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Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 141-145

An exploration of barriers to patients' safety from the perspective of emergency nurses

Department of Nursing, Applied Medical Sciences College, Taif University, Taif, Saudi Arabia

Date of Submission03-Feb-2020
Date of Decision05-Mar-2020
Date of Acceptance10-Mar-2020
Date of Web Publication21-Jul-2020

Correspondence Address:
Abdulellah Al Thobaity
Unit 9, Alrabee, Taif 3966
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjhs.sjhs_15_20

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Background: The roles of emergency nurses include providing high-quality health care to patients, ensuring their safety, and liaising with their families. Identifying barriers by nurses to achieving patients' safety in Saudi Arabia is vital as there is a lack of the evidence on the topic. Objective: The study aim was to identify major barriers to the provision of patients' safety by nurses in the emergency department. Methods: A cross-sectional study was conducted in the nursing departments of two hospitals in Taif City. Data were collected through questionnaires administered at both hospitals between September 20 and October 20, 2019. Purposive sampling was used to recruit participants from the emergency departments who attained a score of 33 after responding to the questionnaire items (Likert scale, 1–5). The data were entered into SPSS® Statistics version 24. Descriptive statistics, such as mean, frequency, and standard deviation were calculated. Principal component analysis was used, with varimax rotation, to ensure high validity and reliability. Results: Sixteen barriers were quantified, validated, and grouped by category: (1) poor competencies, (2) poor evaluation and reporting, and (3) poor management and leadership. The most significant barriers were staff shortages (mean of 4.16), the absence of feedback from leaders (mean of 3.63), and lack of information on safety goals for patients (mean of 3.47). Conclusion: It is necessary to improve nurses' competencies, perform regular evaluations, and enhance nursing leadership to enhance patients' safety. Education, leadership, and research are key tenets.

Keywords: Emergency nursing, patients' safety, Saudi Arabia

How to cite this article:
Al Thobaity A. An exploration of barriers to patients' safety from the perspective of emergency nurses. Saudi J Health Sci 2020;9:141-5

How to cite this URL:
Al Thobaity A. An exploration of barriers to patients' safety from the perspective of emergency nurses. Saudi J Health Sci [serial online] 2020 [cited 2020 Oct 24];9:141-5. Available from: https://www.saudijhealthsci.org/text.asp?2020/9/2/141/290317

  Introduction Top

The safety of patients is of vital importance to health-care providers, including nurses. Most health-care system errors are preventable in the health-care setting.[1] The simplest definition of patients' safety is the prevention of harm and errors and adverse effects, especially, to patients during their care.[1] Nurses play a critical role in enhancing patients' safety,[2] which includes providing them with safe care, reporting errors, ensuring quality standards, and educating them. Despite extensive literature on the need for nurses to protect patients from harm, evidence-based practices on this topic remain limited worldwide.[3],[4],[5],[6]

Nurses are capable of identifying gaps in the health-care system and contributing to safety practices and the quality of care.[7] Competencies, level of education, communication, and collaboration, as well as clinical experience, are necessary for the provision of safe care to patients by nurses.[8] Burn out, low job satisfaction, and violence at work also negatively impact patient safety.[9] It has been proposed that further research is warranted to understand the patient safety culture and identify patient safety outcomes.[10] It has also been suggested that content on how to ensure the safety of patients is not obvious within the nursing curriculum of undergraduate student nurses.[11] In one study, students demonstrated weakness with regard to knowledge of patient safety,[12] while courses on patient safety were found to be highly effective in improving the knowledge and skills of students in another study.[13]

In Saudi Arabia, a relationship between patient safety and an efficient management and reporting system was demonstrated following an investigation into factors that influenced patient safety in terms of the hospital's organizational structures.[14] It was claimed that making changes to the healthcare system would improve patients' safety in general. This finding was confirmed in other research in which a positive association between accredited hospitals and patient safety was demonstrated.[15] A positive association, from the perspectives of nurses, was also found between transformational leadership and patient safety.[16] Nurses in Saudi Arabia were found to hold positive perceptions of patient safety culture.[17] In other research, teamwork and ongoing learning opportunities were observed to enhance nurses' perceptions and understanding of patient safety culture,[18] while poor communication, handoffs, and staff shortages detracted from it. Handoffs and transitions negatively impacted patient safety in another study in which the perceptions of health-care providers in general, including nurses, were evaluated.[19]

The attitudes of health-care professionals, including nurses, toward patient safety in the intensive care unit (ICU) were assessed in Saudi Arabia and were found to be negative.[20] The nursing managers were advised to review the policies and procedures to enhance patient safety culture in the ICU.[20] Elsewhere, the attitudes of nurses in the emergency department toward patient safety were found to be negative; it was reported that greater training and support from upper management was urgently needed.[21]

