The Association between Organizational Culture and Knowledge, Attitudes, and Practices in a Multicenter VA Quality Improvement Initiative to Prevent MRSA

Background: Organizational culture (OC) is defined as the assumptions, values, and norms that can either help or hinder an organization's ability to implement successful prevention initiatives.

Objective: To assess the association between OC and employee knowledge, attitudes, and practices as part of a VA quality improvement (QI) initiative to prevent methicillin-resistant Staphylococcus aureus (MRSA).

Methods:   Baseline and follow-up surveys were conducted at 16 VA medical centers nationally. The surveys included 22 Likert-items designed to measure OC (range: 22 – 110, higher scores = more positive OC) as well as items regarding MRSA-related knowledge, attitudes, and practice.  Factor analysis was performed on the combined baseline and follow-up responses; factor scores were then generated. To assess associations with OC, logistic regression was performed for binary outcomes of knowledge, ordinal logistic regression for categorical outcomes of barriers and attitudes, and linear regression for continuous outcomes of self-reported practice.

Results:  A total of 2,314 participants (43.3% nurses, 8.8% physicians, 47.9% other staff) completed a survey.  The mean total overall OC score was 75.6; three factors emerged accounting for 52.5% of the total variance: “Staff Engagement”, “Overwhelmed/Stress-Chaos”, and “Hospital Leadership.”  Of the three factors, only Staff Engagement was significantly associated with higher total knowledge (answering all MRSA knowledge questions correctly, p=0.021).  All three OC factors were significantly associated with the percent of time participants reported cleaning their hands and gowning/gloving, respectively; Staff Engagement (T-score: 3.32, p=0.001; 4.98, p<0.001) and Hospital Leadership (2.18, p=0.029; 3.35, p=0.001) were positively associated, while Overwhelmed/Stress-Chaos was negatively associated (-3.87, p<0.001; -4.83, p<0.001).  Overall, participants reporting higher levels of Staff Engagement and Hospital Leadership were significantly less likely to report barriers while participants with higher levels of Overwhelmed/Stress-Chaos were more likely to report barriers.  All three factors were significantly associated with participant attitudes, with Overwhelmed/Stress-Chaos demonstrating an opposite directionality in relationship to Staff Engagement and Hospital Leadership (Table 1).

Conclusions:  As part of this multicenter MRSA QI initiative, three OC factors (Staff Engagement, Overwhelmed/Stress-Chaos, and Hospital Leadership) were found to be significantly associated with knowledge, attitudes, and practices as reported by healthcare personnel.  While Staff Engagement alone was found to be associated with knowledge, the data suggest that the combined influence of all three OC factors are important determinants of barriers, attitudes, and practices.