A qualitative study on Iranian nurses’ experiences and perspectives on how to provide safe care in clinical practice

Abstract

Nurses are the healthcare providers who are well positioned to strengthen patient safety through providing safe care in clinical practice. The purpose of this study was to explore and describe the experiences and perspectives of Iranian nurses in relation to how to provide safe care in clinical practice. A qualitative design by using a content analysis approach was applied for the data gathering and analysis. After employing a purposive sampling to choose 16 bachelor’s degree nurses working in the medical and surgical wards of a referral teaching hospital in an urban area of Iran, semi-structured interviews were conducted to collect data. During the data analysis, three main themes emerged: ‘providing safe care as the patient’s right’, with the subthemes: ‘feeling a personal commitment’ and ‘incorporating patients’ feelings of safety into providing safe care’, ‘encouraging reciprocal accountability in healthcare professionals’ and ‘leadership commitment to safe care’. The findings suggest that educators should provide more information during nurses’ education to focus on the moral duty to provide safe care. In addition, the provision of safe care needs the commitment and collaboration of all healthcare professionals, as well as the leadership of nursing for removing obstacles to nurses’ efforts to making the healthcare system safer.

Keywords

Content analysis Iran nurses’ perspectives patient safety providing safe care qualitative research

Introduction

Patient safety indicates the degree to which care does not exert a negative impact on patient health (Teng et al., 2009; WHO, 2011a). While healthcare has become more effective, it has also become more complex, with greater use of new technologies, medicines and treatments (Alfredsdottir and Bjornsdottir, 2008; WHO, 2011a). Therefore, safety risks such as medication errors, patients falling down, infection transmission and bedsores are ever-present, and patients suffer or die as a consequence of their treatment and of flawed hospital systems (Reid and Catchpole, 2011).

Worldwide burden of patient safety issues

A recent report by the Centers for Disease Control and Prevention (CDC) in the US announced that at any given time, approximately 1 in 20 patients have an infection related to his/her hospital care. These infections cost the healthcare system billions of dollars and lead to the loss of tens of thousands of lives every year (CDC, 2011). In developing countries, the probability of patients being harmed in a hospital is higher than in industrialised nations. The risk of a healthcare-associated infection in some developing countries is as much as 20 times higher than in developed countries (WHO, 2011b). For instance, the results of a recent Latin American study of adverse events highlighted that on any given day, 10% of the patients admitted to the participating hospitals were suffering from or were undergoing treatment for a hospital-related adverse event. This risk doubled when taking into account the entire patient’s stay at the hospital, with 20% of inpatients experiencing at least one harmful incident. More than half of them could have been avoided (ICN, 2011).

With overcrowded healthcare settings, nursing shortages and a ratio of nurse per hospital bed between 0.5 and 0.8 (Nurse’s House, 2011), it can be predicted that the probability of patients being harmed in Iranian hospitals is similar to that of other developing countries. There is not yet classified and published data in terms of the level of patient safety in the Iranian healthcare system. This is because of the hidden nature of healthcare professionals’ mistakes, in addition to the prevalent underreporting of incidents, even by nurses who are widely acknowledged as a group that reports incidents more regularly than other healthcare professionals (Kingestone et al., 2004). Nevertheless, the Iranian Medical Organisation (IMO) sometimes publishes reports about healthcare practice errors without making explicit distinctions between the share of medical, nursing and other disciplines in reducing the level of patient safety. According to the latest report by the IMO (2008), patients or their families registered approximately 2258 complaints against healthcare professionals in only one year in relation to the practical errors of medical and allied professionals. It has been claimed that in the presence of a precise registration system, the actual number of the complaints is even higher since it is true that for every four verbal complaints, only one written complaint is registered, whereas four instances of dissatisfaction emerge when only one verbal complaint is given (IMO, 2008).

It is worth noting that the burden of patient safety issues cannot only be depicted in terms of costs on healthcare systems and the number of patients who die each year. In other words, healthcare systems and their workers, as well as patients’ families, pay a high price for problems in patient safety from an economic, moral and ethical perspective, which may lead to an erosion of trust as well as the disengagement and dissatisfaction of healthcare professionals (Eriksson, 2002; Warburton, 2009; Sherwood, 2011). As an ongoing challenge in the design and delivery of healthcare services, patient safety has become an important indicator in the performance of a healthcare system (Ramanujam et al., 2008; Künzle et al., 2010). In this regard, more pressure has been created over the past decade for healthcare settings to focus on this important phenomenon (Wachter, 2010).

Providing safe care in clinical practice

Safe care is defined as the employment of knowledge and skills by nurses for providing high quality care, which at the same time reduces the probability of any sort of patient harm during hospitalisation (Vaismoradi et al., 2011a, 2011b). Nurses account for a large majority of the healthcare workforce (Bartley, 2011), while coordinating and providing care 24 hours a day, seven days a week. When facing today’s healthcare system challenges, nurses are well positioned in the delivery of both ‘safe care’ and the eradication of errors that result in patient harm (Weingart et al., 2005; Butterworth et al., 2011). For instance, Fordyce et al. (2003) found that 400 nurses in the US reported making practice errors during a seven-day study period. Balas et al. (2004) also reported that 119 (30%) of study nurses in the US reported making at least one error, while 127 nurses (33%) reported at least one near error, thus totalling 199 actual errors and 213 near errors during the 28-day data collection period. In 2006, Balas et al. (2006) again in the US found that during the same collection period over one-quarter of the participants (502 critical care nurses) reported making an error, while more than one-third reported catching themselves making an error. Moreover, there were 224 actual errors and 350 near misses reported during the study period. According to a study conducted in South Korea, 85 nurses reported 328 medication administration errors, including 259 actual errors and 69 near misses (Sheu et al., 2009). In a second similar study in South Korea, of the 2358 nurses contacted, 19% reported having made at least one error in the previous year (Hwang and Hwang, 2011). Thus, the nurses’ role in providing safe care should be taken seriously and emphasised, and nurses’ collaboration must be one part of the approach towards the goal of a safe healthcare system (CNA, 2009).

