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P
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Vo
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J
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ttp
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//
ijp
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The ef
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Hea
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Ho
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p
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Nu
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Patien
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CC B
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C
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1.
I
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C
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h
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an
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s
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aid
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cc
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v
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ty
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d
ca
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ac
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ex
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p
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o
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ar
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d
eter
m
in
ed
b
y
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ei
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p
atien
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s
af
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cu
ltu
r
e,
wh
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h
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a
b
y
p
r
o
d
u
ct
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co
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co
m
p
eten
cies,
an
d
b
eh
av
i
o
r
al
p
a
tter
n
s
[
1
]
.
Pro
m
o
tin
g
an
o
p
e
n
cu
ltu
r
e
an
d
th
o
u
g
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tf
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u
ce
ad
v
er
s
e
ev
en
ts
in
h
ea
lth
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v
ices
[
2
]
.
Un
ex
p
ec
ted
i
n
cid
en
ts
in
h
ea
lth
s
er
v
ices
ca
n
o
cc
u
r
wh
en
s
taf
f
m
em
b
er
s
ar
e
u
n
d
er
s
tr
ess
.
I
f
s
o
m
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k
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tak
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o
th
er
wo
r
k
er
s
h
o
l
d
th
em
ac
co
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n
tab
le
[
3
]
.
C
o
n
s
e
q
u
en
tly
,
to
ad
d
r
ess
th
e
r
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s
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s
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is
tak
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d
av
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id
p
lacin
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b
lam
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s
q
u
ar
ely
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n
th
e
m
is
tak
e
m
ak
er
,
o
p
en
co
m
m
u
n
icatio
n
with
in
th
e
team
[
4
]
.
Staf
f
m
em
b
er
s
m
u
s
t
ac
k
n
o
wled
g
e
th
at
we
h
av
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f
allib
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p
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p
le.
Ho
wev
er
,
th
e
in
itial
co
u
r
s
e
o
f
ac
tio
n
m
u
s
t
b
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t
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n
d
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s
tan
d
wh
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wen
t
wr
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g
b
ef
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r
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x
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in
in
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th
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s
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tr
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tin
g
to
s
taf
f
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r
o
r
s
th
at
af
f
ec
t p
atien
t saf
ety
[
5
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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6
I
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b
lic
Hea
lth
Sci
,
Vo
l.
1
3
,
No
.
4
,
Dec
em
b
er
20
24
:
1
90
3
-
1
91
1
1904
E
n
h
an
cin
g
th
e
p
atien
t
s
af
ety
cu
ltu
r
e
in
h
ea
lth
ca
r
e
in
s
titu
tio
n
s
r
eq
u
ir
es
em
p
o
wer
m
en
t
.
T
h
e
v
alu
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attitu
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an
d
p
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ac
tices
th
at
d
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f
in
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a
h
o
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p
ital'
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d
ed
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to
p
atien
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s
af
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ar
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r
ef
er
r
ed
to
a
s
th
e
‘
p
atien
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s
af
ety
cu
ltu
r
e’
[
6
]
.
Or
g
a
n
izatio
n
s
ca
n
f
o
s
ter
a
cu
ltu
r
e
i
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ize
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s
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s
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e
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p
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wer
in
g
h
ea
lth
ca
r
e
p
r
o
f
es
s
io
n
als
[
2
]
.
Hea
lth
p
r
o
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ess
io
n
als
wh
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f
ee
l
em
p
o
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ed
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av
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f
o
r
an
d
o
wn
er
s
h
ip
o
f
p
atien
t
s
af
ety
[
7
]
.
Peo
p
le
a
r
e
m
o
r
e
in
clin
ed
to
s
p
ea
k
u
p
,
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n
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n
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ac
tiv
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atie
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t
s
af
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ac
tiv
ities
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th
ey
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ee
l e
m
p
o
wer
ed
[
8
]
.
T
h
is
s
tr
en
g
th
en
s
th
e
o
r
g
an
iza
tio
n
'
s
ca
p
ac
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to
r
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g
n
ize
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d
m
an
ag
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p
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s
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le
h
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ar
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s
an
d
cu
ltiv
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co
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ativ
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lear
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in
g
-
f
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s
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at
p
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o
m
o
tes o
n
g
o
in
g
d
ev
el
o
p
m
en
t
[
9
]
.
Pro
v
id
in
g
h
ea
lth
ca
r
e
p
r
o
f
ess
io
n
als
with
th
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in
f
o
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m
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an
d
ab
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th
ey
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ee
d
to
id
en
tify
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d
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p
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t
s
af
ety
h
az
ar
d
s
i
s
o
n
e
way
to
g
iv
e
t
h
em
m
o
r
e
au
th
o
r
ity
[
1
0
]
.
I
n
d
iv
i
d
u
als
ca
n
b
e
g
iv
en
th
e
s
k
ills
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ec
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p
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in
to
p
r
ac
tice,
an
d
tak
e
p
r
e
v
en
tativ
e
ac
tio
n
b
y
p
ar
ticip
atin
g
i
n
tr
ain
i
n
g
s
ess
i
o
n
s
,
wo
r
k
s
h
o
p
s
,
an
d
in
s
tr
u
cti
o
n
al
m
ater
ials
[
1
1
]
.
Hea
lth
ca
r
e
wo
r
k
e
r
s
m
ay
f
ee
l
m
o
r
e
co
n
f
id
en
t
a
b
o
u
t
t
h
eir
ab
i
lity
to
s
u
p
p
o
r
t
p
atien
t
s
af
ety
b
y
ex
p
a
n
d
in
g
th
eir
k
n
o
wled
g
e
[
1
2
]
.
E
s
tab
lis
h
in
g
a
welc
o
m
in
g
en
v
ir
o
n
m
en
t
in
w
h
ich
p
e
o
p
le
f
ee
l
em
p
o
we
r
ed
to
ch
allen
g
e
th
e
ac
ce
p
ted
wi
s
d
o
m
an
d
p
r
o
v
id
e
n
o
v
el
s
o
lu
tio
n
s
is
an
o
th
e
r
asp
ec
t
o
f
e
m
p
o
wer
m
e
n
t.
