Author ORCID Identifier

Defense Date


Document Type


Degree Name

Doctor of Philosophy


Health Related Sciences

First Advisor

Cheryl Rathert, PhD

Second Advisor

Lauretta Cathers, PhD

Third Advisor

Wes Campbell, PhD

Fourth Advisor

Suzanne Taylor, PhD

Fifth Advisor

Diane Dodd-McCue, DBA

Sixth Advisor

Paula Kupstas, PhD


Objective: The objective of this study is to examine relations between patient safety culture and processes of care, specifically, how patient safety culture influences the prevention of patient falls. The purpose of this inquiry is to identify the barriers and facilitators that can advance an inpatient rehabilitation facility to become a high reliability organization and advance interdisciplinary teamwork.

Method: A qualitative phenomenological approach was conducted and an interpretive phenomenological analysis explored the experiences of frontline staff with regard to patient safety culture and fall prevention. The study utilized semi-structured interviews with 24 frontline staff from three inpatient rehabilitation hospitals. Participants were selected using purposive sampling and individually interviewed.

Results: Findings revealed barriers and facilitators for each dimension of patient safety culture that drive fall prevention. Teamwork within and across disciplines, such as between nursing and therapy, affect how they communicate with one another. Issues related to staffing were the most common concerns amongst nursing staff; especially the issue of staffing ratio and patient acuity. Leadership played a role in supporting the culture of safety and holding staff accountable.

Conclusion: Fall prevention requires collaborative efforts between nursing and therapy in an inpatient rehabilitation setting. Dimensions of patient safety culture such as good teamwork, effective communication, adequate staffing, nonpunitive response to errors, and strong leadership support are essential in maintaining a high reliability process for adaptive learning and reliable performance.


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