Additionally, nurses’ perspectives can be used in developing appropriate theories to provide specific guidance for healthcare managers and other healthcare professionals in assessing and facilitating safe care in both developed and developing countries (Feng et al., 2008; Richardson and Storr, 2010; International Council of Nurses, 2010). The role of nurses in ensuring ‘patient safety’ through ‘providing safe care’ should be addressed in different cultures and contexts before comprehensive approaches for identifying effective solutions and improving patient safety can be further developed (Attree et al., 2008; Donaldson, 2009; Richardson and Storr, 2010). There were no previous studies on the role of Iranian nurses in providing safe care.

Aim

The aim of this study was to explore and describe the experiences and perspectives of Iranian nurses about how to provide safe care in a clinical practice within an Iranian culture and context.

Methods

The qualitative methodology has been introduced for exploring the cultural and contextual aspects of complex phenomena encountered and lived by healthcare providers within the healthcare system (Holloway and Todres, 2003; Tong et al., 2007). As a qualitative descriptive approach, content analysis was used for making replicable and valid inferences about providing safe care to the contexts of their use. Describing the phenomenon of providing safe care from a nurse’s perspective was the reason for choosing a content analysis approach in the present study (Krippendorff, 2004).

Participants

Since the prevalence of nursing errors is higher in medical and surgical wards of teaching hospitals (Sheu et al., 2009), 16 bachelor’s degree nurses working in the medical and surgical wards (general surgery, urological surgery, orthopaedic surgery, neurosurgery, internal and cardiac) of a referral teaching hospital in an urban area of Iran were chosen through the use of purposive sampling. The first author entered each ward and, after mentioning the study’s aim, invited the potential participants and scheduled an interview date with the willing nurses. The reason that the nurses were selected from different medical and surgical wards was to capture a range of perspectives (Coyne, 1997). The participants were all female, had a mean age of 33.68 years (SD = 4.43 years) and a range of work experience between 1 to 15 years (Mean = 9.94, SD = 3.94).

Data collection

For the purposes of this study, the first author conducted semi-structured interviews in Persian language, and they were then translated into English. As a bilingual translator, one of the co-authors supervised and corroborated the translation process. On average, each interview lasted between 30 and 50 minutes, with the interview questions being:

How do you provide safe care in clinical practice?

What are your experiences on providing safe care in clinical practice?

How will clinical nurses be able to provide safe care?

Moreover, probing questions were asked to elaborate on the nurses’ perspectives as well as increase the depth of the interviews. The data collection and analysis proceeded concurrently, and the interviews were discontinued once the themes were identified and data saturation was achieved (Elo and Kyngäs, 2008).

Ethical considerations

The Research Council and the Ethics Committee affiliated to the Tehran University of Medical Sciences approved the study and corroborated its ethical considerations. All the participants were informed about the purpose and voluntary nature of participating in the study, and permission to tape-record the interviews was obtained. Additionally, they were reassured that their responses would be confidential and that their identities would not be revealed in the publication of the study. Lastly, those who agreed to participate provided their written consent (Lee et al., 2008).

Data analysis

Drawing on the work of Graneheim and Lundman (2004), the researchers transcribed the gathered data verbatim and read them several times to obtain a sense of the whole. They divided the text into meaning units and after condensing and abstracting them, labelled them with codes. Through comparing the codes in terms of their similarities and differences, the researchers sorted the codes into subthemes. Lastly, they formulated themes as the expression of the latent content of the text.

Rigour

The researchers first analysed the data independently and then compared the codes and themes. Whenever they reached a disagreement, discussions and clarifications were continued until a consensus was achieved. In addition, a summary of the interviews was returned to the participants to be checked, hence confirming that the researcher was representing their perspectives (Graneheim and Lundman, 2004). Furthermore, in order to assess the plausibility of the findings, an audit trail was provided that enabled to determine if the analytical comments, or claims, made by the researchers were justifiable (Horsburgh, 2003).

Results

During the data analysis, three main themes emerged: ‘providing safe care as the patient’s right’, with the subthemes: ‘feeling a personal commitment’ and ‘incorporating patients’ feelings of safety into providing safe care’, ‘encouraging reciprocal accountability in healthcare professionals’ and ‘leadership commitment to safe care’. Table 1 summarises the themes and information about the meaning of each theme. The following interpretations and direct quotations from the participants also describe the meaning of each theme.

Table 1.