Hea
lth
c
ar
e
o
r
g
an
izatio
n
s
ca
n
estab
lis
h
s
af
e
p
lace
s
wh
e
r
e
p
r
o
f
ess
io
n
al
o
p
in
io
n
s
ar
e
r
esp
ec
ted
an
d
v
ar
io
u
s
v
ie
wp
o
in
ts
ar
e
en
co
u
r
ag
ed
b
y
p
r
o
m
o
tin
g
o
p
en
co
m
m
u
n
icatio
n
an
d
ac
tiv
e
lis
ten
in
g
[
4
]
.
T
h
is
p
r
o
m
o
tes
a
cu
ltu
r
e
o
f
o
n
g
o
in
g
lear
n
in
g
an
d
d
ev
elo
p
m
en
t,
an
d
p
er
m
its
a
m
o
r
e
th
o
r
o
u
g
h
u
n
d
e
r
s
tan
d
in
g
o
f
p
atien
t saf
ety
c
o
n
ce
r
n
s
.
Pro
v
id
in
g
r
eso
u
r
ce
s
an
d
d
ec
i
s
io
n
-
m
ak
in
g
ab
ilit
ies
f
o
r
h
ea
l
th
ca
r
e
p
r
o
f
ess
io
n
als
to
m
ak
e
d
ec
is
io
n
s
r
eg
ar
d
in
g
p
atien
t
s
af
ety
is
an
o
th
er
asp
ec
t
o
f
em
p
o
wer
m
en
t.
T
h
e
ab
ilit
y
to
im
p
le
m
en
t
ev
id
e
n
ce
-
b
ased
p
r
ac
tices,
p
ar
ticip
ate
in
QI
p
r
o
jects,
an
d
s
p
en
d
m
o
n
ey
o
n
im
p
r
o
v
in
g
p
atie
n
t
s
af
ety
m
ea
s
u
r
es
[
1
3
]
.
E
n
a
b
le
p
eo
p
le
to
tak
e
ch
ar
g
e
o
f
p
at
ien
t
s
af
ety
an
d
m
ak
e
g
o
o
d
c
h
an
g
es
b
y
h
av
i
n
g
f
aith
in
th
eir
k
n
o
wled
g
e
an
d
ju
d
g
m
en
t
[
1
4
]
.
Patien
t
s
af
ety
cu
ltu
r
e
en
c
o
m
p
ass
es
th
e
f
o
llo
win
g
d
im
en
s
io
n
s
:
o
p
en
co
m
m
u
n
icatio
n
,
f
ee
d
b
ac
k
an
d
co
m
m
u
n
icatio
n
ab
o
u
t
m
is
tak
es,
f
r
eq
u
e
n
cy
o
f
i
n
cid
en
t
r
e
p
o
r
tin
g
,
h
a
n
d
o
v
er
a
n
d
tr
a
n
s
itio
n
,
o
r
g
an
izatio
n
al
s
u
p
p
o
r
t
f
o
r
p
atien
t
s
af
ety
,
n
o
n
-
p
u
n
itiv
e
o
r
n
o
n
-
ju
d
g
m
en
t
al
r
esp
o
n
s
e
to
m
is
tak
es,
o
r
g
an
izatio
n
al
lear
n
in
g
(
co
n
tin
u
o
u
s
lear
n
in
g
)
,
s
taf
f
in
g
,
ex
p
ec
tatio
n
s
f
r
o
m
s
u
p
er
v
is
o
r
s
an
d
m
an
ag
er
s
,
ac
tio
n
s
tak
en
to
im
p
r
o
v
e
p
atien
t
s
af
ety
,
cr
o
s
s
-
an
d
in
tr
a
-
u
n
it
c
o
llab
o
r
atio
n
,
an
d
o
v
er
all
p
e
r
c
ep
tio
n
o
f
p
atien
t
s
af
ety
[
1
5
]
.
T
h
e
d
r
o
p
in
n
u
r
s
es'
jo
b
s
atis
f
ac
tio
n
is
th
e
ca
u
s
e
o
f
b
o
th
t
h
e
in
c
r
ea
s
e
in
p
atie
n
t
ca
r
e
ex
p
e
n
d
itu
r
e
an
d
th
e
d
eter
io
r
atio
n
in
t
h
e
q
u
ality
o
f
s
er
v
ices
p
r
o
v
id
e
d
to
p
atien
ts
[
1
6
]
.
E
x
ter
n
a
l
r
ewa
r
d
s
,
s
er
v
ice
s
ch
ed
u
le
s
,
p
o
s
s
ib
ilit
ies
f
o
r
p
r
o
f
ess
io
n
al
g
r
o
wth
,
ac
co
la
d
es
o
r
awa
r
d
s
,
r
esp
o
n
s
ib
ilit
ies
r
ec
eiv
ed
,
wo
r
k
-
life
b
alan
ce
,
co
n
n
ec
tio
n
s
with
co
wo
r
k
er
s
,
an
d
in
ter
ac
tio
n
s
in
th
e
wo
r
k
p
lace
a
r
e
u
s
ed
to
g
a
u
g
e
h
o
w
s
atis
f
ied
n
u
r
s
es
ar
e
with
th
eir
jo
b
s
[
1
7
]
.
T
h
e
u
n
it'
s
em
p
lo
y
ee
s
co
o
p
e
r
at
e,
s
h
o
w
r
esp
ec
t f
o
r
o
n
e
an
o
th
e
r
,
an
d
e
n
co
u
r
ag
e
ea
c
h
o
th
er
.
C
er
tain
em
p
lo
y
m
e
n
t
attr
ib
u
tes
s
u
ch
as
wo
r
k
p
lace
a
d
ap
tab
il
ity
,
f
lex
ib
ilit
y
,
an
d
cr
ea
tiv
ity
in
r
elatio
n
to
d
ec
is
io
n
-
m
ak
in
g
p
r
o
ce
d
u
r
e
s
,
as
well
as
v
is
ib
le
w
o
r
k
an
d
th
e
co
n
ce
n
tr
atio
n
o
f
o
r
g
an
iza
tio
n
al
g
o
als
with
in
ea
ch
o
r
g
a
n
izatio
n
al
u
n
it,
ar
e
s
o
u
r
ce
s
o
f
f
o
r
m
al
au
th
o
r
ity
.
