Dimensions of the internet parenting style (adapted from [8], p. 89).
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This currently occurs from early infancy, due to the rapid diffusion of touchscreen devices among younger children (or “touch generation”; [2, 3]). Children aged 2–4 years actually are able to use touchscreen devices, such as tablets or smartphones, to play or watch movies, and often parents themselves introduce kids to use them in boring social situations (i.e., in the pediatrician’s waiting rooms or in the restaurant; [4]). On the basis of the most recent report on worldwide diffusion of the Internet among young people [1], one in three users is estimated to be a child or teenager (under 18). Generally children use digital technologies in their home, particularly younger children, with intense and prolonged activities especially on weekends. Children often use their digital technologies at school at least a day a week (almost 30% among 9–11 years), although it is prohibited in many countries by school regulations. The access to digital technologies is expanding among young generations, even if many inequalities of resources remain between developed or developing countries [1]: for example, it has been estimated that in Africa (Ghana) children mainly use 0.9 mobile devices to connect to the Internet, against 2.9 in South America (Chile) or 2.6 in Europe (Italy). Similarly, only 12% of children in Africa (Ghana), 21% in the Philippines, and 26% in Albania can connect to the Internet at school, against 63–54% of children in other South America or European countries, such as Argentina, Uruguay, or Bulgaria. This reality raises several questions on how to guarantee the young generations the opportunities offered by new technologies (for studying, enhancing skills, socializing, etc.), protecting them from potential dangers of digitalized world (i.e., contacts with unknown people, exposure to violent/pornographic contents, etc.). In fact, although children grow in a reality permeated by new media, they are not automatically “digitally literate,” that is, able to juggle the digital world and to reflect on it. Studies show that not only young users, but also teenager users “have difficulties in finding, managing and evaluating information, managing their privacy online and ensuring their online personal safety […]and may thus vary in their digital skills” ([5], p. 186).
Together with their children, parents themselves are largely exposed to media experiences in many fields of their life. Digital technologies have quickly changed the way in which family members communicate, enjoy themselves, acquire information, and solve daily problems. Parents are also the first mediators of children’s experiences with digital tools: they have the task of integrating their use into ordinary routines (play, entertainment, learning, mealtime, etc.), promoting constructive and safety uses. Digital parenting describes parental efforts and practices for comprehending, supporting, and regulating children’s activities in digital environments. A growing research on digital parenting identified the main approaches that can allow parents to “mediate” children’s activities with digital technologies [6, 7, 8]. According to Vygotsky’s theory of child development and his concept of proximal development zone [9], parental mediation can be considered a key aspect in facilitating the interactions between children and new media. The proximal development zone is an intermediate area between what the child is able to do alone and what he/she can learn thanks to the guidance of others. In the course of a shared activity, the support and the help are adapted so that the child can improve his/her skills and gradually assume responsibility for acting alone. However, the activities that take place in the virtual environments of the web, unlike the experiences in the real environments, can reverse the relationship between the competent person (the adult) and the learner (the child). Today’s children have an early, almost “intuitive” approach to digital technologies, so in some cases they can become active agents towards their parents. When children’s knowledge and digital competence (e.g., functions/benefits of a new app) overcome that of parents, many shared experiences can be child-initiated, and children can also perform some forms of support and digital teaching to parents. This reverse socialization [10] seems to be a peculiar feature of digital experiences, and it poses new challenges to parental role. Reverse socialization describes all situations where children possess a better understanding or more advanced skills than adults. This gap between generations is more marked in low-income families or low-educated parents who possess limited resources and access to digital technologies [11]. However, over the past years, many parents have developed adequate knowledge and technical skills to share digital experiences with their children [3, 12]; they appreciate benefits of the web and strive to comprehend its complexity.
A common difficulty that parents actually encounter derives from the diffusion of “portable” devices (smartphone and tablet) that children start to use in early infancy (under the age of 2; [13]). Later, due to unlimited Wi-Fi access and enhanced connectivity, children insert activities with mobile devices into many daily routines, for example, during mealtime, school homework, conversations with parents, or before sleeping [14]. Particularly, parents worry about the “pervasiveness” (or ubiquitous) of mobile technologies in daily activities [15], and they fear that an effective guidance and control over them may decrease. Studies with large samples of young digital users (9–16 years old) in many European countries have compared parents’ opinions before (2010 Eu Kids Online Survey; [12]) and after (Net Children Go Mobile; [3]) the diffusion of mobile devices. After 4 years, many parents declare that they know less about their children’s online activities and have more difficulties to closely monitor children’s usage (e.g., time spent connected). Interestingly, parents now are more aware of the risks of using the web [16], and they prefer to talk to children about Internet security (e.g., do not leave personal data online or block unknown people) rather than limiting or prohibiting Internet use [17]. Parents can encourage or limit the use of digital technologies to children according to the opportunities or danger they attribute to them. Since parents themselves are regular, sometimes enthusiastic, users of digital media, their digital skills and confidence and daily frequency of usage (or overuse; [18]), together with beliefs about digital world [3], are all crucial factors that researchers have begun to explore systematically.
Each parent has beliefs, that is, convictions and personal opinions, regarding the usage of media by children, such as their usefulness or damage, or the age at which children should use them. Beliefs are the cognitive dimension of attitudes, guiding individual’s behavior and choices. When parents raise their children, they act and make choices for them following their own perceptions of what is desirable or what they positively value for their child’s development [19]. Although parents are not always aware of their beliefs, these influence parent-child interaction and the child’s opportunity to learn, do experiences [20], and develop digital skills [5]. Parental beliefs are important aspects of parenting and family microsystem, together with factors such as parent’s history and education, socioeconomic status, and culture.
Parents possess personal ideas about modern technologies: they can be considered a source of entertainment/relaxation or a learning tool [21, 22]; conversely, for other people, PC, tablet, and smartphone can be harmful to children’s health (such as sleep problems, obesity, etc.; [23]), for social risks (such as contacts with unfamiliar or social isolation; [24]), or because they interfere with parent-child activities and time spent together [25].
A qualitative study [26] shows that parents have more pessimistic (70.55%) than optimistic opinions (29.45%) on the Internet use by primary school children: for example, parents worry about the excessive time spent online, the interference in face-to-face conversation, or that children lack of skills and maturity in dealing with some contents suitable for older children (such as violence, sex, or drug-related contents). Other worries concern negative consequences on learning and academic performance (i.e., reduced attention span), physical development (i.e., prolonged sedentary activities), social skills and peer interactions (i.e., fewer opportunities to “learn to play together”), and child’s well-being (i.e., using smartphone to overcome boredom). Interestingly, many parents fear losing control over their children’s online behaviors. Conversely, the positive beliefs concern positive effects of digital technologies on child’s entertainment, communication and learning, access to information, and enhancing of child’s skills (such as brain functioning, self-regulation, autonomy, critical attitude, etc.).
Other researchers [27] explored parent’s perceptions about positive (i.e., they are shared by generations) or negative impact (i.e., they expose family privacy to risks) of social media—such as Facebook or WhatsApp—on family open communication. Teenagers are intensely involved in social media use, but adults also are regular users. On the one hand, parents use social networks to communicate; on the other hand, they fear that they negatively impact family relationships, for example, through the phubbing phenomenon (i.e., ignoring someone or interrupting a conversation or mealtime to check the smartphone). Authors found that parents’ perceptions are a meditational variable between the collective family efficacy (i.e., the perceived efficacy to manage family relationships, to support each other, etc.) and the openness of communication: “it is not only the actual impact of social media on family systems that matters but also parents’ perceptions about it and how much they feel able to manage their children’s social media use without damaging their family relationships” (p. 1).
