Worrisome data has emerged regarding the psychosocial wellbeing of health professionals.1 Various factors contribute to psychosocial dissatisfaction among healthcare professionals. Increasingly complex healthcare environments due to population aging, increased comorbidities, more demanding workflow, and constant upgrading of services result in unsustainable workloads.2,3 Moreover, healthcare workers commonly believe that they have insufficient resources to meet clinical demands.4 Consequently, many develop burnout syndrome, which worsens their quality of life and can even put their patients at risk.5,6

On the other hand, health organizations promote non punitive environments, increasing psychological safety, that improves communication and knowledge sharing.7

In recent years, interest in assessing the impact of organizational aspects on healthcare professionals’ wellbeing has grown. The Safety Attitude Questionnaire (SAQ),8 adapted to Spanish culture in 2010,9 explores 6 dimensions: teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management, and working conditions. However, the healthcare system has changed significantly since the questionnaire was developed, and it is necessary to include other domains. As a result, the Safety, Communication, Operational Reliability, and Engagement work survey (SCORE)10 was designed and validated in different clinical settings.11,12

Our team recently developed a proactive safety tool called Real-Time Random Safety Audits (AASTRE) that minimizes errors, especially errors of omission, in clinical practice.13,14 Moreover, AASTRE have led to significant improvements in structural indicators, such as safety climate.15 Considering this data, our hypothesis is that the AASTRE tool can improve some of the dimensions analyzed by the SCORE survey.

This study had two objectives: to adapt the SCORE survey to Spanish culture and to evaluate the impact of AASTRE on all the domains covered in the survey.

Our results validate the cross-cultural adaptation of the SCORE survey into Spanish and demonstrate its usefulness in analyzing the impact of the tool we devised to minimize clinical errors. This adaptation allows important aspects of healthcare organizations to be measured and compared across institutions. This cross-cultural adaptation employed methods similar to those used in other adaptations, relying on healthcare professionals and translators experienced in medical texts.18 Although various approaches to translation of medical questionnaires have been described, there is no evidence to favor any particular approach.19

AASTRE are an evidence-based proactive method to increase safety in healthcare.14,17 Moreover, Improvement proportion related to AASTRE can be considered a process indicator that measures the degree to which the tool can improve compliance with essential tasks that sometimes go uncompleted due to the complexity and shifting circumstances of ICUs’ clinical activity. We found greater than 10% proportional improvement after AASTRE in four of the eight blocks of safety measures. This data means that (in those blocks) when AASTRE was used, in more than 10% of the occasions the clinical practice was changed (converting unsafe situations into safe ones), emphasizing the difficulty of standardizing healthcare.15

When comparing the results of the SCORE survey administered before and after the implementation of AASTRE, we found significant improvements in 6 domains: learning environment, perception of local leadership, teamwork climate, safety climate, participation in decision-making and advancement in the organization. AASTRE approach calls for direct interaction between the senior attending physician and all professionals responsible for the patient (residents, nurses, and nurses’ aides), promoting effective communication in the context of continuous efforts to improve clinical practice, considered essential for building a safety climate.20 Sexton et al.21 found a strong correlation between healthcare workers’ perception that they had received practical feedback after safety rounds and improvements in the domains learning environment and participation in decision-making. Thus, gains from AASTRE likely result from direct and immediate feedback in interactions between professionals.

The improvement in the domain local leadership is not surprising. Effective leadership and a productive teamwork climate require the determination to commit to a common goal and standardize care delivery and to involve all types of professionals in striving toward that goal.22 AASTRE embody these elements because they are based on applying scientific evidence to care delivery. Another interesting finding that could be related with effective leadership is that the improvements in the domains learning environment, local leadership, teamwork climate, safety climate, and professional growth opportunities were significantly greater in hospitals without prior experience in AASTRE than in those that were already using AASTRE before the study. This difference could also be related to effective leadership, since local leaders’ decisions to undertake projects to improve care delivery have been associated with significant changes in the workplace.23,24 In any case, these data open the door to a new working hypothesis: AASTRE tool is more effective in units without experience in its use. This would make it necessary to consider new ways of using AASTRE.

However, not all changes after the implementation of AASTRE were positive. In the post-AASTRE SCORE assessment, the domains burnout climate and workload had worsened. The worsening in burnout climate affected both physicians and nurses and was more pronounced in hospitals with experience in AASTRE and after professionals recognized feedback. In the workload domain, both physicians and nurses experienced a significant increase, regardless of years of working experience, type of hospital, or feedback. These results differ from those reported by Sexton et al.21 who found that appropriate feedback during safety rounds was associated with an improvement in burnout climate. These differences might be due to the different scenarios in which the safety rounds were implemented. Sexton's study took place in general hospital wards, where the diseases and care, organization of teams, and even staff's mindsets and clinical reasoning differ from those of the ICU scenario.25 It cannot be ruled out that the systematic use of AASTRE, and the continuous changes – corrections – that were made in clinical practice, may have caused the professional to have a feeling of “delivery of inappropriate care‿ perception, aspect that can increase the burnout climate.26 Given the complexity of the ICU environment, any added task could be perceived as a significant increase in workload, reflected in affirmative responses to statements in the SCORE survey such as “People in this work setting are working too hard on their jobs‿. These results could also reflect the potential of AASTRE to increase awareness of the difficulties of practicing evidence-based medicine in a highly complex environment.27 Finally, despite the reliability of the instruments used to measure perceived workload, professionals’ responses have a subjective component.28

To maximize the benefits of using AASTRE, it is essential to minimize increases in burnout climate and perceived workload. To this end, it is important to ensure that AASTRE do not disrupt professionals’ workflow. Pastores et al.29 found that fatigue perception in healthcare settings could be reduced if tasks are recognizable and known in advance, alleviating cognitive workload derived from the density of information that transpire in ICUs. Thus, when choosing the time chosen to carry out safety rounds, prompters should take care to minimize disruptions in workflow. Furthermore, it could be beneficial for healthcare professionals to receive periodic feedback on quality indicators to help them appreciate the correlation between their efforts and favorable outcomes.30

There are limitations to this study. First, it was considered only professionals that worked the morning shift; implementing AASTRE in other shifts might yield different results. Second, although no changes have been introduced period in the care protocols during the study, other variables different from those studied may have influenced the results (for example, a plan for improving the humanisation of intensive care, developed in all participating ICU). Third, the study does not consider the analysis of the incidence of adverse events during the study period. Fourth, the results of the study may be less robust due to the participation of a relatively small number of ICU. Moreover, the response rate and resultant sample size are limited. Importantly, we did not measure workload objectively, so we cannot contrast professionals’ perceptions. Finally, some SCORE domains could be affected by cyclical changes that could influence professionals’ perception of their environment.

The cross-cultural adaptation of the SCORE survey into Spanish is a useful tool for ICUs. AASTRE was associated with improvements in six SCORE domains, including safety climate. Perceptions of work overload could be reduced if prompters choose the time to carry out safety rounds to minimize disruptions to workflow.

All authors have contributed equally to the following tasks: conception and design of the study, collection and statistical analysis of results, discussion, drafting of the manuscript and critical review of the manuscript.

This study was supported by grants from the Fondo de Investigación Sanitaria (Carlos III Institute of Health, Spain, FIS grants, project PI16/00491).

None declared.