I
n
f
o
r
m
al
p
o
we
r
is
d
er
iv
ed
f
r
o
m
s
o
cial
co
n
n
ec
tio
n
s
,
p
r
o
f
ess
io
n
al
c
o
m
m
u
n
icatio
n
g
r
o
wth
,
an
d
ea
s
e
o
f
in
f
o
r
m
at
io
n
-
s
h
ar
in
g
with
s
p
o
n
s
o
r
s
,
as
s
o
ciate
s
,
m
an
ag
er
s
,
an
d
o
th
e
r
d
e
p
ar
tm
en
ts
[
1
8
]
.
E
m
p
o
wer
m
en
t
in
itiativ
es
ar
e
cr
itical
f
o
r
im
p
r
o
v
in
g
n
u
r
s
es'
p
a
tien
t
-
s
af
ety
cu
ltu
r
e.
T
h
is
s
tu
d
y
aim
ed
to
ass
e
s
s
th
e
in
f
lu
en
ce
o
f
em
p
o
wer
m
en
t
o
n
n
u
r
s
es’
p
atien
t
s
af
ety
cu
ltu
r
e.
T
h
e
n
o
v
elty
o
f
th
is
s
tu
d
y
is
th
at
it
s
p
ec
if
ically
f
o
cu
s
es
o
n
th
e
im
p
ac
t
o
f
e
m
p
o
wer
m
en
t
in
itiativ
es
o
n
n
u
r
s
es'
p
atien
t
s
af
ety
cu
ltu
r
e,
as p
r
e
v
io
u
s
s
tu
d
ies h
a
v
e
p
r
im
ar
ily
ex
am
in
e
d
o
th
e
r
f
ac
to
r
s
.
2.
M
E
T
H
O
D
2
.
1
.
Desig
n
a
nd
s
a
m
pli
ng
T
h
is
s
tu
d
y
was
a
cr
o
s
s
-
s
ec
tio
n
al
s
tu
d
y
,
an
d
u
s
ed
a
d
escr
ip
tiv
e
an
aly
tical
d
esig
n
.
B
ec
au
s
e
th
e
tr
ea
tm
en
t
r
esu
lts
ca
n
b
e
co
m
p
ar
ed
with
th
e
c
o
n
d
itio
n
s
b
e
f
o
r
e
tr
ea
tm
en
t,
th
e
r
esu
lts
ca
n
b
e
co
n
f
ir
m
ed
m
o
r
e
ac
cu
r
ately
.
S
a
m
a
r
i
n
d
a
R
e
g
i
o
n
al
H
o
s
p
ita
l
was
u
s
ed
as
t
h
e
l
o
c
ati
o
n
f
o
r
t
h
is
s
t
u
d
y
.
T
h
e
s
a
m
p
le
s
i
ze
w
as
1
1
9
,
c
a
l
c
u
l
a
te
d
u
s
i
n
g
t
h
e
S
l
o
v
i
n
f
o
r
m
u
l
a
.
T
h
i
s
s
t
u
d
y
u
s
e
d
a
ll
n
u
r
s
in
g
,
e
x
p
e
r
i
e
n
c
e
w
i
t
h
a
t
l
e
as
t
o
n
e
y
e
a
r
,
r
e
s
p
o
n
d
e
n
t
s
to
th
e
s
u
r
v
e
y
o
n
i
n
p
atien
t w
ar
d
n
u
r
s
in
g
u
n
its
.
T
h
e
s
p
ec
if
ic
s
am
p
lin
g
lo
ca
tio
n
is
s
h
o
wn
in
Fig
u
r
e
1
.
2
.
2
.
I
ns
t
rum
ent
a
nd
a
na
ly
s
is
Data
an
aly
s
is
was
p
er
f
o
r
m
ed
u
s
in
g
SEM
p
a
r
tial
least
s
q
u
ar
es
(
PLS)
v
er
s
io
n
4
.
T
h
is
s
tu
d
y
u
s
ed
an
em
p
o
wer
m
en
t
in
s
tr
u
m
en
t
[
1
9
]
,
n
am
el
y
,
th
e
C
o
n
d
itio
n
f
o
r
wo
r
k
ef
f
ec
tiv
en
ess
-
I
I
(
C
W
E
Q
-
I
I
)
q
u
esti
o
n
n
air
e.
T
h
e
h
o
s
p
ital
s
u
r
v
ey
o
n
p
atien
t
s
af
ety
cu
ltu
r
e
(
HSOPC
)
,
cr
ea
ted
b
y
th
e
Hea
lth
R
esear
ch
an
d
Qu
ality
Ag
en
cy
,
was u
s
ed
to
g
au
g
e
p
atien
t saf
e
ty
cu
ltu
r
e.
2
.
3
.
Va
lid
it
y
a
nd
re
lia
bil
it
y
Sev
en
v
alid
m
ea
s
u
r
em
e
n
t
ite
m
s
wer
e
u
s
ed
to
ass
ess
em
p
o
wer
m
en
t.
T
h
e
s
ev
en
m
ea
s
u
r
e
m
en
t
item
s
h
ad
s
tr
o
n
g
co
r
r
elatio
n
s
with
em
p
o
wer
m
en
t,
as
in
d
icate
d
b
y
th
e
o
u
ter
lo
ad
in
g
v
alu
e,
w
h
ich
r
an
g
e
d
f
r
o
m
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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lth
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8
8
0
6
Th
e
effec
t o
f e
mp
o
w
ermen
t to
imp
r
o
ve
p
a
tien
t sa
fety
cu
ltu
r
e
a
mo
n
g
h
o
s
p
ita
l n
u
r
s
es
(
R
u
s
d
i R
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s
d
i)
1905
0
.