Parental beliefs may influence the degree to which parents give opportunities or restrict their children’s media use, but beliefs should not be considered the “cause” of behavior towards children. Researches show that parents’ positive beliefs (e.g., “the tablet improves reading skills”) are associated with favorable attitudes, co-using approach, communication, or suggestions to enhance their child’s appropriate use of the Internet [28]. For example, when parents think that smartphones are useful tools (i.e., they promote child’s intelligence and knowledge), they more often allow their preschool children to use them (i.e., at the restaurant), and children become regular users, spending more time (at least 2 h a day) with smartphone activities [29]. Conversely, parents who attribute negative effects to digital media tend to limit activities to children (i.e., put time limits or react for smartphone overuse); in turn, these restrictive behaviors can influence how much the children use these devices [28]. Therefore, the influences of parental beliefs on child’s behaviors are not directed, but they are mediated by parental practices and other factors such as parental education or involvement with mobile device (“attachment”; see, e.g., [30]) that can intervene.
Parental beliefs include also self-efficacy [31, 32], that is, parent’s sense of competence in their own digital skills and in managing their children’s technology usage. An example of parental self-referent estimation of competence is “I won’t bother setting parental controls or passwords because my kids will “hack” around them” (cfr. [33]). In many studies, parental self-efficacy is positively associated with active parental practices: when parents feel confident about their Internet skills, they more often are involved in or monitor their children’s media activities [6]. Recently Shin [34] distinguishes general self-efficacy (the confidence to be a good parent; [35]) from two self-efficacy domains assessing parental beliefs more strictly related to digital tasks: parental “media competency” in using media technology (such as sending/receiving email with a smartphone) and “perceived control over mediation strategies” (the degree to which the parent feels to be able to guide or modify their children’s behaviors on smartphone). All these domains of parenting self-efficacy are associated with each other [34], suggesting that perceived competence on their own digital skills can positively influence parents’ involvement with children (e.g., discussing about smartphone use).
Sanders et al. [33] found that when parents are confident to have adequate digital skills, they more often intervene (i.e., with rules and reinforcement strategies) with their children. Parental self-efficacy also influences parental opinions about technologies and how they talk about them with children [33]. Moreover, parental perception of influence in managing technologies decreased with preadolescents that generally are seen as more self-regulated and reluctant to the parental control than younger children. These findings suggest the importance to recognize the influence of child characteristics (such as age, technology usage, perceived competence, etc.) on digital parenting.
Initially studies on parental engagement in children’s activities with media assumed as theoretical basis the traditional parenting styles [36, 37]. According to Darling and Steinberg [38], parenting styles are defined as the context (or emotive climate) in which parents raise and socialize their children, and they are distinct from practices, that is, the distinct actions contingent to the child’s behavior (e.g., scolding when the child uses the smartphone during mealtime). As it is well known, two main dimensions of the parent’s behaviors, and their natural variations along a continuum, describe the styles: responsiveness/warmth (involvement, acceptance, and affect that the parent expresses towards the child’s needs) and demandingness/control (rules, control, and maturity expectations for the child’s socialization). Parenting styles derive from the combination of these variable dimensions: authoritative parenting (high warmth and high control, e.g., parents listen to the child’s wishes, but they put clear limits to the child’s behaviors); laissez-faire parenting (low warmth and low control; the parents are detached from the needs expressed by the child; they did not give rules or limits to child’s behavior); authoritarian parenting (low warmth and high control; parents expect the child to obey; they neither discuss nor listen to the child’s opinions and can react with harsh discipline); and permissive parenting (high warmth and low control; parents are very affectionate, but they lack in guidance through rules and give few limits to the child’s behavior).
Studies that applied these “classic” parenting styles to children’s behaviors with new communication media did not provide convincing results [39]. As an alternative to the “broad” parenting styles, a description of specific media-related practices is more useful in empirical studies for exploring the link between parental behaviors and child outcomes (e.g., time spent online). Therefore, researchers strove to identify the key dimensions of parental warmth/control more strictly referred to children’s behaviors on the Internet or new media (Table 1). These Internet parenting styles are more strictly linked to children’s actual use of digital technologies, for example, low parental control predicted more time of Internet usage by school-aged children [8].
Style dimensions | Item (examples) |
---|---|
Parental control | Supervision: “I’m around when my child surfs on the Internet” |
Stopping internet usage: “I stop my child when he/she visits a less suitable website” | |
Internet usage rules: “I limit the time my child is allowed in the Internet (e.g., only 1 h a day)” | |
Parental warmth | Communication: “I talk with my child about the dangers related to the Internet (costs, addiction to games, computer viruses, privacy violation, etc.)” |
Support: “I show my child “child friendly” websites (library, songs, crafts, school website, etc.)” |
Dimensions of the internet parenting style (adapted from [8], p. 89).
Parenting style dimensions seem influenced by parents’ individual characteristics such as gender, instruction, beliefs, or prior experiences with digital technologies. For example, in Valcke et al. [8] study, mothers are more controlling but also warmer than fathers, both dimensions associated with an authoritative style. In other studies, younger fathers and those who use the Internet more frequently with their teenagers are higher in control [40]. Parental instruction and experiences with digital technologies are other important variables: higher educated parents are more involved and high in control, probably because higher instructional levels also correspond to greater parents’ competence with the Internet [8].
The first studies explored parenting styles related to Internet usage at home, but more recently other authors explored the influence of digital parenting styles on children’s usage of mobile devices (tablet and smartphone). Konok et al. [30] found that children (3–7 years old) who use the devices for more time every day have parents who are more permissive (e.g., they talk with children about applications on devices, but have low levels of demandingness), more authoritative (e.g., they give time limits, but they do not block the use because they expect the child to regulate himself), and less authoritarian (i.e., the parent restricts and prohibits mobile use). Interestingly, these parenting styles are also associated with parental beliefs about positive/negative consequences of early media usage: parents who have higher permissive or authoritative digital style declared more beneficial (i.e., skill improvement, entertainment, and early learning of digital skills) than negative effects (i.e., reduced time for other activities, developmental problems, and danger/addiction) for children’s mobile usage.
Digital parenting styles change also according to children’s characteristics, such as age [41], self-esteem [42], emotion regulation [43], or behavioral problems [44] that can intervene, mediating the link between parenting and children’s actual behavior with digital technologies. Particularly, styles vary and accommodate with children’s age: authoritative parents during infancy become more permissive with older children [41]. Overall, these findings reappraise the idea that there is a linear, cause-effect relationship between parenting and child outcomes on digital behaviors, but bidirectional and transactional parent-child influences [45] should be considered.
Alternatively to digital parenting styles, many researchers adopted parental mediation as perspective for exploring parental influences on children’s digital behaviors. Parental mediation refers to “the diverse practices through which parents try to manage and regulate their children’s experiences with the media” ([7], p. 7). Parental mediation strategies were initially introduced in empirical studies as a potential factor influencing children’s use of television [46] and videogames [47]. These studies, exploring how parents can effectively reduce excessive exposure or enhance children’s self-regulated behaviors, inspired the following researches on digital technologies. Actually in literature two broad mediation approaches are distinct: enabling (or instructive) mediation and restrictive mediation [16]. These strategies are only partially similar to those parents who adopt “traditional” media: for example, co-viewing is a mediation strategy generally applied to television use [48], but it is difficult to apply it to portable media (particularly, smartphone and tablet) that children often use alone or outside the home environment. As a consequence, parents can feel worried because they cannot effectively control their children’s media use and involvement in digital life [11, 49].
