Theoretical (quantitative and qualitative research), advanced

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Citation: Kaware, M.S.; Ibrahim, M.I.;

Shafei, M.N.; Mohd Hairon, S.;

Abdullahi, A.U. Patient Safety

Culture and Its Associated Factors: A

Situational Analysis among Nurses in

Katsina Public Hospitals, Northwest

Nigeria. Int. J. Environ. Res. Public

Health 2022, 19, 3305. https://

doi.org/10.3390/ijerph19063305

Academic Editor: Paul B.

Tchounwou

Received: 17 January 2022

Accepted: 9 March 2022

Published: 11 March 2022

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4.0/).

International Journal of

Environmental Research

and Public Health

Article

Patient Safety Culture and Its Associated Factors: A Situational
Analysis among Nurses in Katsina Public Hospitals,
Northwest Nigeria
Musa Sani Kaware 1,2, Mohd Ismail Ibrahim 1,* , Mohd Nazri Shafei 1 , Suhaily Mohd Hairon 1

and Abduljaleel Umar Abdullahi 2

1 Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia,
Kubang Kerian 16150, Kelantan, Malaysia; [email protected] (M.S.K.);
[email protected] (M.N.S.); [email protected] (S.M.H.)

2 Department of Community Medicine, College of Health Sciences, Umaru Musa Yar’adua University,
Katsina 820101, Katsina State, Nigeria; [email protected]

* Correspondence: [email protected]; Tel.: +60-97676621

Abstract: Background: Patient safety involves identifying, assessing, and managing patient-related
risks and occurrences to improve patient care and reduce patient harm. In Nigeria, there is a
lack of studies on patient safety culture, especially in the northern part of the country. This study
aimed to determine the levels and factors that contribute to nurses’ negative perceptions of patient
safety culture in public health facilities. Methodology: A total of 460 nurses were surveyed across
21 secondary health facilities using the Hospital Survey on Patient Safety Culture, and the response
rate was 93.5%. Descriptive statistics and multiple logistic regression were used to analyze the data.
Results: The results showed that 59.8% of the respondents were female, and 42.6% were within the
age range of 30–39 years old. Most of them (48.3%) had spent 1–5 years working in the hospital. Three
out of 12 composite measures had higher negative responses (staffing—30.5%, non-punitive response
to error—42.8%, and frequency of events reported—43.1%). A multiple logistic regression analysis
affirmed that all three variables, in addition to organizational learning, were significant associated
with overall negative perceptions of patient safety culture, with 3.15, 1.84, 2.26, and 2.39 odds ratios,
respectively. Conclusion: The results revealed that four critical areas of patient safety required
improvement; therefore, intervention is recommended to minimize unnecessary patient harm and
medical expenses.

Keywords: patient safety culture; situational analysis; nurses; public hospitals; medical errors

1. Introduction

Safety culture is a term used to assess “the attitudes, beliefs, and perceptions shared
by natural groups as defining norms and values” [1], which determine how they react con-
cerning reporting, analyzing, and preventing errors that can develop into life-threatening
circumstances or outcomes. This is linked to the concepts of assessing hazards, risk, harm,
and the identification of errors, events, and incidents [2]. Research has been indicated that
the main factors responsible for causing patient harm have been communication prob-
lems, staffing patterns, poor or lack of error reporting systems, organizational transfer of
knowledge, inadequate information flow, individual problems, inadequate policies and
procedures, and technical failures [3].

Some literature from high-income countries has shown that a significant number of
patients are being harmed in the process of healthcare, leading to either increased cost
of medical care, extended time of stay in the healthcare facilities, permanent disabilities,
or even death [4]. Recent studies have revealed that medical errors are the third leading
cause of death in the United States of America after cancer and heart disease [3]. Another

Int. J. Environ. Res. Public Health 2022, 19, 3305. https://doi.org/10.3390/ijerph19063305 https://www.mdpi.com/journal/ijerph

Int. J. Environ. Res. Public Health 2022, 19, 3305 2 of 14

study has also divulged that, on average, every 35 s, at least one case of patient harm is
reported in the United Kingdom [4,5]. In addition, studies conducted in American states,
such as Colorado, Utah, and New York have revealed that no less than 44,000 and as
many as 980,000 American people die in hospitals as a result of preventable medical errors,
such as medication, surgical, and diagnostic errors, every year [6]. The reports further
ascertained that even if the lowest estimate was considered, it surpassed the number of
deaths ascribed to vehicle accidents, breast cancer, and AIDS [6]. Comparatively, in low-
and middle-income countries, a combination of undesirable factors, such as understaffing,
inadequate infrastructure, poor hygiene and sanitation, overcrowding, lack of healthcare
commodities, and shortage of essential equipment, has contributed enormously to the
serious condition of patient safety [4,7].

It is further estimated that the overall annual frequency of hospitalization has reached
up to 421 million worldwide, of which 42.7 million adverse events occur in hospitalized
patients [4,8]. It has also been stated that low- and middle-income countries account for
about two-thirds of all adverse events globally [9]. In a report titled Patient Safety: Making
Healthcare Safer, the World Health Organization (WHO) stated that: “Treating and caring
for patients in a safe environment and protecting them from healthcare-related avoidable
harm should be a national and international priority and called for concerted international
efforts” [4]. In addition, in 2004, the World Alliance for Patient Safety and the WHO
called for attention in sub-Saharan African countries for urgent understanding, action, and
improvement of patient safety culture [8,10].

The lack of sufficient data on incidence reporting among sub-Saharan African countries
has made it difficult to measure the intensity of adverse events and has made the region
an environment of preventable morbidity and mortality due to poor infection control
practices and overcrowding in hospitals [11]. According to the WHO regional director for
Africa, the majority of the countries in the region do not have a national policy on safe
healthcare practices [12]. However, more local organizations have recently emerged in the
region with the goal of developing measures to enhance patient care through accreditation
efforts connected to the Joint Commission International and the Council for Health Service
Accreditation of Southern Africa [13]. An example of such an organization in sub-Saharan
Africa is the Society for Quality Healthcare in Nigeria (SQHN). The SQHN was formed
with a mission to lead, advocate, and facilitate the continuous improvement of quality and
safety in healthcare [13,14]. Despite the calls by the WHO and other health organizations
on improving patient safety culture in the region, there is still not much research on patient
safety culture in Nigeria, particularly in the northern part of the country.

In Nigeria, poor patient safety practices in public healthcare facilities have become
a significant public health challenge due to one or a combination of factors related to
healthcare provider- or patient-related factors. The most common patient safety challenges
in Nigeria include, but are not limited to, surgery, medication, diagnostics, transfusion,
healthcare-associated infection, staff competency, emergency management, medical equip-
ment, communication, accessibility, reduced error reporting, and management systems [9].
Thus, it has become necessary to carry out a baseline assessment of the patient safety
culture to determine the level and associated factors in the region and to identify the areas
that need intervention.

2. Materials and Methods
2.1. Setting and Study Design

This research is a cross-sectional study using the Hospital Survey on Patient Safety
Culture (HSOPSC) developed by the Agency for Health Research and Quality (AHRQ) to
assess patient safety culture among nurses in Katsina State public hospitals in northwestern
Nigeria. The study was conducted among nurses in 20 public secondary health facilities
across the state.

Int. J. Environ. Res. Public Health 2022, 19, 3305 3 of 14

2.2. Study Area

Nigeria’s government is divided into three levels: federal, state, and local. The obliga-
tion to deliver healthcare in the public sector is shared among the three levels of government.
Clinics, dispensaries, and health posts act as the community’s entrance point into the local
government’s healthcare system, providing general preventative, preventive, promotive,
and pre-referral therapy [15,16]. These facilities are generally staffed with nurses, environ-
mental health officers, community health workers, community health extension workers
(CHEWs), and junior CHEWs. Patients referred from primary healthcare are admitted
to secondary facilities that provide general medical and laboratory services, as well as
specialty health services such as surgery, pediatrics, obstetrics, and gynecology. General
hospitals often employ medical officers, nurses, midwives, laboratory and pharmacy pro-
fessionals, and community health officials. Tertiary-level facilities, which include specialty
and teaching hospitals as well as federal medical centers (FMCs), are the highest level of
healthcare in Nigeria. They handle patients referred from the primary and secondary levels
and have specialized expertise and complete technological capability, allowing them to
serve as knowledge-generating and dissemination resource centers. At least one tertiary
institution exists in each state [13,17–19].

2.3. Sampling Method

Before data collection commenced, an introduction letter was obtained from the
Katsina State Hospital Management Board (KSHMB). In addition, in each of the 20 sec-
ondary health facilities, a meeting was conducted with the medical director and head
of nursing services to formally introduce the research and its procedure, purposes, and
benefits, as well as to seek their support for the successful conduct of the study.