A summary of themes/subthemes and their meanings about how nurses provide safe care in clinical practice

Providing safe care in clinical practice
Themes	Subthemes	Meanings
Providing safe care as the patient’s right	Feeling personal commitment	Internalise the culture for providing safe care; Practising based on humanistic and ethical values; Considering nursing practice beyond routine and mechanical daily activities.
Providing safe care as the patient’s right	Incorporating patients’ feelings of safety into providing safe care	Considering that providing safe care goes beyond not doing harm or preventing practice errors; Supporting the patient against anything that reduces his/her feelings of safety; Informing the patient about his/her therapeutic plan and the consequences of his/her treatment; Disclosing the mistake to the patient and healthcare team members; Supporting the patient against the complications of the therapeutic plan;
Providing education to the patient; Respecting the patient’s privacy right.
Encouraging reciprocal accountability in healthcare professionals	—	Attracting the collaboration of other healthcare members; Informing healthcare members about the impact of their activities on providing safe care; Improving the professional communication between physicians and nurses; Checking other clinicians’ activities in relation to their impacts on providing safe care; Not interfering in nurses’ interventions.
Leadership commitment to safe care	—	Improving the work condition for nurses; Removing organisational obstacles to providing safe care; Improving the staffing pattern, organising and division of labour; Reducing work pressure; Providing education about, and giving a priority to, providing safe care; Bringing order to the volunteer support of the patient’s companion.

Providing safe care as the patient’s right

The participants believed that it was the patient’s right to be provided with safe care and be protected against practice errors. As subthemes, ‘feeling a personal commitment’ and ‘incorporating patients’ feelings of safety into providing safe care highlighted how the participants managed to provide safe care.

Feeling a personal commitment

Considering providing safe care, the patient’s right helped the nurses internalise the culture for providing safe care in clinical practice. Through this approach, nurses would feel a personal commitment and duty to provide patients with safe care. The internal motivation and personal commitment of nurses to safe care were mentioned as being crucial to the provision of safe care in practice, which meant that if this commitment was not instilled in and brought up in nurses by the nurses themselves, the healthcare system’s strategies and programmes for ensuring the provision of safe care would not be completely effective.

It is the patient’s right to receive high quality and safe care (medical ward).

It should be conveyed to nurses that providing safe care is an undeniable right of patients. It creates a feeling of duty in the nurses not to do harm in nursing interventions and prevent from practice errors (surgical ward).

It [providing safe care] is something related to nurses’ own commitment to safe nursing practice. They should feel it and behave based on the commitment (surgical ward).

Humanistic and ethical values such as respecting patients’ values, as well as advocating and protecting patients against hazards inherited from Persian culture and context inspired the nurses to provide safe care. In other words, practising these values was pivotal in creating the required motivation and commitment in the nurses to provide safe care. Accordingly, the nurses believed that their nursing practice was beyond routine and mechanical daily activities, and consisted of something more related to a moral duty to help those in need.

Nursing interventions should not be mechanical, but should instead be mixed with ethical and humanistic values. This approach guarantees providing safe care and may prevent practice errors (medical ward).

In order to provide safe care, I [nurse] deliver my care to him/her with passion. For example, I stay beside the patient in critical conditions, talk to him/her and assure him/her that I will do my best to help him/her (medical ward).

Incorporating patients’ feelings of safety into providing safe care

The participants stated that according to their work experiences, providing safe care was beyond its common definition of not doing harm or preventing practice errors. Therefore, it is the patient’s right to be supported during their hospitalisation against anything that may reduce his/her feelings of safety. Hence, providing safe care would be accomplished if the nurses directed their practice towards considering the patient’s feeling of safety in nursing practice.

As one part of providing safe care, informing the patient about his/her therapeutic plan and the consequences of his/her treatment was declared to be important in preserving a feeling of safety in the patients.

We had a patient hospitalised in this ward because of a tracheotomy. He did not know anything about his therapeutic and care plans. He was completely confused by the situation, and was very scared (medical ward).

The patient needs to know what will happen to him/her and what will be done for him/her. The nurse improves the feeling of safety in the patient through providing the appropriate education to him/her (medical ward).

The nurses emphasised that they did their best to provide safe care, but if any sort of mistake was made by the nurses, the error needed to be disclosed to the patient in order to preserve the patient’s feeling of safety, in addition to healthcare team members to help reverse its consequences.

If I make a mistake, I will disclose it to the patient and my colleagues. Maybe something can be done. For example, an antidote can be administered to reverse the consequences of the error (medical ward).

Moreover, providing the patient with support against the complications of the therapeutic plan such as medication administration, environmental hazards and infection transmission during hospitalisation was in accordance with preserving his/her feelings of safety and providing safe care.

It is my [nurse’s] duty to stay beside the patient and check for any complications from medication therapy. If anything happens, I should inform the doctor and do the necessary interventions (surgical ward).

Nurses must be careful when they do nursing interventions. They may make mistakes during medication administration. Therefore, they should be vigilant and do their work with the utmost care (surgical ward).

Standard precautions on the transmission of infectious diseases should be strictly followed as part of the provision of safe care (surgical ward).

‘Not revealing the patient’s private information to others’ and ‘covering the exposed parts of the patient’s body especially in female patients’ were mentioned as having a great influence on preserving the feeling of safety in Iranian hospitalised patients.

Nurses should not reveal patients’ private information to other colleagues or other patients. If not, the feeling of safety may be endangered (medical ward).