The (a) enabling mediation is also defined as “active” or “instructive mediation” in that parents engage different activities with the aim to enhance their child’s appropriate use of the digital technologies: for example, they explain to him/her how to use a media device, talk about the contents of new app/websites, or play a videogame together (co-use mediation). Nevertheless, in many empirical studies, (b) co-use (or co-viewing mediation) does not imply parent-child conversations, but the parent is present when the child displays the activity with the media without discussing the content [13]. The (c) restrictive mediation is characterized by a strict attention to rules and control to the child’s digital activities: for example, parents decide when the child can have his/her tablet, pose time restrictions, or react when the child uses the smartphone too long. The (d) technical restriction is a particular kind of restrictive approach adopting software applications or other technical tools to control the child’s activities (e.g., installing filters on PC for children’s safety). Nevertheless, parents rarely use them and declare they prefer child-directed strategies, such as giving explanations or sharing the device [6].
Active mediation is the most frequent approach adopted in European families with 9–16 years old children, whereas restrictive mediation strategies are more common with younger children [16]. Interestingly, when children are interviewed about the mediation approach adopted in the family, they agree with their parents’ responses [12].
All mediation strategies are linked with changes in children’s digital behaviors, for example, less time exposure with online activities [12], or reduction of negative outcomes (i.e., aggressive behaviors, overuse, etc.; see [50]), but their efficacy is relative and it changes as a function of the child’s development (i.e., age and digital skills) and his/her actual activity with media. Active mediation is linked with positive outcomes (such as social and cognitive skills), particularly with younger children (0–3 ages): for example, during video/movie watching, parents stimulate attention, comment, or pose questions to children, giving them occasions for language exposure and cognitive and digital learning [51]. Nevertheless, we cannot link children’s outcomes uniquely to a distinct mediation strategy, since parent-child interactions are complex and many contextual or individual factors can intervene. Parents often use a combination of mediation strategies, and they change the mediation approach according to the activity the child is doing (e.g., using the tablet for school homework or for visiting Facebook; [11]).
Other authors explored the influence of family sociocultural factors. For mediation to be effective to guide children’s experiences in the web, parents need to have themselves knowledge and skills of the new digital media (see Section 4 in this chapter). Particularly in conditions of sociocultural disadvantage, parents may lack basic digital skills [52], or they may not be able to explain to children how digital reality works and rapidly changes [53]. Unlike the traditional media (such as television or video game console), parents can give a difficult task to assure a help or guide children with the ever-changing technologies. Recently, Nikken and Opree [11] found that mostly low-educated, low-income, and single parents are likely to experience low competence and greater insecurity with new devices (such as electronic screen), declaring that it is difficult to apply co-use or active mediation strategies with their young children (1–9 ages). In addition, Warren and Aloia [49] found that when parents perceive high stress levels, the restrictive mediation and the discussions with children about contents and the use of media increase.
Parental mediation strategies may change according to their child’s age and his/her digital skills, but longitudinal studies are scarce in literature. Developmental changes have been observed from childhood to adolescence: active mediation strategies more often are adopted with younger children, whereas restrictive mediation fades with older and adolescents [17]. Parents generally expect greater autonomy and self-regulation skills from adolescents, and the influence of some parental strategies decrease over time: for example, the efficacy of restrictive strategies (i.e., rules for time or negative consequences for overuse) in reducing screen time decreases with older children [33]. From a developmental perspective, particularly the effects of restrictive approach are unclear. Some studies evidence that restrictive strategies (such as limiting access to media) are effective with younger children [6], but not with older kids. Adolescents can perceive parental control/limitations as a violation of their needs (i.e., self-determination, privacy, peer relationships, etc.) and react with increased online activities [54].
After all, parents wish their children can develop self-regulation, critical view, and awareness of opportunities or risks of digital technologies. In many studies, parental active mediation—for example, discussing with children issues such as cyberbullying, sexting, and online frauds—is more effective than restrictive mediation in reducing risks [16, 55]. Conversely, the efficacy of restrictive mediation must be considered relatively, since in literature both positive and negative associations with online risks emerge [56]. Mascheroni et al. [57] comment, “While restrictive mediation can be effective in reducing children’s exposure to online risks, it has numerous side-effects, because it limits children’s opportunities to develop digital literacy and build resilience and discourages children’s agency within the child-parent relationship. Enabling mediation, instead, encompasses a set of mediation practices (including co-use, active mediation of internet safety, monitoring and technical restrictions such as parental controls) that are aimed at empowering children and supporting their active engagement with online media. The question is, then, how to ensure children’s access to online opportunities while protecting them from potential harmful effects.”
Interestingly, parents adopt their approach according to their child’s competence in digital technology use (digital literacy). In line with a bidirectional model of parent-child influences [45], not only parenting influences child’s behaviors, but also the child’s actual behavior or perceived digital competence influences parental behaviors. Generally, restrictive mediation strategies are more often adopted with less digitally skilled children, but this approach could be counterproductive: limiting online activities for protecting the child from risks, in turn, can deprive him/her to opportunities for developing adequate digital skills [5]. Conversely, parents more often use active mediation strategies (e.g., they share experiences or talk about media) with skilled children than with children who have scarce competencies [58].
The predominance of online activities in the life of many children often worries parents, who observe that spending much time online removes children from face-to-face relationships and social activities. Empirical studies confirm the negative effects of Internet unsuitable use on social participation, since high levels of online activities are associated with few friends, reduced offline relationships [59], and increased loneliness [60]. Particularly loneliness, that is, social isolation and lack of intimacy with close friends, was found to be strongly associated with Internet excessive use [61]. However, causal relationship between Internet excessive use and loneliness is still under investigation [62], in an attempt to understand if loneliness can be the antecedent or the consequence of the individual’s excessive involvement with Internet activities. Two alternative hypotheses have been proposed to explain the link between poor social involvement, feeling lonely, and the development of problematic Internet use in children. According to the first hypothesis, loneliness is one of the main antecedents of excessive online activities, together with low self-esteem, poor social skills, social anxiety, and frequent conflict with parents. Some authors (e.g., [63]) hypothesized that adolescents who feel lonely or experience high anxiety in face-to-face social situations may use social networks and online exchanges more frequently than non-lonely adolescents. According to this “compensation hypothesis,” they are increasingly involved in Internet activities that provide alternative experiences for social life. The second hypothesis assumes that time spent online causes loneliness and social withdrawal, isolating and depriving people of real social experiences. Therefore, loneliness can be considered as a possible outcome of Internet overuse [64], like when prolonged activities online reduce time spent with family and friends. Finally, there are studies that did not confirm the link between loneliness and Internet problematic use [65] or that evidence some positive consequences on individual socioemotional well-being. For example, contradicting the assumption that using the web impoverishes social life and increases isolation, in some studies higher levels of Internet activities are positively associated with social connection and perceived support. Unfortunately studies with children and adolescents are still lacking, but the attention among researchers is growing [60, 66].
