Have our backs‐medical‐surgical nurses’ safety culture experiences: An inductive qualitative descriptive study

Abstract

Aim

This study aims to describe medical‐surgical registered nurses' experiences with safety culture.

Design

Qualitative, Inductive descriptive.

Methods

Registered nurses were recruited from a Midwestern community hospital in the United States using purposive sampling. The participants were interviewed using semi‐structured interview questions from February 6, 2020‐April 9, 2020. Safety huddles were observed and key documents were collected. The interviews were transcribed and analyzed using inductive qualitative content analysis. The COREQ checklist was followed.

Results

A total of 16 registered nurses were interviewed. Six themes emerged: Time to know my patient to keep them safe, using my gut and nursing interventions, getting extra eyes on the patient, not always having what is needed to provide safe care, organization prioritizes patient safety, and learning: have our backs. No Patient or Public Contribution.

1. INTRODUCTION

Health system leaders have focused on creating and sustaining a safety culture to improve patient safety in response to the Institute of Medicine (IOM, 2000) seminal report on preventable patient harm. Although efforts to improve patient safety have had some impact, one in 20 patients continue to experience preventable harm (Panagioti et al., 2019). Safety culture is ‘the product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that can determine the commitment to and the style and proficiency of an organization's health and safety management plan.’ (Health and Safety Commission Advisory Committee on the Safety of Nuclear Installations, 1993, p.339). Although culture is influenced by all members of the healthcare team, Registered Nurses (RNs) are critically important in ensuring patient safety as they are a constant presence at the patient's bedside, interact with all members of the health‐care team and perform many tasks to ensure patients receive safe care (Agency for Healthcare Research and Quality [AHRQ], 2021).

RNs with positive safety attitudes experience fewer patient falls, medication errors, pressure injuries, healthcare‐associated infections, mortality, physical restraints, vascular access device reactions and higher patient satisfaction (Alanazi et al., 2022). Safety culture explains missed nursing care, care that should have been provided to patients but is left undone, quality of care concerns, vascular access device events and is associated with falls (Hessels et al., 2019). Therefore, understanding safety culture from the perspective of the RN will provide a deeper understanding of factors that contribute to patient harm.

Nurses, including RNs, licensed vocational nurses (LVNs) and licensed practical nurses (LPNs) consistently have the lowest perception of safety culture with no significant improvement over time, as measured by the AHRQ Hospital Survey on Patient Safety Culture 1.0 version (Famolaro et al., 2021). Culture is multifaceted and efforts to improve safety culture based on quantitative studies alone have not made a meaningful impact on nurse‐perceived safety culture. Through a better understanding of RN experiences within medical‐surgical units, long‐standing unfavourable safety culture results will be better understood (Churruca et al., 2021).

2. BACKGROUND

Factors contributing to a positive nurse‐perceived safety culture are well known and include a healthy work environment, nursing input to prevent errors, patient safety as a leadership priority and a non‐punitive response to mistakes (Wei et al., 2018). Staffing adequacy, management support for patient safety and continuous organizational learning and improvement are strong predictors of nurse‐perceived patient safety (Lee & Dahinten, 2020). A professional nursing work environment is essential for improving safety and safety culture (IOM, 2004). Staffing and resource adequacy, nurse participation in hospital affairs, quality of care foundations, managerial support for nurses and good nurse–physician relations are work environment components that enable nurses’ ability to deliver safe quality care (National Quality Forum [NQF], 2019).

Work environment barriers to achieving a safety culture have been described and include inadequate organizational infrastructure, inadequate efforts to keep pace with standards and overshadowed values of team participation (Farokhzadian et al., 2018). Exhaustion and lack of sleep also influence less favourable nurse safety culture perceptions (Stimpfel et al., 2020). Staff dimensioning and workload, professional qualifications and training, teamwork, being contracted to the hospital, turnover, lack of job security and disruptive behaviours also interfere with establishing a safety culture (Oliveira et al., 2015). Increased RN staffing has increased safety culture perceptions; however, staffing has an indirect effect on safety culture through better processes such as teamwork and handoffs (Upadhyay et al., 2021).