Based on the available evidence, it is clear that the need to ensure patient safety is imperative for all health-care providers, and nurses, in particular. Patient safety has been evaluated in Saudi Arabia in terms of the effectiveness of accreditation and administration strategies and determining the perceptions of the nurses in this regard through descriptive studies and analysis, as well as their attitudes to patient safety culture. However, greater evidence is required on major barriers to the ability of emergency nurses to achieve patient safety goals during the daily practice. Accordingly, the objective of the current study was to identify major barriers encountered by emergency nurses to the safe provision of care to patients. It is hoped that these findings will inform many aspects of patient safety, such as education, training, policy-making, quality assurance, and further research.

  Methods Top

This was a cross-sectional study to which a quantitative research design was applied. It was conducted in the emergency departments of two main hospitals in Taif City after ethical approval was obtained from the Central Committee, Taif Health Affairs General Directorate. Inclusion criteria were nurses of all nationalities and both genders, with different levels of educational qualifications, working in the hospitals. Nurses with <1 year experience were excluded. Convenience sampling was used, and an attempt was made to ensure that nurses with a diversity of experience participated. The research instrument was developed by the researcher. Factors likely to impact patient safety were sourced from previous studies.[22],[23],[24],[25],[26],[27],[28] Initially, 39 items were included. After revision, two items were deleted owing to duplication. The items were then included in a measurement survey. The survey comprised two parts. The first part contained the demographic data of the participants. This included the participants' gender (male, female, prefer not to say); ages (20–29, 30–39, 40–49, and 50–65 years); nationality (Saudi, Filipino, Indian, Pakistani, and other); qualifications (Higher diploma, Bachelor's degree, Master's degree, and Doctoral degree); and nursing experience (1–5, 6–10, 11–15, and >15 years). The second part included a five-point Likert Scale (37 items), where “1” signified “strongly disagree,” “2” denoted “disagree,” “3” indicated “neutral,” “4” meant “agree,” and “5” signified “strongly agree.” After the first version of the scale was created, it was evaluated by two specialists with considerable experience working in the field of revision to determine if the items were relevant, clear, and easy to read. Five items were deleted because they lacked clarity. The second version of the scale contained 33 items, as well as the demographic data. This version was distributed to the nurses when the researcher visited the hospital. The emergency nursing managers at both hospitals were consulted, and the surveys were distributed. Of the 250 surveys distributed using purposive sampling, 109 responses were returned. Nurses with at least 6 months' experience working in the emergency departments of the hospitals, excluding students and interns, were included in the study. The data in the returned questionnaires were analyzed using SPSS Statistics for Windows, Version 24.0. (Armonk, NY: IBM Corp.). The data were cleaned, the demographic data were assessed, and factor analysis was performed using the criteria suggested by Williams in 2009.[29] Varimax rotation was used to load the factors. The criterion for deleting redundant items was based on cross-loading of the items, with a difference between the primary and secondary loadings of >0.30.

  Results Top

One hundred and nine nurses participated in the study, 77% of whom were women and 22% of whom were men. The majority of the nurses were aged 20–40 years (85%). Almost half of the participants were Saudi citizens. The least represented group were Pakistanis (i.e., only one participant). Seventy percent of the participants held a Bachelor's degree. Only three had a PhD degree. Two-thirds of them (63%) had between 6- and 15-year nursing experience, and the smallest number had experience of ≥15 years' [Table 1].
Table 1: Demographic characteristics of the participants

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After several iterations involving the deletion of items that had no loading on any factor or that had cross-loading (i.e., redundant items), 18 of the 33 items were found to be redundant and were deleted. The remaining 16 items were grouped into three categories [Table 2]. The first category (i.e., poor nursing competencies in relation to patient safety) contained eight factors (experience, skills, confidence, education, and knowledge and awareness) with total communality of 34.60 (lowest to highest loading of 0.74–84). The second category (i.e., poor evaluation and reporting) contained four items (the evaluation of performance, feedback, and dealing with mistakes and medical errors), with lowest to highest loading of 0.69–0.76. The third category (i.e., poor leadership and management) contained four items (staffing, leadership, coordination, and communication), with lowest to highest loading of 0.62–0.77.
Table 2: A summation of the findings using principal component analysis

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  Discussion Top

As evident in the nursing literature, patient safety is a vital aspect of patient care and is of particular concern to the local and global nursing leadership. Therefore, it is worthwhile investigating barriers to nurses, from their perspectives, to achieving the goals of patient safety in Saudi Arabia. Thus, the current study objective was to identify barriers in this regard. Three main categories of barriers were identified: poor core competencies, poor evaluations of performance, and poor leadership and management. This study investigated the topic by utilizing an advance statistical protocol to ensure the validity and reliability of the findings.