The sample size for the study was calculated according to the study objectives using
single-proportion formula and PS Power and Sample Size Calculation software version
3.1.2 by William D. Dupont and Walton D. Plummer, Vanderbilt University, Nashville, TN,
USA. The highest value obtained (460) was therefore used as the study sample size. To
obtain the required sample size, a compiled list of available staff was obtained from the
head of the nursing service in each hospital for a simple random selection of respondents.
In each of the study hospitals, one research assistant was assigned to facilitate the collection
of completed surveys.

The survey instrument for this study was a paper-format self-administered ques-
tionnaire (HSOPSC), which took the respondents 10–15 min to complete. This format
was chosen because of its feasibility for most public hospitals in Nigeria, and the AHRQ
encouraged the use of a paper format for the highest possible response rate [20].

2.4. Research Tool

The research tool used in this study was the Hospital Survey on Patient Safety Culture
(HSOPSC), which was developed by the AHRQ [21]. The agency has been continually using
this survey instrument in hospitals in the United States to compile data for its database and
publish annual reports on the status of patient safety culture since it was developed [21].

In addition, several researchers have reported the applicability of this questionnaire
in healthcare settings from different countries around the globe, including Jordan [22],
Sweden [23], Egypt [24], Afghanistan [25], Saudi Arabia [26–28], Slovenia [29], the Nether-
lands [30], Lebanon [31], Iran [32], Taiwan [33], Kuwait [34], Brazil and Portugal [35],
Switzerland [36], and many other countries. The current survey does not require any
translation or validation, with English being the official language in Nigeria.

The HSOPSC contains 42 items, which are further grouped into 12 composite measures:
teamwork within units or departments; supervisor or manager expectations and actions
promoting patient safety; organizational continuous learning improvement; hospital man-
agement support for patient safety; overall perceptions of patient safety; feedback and
communication about errors; communication openness; frequency of events reported; team-
work across hospital units; staffing; hospital handoffs and transitions; and non-punitive

Int. J. Environ. Res. Public Health 2022, 19, 3305 4 of 14

responses to errors. In addition, the respondents were requested to provide their back-
ground information, such as age, gender, duration of work experience in the current unit
and hospital, and whether they had direct contact or interaction with patients, among
others [20].

The scaling of the survey instrument is based on a 5-point Likert scale as either strongly
disagree, disagree, neutral, agree, or strongly agree. Some of the survey’s composites were
rated as either never, rarely, sometimes, most of the time, or always. Both rating scales were
coded with score numbers (1, 2, 3, 4, and 5, respectively) for easy data entry and analysis.

The AHRQ’s HSOPSC was pilot tested among 1437 respondents in 21 hospitals across
six states in the United States. The factor structure and reliability of the survey composites
were examined and analyzed, and they were confirmed to be psychometrically sound. The
results provided overall evidence supporting the 12 dimensions and 42 items included
in the HSOPSC as having acceptable psychometric properties at all levels of analysis.
Cronbach’s alpha for the composites ranged from 0.62 to 0.85, with an average of 0.77. All
composites had acceptable reliability (0.70 or higher), except for the staffing composite
(α = 0.62) [37]. The lower reliability of the survey tool can be attributed to differences in the
respondents’ demographic characteristics and their levels of heterogeneity. In addition, the
lack of modification and inconsistencies in the assessments of constructive validity were
additional factors to explain the differences [37–40].

2.5. Data Collection

The HSOPSC was distributed to one point of contact in the various units or depart-
ments that were accessible to the respondents at the beginning of their working days in
each hospital. The distribution of the survey was accompanied by a supporting cover letter
guiding the respondents on how to complete and return the survey, and a consent form.
Furthermore, the cover letter requested that the respondents complete the survey within
three days, even though the deadline was not specified in the cover letter, because data
collection might have been delayed or rescheduled [27].

To ensure uniformity, easy tracking of non-respondents, and redistribution of the
survey, each survey tool was given a unique ID-tracking code. This code was recorded on a
tracking log sheet that was given to the research assistant in each hospital. Moreover, this
tracking log sheet was used to trace the unreturned surveys and other staff members who
might not have received the survey. The tracking log sheet carried only the survey tracking
number but no other identity of the respondents to ensure their anonymity. The entire data
collection activity was completed in six weeks.

2.6. Data Processing and Analysis

A total of 460 registered nurses were surveyed from secondary health facilities (general
hospitals), of which 434 responded to the survey tool, making the response rate 93.5%.
Four of the responded surveys were invalid and excluded from the analysis. The data were
analyzed using SPSS version 24, Armonk, NY, USA, IBM Corp, Statistical Package for the
Social Sciences. Before calculating the percentage of positive and negative scores, missing
responses were identified and excluded, and negatively worded questions were reversed.
The top two response categories (strongly agree and agree, or most of the time and always)
were merged and considered positive responses. The remaining three response categories
(strongly disagree, disagree, and neither or never, rarely, and sometimes) were merged and
considered negative responses for the purpose of statistical analysis.

Descriptive statistics (percentage and frequency) were used to describe the background
and job-related characteristics of the respondents and the level of patient safety culture
in the hospitals. A p-value of 0.05 was used as the statistical significance level. Multiple
logistic regression analyses were used to determine the association between the dependent
and independent variables. According to the HSOPSC user guide, there are 12 composites
involved in the questionnaire, each of which is independent and mutually exclusive.
We decided to take the overall perceptions of the patient safety culture composite as a

Int. J. Environ. Res. Public Health 2022, 19, 3305 5 of 14

dependent variable, while the others, including the sociodemographic data, were used as
independent variables. The scores for each item were grouped into positive and negative
to obtain a binary outcome variable based on the HSOPSC guidelines [20]. The regression
analysis was performed using the stepwise backward option for all independent variables
separately. The odds ratio with a 95% confidence interval was examined to determine the
factors associated with overall negative perceptions of patient safety culture.

3. Results

Table 1 shows the background and job-related characteristics of the subjects, which
were divided into different variables. Of the total number of nurses (430) who participated
in the study, 257 (59.8%) were female, and the remaining 173 (40.2%) were male. In addition,
most of the respondents in the study (42.6%) were within the age range of 30–39 years,
while the smallest percentage (3.0%) were aged between 60 and 69 years old. With regard
to the years of experience in the hospital, most of the respondents (48.3%) have spent
1–5 years working in the hospital, followed by those who have worked there 6–10 years
(20.4%), whereas 2.1% have been working in the hospital for 16–20 years.

Table 1. Background and job-related characteristics of the respondents (n = 430).

Variable Frequency
(n)

Percent
(%)

Gender Male 173 40.2
Female 257 59.8

Age group (year) 20–29 93 21.6
30–39 183 42.6
40–49 80 18.6
50–59 61 14.2
60–69 13 3.0

Duration of work experience in the hospital (year) <1 47 11.1
1–5 204 48.3
6–10 86 20.4

11–15 49 11.6
16–20 9 2.1
≥21 27 6.4

Duration of work experience in the current unit (year) <1 135 32.0
1–5 221 52.4
6–10 40 9.5

11–15 16 3.8
16–20 5 1.2
≥21 5 1.2

Number of working hours per week <20 15 3.6
20–39 117 28.3
40–59 192 46.4
60–79 43 10.4
80–99 23 5.6
≥100 24 5.8

Int. J. Environ. Res. Public Health 2022, 19, 3305 6 of 14

Table 1. Cont.

Variable Frequency
(n)

Percent
(%)

Duration of work experience in the profession (year) <1 39 9.4
1–5 169 40.5
6–10 79 18.9

11–15 56 13.4
16–20 19 4.6
≥21 55 13.2

Direct contact with the patients Yes 408 96.9
No 13 3.1

Number of events reported in the past 12 months 0 220 56.7
1–2 86 22.2
3–5 44 11.3

6–10 18 4.6
11–20 10 2.6
≥21 10 2.6

An overall grade on patient safety for the current unit. Excellent 91 22.6
Very good 205 51.0
Acceptable 102 25.4

Poor 4 1.0

Among the 430 nurses participating in the study, 52.4% worked in their current units
for 1–5 years, followed by those who worked in their current units for less than 1 year
(32.0%). Similarly, 46.4% of the respondents reported that they worked 40–59 h per week,
whereas only 3.6% of the respondents said they worked less than 20 h per week. The
findings of this study further revealed that the majority of the nurses (40.5%) had only
worked in the profession for 1–5 years, while only 13.2% of the respondents had been in
the nursing profession for over 20 years. Moreover, it was noticed from the results that
about 96.9% of the study participants had direct contact with patients, and only 3.1% did
not have direct contact with patients.

Table 2 displays the percentages of the respondents answering negatively or positively
to the survey items. It shows that out of the 12 composites of patient safety culture, staffing
had the highest negative responses (69.5%), followed by non-punitive response to error
(57.2%) and frequency of event reporting (56.9%). On the other hand, teamwork within
units scored a higher percentage of positive responses (91.1%), followed by organizational
learning and continuous improvement of patient safety culture (84.7%), teamwork across
units (83.0%), and management support for patient safety (80.3%).