When I do any kind of nursing intervention that may expose the patient’s body, and especially when the patient is a woman, I maintain the patient’s right to privacy and drape him/her as much as possible (medical ward).

Encouraging reciprocal accountability in healthcare professionals

The provision of safe care was stated to not be in the hands of the nurses alone. Healthcare team members were required to feel a commitment and collaborate with each other in order to provide safe care. The participating nurses said that healthcare team members should be informed that they are not only responsible for their own activities, but that they are also accountable for ascertaining that their activities do not hinder the nurses in providing safe care. Therefore, they should coordinate their activities with the nurses’ interventions.

As far as emphasising the influence of all the healthcare team members, the role of physicians was depicted as central through their orders, in addition to their professional communication with nurses. One example of this was the nurse needing information about the patient’s general condition to help plan nursing interventions, which was shared by the physician.

Nurses may make mistakes when the physician’s writing is illegible. Then, we [nurses] get confused and miss some important nursing interventions (medical ward).

The physician did not tell us [nurses] that the patient suffered from diabetes. Therefore, we were not informed that the patient should be cared for with this disease (medical ward).

Since nurses spend the most time with patients, checking other clinicians’ activities in relation to their impact on providing safe care was considered to be the nurses’ responsibility.

The core of patient safety and providing safe care is the nurse’s responsibility because the nurse is always beside the patient and spends the most time with him/her (surgical ward).

The nurse should be accountable for the activities of orderlies and nurse assistants. I should check that their activities do not endanger patient safety, for example when they want to transfer the patient to another ward (medical ward).

A lack of respect for the nurses’ work description, and the interference of assistant nurses or orderlies in nursing interventions, hindered nurses in providing safe care.

The orderly was not authorised to give information to the patient and his companions about his health issues. He interfered in the nurse’s work and gave wrong information and endangered the patient’s safety. We [nurses] spent a lot of time rectifying this misinterpretation (medical ward).

Leadership commitment to safe care

Nurse managers’ and leaders’ commitment to safe care has played a crucial role in empowering nurses to provide safe care and achieve the goal of a safer healthcare system. As a rule, nurses’ needed to feel safe in the workplace before they would be able to help patients feel safe. This means that obstacles to providing safe care, such as a lack of a suitable work environment, an inappropriate staffing pattern and division of labour, and knowledge deficits in nurses should be appropriately handled by the nurse leaders.

The nursing shortage and high-pressure work conditions hindered nurses in providing safe care. For instance, a heavy nurse workload, lots of paper work, working full-time or during night shifts and taking care of two critical patients at the same time were organisational obstacles to providing safe care that should be paid attention to by nursing leaders.

When I am working full-time or in the evening on a night shift, only a few nurses are available in the ward. Therefore, I spend a few minutes on each patient. I get tired and my concentration decreases. This results in making mistakes (medical ward).

When there is a lack of nurses in the ward and two patients need critical care at the same time, the safety of both the nurses and patients is endangered (medical ward).

The participants declared that they had not received an adequate education about providing safe care during their bachelor’s studies and that the healthcare system did not prioritise practical strategies and standards to guarantee the safety of care delivered to patients during their hospitalisation.

One of the causes of endangering patient safety is that some nurses are inexperienced or have not got enough knowledge, or there is not any providing safe care standards to guide nurses about how to provide safe care (surgical ward).

The nurse leader’s role to make the work environment suitable for nurses to provide safe care was claimed to be beyond simply organising the nursing staff. Because of a nursing shortage, the patients’ companions helped the nurses in the patient’s basic care, so the nurses could therefore spend their time on more important tasks related to providing safe care. However, the nurse leaders did not organise their volunteer help, and due to their frequent interruptions in, and interference with, nursing interventions, they hindered the nurses in providing safe care.

Patients’ companions crowd around patients. They talk to each other with loud voices, and sometime manipulate the monitoring machines. Therefore, the nurse’s concentration is lost and the nurses make mistakes (surgical ward).

Discussion

This study is the beginning of an exploration of providing safe care with Iranian nurses. The data analysis resulted in three main themes that indicated the cultural-contextual aspects of providing safe care in the Iranian healthcare system. Our study findings comply with Reason’s (2000) perspective about the management of practice errors that aim at different targets such as the person, the team, the task, the workplace and the institution as a whole. Our first theme, ‘providing safe care as the patient’s right’, describes active failures and the role of the individual person in the formation of errors, which needs to be considered in engineering the culture of providing safe care. The second and third themes, ‘encouraging reciprocal accountability in healthcare professionals’ and ‘leadership commitment to safe care’, introduce the latent causes (the team, the task and the workplace) that provoke the conditions within the workplace that create the possibility of accidents.

According to the first theme, considering providing safe care the patient’s right was the first step towards introducing the culture of providing safe care in clinical practice. This parallels the findings of an Iranian study conducted by Vaismoradi et al. (2011a) on nursing students’ perspectives of patient safety in that enacting the principles of patient safety in daily nursing practice, in addition to becoming better able to care for patients with a knowledgeable commitment, was deemed necessary for providing safe care.

It was found that the internal motivation and personal commitment of nurses were crucial to the provision of safe care in practice. From a general perspective, the level of personal control over practice directly affects nurses’ perception of the ability to assure patient well-being (Ramanujam et al., 2008; Brataas et al., 2009).