Key gaps in the nursing literature relating to patients' safety in Saudi Arabia, discussed in the introduction, were identified as the failure to clearly identify barriers to patient safety encountered by nurses in the emergency department and limitations to the use of statistics previously used with regard to in-patient safety. Therefore, this study contributed to the body of nursing literature by describing these barriers and presenting them in categories. It also contributed to the methods of research used to evaluate patient safety in Saudi Arabia.

An interesting finding and vital contribution of this study to the nursing profession literature was how it provided evidence that poor core competencies significantly prevented the ability of nurses to achieve patient safety goals.[30] Nursing students need to be competent for the provision of patient safety before they become practitioners, otherwise they may require further preparation and intervention.[30] The findings of the current study demonstrated how nurses in Saudi Arabia perceived that a lack of experience, skills, information, confidence, and education with respect to patient safety affected the safety of their patients. This highlights the importance of emergency nurses being able to access adequate information and skills to practice safely. Nursing faculties in universities and hospital nursing education departments need to prioritize these issues and enhance the knowledge and skills of nurses and students through different approaches.

The Quality and Safety Education for Nurses (QSEN) initiative developed and compiled a list of core competencies for nurses that are essential to nurses in the provision of high-quality patient care. The six published domains were (1) patient-centered care, (2) teamwork and collaboration, (3) evidence-based practices, (4) quality improvements, (5) safety, and (6) informatics.[31] These competencies have been utilized and tested in the literature. For example, South Korean researchers used the QSEN survey to evaluate the current status of education in terms of patient safety in nursing curriculums in that country. Significant differences were observed to exist between the nursing schools. The majority scored low for skills and knowledge, but the scores for attitudes were higher.[32] Previous studies in Saudi Arabia have demonstrated that nurses lack education on patient safety, and there is a strong case for improving it, particularly for undergraduate studies (i.e., Bachelor's degree curriculum). Elsewhere, core competencies for nursing subspecialties were shown to need further development, while specialist areas, such as disaster nursing, have been the focus of other research.[33],[34],[35] One of the most important implications of the current research is that there is a need to improve continuous education and training in the emergency department. This was evidenced by the perceptions of nurses in this study, who cited lack of knowledge of patient safety goals as a top barrier. Competencies are one of the most important factors for consideration as they are needed by nurses to engage in safe practices. Improved educational and curricula development is warranted for the incorporation of patient safety competencies. There is also a need to develop and standardize a new set of core competencies to be used in emergency departments in Saudi Arabia.

Poor evaluation procedures governing the performance of emergency nurses and failure to report medical errors were identified as key factors that negatively impacted patient safety in a study conducted recently in Saudi Arabia.[36] Failure by nurses to report mistakes to management and failure by management to provide suitable feedback regarding these errors means that nurses are unable to improve and continue to make the same mistakes, which ultimately impacts patients' safety. Nurses' awareness of the importance of reporting medical errors as per the approved policies and procedures of the hospital must be increased. The application of policies is essential as the orientation of nurses about the relevant procedures to be followed enhances the quality of care to and the safety of patients, thus protecting them from unintentional mistakes.

Poor leadership and management, characterized by a shortage of nurses, poor communication, and poor coordination of care, were demonstrated to significantly impact the safety of patients in the current study. Administrative processes and organizational management and leadership were shown to be important in the provision of safe patient care. Currently, a shortage of nurses in Saudi Arabia[37] is negatively influencing the quality of the care provided to patients, leading to medical errors.[38] The implication of this finding is that there is an urgent need to improve nursing management in hospitals and emergency departments, implement recruitment strategies, and increase the number of admissions to nursing faculties.

  Conclusion Top

The findings of the current study contribute to the literature as the most important barriers to patient's safety, as perceived by emergency nurses in Saudi Arabia, were identified. Most importantly, poor core competencies need to be identified by the emergency nurse manager, and steps must be taken to address this. In addition, to ensure safe practices, patient safety should incorporate more prominently in the nursing bachelor curricula. Continuous education and training on this topic are essential if the culture of patient safety is to be improved. Nurse managers in emergency departments must also improve their policies and procedures to ensure that performance-based evaluations are conducted properly and feedback to nurses is shared to facilitate a constructive approach and improvements. The other vital aspect discussed in this study pertained to poor leadership as a barrier to patients' safety, specifically the shortage of nurses. Thus, more strategies are needed in this regard as nursing shortages negatively affect patients' safety. Finally, nursing scholars, educators, managers, and leaders should place greater effort into patients' safety in research, education, management, and leadership to expedite high-quality patient care and ensure the safety of patients in the emergency department.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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