Failure to improve the work environment may be negatively impacting efforts to improve patient safety and safety culture. A study by Aiken et al. (2018) identified an overall lack of improvement and some deterioration in the nursing work environment over a 13‐year period. RNs working in deteriorating work environments have less favourable perceptions of safety culture and higher burnout than those working in hospitals with improved work environments. RNs with higher levels of burnout, a psychological syndrome associated with chronic stress in the workplace, have less favourable perceptions of safety culture and worsening patient safety outcomes (Garcia et al., 2019; Soosova, 2021). Burnout was associated with factors such as high workload and ineffective interpersonal relationships (Garcia et al., 2019). Overall, unhealthy work environments contribute to poor patient outcomes, lack of safety culture and burnout in nursing.

Understanding safety culture from the perspective of the RN will provide a deeper understanding of factors that contribute to patient harm and long standing poor safety culture perceptions. Therefore, this study aimed to describe medical–surgical RNs' experiences with safety culture in a Midwestern United States community hospital to inform interventions that can positively impact safety culture and safer patient care in nursing. This study is part of a larger study describing the similarities and differences in safety culture experiences between RNs and nurse leaders.

3. METHODS

An inductive qualitative descriptive design was used for data collection and analysis (Sandelowski, 2000; Sullivan‐Bolyai et al., 2005). A purposive sample of RNs with at least 6 months experience working at least 50% of their time providing direct patient care on medical–surgical units were recruited through flyers, a recruitment email and during hospital safety huddles that occurred each morning. Recruitment included the first author's credentials, occupation and purpose of the research while relationships were established prior to commencement through attendance of safety huddles and telephone conversations. Safety huddles were short stand up meetings in which nurse leaders and their staff discussed safety related concerns and incidents, put in plans to mitigate harm and ensured teamwork and support in pursuit of safe patient care.

3.1. Data collection

After informed consent was obtained from the participants, data were collected through a previously piloted semi‐structured interview guide (Figure 1). Interviews were conducted by the first author between February 27, 2020 and April 9, 2020. She has more than 15 years of leadership experience with a commitment to improving a safety culture to achieve safer patient care. Interviews were conducted in secure and comfortable locations chosen by the participants and lasted on average 1 h. Confidentiality was maintained by using pseudonyms during transcription. Audio tapes of interviews were transcribed verbatim, reviewed line by line and compared to the audio recordings to ensure accuracy. A sample of audio recordings and all transcripts were reviewed by the second author to validate transcriptions. She is a nurse researcher with expertise in qualitative research. Key policies, protocols and documents discussed in interviews were collected and reviewed to enhance the credibility of data collection. To enhance understanding of the context of the environment, observations of 16 safety huddles allowed the researcher to observe group safety behaviours and were captured in field notes (Sullivan‐Bolyai et al., 2005). Data saturation was reached at 16 RN participants. Individual participant characteristics varied (Table 1).

FIGURE 1.

Interview Guide.

TABLE 1.

Individual participant characteristics.

Participant code	Gender	Highest education level	Number of years as an RN	Shift worked	Hours worked per week
RN01	F	Bachelor's	2 1/2	Rotating	30
RN02	M	Bachelor's	5	Days	36
RN03	F	Bachelor's	5 1/2	Nights	36
RN04	F	Master's	8	Days	36
RN05	F	Bachelor's	12	Days	24
RN06	F	Bachelor's	2	Days	36
RN07	F	Bachelor's	8	Days	36
RN08	F	Bachelor's	10	Days	36
RN09	F	Bachelor's	5	Days	30
RN10	M	Bachelor's	1	Days	36
RN11	F	Bachelor's	12	Nights	36
RN12	F	Associate's	5	Nights	24
RN13	F	Bachelor's	7 months	Nights	36
RN14	F	Associate's	6	Nights	36
RN15	F	Bachelor's	10	Days	30
RN16	F	Associate's	1	Days	36

There were no repeat interviews and all participants completed the full interview.

