. The LPNs in the rehabilitation ward were also confident in their ability to judge who was at risk of sustaining a fall. When someone fell, they made tailored changes for that patient. At the acute ward, they had more of a medical focus. If a fall occurred, no patient specific changes were made nor were others alerted of the patient’s fall risk. Outcomes such as fall reporting and less restraints use by LPNs in nursing homes are linked to well-functioning patient safety cultures .
We found that mandates for LPNs differed depending on the type of ward where they worked. At the acute ward there was no forum for discussing the issues of fall prediction and prevention among professions and the LPNs felt they lacked words to communicating risk of falling. However, when asked, they could identify fall risk factors that are associated with risk of sustaining a fall. The LPNs in the rehabilitation ward, as a part of their work assignments, were required to complete fall risk assessments to determine who was at risk of falling. They often helped each other describe how the patient moved and behaved. In this way, they created a dialogue and mutual language. Fall risk assessments were routinely discussed at multi-professional meetings that occurred twice a week. The meetings were reported as a significant forum for exchanging information about patient risk of falling. Differences between wards in structure and cultural conditioning may contribute to different ways of working with falls and fall prevention. Many authors emphasize group communication, dialogue, planning, and reflecting as basic ingredients in workplace learning. The team is suggested to have a central role in hospital and long-term care settings [22, 23] as well as in other organizations . This is in line with the statements from the LPNs at the rehabilitation ward who learned and transferred knowledge when attending the multidisciplinary meetings. In comparison, in the acute ward, the team had no central role and therefore it might be more complicated to facilitate learning regarding falls. The LPN knowledge about fall risk and fall prevention actions was never articulated and transferred to others.
Quick and constant changes in patient status make it necessary for continuous communication between team members and this often means that there needed to be mediation. To be able to participate in the mediation, LPNs felt it was important to make one’s own assessment. This was also important in order to provide information to one’s peers. There are tools that can be utilized to help LPNs perform fall risk assessments. The acute ward had not implemented a risk assessment tool and did not routinely discuss risk of falling during their meetings. In a study that compared communication during multidisciplinary meetings in two wards, different communication patterns were seen. One ward used a fall risk assessment tool and the other one who did not. This resulted in different patterns in decision-making. Partly this outcome was due to the use of the fall risk assessment tool that helped to create a common language among the professionals .
In order for learning to be effective, there must be different opportunities for learning within the healthcare organization. Examples include good communication, opportunities for the staff to participate in decision making, and clear organizational goals . To create a safety culture in a nursing home setting, factors as stress level, work climate, efficient work process, and clear organizational goals have been identified . The wards in our study differed in structure. The rehabilitation ward had a clear goal concerning falls and fall prevention whereas the acute ward had many other goals. Studies in primary care settings have shown that learning structures must be designed and implemented at the workplace, otherwise daily clinical routines becomes the priority . The patient safety culture is significantly associated with management commitment to the issue  and steps toward implementation have to come from the organizational level .
The research group consisted of researchers with experience in the area of fall prevention, learning organizations, and qualitative research methodology. This strengthened the study by allowing the information given by the LPNs to be understood and interpreted from different angles.
We acknowledge that the low number of participants in the focus groups can be considered a limitation. The recommended lower limit is four participants, and in our study, the number was three . However, prior to this study, three participants had so much they wanted to tell us that we were concerned a larger group would result in a limited time for participants to speak.
A risk when using focus group methodology is that the participants will be influenced by more dominant participants or will only say what is considered socially acceptable . The methodology can also open up discussions and reflections among the participants, and that is what we experienced. The presence of a moderator and observer ensured that a positive climate was maintained and that everyone was allowed to voice their opinions. Achieving both homogeneity and heterogeneity is preferable for focus group composition . In our groups, homogeneity was ensured by a shared work place. We endeavored to achieve heterogeneity by including both men and women, as well as varying years of experience. The goal of heterogeneity was not achieved in three of the focus groups. Those groups lacked men and one group did not have differing years of experience. However, all participants were carefully chosen and considered key stakeholders.
We did not define a fall when conducting the focus groups. Also, during the focus groups, we did not ask how they defined a fall. This is a limitation of our study that could have an impact on our results as a fall can be defined in a number of ways . However, the participants had previously been educated on fall prevention and worked on wards where falls are common. Hence, they should have had some understanding of the definition of a fall.