According to this study, the patient’s feeling of safety was a cultural-contextual aspect of providing safe care in Iranian nursing. It has been demonstrated that consideration should be given to caring for patients’ well-being and feelings during their hospitalisation in order to reduce their concerns and worries, as well as to attract their trust to healthcare providers (Vaismoradi et al., 2011b).

Informing patients of nursing and therapeutic care plans and relieving their stress about their consequences were considered important for preserving patients’ feelings of safety. A need for a patient-centred practice has been always emphasised in order to ensure providing safe care (Jeffs et al., 2008). Nurses are expected to provide information to patients when it is deemed to be appropriate (Brataas et al., 2009). In relation to this, the caregiver has to be able to establish a good rapport with the patient in order to avoid having the patient become confused and apprehensive during the implementation of the care plan (Anoosheh et al., 2009; Wångblad et al., 2009).

Supporting the patient against medication and therapeutic complications, and being informed about nursing practice errors, were other duties for nurses to preserve the patient’s feeling of safety and provide safe care. It is endorsed that clear policies on the reporting of adverse events, as well as on the disclosure of errors to the patient and the patient’s family, must be implemented to facilitate providing safe care within the healthcare system (Halbach and Sullivan, 2005; Pronovost et al., 2006; McDonald et al., 2010). Furthermore, patients have the right to receive appropriate treatment to address the effects and consequences of this event (CNA, 2009).

In this study, it was declared as the patient’s right to protect the patient against the complications of the therapeutic plan and environmental hazards in order to preserve the patient’s feeling of safety, as nurses are expected to be aware of the physical and psychological dangers posed by environmental factors to patients (Lankshear et al., 2008). In a similar finding in Sweden, Skyman et al. (2010) reported that patients ‘felt violated’ from having contracted an infection at the hospital because the staff did not use proper working methods to avoid transmission, thereby putting their health in danger.

Protecting patients against jeopardising their privacy, such as by not revealing the patient’s private information and covering the exposed parts of the patient’s body were both said to be in accordance with providing safe care. Bondas (2003, 2009) in her theory named as caritative leadership believes that a caring culture is described by trust, safety, supportive relations and flexibility and openness, which is assumed to influence the quality of care (Elf et al., 2007). In this regard, patients will feel safe when they are given assurances that their rights to privacy are being respected and that the information will not be disclosed (Vaismoradi et al., 2011a).

According to the second theme, other healthcare providers were also required to feel a commitment and collaborate with nurses in order to provide safe care. The importance of teams in providing safe care has been emphasised in international literature, and it has become apparent that significant improvements in providing safe care require that caregivers work together in teams (Alfredsdottir and Bjornsdottir, 2008; Leape, 2009).

Nurse–physician communication was also an important factor in terms of influencing the provision of safe care by nurses. Generally speaking, magnet hospitals are institutions that support professional nursing practice by ensuring strong nurse–physician relationships in order to improve the quality and safety of the care delivered to patients (Spence Laschinger and Leiter, 2006). It has been repeatedly stated that poor communication both among and between nurses and physicians has a direct correlation with patient outcomes, adverse events and stressors among healthcare professionals and patients. The barriers to an effective communication should be overcome through creating a premise for fostering communication and understanding each clinician’s information needs (Silén-Lipponen et al., 2005; Curtis et al., 2011; Vaismoradi et al., 2011c).

Nevertheless, the interference of other team members in nurses’ practice was an obstacle to providing safe care. The results from the quantitative portion of a survey conducted by Gran-Moravec and Hughes in the US (2005) indicated that nurses might not practice safely and efficiently due to task overlap and the interference of healthcare team members.

In the third theme, the role of nurse leaders was stated to be vital in helping nurses provide safe care, as unit staff and administration share a joint accountability in providing safe care (Spence Laschinger and Leiter, 2006). To transform our healthcare system, it is essential to have the support of leaders and managers at all levels in a wide variety of organisations (Henderson et al., 2006; Farquhar et al., 2007; Bondas, 2009).

It was reported that workplace issues such as nurses’ workload and working full-time/night shifts were obstacles to the provision of safe care that should be handled by nursing leaders. According to a qualitative study conducted by Silén-Lipponen et al. (2005) on the experiences of Finnish, American and British nurses about potential sources of errors, at the organisational level, the scheduling of work, good management and a reasonable physical environment, such as improving work conditions, will most likely facilitate providing safe care. Workplace improvements for building a safe healthcare system include less paperwork, working in part-time shifts, having a lighter workload and increasing nurse satisfaction with their work environment (Mastal et al., 2007; Stone et al., 2007; Anoosheh et al., 2008; Ramanujam et al., 2008; Vaismoradi et al., 2012).

A lack of knowledge by nurses, and having no standards and evidence-based care plans to provide safe care were other organisational barriers mentioned by the nurses. It is known that improving nurses’ knowledge and implementing evidenced-based care plans increase the quality of care and patient outcome (Anoosheh et al., 2008; Olsson et al., 2009). Clearly, to be safe and effective practitioners in today’s healthcare environment, nursing graduates need to internalise the critical competencies set forth by the Quality and Safety Education for Nurses (QSEN) initiative. Developing the QSEN initiative focuses on enhancing nursing curricula and fostering faculty development to support student achievement of quality and safety competencies (Cronenwett et al., 2009; Brown et al., 2010).