Similarly, the table also displays the item with the highest negative perception: “Staff
in this unit work longer hours than is best for patient care” (85.3%); then “We have enough
staff to handle the workload” (78.9%); followed by “When a mistake is made but has
no potential to harm the patient, how often is this reported?” (69.4%); “Staff worry that
mistakes they make are kept in their personnel file” (67.8%); “We work in ‘crisis mode’
trying to do too much, too quickly” (67.2%); “Staff feel like their mistakes are held against
them” (56.0%); and “It is just by chance that more serious mistakes don’t happen around
here” (55.4%).

Int. J. Environ. Res. Public Health 2022, 19, 3305 7 of 14

Table 2. Summary of the percentage of negative and positive responses to patient safety culture by
composites and items (n = 430).

Composites and Items
Negative Responses Positive Responses

n (%) n (%)

Teamwork within Units 151 (8.9) 1550 (91.1)
a1. People support one another in this unit. 20 (4.8) 399 (95.2)

a3. When a lot of work needs to be done quickly, we work together as a team
to get the work done. 24 (5.6) 404 (94.4)

a4. In this unit, people treat each other with respect. 18 (4.2) 411 (95.8)
a11. When one area in this unit gets really busy, others help out. 89 (20.9) 336 (79.1)

Supervisor’s or Manager’s Expectations and Actions Promoting Patient Safety 422 (25.2) 1253 (74.8)

b1. My supervisor or manager says a good word when he or she sees a job
done according to established patient safety procedures. 37 (8.8) 386 (91.3)

b2. My supervisor or manager seriously considers staff suggestions for
improving patient safety. 32 (7.6) 391 (92.4)

b3r. Whenever pressure builds, my supervisor or manager wants us to work
faster, even if it means taking shortcuts. 183 (44.1) 232 (55.9)

b4r. My supervisor or manager overlooks patient safety problems that
happen repeatedly. 170 (41.1) 244 (58.9)

Organizational Learning—Continuous Improvement 194 (15.3) 1072 (84.7)
a6. We are actively doing things to improve patient safety. 9 (2.1) 419 (97.9)
a9. Mistakes have led to positive changes here. 150 (36.1) 265 (63.9)

a13. After we make changes to improve patient safety, we evaluate their
effectiveness. 35 (8.3) 388 (91.7)

Management Support for Patient Safety 249 (19.7) 1012 (80.3)

f1. Hospital management provides a work climate that promotes
patient safety. 57 (13.3) 371 (86.7)

f8. The actions of hospital management show that patient safety is a
top priority. 64 (15.4) 353 (84.7)

f9r. Hospital management seems interested in patients’ safety only after an
adverse event happens. 128 (30.8) 288 (69.2)

Overall Perceptions of Patient Safety 681 (41.3) 968 (58.7)
a10r. It is just by chance that more serious mistakes don’t happen around here. 226 (55.4) 182 (44.6)
a15. Patient safety is never sacrificed to get more work done. 202 (50.5) 198 (49.5)
a17r. We have patient safety problems in this unit. 206 (49.3) 212 (50.7)

a18. Our procedures and systems are good at preventing errors
from happening. 47 (11.1) 376 (88.9)

Feedback and Communication About Error 355 (27.8) 920 (72.2)

c1. We are given feedback about changes put into place based on
event reports. 172 (40.8) 250 (59.2)

c3. We are informed about errors that happen in this unit. 110 (25.9) 315 (74.1)
c5. In this unit, we discuss ways to prevent errors from happening again. 73 (17.1) 355 (82.9)

Communication Openness 385 (30.2) 888 (69.8)

c2. Staff will freely speak up if they see something that may negatively affect
patient care. 66 (15.5) 361 (84.5)

c4. Staff feel free to question the decisions or actions of those with
more authority. 207 (49.3) 213 (50.7)

c6r. Staff are afraid to ask questions when something does not seem right. 112 (26.3) 314 (73.7)

Int. J. Environ. Res. Public Health 2022, 19, 3305 8 of 14

Table 2. Cont.

Composites and Items
Negative Responses Positive Responses

n (%) n (%)

Frequency of Events Reported within last 12 months 712 (56.9) 539 (43.1)

d1. When a mistake is made but is caught and corrected before affecting the
patient, how often is this reported? 219 (52.3) 200 (47.7)

d2. When a mistake is made but has no potential to harm the patient, how
often is this reported? 290 (69.4) 128 (30.6)

d3. When a mistake is made that could harm the patient, but does not, how
often is this reported? 203 (49.0) 211 (51.0)

Teamwork Across Units 286 (17.0) 1397 (83.0)
f2r. Hospital units do not coordinate well with each other. 78 (18.3) 349 (81.7)

f4. There is good cooperation among hospital units that need to
work together. 40 (9.4) 386 (90.6)

f6r. It is often unpleasant to work with staff from other hospital units. 131 (32.0) 279 (68.1)
f10. Hospital units work well together to provide the best care for patients. 37 (8.8) 383 (91.2)

Dimensions and Items
Negative Response Positive Response

n (%) n (%)

Staffing 1156 (69.5) 508 (30.5)
a2r. We have enough staff to handle the workload 336 (78.9) 90 (21.1)
a5r. Staff in this unit work longer hours than is best for patient care 359 (85.3) 62 (14.7)
a7r. We use more agency/temporary staff than is best for patient care 191 (46.0) 224 (54.0)

a14r. We work in “crisis mode” trying to do too much, too quickly 270 (67.2) 132 (32.8)

Handoffs and Transitions 478 (28.6) 1196 (71.4)

f3r. Things “fall between the cracks” when transferring patients from one
unit to another 132 (32.0) 281 (68.0)

f5r. Important patient care information is often lost during shift changes 85 (20.1) 337 (79.9)
f7r. Problems often occur in the exchange of information across hospital units 191 (45.7) 227 (54.3)
f11r. Shift changes are problematic for patients in this hospital 70 (16.6) 351 (83.4)

Nonpunitive Response to Errors 696 (57.2) 520 (42.8)
a8r. Staff feel like their mistakes are held against them 228 (56.0) 179 (44.0)

a12r. When an event is reported, it feels like the person is being written up, not
the problem 184 (47.2) 206 (52.8)

a16r. Staff worry that mistakes they make are kept in their personnel file 284 (67.8) 135 (32.2)

Keys: r = reversed question. n = number of responses. Positive responses = sum of agree and strongly agree
responses. Negative responses = sum of disagree, strongly disagree, and neither response.

For the positive perception, the survey item having the highest score was “We are
actively doing things to improve patient safety” (97.9%); then “In this unit, people treat
each other with respect” (95.8%); followed by “When a lot of work needs to be done quickly,
we work together as a team to get the work done” (94.4%); “My supervisor or manager
seriously considers staff suggestions for improving patient safety” (92.4%); “After we make
changes to improve patient safety, we evaluate their effectiveness” (91.7%); “My supervisor
or manager says a good word when he or she sees a job done according to established
patient safety procedures” (91.3%); and “Hospital units work well together to provide the
best care for patients” (91.2%).

Table 3 presents the results for simple and multiple logistic regression analyses to de-
termine the odds ratio of possible risk factors associated with an overall negative perception
of patient safety culture. From the simple logistic regression performed, a total of 16 vari-
ables had p-values of <0.25. On the basis of a study by Bursac et al. (2008), it was noted
that using a cutoff point of 0.05 can fail to identify variables known to be important [41].
Hence, the variables with a p-value < 0.25 were included in the multiple logistic regression
analysis. Four variables were retained in the final model, and they were included using the
enter method to obtain the preliminary main effect model. Overall negative perceptions
of patient safety culture was used as a dependent variable. The results in Table 3 show

Int. J. Environ. Res. Public Health 2022, 19, 3305 9 of 14

that there are four factors that are significantly associated with staff’s overall negative
perceptions of patient safety culture. Staff who had reported fewer events (five or less)
are more likely to have overall negative perceptions of patient safety culture than those
who had reported more than five, with an odds ratio of 2.66 (95% CI = 1.03–4.97). Nurses
who had negative perceptions of organizational learning and continuous improvement,
negative perceptions of staffing, and negative perceptions of handoffs and transition were
significantly associated with overall negative perceptions of patient safety culture, with
adjusted odds ratios of 2.39 (95% CI = 1.40–4.10), 3.15 (95% CI = 1.34–7.17), and 1.48 (95%
CI = 1.09–3.12), respectively.

Table 3. Logistic regression analysis to determine the factors associated with negative perceptions of
patient safety culture (n = 430).