9
0
6
-
0
.
9
5
2
.
W
ith
a
C
r
o
n
b
ac
h
'
s
alp
h
a
v
alu
e
o
f
0
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9
7
3
,
wh
i
ch
is
g
r
ea
ter
th
a
n
0
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7
0
;
a
co
m
p
o
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ite
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9
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o
v
e
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7
0
;
an
d
co
n
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er
g
en
t v
alid
ity
,
as
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em
o
n
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tr
ated
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0
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e
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Acc
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w
h
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em
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en
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o
s
t e
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o
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F=0
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9
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.
2
.
4
.
E
t
hica
l c
lea
ra
nce
T
h
is
s
tu
d
y
was
ap
p
r
o
v
ed
b
y
th
e
Sam
ar
i
n
d
a
H
o
s
p
ital
E
th
ics
C
o
m
m
ittee
o
f
I
n
d
o
n
esia
(
No
.
4
6
2
/DI
R
/I
X)
.
T
h
e
co
m
m
ittee's
ap
p
r
o
v
al
en
s
u
r
ed
th
a
t
th
e
r
esear
ch
co
n
d
u
cted
at
Sam
ar
in
d
a
Ho
s
p
ital
ad
h
er
ed
to
eth
ical
g
u
id
elin
es
an
d
s
af
e
g
u
ar
d
ed
th
e
r
ig
h
ts
an
d
well
-
b
ein
g
o
f
th
e
p
ar
ticip
an
ts
in
v
o
lv
ed
.
T
h
is
r
esear
ch
ap
p
r
o
v
al
was
a
test
am
en
t
to
th
e
h
o
s
p
ital'
s
co
m
m
itm
en
t
to
u
p
h
o
ld
in
g
eth
ical
s
tan
d
ar
d
s
i
n
m
e
d
ical
r
esear
ch
.
2
.
5
.
Lo
c
a
ti
o
n
T
h
e
lo
ca
tio
n
o
f
th
e
r
esear
ch
ar
ea
is
clea
r
ly
d
ef
in
ed
in
f
o
u
r
d
if
f
er
en
t
p
e
r
s
p
ec
tiv
es,
p
r
o
v
id
in
g
a
co
m
p
r
eh
e
n
s
iv
e
v
iew
f
o
r
f
u
r
th
er
an
aly
s
is
.
Fig
u
r
e
1
o
f
f
er
s
a
d
etailed
v
is
u
al
r
ep
r
esen
tatio
n
o
f
th
e
l
o
ca
tio
n
f
r
o
m
v
ar
io
u
s
s
ca
les,
aid
in
g
i
n
b
etter
u
n
d
er
s
tan
d
in
g
t
h
e
g
eo
g
r
a
p
h
i
ca
l
co
n
tex
t
o
f
th
e
s
tu
d
y
.
T
h
e
r
esear
ch
lo
ca
tio
n
is
s
h
o
wn
in
Fig
u
r
e
1
with
th
e
f
o
llo
win
g
d
etails
Fig
u
r
e
1
(
a
)
.
L
o
ca
tio
n
Ma
p
Viewe
d
f
r
o
m
th
e
Natio
n
al
T
er
r
ito
r
y
(
I
n
d
o
n
esia)
.
Fig
u
r
e
1
(
b
)
.
L
o
ca
tio
n
m
a
p
s
ee
n
f
r
o
m
t
h
e
Kalim
an
tan
I
s
lan
d
ar
ea
.
Fig
u
r
e
1
(
c)
.
L
o
ca
tio
n
m
ap
s
ee
n
f
r
o
m
E
ast
Kalim
an
tan
Pro
v
in
ce
.
Fig
u
r
e
1
(
d
)
.
L
o
ca
tio
n
m
a
p
se
e
n
fro
m
with
i
n
th
e
c
it
y
o
f
S
a
m
a
rin
d
a
.
F
o
r
m
o
re
d
e
tail,
it
c
a
n
b
e
se
e
n
i
n
t
h
e
F
ig
u
re
1
.
(
a)
(
b
)
(c
)
(d
)
Fig
u
r
e
1
.
L
o
ca
tio
n
o
f
th
e
s
tu
d
y
(
a)
L
o
ca
tio
n
m
a
p
v
iewe
d
f
r
o
m
th
e
n
atio
n
al
te
r
r
ito
r
y
(
I
n
d
o
n
esia)
; (
b
)
L
o
ca
tio
n
m
ap
s
ee
n
f
r
o
m
th
e
Kalim
an
ta
n
I
s
lan
d
ar
ea
;
(
c)
L
o
ca
tio
n
m
a
p
s
ee
n
f
r
o
m
E
ast Ka
lim
an
tan
Pro
v
in
ce
; (
d
)
L
o
ca
tio
n
m
ap
s
ee
n
f
r
o
m
with
i
n
th
e
city
o
f
Sam
ar
in
d
a
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
1
3
,
No
.
4
,
Dec
em
b
er
20
24
:
1
90
3
-
1
91
1
1906
3.
RE
SU
L
T
S AN
D
D
I
SCU
SS
I
O
N
Dem
o
g
r
ap
h
ic
ch
ar
ac
ter
is
tics
o
f
r
esp
o
n
d
en
t
d
etails
ca
n
b
e
s
ee
n
in
T
ab
le
1
.
T
h
ese
f
i
n
d
in
g
s
s
u
g
g
est
th
at
r
esp
o
n
d
en
ts
f
elt
th
e
m
o
s
t
em
p
o
wer
ed
wh
e
n
it
ca
m
e
to
ac
tiv
ity
o
p
p
o
r
tu
n
ities
,
as
in
d
icate
d
b
y
th
e
h
ig
h
est
s
co
r
e
o
f
1
5
.
8
.
Ho
we
v
er
,
th
e
r
e
s
ee
m
s
to
b
e
r
o
o
m
f
o
r
im
p
r
o
v
em
en
t
in
ter
m
s
o
f
o
v
er
all
em
p
o
wer
m
en
t,
with
an
av
er
ag
e
s
co
r
e
o
f
7
.