It was claimed that patients’ companions helped the nurses in the patients’ basic care. However, due to a lack of organisation by nurse leaders, this volunteer help could hinder providing safe care. This parallels the findings of Biron et al. (2009) in Canada that patients and families interrupted nurses during the administration of medication for diverse reasons such as obtaining information on upcoming procedures or discharge plans, hence creating barriers to providing safe care.

Conclusion

The findings of this study suggest that considering providing safe care, the patient’s right is a priority to ensure the provision of safe care by nurses. In addition, the provision of safe care needs the commitment and collaboration of all healthcare professionals as well as the leadership of nursing for removing obstacles to the development of a safer healthcare system. With regard to this matter, familiarising nurses about patient safety issues in both nursing degree education and on-the-job training will help guarantee the implementation of the principle of providing safe care in clinical practice.

This study points to the importance of further research, seeking the perspectives of other healthcare team members, such as physicians and leaders to draw a more complete picture of providing safe care in the healthcare system.

Key points

Iranian nurses achieve the internal motivation and personal commitment to safe care through considering the providing of safe care to be the patient’s right.

According to this study, providing safe care is beyond simply not doing harm or preventing practice errors, and encompasses incorporating patients’ feelings of safety into the notion of providing safe care.

Practising humanistic and ethical values inherited from a Persian culture and context inspires Iranian nurses to provide safe care.

Informing other healthcare members about the impact of their activities on nursing interventions, as well as improving the professional communication between physicians and nurses, are essential to attract their collaboration in providing safe care.

Footnotes

Acknowledgements

This research is one part of the first author’s PhD dissertation on patient safety using the grounded theory approach, which was supported financially by Tehran University of Medical Sciences, Iran and University of Nordland, Norway. The authors would like to thank the nurses who, with their cooperation, resulted in the production of this paper.

Funding

The study was supported financially by Tehran University of Medical Sciences, Iran and University of Nordland, Norway.

Conflict of interest statement

None declared.

Author contributions

Mojtaba Vaismoradi (BScN, MScN, PhD candidate in nursing) started his nursing career in 2000. Because of his interest to the development of nursing knowledge, he has conducted many studies on important issues in nursing education and practice using the qualitative design in the Iranian healthcare system. At this moment, he is working on patient safety and providing safe care in his PhD thesis and is going to develop a theoretical model about how to provide safe nursing care. The main strength of his studies on patient safety is that their processes of data gathering and analysis have been supervised and endorsed by expert international professors such as Professor Hannele Turunen (University of Eastern Finland, Kuopio, Finland) and Professor Terese Bondas (University of Nordland, Bodø, Norway). Email: vaismoradi@razi.tums.ac.ir

Mahvash Salsali (PhD) received his PhD in nursing in 1998 from the University of Alberta, Faculty of Nursing. She is a full professor in Tehran University of Medical Sciences. In addition, she has completed a postgraduate diploma in educational administration in the Educational Administration Department, University of Alberta, Edmonton, Alberta, Canada. Her research and scholarly interests are nursing education including medical-surgical nursing, nursing theory and nursing research. She has published 12 books and over 50 articles in international journals on different topics such as cardiac nursing, research issues in nursing, nursing theory, power in nursing, research utilisation, evidence-based nursing practice, knowledge transformation in nursing and therapeutic communication in nursing practice. She has contributed significantly to the development and publication of clinical nursing practice standards and guidelines in the Iranian healthcare system and has plenty of experiences regarding nursing management. Email: m_salsali@hotmail.com

Hannele Turunen (PhD, RN) is a professor of nursing science and head of the Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland. Hannele leads the Patient Safety Culture research project and research groups including international and national collaborators, and theses and dissertations of doctoral and Master’s students. Hannele’s main research interests are healthcare services, competency of nursing staff and health promotion. Hannele has applied mixed methods approach in her projects and works in close collaboration with nurse leaders of healthcare organisations. Email: hannele.turunen@uef.fi

Terese Bondas (PhD, RN) is a professor of nursing science at Faculty of Professional Studies, University of Nordland, Norway and adjunct professor (Methods of Health Research), University of Eastern Finland, Department of Nursing Science. Terese has initialised and led the interdisciplinary research network ‘Childbearing in the European countries – a qualitative research network’ (www.uin.no/bfin). She is also the leader of an interdisciplinary research network in healthcare leadership NiV () that unites Nordic researchers, doctoral students and Master’s level healthcare leaders. Terese has had an overarching interest to apply qualitative approaches and develop their contribution to evidence-based care. She supervises doctoral students in several countries. Terese is involved in research that develops the caritative leadership theory that she has created and several research projects in the research areas of caring and patient safety. Email: terese.bondas@uin.no

References

Alfredsdottir

Bjornsdottir

(2008) Nursing and patient safety in the operating room. Journal of Advanced Nursing. 61: 29–37.

Anoosheh

Ahmadi

Faghihzadeh

(2008) Causes and management of nursing practice errors: A questionnaire survey of hospital nurses in Iran. International Nursing Review. 55: 288–295.

Anoosheh

Zarkhah

Faghihzadeh

(2009) Nurse-patient communication barriers in Iranian nursing. International Nursing Review. 56: 243–249.

Attree

Cooke

Wakefield

(2008) Patient safety in an English pre-registration nursing curriculum. Nurse Education in Practice. 8: 239–248.