Given the paucity of research with adolescents, we conducted an unpublished study1 to explore the relationships among excessive Internet use, preferred online activities, and adolescent’s perceived loneliness. In addition, we hypothesized that among adolescents better parent-child communication and higher parental emotional availability were positively related with less time spent online and less frequent online activities. In fact, studies indicate that parent-child communication and parental involvement play a protective role to excessive online activities [67]. A community sample of 177 high school students (66% females), aged 16–22 years old (M = 18, DS = 1.01), completed a questionnaire measuring the sense of loneliness (UCLA Loneliness Scale; [68]) and the Compulsive Internet Use2 Scale (CIUS, [69]) for assessing problematic involvement in Internet activities. Daily frequency of favorite online activities (chatting, e-mailing, visiting social networking sites, listening to music, watching videos, playing online games, etc.) was also measured. Regarding parenting factors, adolescents filled out (a) the Lum Emotional Availability of Parents questionnaire (LEAP; [71]) assessing adolescent’s perception of parental responsiveness, sensitivity, and emotional involvement and (b) two scales (derived from [70]) measuring the frequency of communication (how often the adolescent communicates with parents about his/her online activities) and the quality of parent-child communication (the adolescent feels understood, or comforted, or taking seriously from parents when he/she talks about Internet activities). In our study loneliness was not associated with Internet compulsive use (CIUS scores), but with specific online activities. Adolescents with higher loneliness levels reported higher frequency of music listening, but they declared less access to social networks (such as Facebook). This result contradicts the hypothesis of social compensation assuming that the teenagers use online exchanges to replace the sense of loneliness in real life [61]. An alternative explanation, proposed by others [72] is that a process downward with a “spiral pattern” is activated: loneliness leads to a decrease in social involvement which in turn increases the sense of isolation. Interestingly, those who spent more time online and were problematic users (higher CIUS scores) were more frequently involved in solitary activities, such as watching videos, listening to music, playing games offline, and visiting social networking sites. Perceived emotional availability from the father (but not from the mother) was negatively related with time that adolescents spent online. Teenagers who perceived greater emotional availability from both parents used the Internet more often for working on school projects and homework or doing search. A better quality of communication with parents is associated with less use of the Internet for gambling and online games. Overall these results confirm a virtuous relationship between quality of family communication, emotional availability of parents, and productive use of the web.
An interesting evidence emerging from empirical literature is the protective role of parent-child communication for preventing Internet unsuitable use in children [73]. Conversely, Internet excessive use is associated with low quality of communication in the family [74]. Particularly with teenagers, the open and effective parent-child communication is a key dimension of family relationships and climate. Assuming a bidirectional perspective of adolescent-child influences, some authors focus on the role of youths’ self-disclosure and spontaneous communication on parenting. Stattin and Kerr [75] claim that parental efforts to monitor adolescent’s activities or to discuss about them are ineffective if teenagers do not trust their parents and if they are not willing to open up spontaneously. Parental monitoring on children’s activities can be less effective when it is parent-driven (e.g., the parent tries to follow the child’s activities on Facebook) than when it is child-driven, that is, activated by children’s self-disclosure and open communication. Conversely, when parents try to control teenagers’ online communication (e.g., the friends on Facebook, the photos posted on Instagram, etc.), parent-child conflicts increase, and adolescents can perceive parental behaviors as an obstacle to their autonomy or an intrusion to privacy [76].
Van den Eijnden et al. [70] identify two key dimensions of parent-child communication about children’s digital behaviors. The first parenting practice refers to the frequency of communication about Internet usage (e.g., “How often do you and your parents talk about who you have Internet contact with?”), whereas the quality of communication about Internet use measures adolescent’s perception of mutual respect and acceptance during conversation (“When my parents and I talk about my Internet use, I feel taken seriously”). Authors explore how these parental behaviors, together with other Internet-specific parental practices (rules about time online, rules about contents, reactions to excessive use), link to compulsive Internet use (CIU) in adolescents. Findings from their longitudinal study are particularly interesting, showing a protective effect of the quality of communication, but not of frequency of communication, on the risk of developing CIU. In other words, a good quality of parent-child communication about the use of Internet decreased the risk of CIU (6 months later), whereas this relationship was not observed for the frequency of parent-child exchanges about adolescent’s online activities. Authors discuss these findings by highlighting the bidirectional nature of parent-child influences. When adolescents show compulsive Internet behaviors, the frequency of parent-child communication decreases. Probably gradually parents get discouraged and give up the idea of achieving a positive change in their child’s problematic behaviors through frequent conversations.
Regarding the parental rules about online activities, studies evidence some mixed results. When parents give their children rules about the content of the Internet, the compulsive use of web decreases; conversely, strict rules about time allowed for online activities seem to be counterproductive, linking to compulsive Internet behaviors in children [70]. Moreover, considering the child’s influences on parent’s behaviors, it is possible that when the child remains connected online without time limits, her/his behavior in turn stimulates stricter rules by parents. Other studies evidence that parental rules about Internet use are less influential on their children’s behaviors than their parents’ behaviors. Liu et al. [77] found that when parental behaviors are consistent with parental rules regarding digital technologies and the Internet (e.g., the smartphone must not be used during mealtime, personal data cannot be given online, etc.), the rules negatively predict Internet problematic use in adolescents. This result reminds us the importance of educational consistency (i.e., rule-behavior agreement) from parents. Conversely, when parental rules and parental behaviors do not agree, only the parents’ behaviors are positively predictive of children’s excessive Internet use. According to social learning theory [78], a parental modeling process intervenes, that is, an observational learning in which the parent’s behavior acts as antecedent for similar behavior in the child. Therefore, parents act as a role model for their children’s digital behaviors, and young children learn how and under what circumstances to use a mobile, for example, the smartphone, observing parents’ activities with that device. Interestingly, studies show that the time parents spend with computers positively relates with time spent by their children [79]. Similarly, parental involvement in favorite Internet activities (visiting social networking sites, video streaming, etc.) is positively associated with the same activities engaged by children. In addition, as some researchers remind us “it is not only overt parental behavior (i.e., digital device use) but also attitudes and emotions that can be modelled for children to imitate” ([30], p. 4). Taken together, these findings suggest that parents’ agreement and modeling of adequate behaviors are crucial factors for promoting self-regulation and safety use of digital technologies in young children.
Today’s reality is widely digitized, and it offers people of all ages opportunities for socialization, amusement, learning, job, and knowledge that were unthinkable until a few decades ago. Precisely in the weeks in which the authors were engaged in the revision of this chapter, COVID-19 pandemic was involving more than 130 countries in the world. The lockdown and restrictions at home quickly changed daily activities of children and parents, transferring to the screen of the devices many activities previously carried outdoor (school lessons, play with peers, etc.). It is still too early to know what impact the epidemic will have on children’s physical and mental health, but the attention of professionals and researchers is not lacking [80]. Surely during COVID-19 screen time has increased exponentially in the families: in some ways for the parents it was a relief, because through the Internet children continued their school courses and contact with peers. In addition, children avoided boredom through videogames or website dedicated to music, creativity, etc. On the other hand, the intensive online activities have renewed parents’ concerns about the well-known risks [23, 81], such as increased sedentary and physical inactivity, prolonged use at night, sleep disorders, isolation, and escape in digital world by teenagers.
Following social distancing and the temporary closure of schools for limiting COVID-19 infection, the Ministries of Education in many developed countries quickly activated online courses and other websites for distance learning. These online solutions have the aim to guarantee children’s right of instruction but also to mitigate the negative effects of home confinement [82]. However, online courses shift the teaching from school to home and make the parents a resource for support and effective learning. The question is: what can be the role of parental mediation and digital competence? As the authors know, there are no empirical studies on this topic, but previous studies with primary school children showed negative associations between parental control, interference in homework, and children’s learning [83]. Currently, in many cases teachers expect parents to ensure that their children connect on time and follow the video lessons, so parental support could be useful, but tensions and parent-child conflicts can also occur. There is also the risk that parents may help children, interfering with digital learning or impeding them from carrying out the assigned activities independently. Close attention and research effort are needed for comprehending how this aspect of digital parenting works, supporting parents in their efforts and ensuring a good home learning to children.