9
.
Similar
ly
,
wh
ile
c
o
o
p
e
r
atio
n
with
in
t
h
e
u
n
it
was
p
er
ce
i
v
ed
p
o
s
itiv
ely
with
a
s
co
r
e
o
f
1
3
.
3
,
th
er
e
was
a
lo
wer
f
r
eq
u
en
cy
o
f
r
e
p
o
r
tin
g
ev
en
ts
wi
th
a
s
co
r
e
o
f
8
.
9
,
in
d
icatin
g
p
o
ten
tial
ar
ea
s
f
o
r
en
h
an
ce
m
e
n
t in
th
e
p
atien
t saf
ety
cu
ltu
r
e.
M
o
r
e
d
etails ca
n
b
e
s
ee
n
in
T
ab
le
2
.
All
p
atien
t
s
af
ety
cu
ltu
r
e
em
p
o
wer
m
en
t
in
d
icato
r
s
wer
e
s
ig
n
if
ican
t,
as
in
d
icate
d
b
y
a
v
alu
e
o
f
0
.
0
0
<=
0
.
0
5
.
T
h
e
p
atien
t
s
af
ety
cu
ltu
r
e
h
as
im
p
r
o
v
e
d
with
g
r
ea
ter
em
p
o
wer
m
en
t
in
th
e
h
o
s
p
itality
in
d
u
s
tr
y
.
T
h
r
o
u
g
h
o
p
p
o
r
tu
n
iti
es
an
d
ac
ce
s
s
to
r
eso
u
r
ce
s
,
s
u
p
p
o
r
t,
an
d
in
f
o
r
m
atio
n
,
n
u
r
s
es
d
ev
elo
p
a
s
en
s
e
o
f
em
p
o
wer
m
en
t.
Patien
t
s
af
ety
cu
ltu
r
e
is
in
f
lu
en
ce
d
b
y
s
ev
er
al
f
ac
to
r
s
i
n
clu
d
in
g
s
taf
f
in
g
,
m
an
a
g
er
s
’
ex
p
ec
tatio
n
s
an
d
b
eh
av
i
o
r
s
,
n
u
r
s
es’
v
iews,
an
d
m
an
a
g
em
en
t
s
u
p
p
o
r
t.
M
o
r
e
d
etails ca
n
b
e
s
ee
n
in
T
ab
le
3
.
Sev
en
v
alid
m
ea
s
u
r
em
en
t
item
s
wer
e
u
s
ed
to
ass
ess
em
p
o
wer
m
en
t.
T
h
e
s
ev
en
m
ea
s
u
r
e
m
en
t
item
s
h
ad
s
tr
o
n
g
co
r
r
elatio
n
s
with
em
p
o
wer
m
en
t,
as
in
d
icate
d
b
y
th
e
o
u
ter
lo
ad
in
g
v
al
u
e,
wh
ich
r
an
g
ed
f
r
o
m
0
.
9
0
6
-
0
.
9
5
2
.
W
ith
a
C
r
o
n
b
ac
h
'
s
alp
h
a
v
alu
e
o
f
0
.
9
7
3
,
wh
i
ch
is
g
r
ea
ter
th
a
n
0
.
7
0
;
a
co
m
p
o
s
ite
r
eliab
ilit
y
v
alu
e
o
f
0
.
9
7
3
a
b
o
v
e
0
.
7
0
;
an
d
co
n
v
er
g
en
t v
alid
ity
,
as
d
em
o
n
s
tr
ated
b
y
a
n
AVE
o
f
0
.
8
5
9
>0
.
5
0
,
th
e
d
eg
r
ee
o
f
r
eliab
ilit
y
o
f
th
e
em
p
o
wer
m
e
n
t
v
ar
iab
le
was
d
ee
m
ed
s
atis
f
ac
to
r
y
.
Acc
ess
to
h
elp
was
wh
er
e
em
p
o
wer
m
en
t
was
m
o
s
t
ex
p
r
ess
ed
am
o
n
g
th
e
s
ev
en
v
alid
ass
ess
m
en
t
m
ea
s
u
r
es
(
L
F=0
.
9
5
2
)
.
M
o
r
e
d
e
tails
ca
n
b
e
s
ee
n
in
T
ab
le
4
.
Patien
t
s
af
ety
cu
ltu
r
e
is
class
if
ied
as
an
en
d
o
g
e
n
o
u
s
co
m
p
o
n
e
n
t
o
f
th
e
s
tr
u
c
tu
r
al
m
o
d
el,
wh
ile
em
p
o
wer
m
en
t
is
an
ex
o
g
en
o
u
s
elem
en
t.
W
ith
an
R
2
v
alu
e
o
f
0
.
4
5
8
,
it
ca
n
b
e
d
e
d
u
ce
d
th
at
4
5
.
8
0
%
o
f
th
e
v
ar
iab
ilit
y
in
th
e
em
p
o
wer
m
en
t
co
m
p
o
n
e
n
t
ac
co
u
n
ted
f
o
r
th
e
v
ar
iab
ilit
y
i
n
th
e
p
ati
en
t
s
af
ety
cu
lt
u
r
e
co
n
s
tr
u
ct.
W
h
er
ea
s
,
th
e
r
em
ai
n
in
g
5
4
.
2
0
% wa
s
ex
p
lain
e
d
b
y
v
ar
iab
les n
o
t in
clu
d
e
d
in
th
e
s
tu
d
y
.
E
x
am
in
e
t
h
e
co
n
n
ec
tio
n
b
etw
ee
n
"p
atien
t
s
af
ety
c
u
ltu
r
e"
a
n
d
"e
m
p
o
wer
m
en
t".
T
h
is
ass
o
c
iatio
n
h
as
an
in
itial
v
alu
e
o
f
0
.
6
7
7
,
s
am
p
le
m
ea
n
o
f
0
.
6
8
1
,
s
tan
d
a
r
d
d
ev
iatio
n
o
f
0
.
0
4
5
,
an
d
co
m
p
u
ted
t
-
s
tatis
tic
o
f
1
5
.