Balas

Scott

Rogers

(2004) The prevalence and nature of errors and near errors reported by hospital staff nurses. Applied Nursing Research. 17: 224–230.

Balas

Scott

Rogers

(2006) Frequency and type of errors and near errors reported by critical care nurses. Canada Journal of Nursing Research. 38: 24–41.

Bartley

(2011) Review: Building capacity and capability in patient safety, innovation and service improvement: An English case study. Journal of Research in Nursing. 16: 252–253.

Biron

Lavoie-Tremblay

Loiselle

(2009) Characteristics of work interruptions during medication administration. Journal of Nursing Scholarship. 41: 330–336.

Bondas

(2003) Caritative Leadership: Ministering to the patients. Nursing Administration Quarterly. 27: 249–253.

10.

Bondas

(2009) Preparing the air for nursing care: A grounded theory study of first line nurse managers. Journal of Research in Nursing. 14: 351–362.

11.

Brataas

Thorsnes

Hargie

(2009) Cancer nurses narrating after conversations with cancer outpatients: How do nurses’ roles and patients’ perspectives appear in the nurses’ narratives? Scandinavian Journal of Caring Sciences. 23: 767–774.

12.

Brown

Feller

Benedict

(2010) Reframing nursing education: The Quality and Safety Education for Nurses initiative. Teaching and Learning in Nursing. 5: 115–118.

13.

Butterworth

Jones

Jordan

(2011) Building capacity and capability in patient safety, innovation and service improvement: An English case study. Journal of Research in Nursing. 16: 243–251.

14.

Canadian Nurses Association (CNA) (2009) Patient safety. Available at: www.cnaaiicca/CNA/documents/pdf/publications/PS102_Patient_Safety_epdf. (accessed 9 June 2010).

15.

Centers for Disease Control and Prevention (CDC) (2011) The CDC supports national initiatives to improve patient safety. Available at: www.cdc.gov/media/releases/2011/s0415_patientsafety.html (accessed 22 December 2011).

16.

Coyne

(1997) Sampling in qualitative research: Purposeful and theoretical sampling; Merging or clear boundaries? Journal of Advanced Nursing. 26: 623–630.

17.

Cronenwett

Sherwood

Gelmon

(2009) Improving quality and safety education: The QSEN learning collaborative. Nursing Outlook. 57: 304–312.

18.

Curtis

Tzannes

Rudge

(2011) How to talk to doctors – A guide for effective communication. International Nursing Review. 58: 13–20.

19.

Donaldson

(2009) Is safety safe in the market’s hands? Quality and Safety in Health Care. 18: 87–88.

20.

Elf

Poutilova

Öhrn

(2007) A dynamic conceptual model of care planning. Scandinavian Journal of Caring Sciences. 21: 530–538.

21.

Elo

Kyngäs

(2008) The qualitative content analysis process. Journal of Advanced Nursing. 62: 107–115.

22.

Eriksson

(2002) Caring science in a new key. Nursing Science Quarterly. 15: 61–65.

23.

Farquhar

Sharp

BAC

Clancy

(2007) Patient safety in nursing practice. AORN Journal. 86: 455–457.

24.

Feng

Bobay

Weiss

(2008) Patient safety culture in nursing: A dimensional concept analysis. Journal of Advanced Nursing. 63: 310–319.

25.

Fordyce

Blank

FSJ

Pekow

(2003) Errors in a busy emergency department. Annals of Emergency Medicine. 42: 324–333.

26.

Graneheim

Lundman

(2004) Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today. 24: 105–112.

27.

Gran-Moravec

Hughes

(2005) Nursing time allocation and other considerations for staffing. Nursing & Health Sciences. 7: 126–133.

28.

Halbach

Sullivan

(2005) Teaching medical students about medical errors and patient safety: Evaluation of a required curriculum. Academic Medicine. 80: 600–666.

29.

Henderson

Forrester

Heel

(2006) The establishment of structures and processes for the safe and effective clinical placement of nursing students. Nurse Education in Practice. 6: 275–280.

30.

Holloway

Todres

(2003) The status of method: Flexibility, consistency and coherence. Qualitative Research. 3: 345–357.

31.

Horsburgh

(2003) Evaluation of qualitative research. Journal of Clinical Nursing. 12: 307–312.

32.

Hwang

(2011) Individual and work environment characteristics associated with error occurrences in Korean public hospitals. Journal of Clinical Nursing. 20: 3256–3266.

33.

International Council of Nurses (ICN) (2010) Supporting safe and competent nursing practice: A conversation with Jean Barry. International Nursing Review. 5: 409–411.

34.

International Council of Nurses (ICN) (2011) Patient safety: New evidence of unsafe care from Latin America. Available at: www.icn.ch/news/whats-new/patient-safety.html (accessed 5 March 2012).

35.

Iranian Medical Organization (IMO) (2008) The registration of 66,000 abnormal deaths in Iran. Available at: www.irimc.org/NewsList.aspx?id=6940 (in Persian) (accessed 20 August 2010).

36.

Jeffs

Affonso

MacMillan

(2008) Near misses: Paradoxical realities in everyday clinical practice. International Journal of Nursing Practice. 14: 486–494.

37.

Kingestone

Evans

Smith

(2004) Attitudes of doctors and nurses towards incident reporting: A qualitative analysis. Medical Journal of Australia. 181: 36–39.