In line with the available studies before COVID-19 [4], we believe that during lockdown the digital activities satisfy children’s basic psychological needs, such as socialization and emotional support by the family (grandparents and cousins) and other significant people (teachers and peers). Social media facilitate the expression of emotions (such as fear and sadness), self-disclosure, and the keeping of romantic relationships by adolescents particularly [84]. Video calling and regular contacts through smartphone have been recommended as an important source of reassurance in the cases of isolation of the caregiver or family due to prevention of COVID-19 infection or recovery [85].
What probably becomes necessary in the time of COVID-19 is a renegotiation of family routines, that is, a balance between screen time and other moments of family life. In this regard, the WHO [85] recommends that parents maintain regular routines for children (school/learning, free time/relaxing, bedtime, etc.) and also to create new opportunities for joint activities (such as co-use for creative, amusing, or physical activity in front of the screen). With young children, many shared activities offer also a context to express and communicate their feelings (both fears and wishes) in a supportive parental relationship. Even in actual COVID-19 circumstances, we believe that parental behaviors (such as self-limiting screen time for smart working, chatting, or gaming) are more influential than restrictive mediation or limitations imposed to children.
Having the digital knowledge and the skills to move in the digital world, without suffering the dangers, is not a matter of age, but of education and learning, that is, digital literacy. It is a serious responsibility towards the new generations and a complex challenge for which the adults (parents, teachers, psychologists, or educators) do not feel prepared. As Martin ([86], p. 135) reminds us: “Digital literacy is the awareness, attitude and ability of individuals to appropriately use digital tools and facilities to identify, access, manage, integrate, evaluate, analyze and synthesize digital resources, construct new knowledge, create media expressions, and communicate with others, in the context of specific life situations, in order to enable constructive social action; and to reflect upon this process.” Currently, parents’ difficulties stem from the fact that they—as digital users—have different levels of involvement, technical skills, and beliefs that influence mediation practices towards their children. If parents feel less skilled or worry about unknown dangers of the web, they could activate more restrictive practices, but rarely they will be able to critically discuss with their children in a constructive manner. In addition, parents believe not to be up to their children in juggling in the digital world, in pursuing technological innovations, or in protecting children from danger or media abuse. Sometimes parents consult the websites for suggestions on how to effectively manage kids in their digital activities, but information disseminated through the websites is not always scientifically founded (fake news). The researcher Danah Boyd [87], in describing the complexity (“It’s complicated”) of teenagers’ life on the web, claims that the media magnify the virtues (the “superpowers”) of digital natives, but at the same time they trigger parental fears talking about serious dangers such as Internet addiction, sexual enticement, or incitement to suicide. Conversely, rarely parents turn to professionals for advice. A study [28] conducted with families of very young children (under 7 years) shows that parents choose the type of help (professionals such as pediatricians, or friends and family) based on the child’s problems and his/her digital activities. The professionals are consulted if the child is an only son or he/she uses the media too long. Parental sense of competence in managing the child’s activities increases if parents are confident of the usefulness of the media (e.g., educational games for learning) and if there are more kids in the family. Parents turn to friends and family for advice when they have a negative view of the effects of the media. This result makes us reflect, but unfortunately there are not many similar studies.
A correct parental mediation of children’s digital activity must build on the information and recommendations that come from the scientific community. The American Academy of Pediatrics [2] has taken a clear stance for prudent and moderate use of the web in infancy (0–5 years) and has prohibited touchscreen device use under the age of 2. The careful use of these devices at such an early age is crucial for the infants’ brain and social development. However, in contrast to these professional recommendations, often parents themselves introduce babies to media use during infancy (e.g., to “take calm” the kid, or to stop whims and cry; [30]). Young children spent daily an amount of time with screen media (iPod, smartphone, video game player, etc.) that grows during infancy (42 min under 2 years and 2 h/39 min at 2–4 years, respectively; [88]). The risks for excessive screen exposure are extensively confirmed in literature and particularly the negative consequences for early users who may present physical problems (such as obesity), developmental difficulties (i.e., language or learning), and unhealthy routines (low sleep quality) (Figure 1).
Developmental risks associated with excessive media exposure (from [88]).
The recommendations for effective parental mediation on children’s digital activities are unequivocal [2]: (a) avoid the use of digital devices before 18–24 months with the exception of video chatting in the presence of the parent; (b) do not allow the child (18–24 months older) to use the devices alone and for more than 1 h a day; (c) do not press for an early use, the child will spontaneously approach the media when ready; (d) help the child apply what he/she learns from using the device to the real world; (e) know that in infancy, direct experiences, manipulation, and unstructured play are crucial for the child’s brain and for social, cognitive, and linguistic development; (f) void the vision of fast programs, with too many distracting elements, or violent contents that the child is unable to understand; (g) avoid using devices to calm the baby, an hour before bedtime; and (h) constantly monitor the media contents to which the child is exposed. Finally, the experts (pediatricians and psychologists) turn also to the industry that produces media devices, so that it adopts a scientifically founded and more ethical approach, for example, installing apps (such as connection stop or automatic shutdown during night hours) that can protect very young children from the risks of overuse.
Therefore, parent education interventions are necessary both to disseminate scientific knowledge on the influence of new technologies on children’s health and development and to help parents to cope with the challenges of digital reality. Parent education cannot be reduced to merely correcting ineffective parenting practices or to a list of instructions on what the parent should do. In fact, all studies indicate that the effectiveness of mediation strategies (restrictive or active approach) is relative, because parental practices interact with the characteristics of both adults (digital skills, beliefs, and activities on the media) and children (age, development, digital literacy skills, etc.). Instead, professionals should help parents to improve and adjust their guidance according to children’s age and developing skills. This is possible to be realized if parents also increase their knowledge and digital skills (media literacy programs), given the importance of these factors in parenting. Less skilled parents, or those who fear the unknown pitfalls of the web, are more likely to intervene only on restricting or prohibiting children’s activities. Conversely, “it is likely that more skilled children and parents are more free to explore and benefit from online opportunities, while also building up resilience against harm by meeting a degree of online risk” ([16], p. 19).
Digital parenting is a very complex and “complicated” task not only because the digital technologies rapidly change, but also because they offer children multiple experiences (learning, communication, socialization, entertainment, etc.) that influence their development, but which are not entirely overlapping to the experiences that take place in the real environment [89]. Particularly, digital natives have the opportunity to know the reality and themselves, developing their own identity [76], with a multiplicity of means and without the supervision of the traditional agents of socialization, primarily the parents (or the teachers). With the awareness of how difficult it is to give definitive answers about the advantages or dangers of digital technologies, more effort is needed from researchers. More evidence-based studies are needed, to understand how technological progress is changing the psychological (neurocognitive, emotional, and social) development of young digital users. However, despite the growing diffusion of digital tools in infancy, studies with very young children are still lacking. Particularly, future research could benefit from longitudinal studies to which to explore the relationships between parenting and children’s experiences in digital environments, their opportunities, or risks.
Health care over time has become a complex and very careful act, which, in addition to providing users with adequate treatment for their health problems, represents a latent risk since it can cause involuntary damage. This, for obvious reasons, since 2002 the World Health Organization (WHO), requested in Resolution WHA55.18 the member states to pay as much attention as possible to the problem of patient safety [1]. This difficulty being an attenuator over time has become a public health problem that directly impacts the quality of care of users of health services and the fall in their indicators.