1
8
0
.
T
h
e
r
e
is
a
h
ig
h
ly
s
ig
n
if
ican
t
d
if
f
er
en
ce
b
etwe
en
th
e
s
am
p
le
an
d
th
e
s
am
p
le
m
ea
n
,
as
in
d
icate
d
b
y
th
e
ex
tr
em
ely
lo
w
p
-
v
alu
e
o
f
0
.
0
0
0
.
T
h
e
r
esu
lts
o
f
th
is
an
aly
s
i
s
d
em
o
n
s
tr
ated
a
s
u
b
s
tan
tial
co
r
r
elatio
n
b
etwe
en
th
e
two
v
ar
ia
b
les,
with
th
e
lev
el
o
f
p
atien
t
s
af
ety
cu
ltu
r
e
em
p
o
wer
m
en
t b
ein
g
co
n
s
id
er
a
b
ly
d
if
f
e
r
en
t
f
r
o
m
th
e
s
am
p
le
av
er
ag
e.
T
h
e
s
ig
n
if
ica
n
ce
o
f
th
is
ass
o
ciatio
n
was f
u
r
th
er
s
u
p
p
o
r
ted
b
y
lo
w
p
-
v
alu
e
s
.
E
d
u
ca
tio
n
,
clin
ical
ex
p
e
r
tis
e,
k
n
o
wled
g
e
,
an
d
s
elf
-
ass
u
r
an
ce
ca
n
co
n
tr
ib
u
te
to
em
p
lo
y
ee
em
p
o
wer
m
en
t.
No
n
eth
eless
,
a
n
u
m
b
er
o
f
elem
en
ts
,
in
clu
d
in
g
in
ad
eq
u
ate
lead
e
r
s
h
ip
an
d
m
an
ag
em
en
t,
lack
o
f
tr
ain
in
g
o
r
o
p
p
o
r
t
u
n
ities
f
o
r
p
r
o
f
ess
io
n
al
g
r
o
wth
,
an
d
lack
o
f
r
esp
ec
t
an
d
s
u
p
p
o
r
t
f
r
o
m
co
wo
r
k
er
s
ca
n
lo
we
r
th
e
d
eg
r
ee
o
f
em
p
o
wer
m
e
n
t in
th
e
wo
r
k
p
lace
.
Mo
r
e
d
etails ca
n
b
e
s
ee
n
in
Fig
u
r
e
2
.
T
h
e
d
im
e
n
s
io
n
s
th
at
b
u
ild
a
p
atien
t
s
af
ety
cu
ltu
r
e
in
v
o
lv
e
m
an
y
p
ar
ties
in
th
e
h
o
s
p
itality
s
ec
to
r
,
in
clu
d
in
g
m
an
a
g
em
en
t
an
d
lo
wer
-
,
m
id
d
le
-
,
an
d
u
p
p
er
-
lev
el
m
an
ag
e
m
en
t
as
well
as
n
u
r
s
es
wh
o
im
p
lem
en
t
a
p
atien
t
s
af
ety
cu
ltu
r
e
in
th
eir
s
er
v
ices
to
p
atien
ts
.
T
h
u
s
,
th
er
e
is
s
u
p
p
o
r
t
f
r
o
m
th
e
m
an
ag
em
en
t
in
ter
m
s
o
f
b
o
th
ad
v
ice
an
d
in
f
r
astru
ctu
r
e
r
elate
d
to
th
e
latest
in
f
o
r
m
ati
o
n
r
e
g
ar
d
in
g
th
e
g
o
als
ac
h
iev
ed
b
y
th
e
h
o
tel
in
im
p
r
o
v
in
g
p
atien
t
s
af
ety
[
2
0
]
.
Nu
r
s
es
'
p
er
ce
p
tio
n
s
o
f
s
tr
u
ctu
r
al
em
p
o
wer
m
e
n
t
in
f
lu
en
ce
d
th
eir
ef
f
ec
tiv
en
ess
at
wo
r
k
.
Oth
er
th
in
g
s
th
at
ca
n
b
e
d
o
n
e
with
th
e
s
u
p
p
o
r
t
th
at
n
u
r
s
es
r
ec
eiv
e
ca
n
also
in
f
lu
e
n
ce
o
r
g
a
n
izatio
n
al
ef
f
ec
tiv
en
ess
[
2
1
]
.
Nu
r
s
es
wh
o
h
av
e
wo
r
k
ed
f
o
r
m
o
r
e
th
an
ten
y
ea
r
s
an
d
h
av
e
e
x
p
er
ien
ce
s
h
o
w
h
ig
h
e
r
p
atien
t
s
af
ety
c
u
ltu
r
e
s
co
r
es
in
s
er
v
ice
[
2
2
]
.
Var
io
u
s
s
tr
ateg
ies
h
av
e
b
ee
n
ad
o
p
ted
to
s
u
p
p
o
r
t
p
atien
t
s
af
et
y
cu
ltu
r
e.
L
ittl
e
ev
id
en
ce
s
u
g
g
e
s
ts
th
at
p
atien
t
s
af
ety
cu
ltu
r
e
in
f
lu
e
n
ce
s
th
e
p
atien
t
s
af
ety
clim
ate
[
2
3
]
.
T
h
e
d
im
en
s
io
n
s
th
at
h
a
v
e
a
p
o
s
itiv
e
p
er
ce
p
tio
n
o
f
p
atien
t
s
af
et
y
cu
ltu
r
e
a
r
e
"a
s
p
ec
ts
r
elate
d
t
o
p
atien
t
s
af
ety
a
n
d
q
u
ality
,
"
"e
x
c
h
an
g
e
o
f
in
f
o
r
m
atio
n
b
etwe
en
o
t
h
er
u
n
its
,
"
an
d
"tea
m
wo
r
k
"
[
2
4
]
.