38.

Krippendorff

(2004) Content Analysis: An Introduction to Its Methodology. 2nd edn.Thousand Oaks, CA: SAGE Publications.

39.

Künzle

Kolbe

Grote

(2010) Ensuring patient safety through effective leadership behaviour: A literature review. Safety Science. 48: 1–17.

40.

Lankshear

Lowson

Harden

(2008) Making patients safer: Nurses’ responses to patient safety alerts. Journal of Advanced Nursing. 63: 567–575.

41.

Leape

(2009) Errors in medicine. Clinica Chimica Acta. 404: 2–5.

42.

Lee

Kim

Kong

(2008) Probing the issue of informed consent in health care in Korea – Concept analysis and guideline development. Asian Nursing Research. 2: 102–112.

43.

Mastal

Joshi

Schulke

(2007) Nursing leadership: Championing quality and patient safety in the boardroom. Nursing Economics. 25: 323–323.

44.

McDonald

Helmchen

Smith

(2010) Responding to patient safety incidents: The seven pillars. Quality and Safety in Health Care. 19: 1–4.

45.

Nurse’s House (2011) Low ration of nurse per hospital bed in the Iranian healthcare system. Available at: www.khp.ir/NewsDetails.aspx?id=2390 (accessed 26 August 2011).

46.

Olsson

Petersson

Willman

(2009) Standardized care plans in Swedish health care: Their quality and the extent to which they are used. Scandinavian Journal of Caring Sciences. 23: 820–825.

47.

Pronovost

Miller

Wachter

(2006) Tracking progress in patient safety: An elusive target. Journal of American Medical Association. 296: 696–699.

48.

Ramanujam

Abrahamson

Anderson

(2008) Influence of workplace demands on nurses’ perception of patient safety. Nursing & Health Sciences. 10: 144–150.

49.

Reason

(2000) Human error: Models and management. British Medical Journal. 320: 768–770.

50.

Reid

Catchpole

(2011) Patient safety: A core value of nursing – So why is achieving it so difficult? Journal of Research in Nursing. 16: 209–223.

51.

Richardson

Storr

(2010) Patient safety: A literature review on the impact of nursing empowerment, leadership and collaboration. International Nursing Review. 57: 12–21.

52.

Sherwood

(2011) Integrating quality and safety science in nursing education and practice. Journal of Research in Nursing. 16: 226–240.

53.

Sheu

Wei

Chen

(2009) Using snowball sampling method with nurses to understand medication administration errors. Journal of Clinical Nursing. 18: 559–569.

54.

Silén-Lipponen

Tossavainen

Turunen

(2005) Potential errors and their prevention in operating room teamwork as experienced by Finnish, British and American nurses. International Journal of Nursing Practice. 11: 21–32.

55.

Skyman

Sjöström

Hellström

(2010) Patients’ experiences of being infected with MRSA at a hospital and subsequently source isolated. Scandinavian Journal of Caring Sciences. 24: 101–107.

56.

Spence Laschinger

Leiter

(2006) The impact of nursing work environments on patient safety outcomes: The mediating role of burnout/engagement. Journal of Nursing Administration. 36: 259–267.

57.

Stone

Mooney-Kane

Larson

(2007) Nurse working conditions and patient safety outcomes. Medical Care. 45: 571–578.

58.

Teng

Chang

Hsu

(2009) Emotional stability of nurses: Impact on patient safety. Journal of Advanced Nursing. 65: 2088–2096.

59.

Tong

Sainsbury

Craig

(2007) Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 19: 349–357.

60.

Vaismoradi M, Bondas T, Salsali M, et al. (2012) Facilitating safe care: A qualitative study of Iranian nurse leaders. Journal of Nursing Management. DOI: 10.1111/j.1365-2834.2012.01439.x.

61.

Vaismoradi

Salsali

Marck

(2011a) Patient safety: Nursing students’ perspectives and the role of nursing education in developing their capabilities to provide safe care. International Nursing Review. 58: 434–442.

62.

Vaismoradi

Salsali

Turunen

(2011b) Patients’ understandings and feelings of safety during hospitalization in Iran: A qualitative study. Nursing & Health Sciences. 13: 404–411.

63.

Vaismoradi

Salsali

Esmaeilpour

(2011c) Perspectives and experiences of Iranian nurses regarding nurse–physician communication: A content analysis study. Japan Journal of Nursing Science. 8: 184–193.

64.

Wachter

(2010) Patient safety at ten: Unmistakable progress, troubling gaps. Health Affairs. 29: 165–173.

65.

Wångblad

Ekblad

Wijk

(2009) Experiences of physical strain during person transfer situations in dementia care units. Scandinavian Journal of Caring Sciences. 23: 644–650.

66.

Warburton

(2009) Improving patient safety: An economic perspective on the role of nurses. Journal of Nursing Management. 17: 223–229.

67.

Weingart

Pagovich

Sands

(2005) What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. Journal of General Internal Medicine. 20: 830–836.

68.

World Health Organization (WHO) (2011a) Patient safety. Available at: www.euro.who.int/en/what-we-do/health-topics/Health-systems/patient-safety (accessed 1 May 2011).

69.

World Health Organization (WHO) (2011b) 10 facts on patient safety. Available at: www.who.int/features/factfiles/patient_safety/en/index.html (accessed 22 December 2011).