This World Alliance, which aims to coordinate, disseminate, and accelerate the improvement of patient safety worldwide, is a means that fosters international collaboration and the adoption of measures among member states, the WHO secretariat, the technical experts and consumers, professionals, and industrial groups [2]. Different studies conducted in our country at different levels of care, such as the ENEAS study, the National Study on Adverse Effects linked to Hospitalization [3], and the Study on Patient Safety in Primary Health Care (APEAS) [4], have quantified the importance of these effects.
Different investigations have been found in relation to patient safety, where the one carried out by Villareal [5] is found, in Third World countries and in those with transition economy; there is evidence that the probability in the occurrence of adverse events is caused due to the poor state of the infrastructure and the equipment, the quality of the medicines, the irregularity in the supply, the deficiency in waste disposal and infection control, and the poor performance of the staff due to lack of motivation or knowledge is insufficient and due to the serious lack of resources to cover essential operating costs.
Also in 2011, Blandón, Gómez, Muñoz, and Zafra [6] carried out a patient safety audit process from the analysis of the adverse event report at the Francisco Luís Jiménez Martínez de Carepa hospital (Antioquia), where flaws were evident in the fulfillment of the processes related to the prevention of events and where improvement activities were proposed in order to minimize and prevent the recurrence of events highlighting the awareness of all personnel prioritizing those who work in the emergency department on adverse events, in addition to developing improvement plans regarding the control of dangerous conditions in the physical environment.
In 2013, an investigation was conducted on safety culture and adverse events in a first-level clinic [7]; this shows the prevalence of adverse events in nursing staff, where the main errors were the lack of communication and techniques of poor application of medications in nursing staff which affects patients in 29.9% producing an adverse event. In 2014 Meléndez Concepción, Garza, González, Castillo, González, and Hernández [8] conducted an investigation on the perception of nurses towards the culture of safety in a pediatric hospital in Mexico, where the average age of the respondents was 49 years old for men, 91% were women, and 70% were general nurses. Nurses believe that the strengths that are available in the hospital are few and that many things are missing to ensure patient safety.
Poma Vanessa [9] developed an investigation with the purpose of contributing to the improvement of quality and safety in the care of patients of the internal medicine service of the Eugenio mirror hospital in the city of Quito, in 2015, for which it was carried out a parallel between the reality evidenced in the service and the national and international quality standards of process and results structure where it could be established that the institution did not meet the specific criteria in terms of structure and results compared to international standards, so which emphasized the safety culture of internal users as well as of patients as a fundamental axis for continuous improvement, revealing not only the failures of the institution but also the responsibility of the collaborators of the institution.
In the IBEAS study, Colombia specifically showed a prevalence of adverse events of 13.1%, 27.3% of the events occurred in children under 15 years, and 27.7% occurred during the performance of a procedure [10] and where it has been estimated by WHO under its studies that one in 10 hospitalized patients suffers an incident that will cause damage during their stay. Studied in countries with medium and high economies, is not yet known in countries with emerging economies, but it is thought that in these, the magnitude of the problem may be even greater [11], which allows to demonstrate that in general terms, health in Colombia is going through a difficult stage in terms of quality.
For its part, the state social enterprise Norte 2 located in the municipality of Caloto, department of Cauca, is a social enterprise of the state that provides health care of low complexity for around 7000 people living in the municipality. This institution as a company that currently provides health services has found that the patient safety protocol established by the Ministry of Health and Social Protection is not being applied under the guidelines of the patient safety policy in Resolution 0112 of 2012. In addition to this, health professionals for unknown reasons do not apply the London protocol and generally do not exercise the functions of inspection, surveillance, and control in order to provide reports in a timely manner, to take corrective actions and relevant improvement to mitigate adverse events that are becoming increasingly evident.
The objective of the present investigation is to identify the adherence of the health personnel of the state social enterprise Norte 2 health institution, Caloto, Cauca, during the first quarter of 2019, in the application of the London protocol, referring to the security policy of the patient, to propose an improvement plan according to the results obtained. In this sense, the application of the London protocol in patient safety policy in the state social enterprise Norte 2 health institution is of vital importance, in order to impact on the improvement of the quality of health care as a systematic tool for a continuous improvement defined in the mandatory quality assurance system, increasing its quality of service making it a competitive entity.
In Colombia, the Ministry of Health and Social Protection [12] defines patient safety as the set of structural elements, processes, instruments, and methodologies based on scientifically proven evidence that tend to minimize the risk of suffering, an adverse event in the process of health care or mitigate its consequences. Under the obligatory system of quality assurance of health care, the country, through its components, seeks and promotes a patient safety policy whose objective is to prevent the occurrence of situations that affect patient safety and reduce and if possible eliminate the occurrence of adverse events to have safe and competitive institutions internationally [13].
In addition to this, Resolution 2003 of 2014 [14] dictates the design of processes and procedures focused on the promotion of safe health care, the identification of the risks in health care provided to patients in different services and its prioritization and intervention, the definition of safe care processes, the education of patients and their families in the knowledge and approach of the factors that can influence in improving the safety of the care processes of which they are subjected, and the application of mandatory safe practices, reporting, measurement, analysis, and management of adverse events.
More than a concept, it is a movement that emerges worldwide as a rethinking of the effectiveness of health systems in different countries. Health systems and especially the professionals that integrate it, without a doubt, aim at the well-being of patients; however, despite their good intentions, they can also cause harm [15]. The effectiveness of health systems then depends not only on the impact caused by the improvement of the health of the users but also on the safety conditions in which care is given, which is the raison d’être of the patient’s safety policy: provide safe and effective care.
According to the Ministry of Social Action [16], the guidelines of the London protocol are taken under the guiding principles of the policy in order to achieve the purpose of establishing safe attention; it goes beyond the establishment of standards; these are only the frame of reference. The commitment and cooperation of the different actors is necessary to raise awareness and promote, arrange, and coordinate actions that really achieve effective achievements. Patient safety problems are inherent in health care. For this purpose it is relevant to establish transversal principles that guide all the actions to be implemented.
Patient safety is presented as a fundamental pillar within the patient safety protocol, which is defined as the set of organizational structures or processes that reduce the probability of adverse events resulting from exposure to the care system. Have medical attention throughout the procedures or diseases [17]. In this way, patient safety is part of a whole set of legal requirements, which must be fully complied with by health professionals, which guarantee that the patient is prevented from any risk present in medical services.
In this regard and under the London protocol in patient safety policy, according to the Ministry of Social Action [18], the guidelines of the London protocol are taken. The guiding principles of the policy are that achieving the purpose of establishing safe attention goes beyond the establishment of standards; these are only the frame of reference. The commitment and cooperation of the different actors is necessary to raise awareness and promote, arrange, and coordinate actions that really achieve effective achievements. Patient safety problems are inherent in health care. For this purpose, it is relevant to establish transversal principles that guide all the actions to be implemented [19]. These principles are as follows:
User-centered focus of attention. It means that the important thing is the results obtained in it and its safety, which is the axis around which all the patient’s safety actions revolve.
Security culture. The environment for the deployment of patient safety actions must take place in an environment of confidentiality and trust between patients, professionals, insurers, and the community. It is the duty of the different actors of the system to facilitate the conditions that allow the said environment.
Integration with the mandatory quality assurance system of health care. The patient safety policy is an integral part of the mandatory quality assurance system of health care and is transversal to all its components.
Multicausality. The problem of patient safety is a systemic and multicausal problem in which different organizational areas and different actors must be involved [20].
Under the conceptual model and basic definitions of patient safety policy, the following figure shows in a pictorial way the conceptual model on which the terminology used in this document is based, and then the definitions related to the different items raised and used are included in the patient safety policy of the compulsory quality assurance system of health care. It is necessary to integrate international terminology with specificities of the terminology requirements identified in the country [21].