E
n
c
o
u
r
a
g
i
n
g
a
n
d
e
n
h
a
n
c
i
n
g
p
a
t
i
e
n
ts
'
g
e
n
e
r
a
l
w
e
ll
-
b
e
i
n
g
w
h
ile
g
i
v
i
n
g
t
h
e
m
t
h
e
t
o
o
ls
t
h
e
y
n
ee
d
t
o
t
a
k
e
c
h
a
r
g
e
o
f
t
h
e
i
r
h
e
a
l
t
h
a
n
d
m
a
k
i
n
g
w
is
e
d
e
ci
s
i
o
n
s
a
r
e
t
h
e
r
e
s
p
o
n
s
i
b
i
l
it
y
o
f
e
m
p
o
w
e
r
i
n
g
n
u
r
s
e
s
.
T
h
e
t
h
r
e
e
m
a
i
n
g
o
a
l
s
o
f
e
m
p
o
w
e
r
i
n
g
n
u
r
s
e
s
a
r
e
t
o
p
r
o
m
o
t
e
i
n
d
e
p
e
n
d
e
n
c
e
,
s
e
lf
-
c
a
r
e
b
e
h
a
v
i
o
r
s
[
2
5
]
,
a
n
d
h
i
g
h
-
q
u
a
l
i
t
y
c
a
r
e
[
2
6
]
.
P
a
t
i
e
n
t
s
a
r
e
e
d
u
c
a
t
e
d
b
y
e
m
p
o
w
e
r
i
n
g
n
u
r
s
e
s
r
e
g
a
r
d
i
n
g
t
h
e
i
r
m
e
d
i
c
a
l
is
s
u
es
,
a
v
a
i
l
a
b
l
e
t
r
e
a
tm
e
n
t
s
,
a
n
d
w
a
y
s
t
o
a
v
o
i
d
t
h
e
m
[
2
7
]
.
B
y
p
r
o
v
i
d
i
n
g
p
a
t
i
e
n
ts
wi
t
h
c
le
a
r
a
n
d
s
i
m
p
l
e
i
n
f
o
r
m
a
t
i
o
n
,
t
h
e
y
e
m
p
o
w
e
r
t
h
em
s
e
l
v
es
t
o
p
l
a
y
a
n
ac
tiv
e
r
o
le
in
th
eir
ca
r
e,
m
a
k
e
h
ea
lth
y
d
ec
is
io
n
s
,
an
d
g
ain
a
b
etter
u
n
d
er
s
tan
d
i
n
g
o
f
th
eir
h
e
alth
[
2
8
]
.
Nu
r
s
e
em
p
o
wer
m
e
n
t
is
cr
u
cial
in
h
ea
lth
ca
r
e
s
ettin
g
s
,
b
ec
au
s
e
it
ca
n
lead
t
o
in
cr
ea
s
ed
jo
b
s
atis
f
ac
tio
n
an
d
b
etter
s
er
v
ic
es.
B
y
u
s
in
g
co
llab
o
r
ativ
e
d
ec
is
io
n
-
m
ak
in
g
,
e
m
p
o
wer
m
e
n
t
n
u
r
s
es
ac
tiv
ely
in
v
o
lv
e
p
atien
ts
in
cr
ea
tin
g
tr
ea
tm
en
t
p
lan
s
th
at
r
ef
lect
th
ei
r
ch
o
ices
an
d
asp
ir
atio
n
s
[
2
9
]
.
T
o
g
u
ar
an
tee
th
at
tr
ea
tm
en
t
is
p
atien
t
-
ce
n
ter
ed
an
d
g
u
id
e
d
b
y
m
u
tu
al
co
n
s
en
t,
p
atien
ts
p
ay
atten
tio
n
to
th
eir
co
n
ce
r
n
s
,
v
alu
es,
an
d
b
elief
s
[
3
0
]
.
E
m
p
o
wer
m
e
n
t
n
u
r
s
es
f
o
cu
s
o
n
illn
ess
p
r
e
v
en
tio
n
an
d
h
ea
lth
p
r
o
m
o
tio
n
[
3
1
]
.
T
h
e
y
p
r
o
v
id
e
p
atien
ts
with
th
e
k
n
o
wled
g
e
t
h
ey
n
ee
d
to
tak
e
ch
ar
g
e
o
f
th
eir
h
ea
lth
b
y
teac
h
in
g
th
em
s
t
r
ess
m
an
ag
em
en
t,
ex
er
cise,
d
iet,
an
d
o
th
er
h
ea
lth
-
r
elate
d
to
p
ics
[
1
1
]
.
E
m
p
o
wer
m
e
n
t
n
u
r
s
es
ass
is
t
p
atien
ts
in
o
v
er
co
m
in
g
o
b
s
tacle
s
a
s
s
o
ciate
d
wi
th
th
eir
m
ed
ical
p
r
o
b
lem
s
b
y
p
r
o
v
id
in
g
em
o
ti
o
n
al
s
u
p
p
o
r
t
an
d
en
co
u
r
ag
e
m
en
t.
T
h
e
y
e
n
ab
le
p
atien
ts
t
o
lo
o
k
f
o
r
th
e
r
i
g
h
t
s
er
v
ices
an
d
s
u
p
p
o
r
t
s
y
s
tem
s
,
an
d
en
c
o
u
r
ag
e
s
elf
-
ad
v
o
ca
cy
[
3
2
]
.
Nu
r
s
e
em
p
o
wer
m
en
t
g
u
ar
an
tees
co
n
tin
u
it
y
Evaluation Warning : The document was created with Spire.PDF for Python.
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8
8
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6
Th
e
effec
t o
f e
mp
o
w
ermen
t to
imp
r
o
ve
p
a
tien
t sa
fety
cu
ltu
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e
a
mo
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g
h
o
s
p
ita
l n
u
r
s
es
(
R
u
s
d
i R
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s
d
i)
1907
o
f
ca
r
e
b
y
p
r
o
m
o
tin
g
ef
f
i
cien
t
co
m
m
u
n
icatio
n
an
d
co
llab
o
r
atio
n
a
m
o
n
g
h
ea
lth
ca
r
e
team
s
,
n
u
r
s
e
em
p
o
wer
m
en
t
g
u
ar
an
tees
co
n
tin
u
ity
o
f
ca
r
e
[
3
3
]
.