Variable Categories
Simple Logistic Regression Multiple Logistic Regression

COR (95% CI) p-Value AOR (95% CI) Wald Stat (df) p-Value

Age <40 years old 1
≥40 years old 0.87 (0.58–1.29) 0.479

Gender Male 1
Female 0.84 (0.57–1.23) 0.371

Years of experience in the
hospital <5 years 1

≥5 years 0.63 (0.39–1.03) 0.063

Years of experience in the
current unit <5 years 1

≥5 years 0.56 (0.24–1.28) 0.168

Working hours per week <40 h 1
≥40 h 1.14 (0.75–1.72) 0.546

Years of experience in the
profession <5 years 1

≥5 years 0.63 (0.41–0.96) 0.033

Number of events reported in
last 12 months High 1 1

Low 1.78 (0.90–3.53) 0.098 2.26 (1.03–4.97) 4.109 0.043

Direct contact with patients No 2.52 (1.01–6.31) 0.048
Yes 1

Teamwork within units Positive 1
Negative 2.22 (0.95–5.18) 0.066

Supervisor’s expectations and
actions promoting patient safety Positive 1 1

Negative 2.83 (1.74–4.62) <0.001 2.39 (1.40–4.10) 10.139 0.001

Organizational learning
continuous improvement Positive 1

Negative 1.70 (1.06–2.73) 0.029

Management support for patient
safety Positive 1

Negative 2.07 (1.31–3.27) 0.002

Feedback and communication
about error Positive 1

Negative 2.00 (1.24–3.22) 0.005

Int. J. Environ. Res. Public Health 2022, 19, 3305 10 of 14

Table 3. Cont.

Variable Categories
Simple Logistic Regression Multiple Logistic Regression

COR (95% CI) p-Value AOR (95% CI) Wald Stat (df) p-Value

Communication openness Positive 1
Negative 1.65 (1.07–2.55) 0.023

Frequency of events reported Positive 1
Negative 1.30 (0.88–1.91) 0.195

Teamwork across nits Positive 1
Negative 1.57 (0.90–2.75) 0.111

Staffing Positive 1 1
Negative 3.25 (1.62–6.51) 0.001 3.15 (1.39–7.17) 7.492 0.006

Handoffs and transitions Positive 1 1
Negative 1.85 (1.18–2.90) 0.007 1.84 (1.09–3.12) 5.159 0.023

Nonpunitive response to errors Positive 1
Negative 1.60 (1.04–2.46) 0.034

Key notes: COR = crude odds ratio. AOR = adjusted odds ratio. CI = confidence interval. Variables with a
p-value < 0.25 were included in the multiple logistic regression [41]. Forward or backward LR method used, no
multicollinearity and no interaction, area under the curve 69.6%, classification table 65.6%, Hosmer–Lemeshow,
p = 0.167. High = 6 or more events reported. Low ≤ 5 events reported.

4. Discussion

To the best of our knowledge, this study is the first of its kind to be conducted in
northwestern Nigeria. In this study, we tried to assess the level of patient safety culture
and its associated factors among nurses in certain public health facilities. The findings
showed that a majority of the survey composites scored more than the average level of
positive perceptions and are referred to as areas of strength. These include teamwork
within a unit; organizational learning and continuous improvement; teamwork within
units; management support for patient safety; supervisor’s expectations and actions pro-
moting patient safety, feedback, and communication about errors; handoffs and transitions;
communication openness; and overall perceptions of patient safety. The only three compos-
ites that scored below average were staffing, non-punitive response to error, and frequency
of events reported.

Most of the nurses reported that they work longer hours than is good for the patient,
while some mentioned that they do not have enough staff to handle the workload. Staffing
is one of the key aspects in the quality of healthcare services and patient care outcomes.
Whenever there is poor staffing in a hospital, many areas of service delivery cannot work
effectively. However, the issue of understaffing in healthcare facilities is a global problem,
as many studies have also revealed evidence of poor staffing in many countries. These
include research conducted on patient safety culture and associated factors in hospitals in
the Jima zone in southwest Ethiopia [42], Saudi Arabi [43], Lebanon [31], Sweden, Spain,
Hungary, and Croatia [44]. This finding was further attested by a logistic regression analysis
in the present study, which showed that an increase in the negative perception of staffing
composite has the odds of 3.15 to a negative perception of the overall patient safety culture.

Nonpunitive response to error is another weak dimension that requires serious atten-
tion. It is all about how staff feel that when they make mistakes or report an event, it will
be held against them, and the mistakes will be reported in their personnel files. The overall
score of the average positive response to non-punitive response to error in this study is
42.8%. This indicated that the nurses in the studied hospitals feared being blamed when
they made mistakes instead of correcting them. Moreover, they showed their fears that
when they made mistakes, they would be kept in their files. The consequences of this fear
may result in continuously occurring medical errors in hospitals without identifying and
correcting them. Thus, it is of paramount importance for hospital management to create
an avenue where healthcare workers at liberty to report errors and contribute to ways of

Int. J. Environ. Res. Public Health 2022, 19, 3305 11 of 14

minimizing them. However, in comparison with previous studies [26,30,32,33], the present
findings show a better result. In addition, a study conducted to assess patient safety culture
in hospital settings by Abdulmajeed et al. (2021) identified error reporting as one of the
factors that required improvement [45]. However, the present findings showed a better
result, which is even closer to the AHRQ benchmark of 43% [33].

The dimension of frequency of error reporting measured the rate of occurrence of
medical events or mistakes that have the potential to harm patients directly or indirectly.
In some instances, the error can occur and be corrected before affecting the patient, and
sometimes it may happen and cause serious injury or even death to the patient.

In the present study, most of the nurses expressed negative perceptions of the fre-
quency of error reporting. A majority of them said that when a mistake is made but has
no potential to harm the patient, they do not report it, or they rarely report it. Meanwhile,
half of them said that they did not normally report errors that were caught and corrected
before affecting the patient. This indicates that many errors are happening daily in the
hospitals, and that there is a tendency to not report even the errors that have the potential
of harming the patients, which may be the result of understaffing, fear of punishment, or
lack of error reporting systems. This failure of error or adverse event reporting made it
difficult to understand the true number of errors, the types of errors, and the magnitude of
harm to patients. This study is in agreement with the findings of a study conducted on the
assessment of patient safety culture among healthcare providers at Ain Shams University
hospitals in Cairo, Egypt [46], which showed that the average positive response score for
error reporting is 33.4%. However, it is also inconsistent with the results of an evaluation
of patient safety culture in a secondary care setting in Kuwait conducted by Alqattan in
2017 [47].

Another dimension identified as an important determinant of patient safety culture
in this study is hospital staff handoffs and transitions. Handoff is the process that deals
with the transfer of essential patient information during shift changes between healthcare
providers or from one hospital unit to another to ensure the continuity of patient care [48].
Even though the dimension received a high positivity score, the logistic regression analysis
identified it as a significant predictor of patient safety culture. As presented in the results
section, we realized that a negative perception of handoffs and transition would increase a
likely negative perception of the overall perception of patient safety culture by the odds
of 1.48, when compared with a positive perception. This can be attributed to the lack of
enough nursing staff to take care of the patients, which means that they are too busy to carry
out a formal handover in their units and departments of work. In addition, time constraints
may be another factor that can lead to a poor perception of handoffs and transitions. The
results of similar research conducted in primary healthcare units in Turkey [49] and in a
Saudi Arabian hospital [50] were consistent with the present study.

Limitations of the Study

This study was based on nurses’ experience only, and thus it did not cover all the
healthcare professional groups working in Katsina State secondary health facilities. In
addition, primary, tertiary, and private health facilities were not covered, which makes it
difficult to generalize the perceived overall patient safety culture results among healthcare
providers. However, despite these limitations, this study has provided baseline data on
the current situation of patient safety culture among nurses in public secondary health
facilities. It also identified areas of weakness that require further improvement for better
patient care.

5. Conclusions

This study examined the level of patient safety culture and its associated factors
among nurses. The findings revealed that the majority of the survey composites scored
positively above average. However, there are four critical areas of patient safety culture
that require improvement: organizational learning, staffing, handoffs and transitions, and

Int. J. Environ. Res. Public Health 2022, 19, 3305 12 of 14

frequency of event reporting. Thus, it is recommended that all stakeholders in hospital
management and policy makers establish a voluntary and mandatory error reporting
system that will focus on identifying all sorts of errors or mistakes that may affect the
quality of patient care in hospitals. In addition, similar research is recommended that
will cover both public and private, primary, secondary, and tertiary health facilities across
the region among all the professional groups in the healthcare system. Furthermore, an
intervention is recommended to improve nurses’ knowledge of medical error reporting,
its importance, and the possible consequences attached to it. For future research, a larger
sample size should be used to cover all professional groups in the health service system.