The methods used were designed with the aim of promoting an open environment that contrasts with the traditional ones based on personal accusations and fault allocation. This protocol covers the process of research, analysis, and recommendations. There is no need to insist that the proposed methodology has to be separated, as far as possible, from disciplinary procedures and those designed to address permanent individual poor performance. In health, very often when something goes wrong, bosses tend to overestimate the contribution of one or two individuals and assign them to blame for what happened [22].
This does not mean that the indictment cannot exist, what it means is that this should not be the starting point, among other things, because the immediate allocation of guilt distorts and hinders subsequent serious and thoughtful investigation. Effectively reducing the risks implies taking into account all the factors, changing the environment and dealing with the failures by action or omission of the people. This is never possible in an organization whose culture puts disciplinary considerations first. In order for incident investigation to be fruitful, it must be carried out in an open and fair environment [22].
For its part, the organizational model of causality of clinical incidents is supported under the theory of the protocol, and its applications are based on research conducted outside the field of health. In aviation and in the oil and nuclear industries, accident investigation is an established routine. Safety specialists have developed a wide variety of methods of analysis, some of which have been adapted for use in clinical care contexts [23].
In this way, they raise the need to conduct the investigation and analysis of incidents (errors or adverse events), which refer to the basic process of investigation and analysis is quite standardized. It was designed with the idea that it is useful and can be used both in minor incidents and in serious adverse events. It does not change if it is executed by a person or a large team of experts. In the same way, the investigator (person or team) can decide how fast he goes through it, from a short session to a full investigation that can take several weeks, including a thorough examination of the chronology of the facts, of the unsafe actions, and of the contributory factors. The decision about the length and depth of the investigation depends on the severity of the incident, the resources available, and the potential institutional learning [24].
And where under the Reason model of causality (Swiss cheese model), belonging to the problem solving and identification models, it works to identify what aspects or decisions of the organization may have been a conditioning factor in an accident and how the organization can learn from an accident, perfecting the defenses in a cycle of continuous improvement [25, 26]. Also called Swiss cheese model, which was raised in order to analyze the possible causes that develop potential risks, the model compares the causes of risk with layers of Swiss cheese, where for an action to be generated, several failures are required to reach this, since, if there is a barrier, that potential cause will undoubtedly not allow it to become damage. It speaks of four factors that contribute to the extent of the damage: insufficient training, poor communication, lack of supervision, and inadequate apparatus [27].
On the issue of safety, the causes identified have been grouped in different ways (organizational causes, equipment, supplies, people, etc.) and specifically on the issue of patient safety. In the United Kingdom, an organizational model for the causality of errors and adverse events (organizational accident causation model) was developed in the context of the so-called London protocol or “systems analysis of clinical incidents—the London protocol” [28, 29]. Among the possible solutions is the fishbone formulated by Ishikawa who was an industrial chemist and a business administrator, in response to the need to implement quality in business processes and services. Through its proposal it is easy to observe the relationship between cause and effect. Mention six components that lead to the problem which are labor, material, method, machine, measuring, and environment [30].
This research is quantitative, observational, and descriptive, and a census was carried out on the 92 officials of the state social enterprise Norte 2, Caloto, Cauca (Colombia, Sur America) institution, under the inclusion criteria: be a worker linked to the institution by employment contract, have the institutional consent of the company, and have informed and understood consent with each of the units of analysis and where exclusion criteria are not contemplated. Study variables such as sociodemographic characteristics, knowledge variables, and improvement variables were taken into account.
The analysis plan of the present investigation had the collection of information through a survey created by the researchers and reviewed by four experts in the field; for the tabulation of the data, the researchers created an instrument to obtain a database in the Epiinfo 7.2 program; this program is a free epidemiological analysis software supplied by the World Health Organization and in which the analysis of results with descriptive statistics was performed. The bioethical component was aligned in accordance with Resolution 008430 of 1993 and Resolution 0314 of 2018 which regulates ethical responsibilities in research in humans and health institutions, taking into account that the research has a lower risk than the minimum. Complying with Colombian regulations, institutional consent and informed consent were obtained by each participant. The credits of the institution in which the research is carried out are included, according to copyright.
For research the guidelines of the London protocol are taken. The guiding principles of the policy with which, to achieve the purpose of establishing safe attention, goes beyond setting standards; these are only the frame of reference. The commitment and cooperation of the different actors is necessary to raise awareness, promote, arrange, and coordinate actions that really achieve effective achievements. Patient safety problems are inherent in health care. The transversal principles that guide the actions to be implemented are:
User-centered focus of attention. It means that the important thing is the results obtained in it and its safety, which is the axis around which all the patient’s safety actions revolve.
Security culture. The environment for the deployment of patient safety actions must take place in an environment of confidentiality and trust between patients, professionals, insurers, and the community. It is the duty of the different actors of the system to facilitate the conditions that allow the said environment.
Integration with the mandatory quality assurance system of health care. The patient safety policy is an integral part of the mandatory quality assurance system of health care and is transversal to all its components.
Multicausality. The problem of patient safety is a systemic and multicausal problem in which different organizational areas and different actors must be involved.
An instrument with 12 specific questions about patient safety and questions about demographic aspects was implemented. The specific questions, with multiple answer options, and yes or no, were:
What is the definition of adverse event?
Do you know the protocol model for the report of adverse events?
Have you received trainings from the institution in protocols that guarantee patient safety?
Does the institution have the patient safety program to obtain safer care processes? Do you know?
In case of an adverse event, would you ask for support for report?
Who is the official in charge of performing the report of the adverse event?
What is the main cause why you do not report the adverse events?
Do you notify all reports of adverse events, clinical incidents, and complications related to health care?
What do you consider is the main cause for not reporting adverse events related to health care?
What is the definition of clinical incident?
What is the definition of clinical complication?
Does the institution perform the feedback of adverse events?
It was found that demographically the female gender represents more than half of the population, being mostly people with a technical academic level, who have been in ESE for more than a year, and of which three out of four are auxiliary of nursing, which represents a population trained in technical tasks linked to day-to-day work in the ESE, with an experience of more than 1 year within the said institution in three out of four officials; on the other hand, it is observed that only 1 of every 11 people in the population are nurses, who are in charge of coordinating these assistants and are the guarantors of the proper performance of all protocols within the institution (Table 1).
Variable | Answer | Frequency | Percentage |
---|---|---|---|
Sex | Female | 61 | 66 |
Male | 31 | 34 | |
Education level | Technical | 67 | 73 |
Professional | 14 | 15 | |
Support | 6 | 7 | |
Others | 5 | 5 | |
Antiquity | Under one year | 29 | 32 |
Older than one year | 63 | 68 | |
Job that performs | Doctor | 4 | 4 |
Nurse | 6 | 7 | |
Dentist | 3 | 3 | |
Nursing assistant | 64 | 70 | |
Other | 15 | 16 |
Frequency of demographic variables of health personnel of state social enterprise Norte 2, Caloto, Cauca, Colombia, in the first half of 2019.
Main cause for not reporting adverse events related to health care.
For the frequency of response according to the definition of adverse events according to the London protocol, it is possible to justify that the entire population surveyed is clear about the concept of the definition of adverse events under current regulations, which demonstrates that the ESE performs an adequate accompaniment regarding the acquisition of knowledge regarding the definitions of the terminology used within its facilities, which allows all its collaborators to be in the same tuning, avoiding communication problems in terms of technical terminology and knowledge of the laws and resolutions of the ministry of health that define under presidential ruling the conception of these.