T
h
ey
s
u
p
p
o
r
t
p
atie
n
ts
b
y
f
o
llo
wi
n
g
th
ei
r
tr
ea
tm
e
n
t
p
r
o
g
r
a
m
s
,
n
av
ig
atin
g
th
e
h
ea
lth
ca
r
e
s
y
s
tem
,
an
d
o
b
tain
in
g
r
e
q
u
ir
ed
r
eso
u
r
ce
s
[
3
4
]
.
T
h
e
u
ltima
te
g
o
al
o
f
n
u
r
s
in
g
e
m
p
o
wer
m
en
t
is
to
im
p
r
o
v
e
it.
T
h
eir
g
o
al
is
to
e
m
p
o
wer
p
atien
ts
with
th
e
m
ea
n
s
to
ac
tiv
el
y
en
g
ag
e
in
th
eir
h
ea
lth
ca
r
e,
m
ak
e
i
n
f
o
r
m
ed
d
ec
is
io
n
s
,
an
d
ass
u
m
e
r
esp
o
n
s
ib
ilit
y
f
o
r
h
ea
lth
o
u
tc
o
m
es
[
3
5
]
.
B
y
e
m
b
r
ac
in
g
th
e
p
r
in
cip
le
o
f
e
m
p
o
wer
m
en
t,
n
u
r
s
es
ac
t
as
ca
taly
s
ts
f
o
r
p
o
s
itiv
e
ch
an
g
e,
h
elp
in
g
p
atien
ts
to
b
e
co
m
e
ag
en
ts
o
f
th
eir
h
ea
lth
a
n
d
well
-
b
ein
g
.
Patien
t
s
af
ety
cu
ltu
r
e
in
h
ea
lth
ca
r
e
o
r
g
an
izatio
n
s
co
n
s
is
ts
o
f
m
en
tality
,
b
elief
s
,
d
is
p
o
s
itio
n
s
,
an
d
s
h
ar
ed
p
r
i
n
cip
les
th
at
p
r
io
r
i
tize
p
atien
t
s
af
ety
an
d
s
u
p
p
o
r
t
p
r
o
g
r
ess
.
T
h
is
r
e
lates
to
th
e
h
ea
lth
p
r
ac
titi
o
n
e
r
'
s
s
tead
f
astn
es
s
an
d
d
e
d
icatio
n
to
en
s
u
r
i
n
g
th
e
h
ea
lth
an
d
s
af
ety
o
f
in
d
iv
i
d
u
a
ls
th
r
o
u
g
h
o
u
t
th
eir
h
ea
lth
ca
r
e
ex
p
er
ien
ce
[
3
6
]
.
A
s
tr
o
n
g
p
a
tien
t
s
af
ety
cu
ltu
r
e
p
r
ev
en
ts
m
ed
ical
er
r
o
r
s
,
ad
v
e
r
s
e
ev
en
ts
,
an
d
h
ar
m
.
I
t
em
p
h
asizes
o
p
en
co
m
m
u
n
icatio
n
,
co
llab
o
r
atio
n
,
a
n
d
co
n
tin
u
o
u
s
im
p
r
o
v
em
en
t to
im
p
r
o
v
e
p
atien
t o
u
tco
m
es a
n
d
r
ed
u
ce
r
is
k
s
[
3
7
]
.
Patien
t
s
af
ety
d
e
p
en
d
s
o
n
ef
f
icien
t
co
m
m
u
n
icatio
n
b
etwe
e
n
m
e
d
ical
p
er
s
o
n
n
el,
d
ep
a
r
tm
en
ts
,
an
d
p
atien
ts
.
T
h
is
p
r
o
m
o
tes
th
e
s
h
ar
in
g
o
f
i
d
ea
s
,
tr
an
s
m
is
s
io
n
o
f
cr
itical
in
f
o
r
m
atio
n
,
an
d
th
e
ea
r
ly
d
etec
tio
n
o
f
p
o
s
s
ib
le
h
az
ar
d
s
.
Patien
t
s
af
ety
ca
n
b
e
in
cr
ea
s
ed
b
y
h
ea
lth
ca
r
e
p
r
o
v
id
er
s
wo
r
k
i
n
g
to
g
eth
er
an
d
s
h
o
win
g
r
esp
ec
t
f
o
r
o
n
e
an
o
th
e
r
[
3
8
]
.
E
r
r
o
r
s
ca
n
b
e
r
e
d
u
ce
d
,
an
d
a
s
af
ety
c
u
ltu
r
e
is
s
u
p
p
o
r
ted
b
y
p
r
o
m
o
tin
g
in
ter
d
is
cip
lin
ar
y
team
wo
r
k
,
c
r
ea
tin
g
a
f
r
ien
d
ly
wo
r
k
atm
o
s
p
h
er
e,
an
d
ap
p
r
ec
iatin
g
th
e
v
alu
e
o
f
ea
ch
team
m
em
b
er
'
s
co
n
tr
ib
u
tio
n
[
3
9
]
.
I
m
p
r
o
v
i
n
g
p
a
t
i
e
n
t
s
a
f
e
t
y
r
e
q
u
i
r
e
s
a
c
u
l
t
u
r
e
t
h
a
t
e
n
c
o
u
r
a
g
e
s
t
h
e
r
e
p
o
r
t
i
n
g
o
f
m
i
s
h
a
p
s
,
n
e
a
r
-
m
i
s
s
e
s
,
a
n
d
u
n
f
a
v
o
r
a
b
l
e
e
v
e
n
t
s
w
i
t
h
o
u
t
co
n
c
e
r
n
f
o
r
r
e
p
r
i
s
a
l
s
.
A
d
e
t
ail
e
d
i
n
v
e
s
ti
g
a
t
i
o
n
is
r
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q
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i
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d
t
o
d
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t
e
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m
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h
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n
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e
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l
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r
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s
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f
o
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o
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c
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n
d
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a
t
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p
r
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v
e
n
t
at
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v
e
m
e
a
s
u
r
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