Author Contributions: Conceptualization, M.I.I. and M.N.S.; data curation, S.M.H.; formal analysis,
M.S.K., M.I.I., M.N.S. and S.M.H.; funding acquisition, M.I.I.; investigation, M.S.K. and A.U.A.;
methodology, M.S.K., M.I.I., M.N.S. and S.M.H.; project administration, A.U.A.; resources, A.U.A.;
supervision, M.I.I. and A.U.A.; writing—original draft, M.S.K.; writing—review, and editing, M.I.I.,
M.N.S. and S.M.H. All authors have read and agreed to the published version of the manuscript.

Funding: The study was funded by the Universiti Sains Malaysia under the Graduate Development
Incentive Grants Ph.D. (GIPS-Ph.D.): 311/PPSP/4404805.

Institutional Review Board Statement: The project was ethically reviewed and approved by the
Research Ethics Committee (JEPeM) of the Universiti Sains Malaysia (USM/JEPeM/20010001 on 12
May 2020) and Katsina State Ministry Health Nigeria (MOH/ADM/SUB/1152/1/358 on 10 March
2020), and conducted according to the guidelines of the Declaration of Helsinki.

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement: The authors can make the raw data from this study available to
interested scholars upon request.

Acknowledgments: The authors would like to acknowledge the efforts and cooperation of the
Katsina State Hospital Management Board and the management of all the secondary health facilities
in Katsina State that give ethical consent to conduct the study. We also want to express our gratitude
to all of the nurses who consented to participate in this study and share their thoughts.

Conflicts of Interest: The authors declare that there are no conflict of interest in this research.

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230  |  Nursing Open. 2017;4:230–239.wileyonlinelibrary.com/journal/nop2

Received: 19 October 2016  |  Accepted: 19 June 2017

DOI: 10.1002/nop2.89

R E S E A R C H A R T I C L E

Patient involvement for improved patient safety: A qualitative
study of nurses’ perceptions and experiences

Janna Skagerström1  | Carin Ericsson2 | Per Nilsen3 | Mirjam Ekstedt4,5  | 
Kristina Schildmeijer4

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2017 The Authors. Nursing Open published by John Wiley & Sons Ltd.

1Research and Development Unit in Region
Östergötland and Department of Medical
and Health Sciences, Linköping University,
Linköping, Sweden
2Centre of Heart and Medicine, Region
Östergötland, Linköping, Sweden
3Department of Medical and Health
Sciences, Linköping University, Linköping,
Sweden
4Department of Health and Caring
Sciences, Linnaeus University, Kalmar, Sweden
5Department of Learning, Informatics,
Management and Ethics, Karolinska Institutet,
Stockholm, Sweden

Correspondence
Janna Skagerström, Research and
Development Unit in Local Health Care,
Region Östergötland, Linköping, Sweden.
Email: [email protected]
se

Funding information
This study was funded by The Swedish Research
Council for Health, Working Life and Welfare,
FORTE, 2014-4567

Abstract
Aim: To explore nurses’ perceptions and experiences of patient involvement relevant
to patient safety.
Design: Qualitative design using individual semi- structured interviews.
Methods: Interviews with registered nurses (n = 11) and nurse assistants (n = 8) were
conducted in 2015–2016. Nurses were recruited from five different healthcare units
in Sweden. The material was analysed using conventional content analysis.
Results: The analysis resulted in four categories: healthcare professionals’ ways of in-
fluencing patient involvement for safer care; patients’ ways of influencing patient in-
volvement for safer care; barriers to patient involvement for safer care; and relevance
of patient involvement for safer care. The nurses expressed that patient involvement
is a shared responsibility. They also emphasized that healthcare provider has a respon-
sibility to create opportunities for the patient to participate. According to the nurses,
involvement can be hindered by factors related to the patient, the healthcare provider
and the healthcare system. However, respondents expressed that patient involvement
can lead to safer care and benefits for individual patients.

K E Y W O R D S

barriers, determinants, facilitators, nurses, patient involvement, patient safety

1  | INTRODUCTION

Patient safety has progressed over the last 15 years from being a
relatively insignificant issue to a position high on the agenda for
healthcare professionals, managers and policy makers as well as
the public. Sweden has seen increased patient safety efforts since
2009 when a national study on adverse events in Swedish hospi-
tal care was published (Soop, Fyksmark, Köster, & Haglund, 2009).
The study estimated the percentage of preventable adverse events
as high as 8.6% in hospital care, demonstrating that the magni-
tude of the patient safety problem was not smaller in Sweden than

elsewhere. Efforts for improved patient safety in Sweden were
further enhanced in 2011 with the introduction of a new law on
patient safety and a financial incentive for county councils (respon-
sible for providing health care in Sweden) that performed certain
patient safety- enhancing activities (Ridelberg, Roback, Nilsen, &
Carlfjord, 2016).

There is increasing interest in involving patients in safety-
related initiatives, premised on the assumption that their interac-
tion with healthcare professionals can improve the safety of health
care in many ways (Berger, Flickinger, Pfoh, Martinez, & Dy, 2014,
World Health Organization, 2013a). The importance of eliciting and

     |  231SKAGERSTRÖM ET Al.

acting on patients’ concerns has been emphasized. The patients are
privileged witnesses of health care because they are at the centre
of the process of care and observe the whole process (Schwappach
& Wernli, 2010). Patients also carry out hidden work to compen-
sate for inefficiencies of the healthcare system, such as relaying
information between healthcare professionals (Vincent & Davis,
2012). Various policy initiatives have been undertaken aimed at
encouraging patients in a range of safety- relevant behaviours. The
World Health Organization (WHO) promotes the program “Patients
for Patient Safety” to bring together patients and various stake-
holders to improve patient safety through advocacy, collaboration
and partnership (WHO, 2013b). In Sweden, the National Board of
Health and Welfare and Swedish Association of Local Authorities
and Region (SALAR), representing the county councils and munic-
ipalities, have emphasized the importance of a new perspective
on the patient for improved quality and effectiveness of health
care (National Board of Health and Welfare, 2015, SALAR, 2011).
Healthcare professionals are also obliged by the law to give patients
an opportunity to take part in patient safety work (SFS, 2010).

1.1 | Background

Research indicates that there is a potential for patients to improve
safety (Davis, Jacklin, Sevdalis, & Vincent, 2007; Vincent & Coulter,
2002) and that patients are willing and able to be involved in safety-
related work (Waterman et al., 2006 Wright et al., 2016). However,
several barriers to involving patients in improving patient safety has
been identified and organized into three key barriers: (i) patients
are not always willing or prepared to commit their time and energy
to improve their care because they have enough to worry about
being ill; (ii) healthcare professionals represent traditional medi-
cal authority and questioning or advising professionals about what
they do is unacceptable for many patients; and (iii) patients may be
apprehensive about reporting problems in their care when provid-
ers’ responses are unappreciative or when the patients believe that
their feedback may jeopardize the providers’ goodwill towards the
patient (Iedema, Allen, Britton, & Gallagher, 2012). Organizational
factors such as a busy setting, lack of continuity of care and pa-
tients being unaware of incident reporting systems have also been
identified as barriers to active patient participation (Doherty &
Stavropoulou, 2012).

Nurses comprise the largest professional group in health care
in Sweden. The main categories of nurses in Swedish health care
are registered nurses and nurse assistants, who differ with regard to
their level of education, work duties and responsibilities. Registered
nurses are critically important to achieve patient safety since they
often have a role as coordinator of multidisciplinary care and are in-
volved with many aspects of patient care, from providing comfort
and hygiene to administering injections, updating medical records,
as well as handling some therapeutic and diagnostic procedures.
Several studies have stressed the importance of nurses’ role for iden-
tifying, interrupting and correcting medical adverse events (Gaffney,
Hatcher, & Milligan, 2016) and for reducing patients’ feelings of

being unsafe and vulnerable in the health care setting (Kenward,
Whiffin, & Spalek, 2017).

Thus far, very few studies have investigated nurses and other
healthcare professionals’ attitudes, beliefs and behaviours concern-
ing patient involvement for improved patient safety. Research con-
ducted hitherto suggests that providers may be willing to support
patient involvement in safety- relevant behaviours, although the
factors behind these preliminary findings remain largely unexplored
(Davis, Briggs, Arora, Moss, & Schwappach, 2014; Hochreutener
& Wernli, 2010; Schwappach, Frank, & Davis, 2012). A previous
Swedish study assessing nurses’ perceptions of factors influencing
patient safety found that patient- nurse interaction was an import-
ant factor that could hinder or facilitate enhanced patient safety
depending on the quality of the communication (Ridelberg, Roback,
& Nilsen, 2014). This study provides an in- depth investigation into
nurses’ perspectives on patient involvement for safer care in meet-
ings with healthcare professionals, being the first Nordic study on
this topic. The aim was to explore nurses’ experiences and percep-
tions with regard to patient involvement of relevance for patient
safety.

Why is this research needed?
• The patient has an overall perspective of their care and

observes the whole care process.
• Most research on patient involvement concern the pa-

tient perspective and there is limited knowledge about
the healthcare professionals’ views on patient participa-
tion for patient safety.