For the knowledge of the London protocol model for the reporting of adverse events, officials have one out of five present ignorance of the protocol, which can lead to failures in the practice of this, either due to lack of training and induction or recognition and omission which generates a latent risk both in terms of the quality of the service provided and in the care provided to the patient, putting his integrity at risk. In addition to the frequency in terms of training carried out by staff in the institution in protocols that guarantee patient safety, there is a group of people who have not received training in the patient safety protocol, which is presented as an administrative failure on the part of the institution, and the area in charge of carrying out the training of the collaborators, 1 of every remaining 11 has omitted the training provided by the ESE, generating problems that directly compromise patients and their safety.
The institution has the patient safety program to obtain safer care processes. Less than half of the respondents acknowledge that the institution has the patient safety program in terms of obtaining safer care processes, this amount being less than half of the officials surveyed, which describes a total lack of awareness for more than half of these, which generates a critical picture given that ignorance is counterproductive, given the nature of the ESE, demonstrating that more socialization of the documentation that the institution possesses, as well as training and documentation, is needed of the programs.
When an adverse event occurs, who is the person in charge of supporting the report of an adverse event? According to the established protocol, it was found that the person in charge of supporting the report of an adverse event is intended to guarantee quality of health care and serve as a bridge to generate a solution to the event presented; in this sense there is no consensus, given the ignorance of the protocol and the poor socialization of this both by the administrative area and by the same care staff, where more than half of the officials have full knowledge of who is the person in charge of carrying out the accompaniment and providing support if necessary when an adverse event occurs.
Likewise, within the knowledge of the official responsible for making the report of the adverse event according to the established protocol, it is described that within the report of the adverse event, the immediacy in the realization of this has its incidence within the quality system and of the patient safety protocol; for this reason the person who detects the adverse event must perform it in a short period of time when it is detected; in this sense more than half of the respondents know who should do it, with which you can affirm that some of these seek to separate themselves from their functions or they are not aware of the protocol and the step by step to follow when an event of these occurs, looking for a way to lighten your workload, Figure 1.
The frequency of response regarding the most frequent cause of not reporting adverse events, it was found that the main causes of failure to report adverse events are divided perceptions, since on average 3 of every 11 believe that the mistakes made within their daily work will be a cause for dismissal, which shows the lack of knowledge of the internal regulations of the institution regarding the grounds for withdrawal, and a similar average thinks that the they have used it during their rest or active breaks, which is linked to another portion, which states that the workload does not allow their report, which must be reported immediately after its occurrence, as evidenced by the ignorance of both its functions and the patient safety protocol.
Within the culture of patient safety, the reporting of adverse events, clinical incidents, and related complications in health care allows the generation of corrective and improvement actions within the health system, which by not reporting or reporting spontaneously, like 4 out of 11 of the officials surveyed, it does not allow for the maturation or improvement of this, since the causes for which adverse events are being generated are unknown and opportunities for the quality team to solve underlying problems are lost. In this sense, a percentage close to half of the respondents duly report the adverse events and other incidents and complications, this being a lack of empowerment by the collaborator who does not have a safety culture present in their work.
The most frequent cause of not reporting adverse events related to health care, evidence within the different research questions, that the workload prevails, in this sense in more than half being the main cause for not reporting an adverse event, this situation being an attenuating one, since it is possible to relate directly to the lack of human resources within the institution, or the charges within it are not level with the staff, which is supported by two out of ten who affirm that the overload of patients also does not allow an adverse event to be reported, missing opportunities for improvement within the institution that manage to generate a positive effect within the care of patients.
For the frequency of response for the definition of clinical incident according to the London protocol, it can be affirmed that within the theoretical knowledge of ESE officials, it is found that more than half of the respondents know the definition of clinical incident, and a small part present difficulties in answering correctly, this being a serious failure, when making the report of an adverse event, since the misrepresentation of the terms can cause misunderstandings and that at the time of generating a report, the indicators are erroneous regarding the nature of adverse events. However, for the definition of clinical complication, approximately four out of every five officials know its concept, which shows that only a considerable minority represents confusion, which, in a real plane, can generate confusion and ignorance of the steps to follow or perform incorrect procedures, since the nature of each event is different and must be known from the theoretical basis in order to be clear about the concepts.
Within the administrative failures found, the socialization of adverse events in the institution, only half of these are carried out, which demonstrates that the commitment that exists within the protocol is not adequate within the nature of this; there is also one in five people who do not know if they do it or not, which allows us to affirm that there is a problem of latent communication within the ESE and the collaborators; they do not know everything, given the different shifts they have and the changes in the staff schedules, as well as their lack of commitment to the quality system of the institution, being a very marked problem within the institution, seeking to improve this perception within the collaborators.
After the analysis of the results, investigations found that, under the same study theme, they manage to show similar results regarding the patient’s safety policy and what was found in state social enterprise Norte 2 of Caloto, Cauca. It was found in the study carried out by Villareal [15] that the results obtained show that the institutions of Third World countries such as Colombia do not fully meet certain requirements for the reduction of adverse events, taking into account variables such as infrastructure, the state of the equipment, the quality and adequate supply of medicines, and the motivation of the staff, which confirms what was found in state social enterprise Norte 2, where professional and care personnel do not have full knowledge of the policies, in addition there was little motivation given the high workload they maintain and the low culture of patient safety that exists.
In 2014, Meléndez, Concepción, Garza, González, Castillo, González, and Hernández [19] found that within the demographic variables, the care staff has an age greater than 6 months, and where the average age of the respondents was 49 years, 91% were women and 70% are general nurses, who presented adherence to the patient safety protocol, which differs from what was found in the state social enterprise in Caloto, Cauca, since although the majority of the population were 69% women and nurses, older than 1 year, they did not show adherence to the humanization protocol of the patient due to different causes such as ignorance of the general concepts and the low report of adverse events.
Blandón, Gómez, Muñoz, and Zafra [16] carried out a security audit process that showed flaws in the fulfillment of the processes related to the prevention of events, where improvement activities were proposed in order to minimize and prevent the recurrence of events highlighting the awareness of all personnel, which corroborates what was found in the present investigation, since the staff does not comply with the safety culture regarding the reporting of adverse events, being necessary to propose actions which improves proposals, a plan prepared for them in order to reduce this problem.
In general, the research presented a difficulty which was access to primary information, and some of the professionals were reluctant to conduct the survey, as well as access to these for their work shifts was complicated, but nevertheless within the achievements, the latent problem was found in terms of both administrative and assistance failures of professionals, which do not present a culture of patient safety, and therefore, opportunities for improvement were found by creating a plan for improvement.
Converting the organizational culture for the improvement of the processes is one of the main objectives since adopting it as a culture will be immersed in the daily life of the institution, thus leading to continuous improvement reaching the expected quality. The contribution of reading about this program executed in the aforementioned institution serves as a guide and guidance that contributes to the enrichment of knowledge that allows the implementation of the audit plan to improve the quality of health care in the institution providing health services.
With the completion of the previous investigation, it is concluded that state social enterprise Norte 2, CALOTO CAUCA does not comply with the adherence to the London protocol in patient safety policy, taking into account that only 70% of officials It has adherence to this protocol, in addition, only 52% of adverse events are reported, the main cause of not being carried out, the workload and the little time they have for administrative work.
The investigators do not declare conflicts of interest.
We thank the institution state social enterprise Norte 2 Caloto, Cauca, manager, officials, quality team, and coordinating chiefs, who allowed our research team to be part of their institution to carry out our purpose and successfully complete the planned, and the University Foundation of the Andean area that were present to give us their support through their work team offering an education with excellence.
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