What are the key findings?
• The nurses believed that healthcare professionals and pa-

tients had a shared responsibility for patient participation
to occur.

• The nurses emphasized the importance of their own ini-
tiatives to achieve patient involvement for enhanced pa-
tient safety by initiating dialogue and inviting the patients
to ask questions.

• The nurses expressed that barriers to achieve patient
participation for safer care were seen both within
patients, healthcare professionals and the healthcare
system.

How should the findings be used to influence policy/prac-
tice/research/education?
• The healthcare system should allocate time and support-

ive environments to facilitate open dialogue between
healthcare professionals and patients.

• Healthcare professionals should be offered training in
how to encourage the patients to be involved in their
health care.

232  |     SKAGERSTRÖM ET Al.

2  | THE STUDY

2.1 | Study setting

The study was set in Sweden. Health care in Sweden is mainly tax-
funded although private health care also exists. All residents are
insured by the state, with equal access for the entire population.
Out- of- pocket fees are low and regulated by law. The responsibility
for health and medical care in Sweden is shared by the central gov-
ernment, county councils and municipalities throughout Sweden.
The health care system is financed primarily through taxes levied by
county councils and municipalities.

2.2 | Study design

A qualitative study approach using standardized (also referred to as
structured) open- ended interviews was deemed appropriate regard-
ing the explorative aim of the study. This qualitative descriptive study
is grounded in the assumption that human beings construct the mean-
ing of their experiences in social interaction with their environment.
Qualitative descriptive studies comprise a valuable methodologic
approach, by using open- ended interviews where the phenomenon
under study is explored in an interaction between the interviewer and
the interviewee (Sandelowski, 2000).

2.3 | Participants

We used a purposeful sampling strategy to achieve a heterogene-
ous sample of nurses working in different healthcare facilities, with
patients who varied in terms of health status (from patients seen in
primary health care to ill patients receiving hospital care and, for ex-
ample, surgery patients), length of stay in health care (from patients
visiting outpatient facilities to in- hospital patients) and age. The aim
was to achieve a sample of nurses that represented a broad spectrum
of perceptions and experiences concerning patient involvement in re-
lation to patient safety.

The nurses were recruited using an email that briefly described
the study. The email request was sent to the manager of each work
unit, explaining that we wanted a sample of three or four nurses. The
manager in turn forwarded the request to all or a sample of registered
nurses and nurse assistants at the unit. An information letter describ-
ing the study was sent to interested nurses and the interviews were
scheduled. No respondents declined involvement after receiving the
information letter.

2.4 | Data collection

The interview guide used in the study was developed by the au-
thors and concerned the nurses’ experiences and perceptions re-
garding patient involvement of relevance for patient safety. There
were general questions on patient involvement of relevance for
patient safety. There were also specific questions on the respond-
ent’s own experiences and examples of patients who have ob-
served and highlighted something of importance for patient safety.

The interview guide ended with questions on existing routines to
account for patients’ views and experiences and on the nurses’
suggestions on how patient involvement for safer care can be
achieved.

Patient safety was defined in accordance with the definition used
in Swedish law (SFS, 2010), that is: “protection against adverse events”
where adverse events is defined as “suffering, bodily or mental harm
or illness and deaths that could have been avoided if adequate mea-
sures had been taken at the patient contact with the healthcare sys-
tem”. The definition was read to the nurses at the beginning of the
interview and a printed definition was placed on the table during the
interview so that the respondents could read it.

The questions were pilot tested in one test interview, not anal-
ysed. The test interview indicated that the questions were generic
enough to be used in different healthcare contexts and that the word-
ing was clear. The interviews were conducted by KS, CE and JS and
were digitally recorded using a Dictaphone. Interviews were held
during regular working hours to facilitate involvement. Each interview
lasted between 18–53 min. The interviews were transcribed verbally
by a firm specialized in transcription. The researchers checked the
transcripts and removed statements that could reveal the identity of
the informant.

Before starting the interviews, the participants were asked to re-
read the information letter and give their written informed consent
to participate. Each interview started with an open question asking
the participants to describe their thoughts on how patients can in-
fluence patient safety. The questions were open ended to stimulate
narratives of the participants’ own experiences. During the inter-
views, probing questions were asked, for example: “what do you
mean?” and “can you explain this a little further?” to deepen or clarify
the descriptions or drawing the attention back to the topic (Kvale &
Brinkman, 2009).

2.5 | Data analysis

Data were analysed using content analysis. We followed the analyti-
cal procedure for conventional content analysis as detailed by Hsieh
and Shannon (2005). The analysis was data driven and based on the
participants’ unique perspectives rather than guided by a pre- defined
theory or hypothesis. Investigator triangulation was used to validate
the findings. All researchers read and re- read the transcripts to gain a
sense of the content and an overview of the whole material. With the
aim of the study in mind, the researchers highlighted text and made
notes and headings in the margins to include all aspects of the content.
Initial thoughts and impressions regarding the material were written
down. No pre- defined structures were used as the codes were derived
from the data to capture key concepts. Codes that were related to
each other were grouped and organized into subcategories and cat-
egories. This process was iterative, going back and forth checking the
codes against the whole material. The subcategories and categories
were subsequently compared for differences and similarities, with the
aim of being as internally homogeneous and as externally heterogene-
ous as possible.

     |  233SKAGERSTRÖM ET Al.

2.6 | Rigour

Credibility in the data analysis was strengthened by the fact that the
initial coding of the data was performed by several researchers inde-
pendently (JS, CE and KS). The classification of categories and subcat-
egories was then discussed by two researchers (JS and CE). After they
reached consensus, the classification was discussed by all the authors
and adjustments were made until all were satisfied. The multidisci-
plinary research team allowed different perspectives on the issue of
patient involvement in relation to patient safety. The team consisted
of a nurse with experience in clinical patient work as well as work with
miscellaneous patient safety issues (KS), a public health researcher
(JS), a behavioural science practitioner working with organizational
development and experience in developing and implementing patient
involvement policies (CE), a nurse experienced in qualitative methods,
patient involvement and system safety issues (ME) and an experi-
enced implementation and patient safety researcher (PN).

2.7 | Ethical considerations

The study was performed according to the World Medical Association
Declaration of Helsinki ethical principles for medical research involving

human subjects. All the participants gave their consent to participate
in the interviews. The study did not require ethical approval because it
did not involve sensitive personal information, as specified in Swedish
law regulating ethical approval for research concerning humans (SFS,
2003).

3  | FINDINGS

Interviews were conducted with 19 nurses, of which 11 were regis-
tered nurses and 8 were nurse assistants. They were employed in five
different work units: (i) pulmonary medical unit in a university hos-
pital (550 beds); (ii) surgery unit in a mid- sized hospital (350 beds),
(iii) ear, nose and throat unit in a mid- sized hospital (500 beds); (iv)
one maternity care unit (outpatient care); and (v) one nursing home
(18 residents). Table 1 provides information on the participants. The
interviews were carried out from May 2015 – February 2016 at the
participants’ work units.

Analysis of the data yielded four categories related to patient
involvement for enhanced patient safety: healthcare professionals’
ways of influencing patient involvement for safer care; patients’ ways
of influencing patient involvement for safer care; barriers to patient
involvement for safer care; and relevance of patient involvement for
safer care (Table 2).

3.1 | Healthcare professionals’ initiatives to achieve
patient involvement for safer care

The nurses expressed that there were a few ways they and other
healthcare professionals can influence patient involvement of po-
tential relevance for patient safety. They believed that they could
facilitate patient involvement by ensuring favourable conditions for
dialogue with the patients, making sure that information is received
and understood by the patients and creating a trustful relationship
with the patients.

3.1.1 | Dialogue

The nurses described that they can facilitate patient involvement by
providing conditions that are conducive to this involvement, including
taking sufficient time to listen to patients and inviting them to ask
questions and be active in the dialogue. Specific ways of achieving this
included telling the patients that they are happy to answer any ques-
tions they might have, informing the patients that there will be time
for their questions or concerns at the end of the consultation (after
finishing medical examinations) and encouraging the patients to share
their opinions regarding the health care:

Instead you have to be inviting and show a friendly re-
sponse, encourage conversation and dialogue. You have to
make sure it doesn’t become a monologue, where you just
sit and talk without… We, the staff, must encourage them
to ask questions and to become involved. Participant 24

TABLE  1 Participant characteristics

Characteristics
Registered
nurses (n = 11)

Nurse assistants
(n = 8)

Sex, n(%)

Male 0 (0) 0 (0)

Female 11 (100) 8 (100)

Years of practice, n(%):

0–1 years 0 (0) 0 (0)

2–4 years 1 (9) 2 (25)

5–9 years 1 (9) 0 (0)

10–20 years 7 (64) 2 (25)

21 years or more 2 (18) 4 (50)

Median years of practice, years 16 22

Years in the work unit, n(%)

0–1 years 3 (27) 0 (0)

2–4 years 2 (18) 2 (25)

5–9 years 3 (27) 1 (13)

10–20 years 3 (27) 2 (25)

21 years or more 0 (0) 3 (38)

Median years in the work
unit, years

5 10

Work unit, n(%):

Pulmonary medicine unit 2 (18) 2 (25)

Surgical ward 2 (18) 2 (25)

Ear, nose and throat clinic 3 (27) 0 (0)

Maternity care centre 4 (36) 0 (0)

Nursing home 0 (0) 4 (50)

234  |     SKAGERSTRÖM ET Al.

Some nurses mentioned that it is important to adapt to each individ-
ual patient they meet. It is especially important to be observant and take
in facial expressions with patients who are unable to express themselves
verbally.

3.1.2 | Information

The nurses expressed that they can influence the patients’ poten-
tial to be involved in their care by making sure that the patients
receive and understand information provided to them. The informa-
tion should be given in a language that can be understood by the
patients and without medical terms that may be unfamiliar to the
patients. The nurses mentioned that the patients’ abilities to assimi-
late information vary considerably and it may be necessary to repeat
information at several time points. Patients with new diagnoses or
treatments, patients with fatigue and patients discharged after a
longer stay in hospital were all mentioned as groups that could ben-
efit from repeated information:

Sometimes I think you could ask…”Do you think you got
the information you needed, did you understand it?” or
something like that, so it’s not too much [information].
Participant 23

3.1.3 | Trustful relationship

The importance of a trustful relationship between the healthcare pro-
fessional and patient to make the patients feel comfortable raising
any concerns was made clear in the interviews. Although the nurses
believed that the provider and patient have a shared concern for cre-
ating this relationship, the nurses argued that the ultimate responsibil-
ity to facilitate a trustful provider- patient relationship rested with the
providers of health care.

The importance of building a trustful relationship was primarily
mentioned by nurses working in specialties which patients visit sev-
eral times. Continuity of healthcare staff to ensure that the patient
can meet the same professionals over time was mentioned as a factor
that influenced the opportunity to establish a trusting relationship.
The presence of a specific contact person to whom the patient could

turn with their thoughts or questions was believed to enhance the pa-
tients’ confidence to engage in issues of potential relevance for patient
safety.

Specific personal behaviours such as being empathic and humble
as well as the ability to facilitate an open climate and allow sufficient
time were seen as important to build a trustful relationship:

Yes, you have to be open, responsive in order for them [the
patients] to open up. You can’t just walk in and be really
tough…that’s not going to make it easy to open up if you
have problems. Participant 16

3.2 | Patients’ initiatives to achieve patient
involvement for safer care

The nurses’ perceptions about what the patients can do differed
somewhat depending on the healthcare context and what types
of patients they typically meet. However, in general, nurses con-
veyed that the patients can assume responsibility for their health
and treatment and be active in communication with healthcare
professionals.

3.2.1 | Assuming responsibility for one’s
treatment and care

The nurses expressed that the patients can participate in their care
and enhance patient safety by taking an active interest in their health
and treatment. The interest could be manifested as searching for in-
formation or actively reading information. Further, using and asking
for medical aids such as rollators, reading user manuals for medical
devices used in home care or watching out for complications or abnor-
malities when in treatment were provided as examples of responsible
patient actions to increase patient safety:

They [the patients] could get more involved in… to make
sure things aren’t forgotten, because we have a lot of dif-
ferent hoses and drainage, venous catheters and things
like that, where they could help and be observant to pre-
vent infections. Participant 4

Category Subcategory

Health care professionals’
initiatives to achieve patient
involvement for safer care

Dialogue
Information
Trustful relationship

Patients’ initiatives to achieve
patient involvement for safer
care

Assuming responsibility for one’s health and treatment
Being active in communication with healthcare professionals

Interaction between healthcare
professionals and patients to
achieve patient involvement
for safer care

Patients’ hesitancy to interact
Constraints related to the healthcare system
Healthcare professionals’ ambivalent feelings

Relevance of patient involve-
ment for safer care

Patients receiving personal benefits
Safer care

TABLE  2 Categories and subcategories

     |  235SKAGERSTRÖM ET Al.

3.2.2 | Being active in communication with
healthcare professionals

Nurses stated that patients who are active in dialogue with healthcare
professionals can improve patient safety. Writing down questions and
thoughts or bringing a relative to appointments were tips for patients
to prepare for communication with the professionals. Also, the nurses
stated that the patients could be active by attending regular check-
ups, reminding staff about return visits or treatments and reporting
any side effects:

They [the patients] have to tell us about, for example, side
effects and things like that, that’s nothing we can see our-
selves. So, if I don’t get that feedback, they might get med-
ications that don’t make them feel so good. Participant 3

Sharing detailed information about their medical conditions, hered-
ity and side effects was viewed as important because this could help the
healthcare professionals to understand the patients’ symptoms and health-
care needs and reduce the risk of important aspects being neglected:

Well, how it feels and… how they understand the situa-
tion, both physically and mentally, how they describe an
ailment, how detailed they are… can actually make me re-
consider and think otherwise. Participant 21

3.3 | Interaction between healthcare
professionals and patients to achieve patient
involvement for safer care

The nurses were generally in favour of patient involvement and be-
lieved that it could lead to improved patient safety. However, they
identified numerous potential problems and disadvantages associated
with patient involvement, including problems relating to the patients’
lack of will and ability to participate, constraints related to the health-
care system and healthcare professionals’ ambivalent feelings con-
cerning patient involvement.

3.3.1 | Patients’ hesitancy to interact

The nurses described that there are many obstacles to patients being
active and participating in their care. They argued that some patients
are unwilling to question healthcare professionals because they view
them as authorities and reason that they, the doctor in particular,
know what is best for them. Nurses believed that some patients might
refrain from offering criticisms for fear of receiving suboptimal treat-
ment or care. Patients who perceive that the healthcare professionals
are stressed are unwilling to ask questions or start a dialogue because
they feel that they might disturb or interrupt more important tasks:

When we seem stressed, they [the patients] feel they
should not ask that simple question. You often hear that “I
won’t bother you [the staff] about this”. Participant 1

For some patients, participating in their treatment or care is hindered
by health problems, difficulties with understanding, language problems
or feeling uncomfortable with disclosing sensitive issues.

3.3.2 | Constraints related to the healthcare system

Several factors in the healthcare system were brought up by the
nurses as hindering patient involvement to achieve safer care. Lack
of privacy was a problem mentioned by nurses working in clinical
wards where patients often share rooms. Shortage of the healthcare
professionals’ time was another limitation for patient involvement.
Appointments are sometimes just long enough for physical examina-
tions but leave little time for dialogue or questions from the patients.
The nurses thought that problems with availability and staff disconti-
nuity can lead to disenchantment for the patients. Further, the pos-
sibility of building trustful relationships is decreased:

Temporary doctors mean that they [the patients] won’t
meet the same [doctor] next time and then they [the
patients] say, “It’s no use asking.” You often hear that.
Participant 12

3.3.3 | Healthcare professionals’ ambivalent feelings

The nurses described a range of feelings towards active patients who
are informed and may ask more critical questions. By and large, the
nurses were pleased to learn from the patients. If they made a mistake,
they were grateful that someone pointed it out to them, although the
mistake itself could make them ashamed. Some informed and active
patients could make the nurses feel incompetent or question their
profession. Some nurses expressed concern that patients who ques-
tion a great deal or want detailed information can take too much time:

They [the patients] have too little knowledge. At the same
time, they want to be involved, which requires a lot… a sort
of pedagogical responsibility rests with me that demands a
lot [of time and energy]. Participant 21

3.4 | Relevance of patient involvement for safer care

This category concerns the nurses’ perceptions of the “results” of pa-
tient involvement. Some of the nurses could not think of any example
where a patient had recognized or reported something relevant for
patient safety. They described situations where the patients’ involve-
ment had not directly affected patient safety but had led to positive
effects for the patients. Others shared examples of varying relevance
for patient safety, for example, how patients’ involvement had directly
prevented a mistake or eliminated potential patient safety hazards.

3.4.1 | Patients receiving personal benefits

The nurses believed that patients who were active and questioned as-
pects of their treatment or care, such as long waiting times or outdated

236  |     SKAGERSTRÖM ET Al.

medical aids, could gain advantages compared with patients who did
not raise any complaints or concerns. Advantages such as getting help
quicker, shorter waiting times for medical examinations or receiving a
more modern type of medical aid were brought up in the interviews:

If you’re active as a patient and ask when you can get an
appointment that could definitely shorten the waiting time
compared with if you remain quiet and wait. Participant 8

3.4.2 | Safer care

Several nurses shared examples of situations when involvement by
patients led to improvements in patient safety. The examples included
patients reminding about allergies, asking for aids to avoid fall injuries,
observing defects in medical devices and asking about referrals that
their healthcare provider had forgotten about:

There was one [patient] with coeliac disease who almost
ate food that she should certainly not have. And, of course
it was [detected] because she asked, “Is this really gluten-
free?” Participant 9

Another example of indirect patient involvement was when the
nurses themselves thought of some hazard, such as giving a patient a
double dose of medication and asked the patient to verify whether the
mistake had been made or not. Although the patients did not notice
the error themselves, they could participate by confirming the nurses’
suspicions.

4  | DISCUSSION

The aim of this study was to explore nurses’ perceptions and experi-
ences with regard to patient involvement of potential relevance for
patient safety. The study contributes to the research field by address-
ing the nurses’ perspective in contrast to much previous work that
has concerned patient views. Further, the study provides insights
into how patient involvement for safer care can be achieved in the
provider- patient interaction. In general, the nurses expressed positive
attitudes to patient involvement and believed it could have a posi-
tive impact on patient safety. However, patient involvement does not
occur by itself. Rather, both patients and healthcare professionals
must take responsibility if patient involvement for safer care is going
to be realized.

The nurses in our study emphasized the importance of their own
initiatives to achieve patient involvement. They stated that healthcare
professionals can facilitate this involvement by initiating dialogue and
inviting the patients to ask questions. Our findings are consistent with
previous research from the patient perspective, which has shown
the importance of healthcare professionals encouraging patients to
speak their opinion (Davis, Koutantji, & Vincent, 2008; Entwistle et al.,
2010; Rainey, Ehrich, Mackintosh, & Sandall, 2015). It has been sug-
gested that patients, due to imbalance of power and health literacy,

are unwilling to speak their mind if they fear negative or judgemental
reactions from the providers, or being ignored or not taken seriously
(Davis, Sevdalis, Jacklin, & Vincent, 2012). This is supported by our
findings from the nurses’ viewpoint, because the nurses highlighted
the relevance of building a trustful relationship with the patient by
actively listen to them and encourage them to express opinions and
ask questions.

Further, the nurses pointed to the importance of providing indi-
vidualized information to the patients. In a previous Swedish study
examining facilitators and barriers to patient safety, nurses expressed
that providing well- structured information to patients is a facilita-
tor for patient safety (Ridelberg et al., 2014). Further, research from
the patient perspective has highlighted the value of patients under-
standing of information for them to participate in their care and to
make informed decisions (Davis et al., 2012; Eldh, Ehnfors, & Ekman,
2006; Longtin et al., 2010). Patients who have been comprehensively
informed are also more likely to feel confident and trust their own
decisions (Forsyth, Maddock, Iedema, & Lessere, 2010; Longtin et al.,
2010). Provision of appropriate and sufficient information in a sup-
portive environment are key points in patient involvement (Larsson,
Sahlsten, Sjostrom, Lindencrona, & Plos, 2007). Patients who have
access to information on their health and care are more willing and
able to be involved in safety issues (Forsyth et al., 2010; Iedema et al.,
2012). It is likely that patients who receive adequate information be-
come more knowledgeable about what to expect from nursing ac-
tivities, treatment and care, which enables them to detect potential
deviations of relevance for patient safety.

The hindering factors associated with patient involvement for
safer care that we found in this study are largely consistent with the
barriers identified in research on patient involvement from the pa-
tient perspective (Howe, 2006; Iedema et al., 2012; Larsson, Sahlsten,
Segesten, & Plos, 2011). With regard to shared decision making in
health care, Joseph- Williams, Elwyn, and Edwards (2014) concluded
in a systematic review that patients’ participation depends on their
knowledge (about the condition, options for care, outcomes and per-
sonal preferences) and power, that is, perceived influence on decision
making. The two factors, knowledge and power, are in turn influenced
by interpersonal patient- provider factors, patient characteristics, trust
and time allocated for discussions. Assessing nurses’ opinions of fac-
tors influencing patient safety in general, Ridelberg et al. (2014) found
factors relating to both patient interactions and healthcare providers
skills and feelings to be potential barriers for patient safety.

It has been suggested that nurses believe patients lack sufficient
medical knowledge, making it necessary for nurses to retain power
and control (Henderson, 2003). Grimen (2009) has highlighted the in-
terconnection between power and trust, arguing that many healthcare
professionals fail to recognize the power associated with professional
autonomy, which makes equal dialogue between patients and health-
care professionals unrealistic; patients are in an inferior position vis
à vis healthcare professionals. Hence, being a patient is to trust that
professionals know what they are doing and to temporary delegate
power to them. On the other hand, knowledge and power is a two-
edged sword, which if used wisely in a patient- provider encounter, can

     |  237SKAGERSTRÖM ET Al.

foster mutual respect for the knowledge possessed by both patients
and healthcare professionals (Eldh, Ekman, & Ehnfors, 2010).

Ignorance of this provider- patient power imbalance could make
nurses resistant to patient involvement because they do not believe in
and inform themselves about the patients’ opportunities to make in-
formed contributions. This in turn contributes to creating a culture of
professional defensiveness towards patient involvement (Henderson,
2003; Howe, 2006). Some nurses in this study mentioned that active
patients can be time consuming and that too much time is wasted on
explaining irrelevant matters to the patients. Communication with pa-
tients cannot always be prioritized, because nurses also need to focus
on taking care of risk situations and complete tasks (Tobiano, Marshall,
Bucknall, & Chaboyer, 2016). As pointed out by Ekdahl, Hellström,
Andersson, and Friedrichsen (2012), the remuneration system used in
Swedish health care favours treating a large number of patients, which
leads to time restrictions and insufficient time for many patients.
Time barriers exist not only in Sweden. In a study on patient involve-
ment conducted in 15 European countries, time spent with patients
and communications were perceived as the most important areas for
improvement of patient involvement (European Commission, 2012).
Organizational factors such as time constraints (Bolster & Manias,
2010; Entwistle et al., 2010) and lack of continuity in care (Unruh &
Pratt, 2007) have previously been suggested to have a negative im-
pact on patients’ active involvement in safety work. For individual
healthcare professionals to be able to invite patients to be involved in
their care, as suggested by the nurses in our study, requires a shift in
the healthcare system to allow more time for conversations with each
patient. Our study also pointed to the relevance of the nurses’ am-
bivalent feelings towards patient involvement. Perceiving that one’s
professionalism is questioned could hinder providers from actively in-
volving patients in some situations.

4.1 | Limitations

This study has several shortcomings that must be considered when
interpreting the results. The recruitment strategy could have led to
a bias towards participation by nurses who were more interested in
patient involvement and/or patient safety issues. The importance of
patient involvement has recently been highlighted in Sweden. This
might have led to the participants providing more positive answers
in the interviews because they want to provide responses that are
somehow politically correct. On the other hand, the interview guide
was constructed to give the responders the opportunity to answer in
general terms rather than revealing their personal opinions.

Nineteen individual interviews with registered nurses and nurse
assistants working in different types of healthcare settings were con-
ducted. Various ages, work experience and types of patients contrib-
ute to a large variation in the sample. This heterogeneity increases
the possibility of viewing patient involvement for improved patient
safety from different angles, which can be considered a strength in the
study. Inclusion of male nurses in the sample would have increased
the heterogeneity further. However, the lack of male participants was
deemed acceptable since 88% of registered nurses and 84% of nurse

assistants working in Swedish health care are female (SALAR, 2015).
Transparency was sought by describing the sampling procedure and
data analyses in detail.

During the interviews and data analysis, it became evident that the
nurses did not always share our definition of patient safety. Although
the official definition of patient safety was read to the participants at
the beginning of the interview, they tended to interpret the concept
more broadly to encompass various aspects of health care in general.
This was especially common among the nurse assistants; they pro-
vided examples that had more to do with regular health care provision
than with patient safety as defined. We found this interesting and did
not want to interrupt to impede the nurses’ willingness to tell stories
they found important. However, our findings primarily relate to vari-
ous aspects of patient safety, as defined in this study.

5  | CONCLUSIONS

We found that nurses are in general positive to patient involvement
and believe it can contribute to increased patient safety. The nurses
believe that they can influence patient involvement and that they
have a responsibility to do so, but that the patients are responsible
for being active in meetings with healthcare professionals. Patient
involvement also depends on a well- functioning provider- patient in-
teraction. The finding also suggest that healthcare professionals need
support from the healthcare system to achieve patient involvement of
relevance for patient safety.

ACKNOWLEDGEMENTS

The authors thank all registered nurses and nurse assistants who par-
ticipated in the interviews.

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interests.

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How to cite this article: Skagerström J, Ericsson C, Nilsen P,
Ekstedt M, Schildmeijer K. Patient involvement for improved
patient safety: A qualitative study of nurses’ perceptions and
experiences. Nursing Open. 2017;4:230–239. https://doi.org/
10.1002/nop2.89