3.2. Data analysis

Data analysis was conducted by two qualitative nurse researchers. Inductive qualitative content analysis was applied to analyse and summarize data resulting in six themes (Sandelowski, 2000). Analysis was manual and occurred concurrently with data collection using a five‐step process (Miles et al., 2014). First, data were managed and organized into secure files. Second, data was read and re‐read while memoing emergent ideas to capture phrases and words to identify initial codes. Third, in vivo coding allowed clustering of similar data using first cycle coding that was continuously revised to accommodate new data. Then, pattern codes were generated through second cycle coding to identify emerging themes. Sub‐themes provided rich description of participant experiences by providing quotes, emotions and context to ensure that the voices, feelings, meanings and actions of the participants were described in sufficient detail. In the fourth step, interpretations were developed and assessed. Fifth, results were validated by member checking and by researcher triangulation through consensus. Results were also validated with the Nurse Practice Council. Findings were compared to what is known in the literature.

3.3. Rigour

Rigour was established by adhering to the four criteria described by Lincoln and Guba (1985). Credibility was ensured by pilot testing the interview guide, flexible, systematic, purposive sampling, ensuring participants had the freedom to provide descriptive details, participant driven data were collected until saturation was reached, triangulation of data collection through multiple sources, accurate and timely transcription, data‐driven coding with member checking, investigatory triangulation and on‐going attention to context. Researcher credibility was fostered by the authors use of a personal journal for reflection on how the author was influencing and being influenced by the research and observational experiences. The author also visited with the second author at regularly scheduled meetings to discuss research experiences, any areas of difficulties and strategies to improve the remaining time conducting the research. It was recognized that fieldwork requires participant trust, yet, as a researcher the author also maintained a degree of objectivity to promote openness and awareness to the multiple experiences described by the participants. Credibility of the analysis was promoted by having the second author review the analysis and by returning to a random set of participants with preliminary analysis for participant validation of results.

Confirmability was promoted through bracketing personal bias, investigator triangulation and member checking. Dependability was ensured through a documented extensive, detailed audit trail. Transferability or fittingness of the results is determined by the reader. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (Tong et al., 2007) and Standards for Reporting Qualitative Research (SRQR) checklist (O’Brien et al., 2014) were followed (Datas S1 and S2).

3.4. Research ethics committee approval

The study was approved by the University IRB and the study site research ethics review committee.

4. RESULTS

The 16 RN participants were predominantly female (87.5%) and held a bachelor's degree in nursing (75%). All RNs worked 12 h shifts with most working 3 shifts a week (87.5%). There was variation in shift worked, age and years of experience (Table 2).

TABLE 2.

RN demographics.

Characteristic	RN (n = 16) % %	n
Gender
Male	12.5	2
Female	87.5	14
Role
Staff nurse	69	11
Charge nurse	31	5
Age
20–29	37.5	6
30–39	56.25	9
40–49	6.25	1
Highest education level completed
Associate's
Bachelor's	18.75	3
Master's	75	12
	6.25	1
RN, number of years
0–1	19	3
2–3	12.5	2
4–5	25	4
6–10	31	5
>10	12.5	2
Hours worked per week
0–24	12.5	2
25–40	87.5	14
Shift most often worked
Days	62.5	10
Nights	31.25	5
Rotating	6.25	1

Six themes emerged to describe RN experiences with safety culture. Within the themes, 18 sub‐themes provided rich description of the meaning of those experiences (Figure 2). Safety culture was described as making sure patients were safe by being able to provide safe care.

FIGURE 2.

RN Results.

4.1. Time to know my patient to keep them safe

RNs obtained information about and from the patient. They used nursing intuition, guided by experience, to understand the patient's health and safety risks. RNs’ sub‐themes described needing time to know my patients by reviewing the electronic medical records (EMRs), getting eyes on my patient through bedside shift report, bedside risk assessments supported by going with my gut and frequent rounds to understand patient health and safety risks. Time was the biggest barrier to know the patient.

When I was a nurse starting out…you really liked the one‐on‐one time you would get [with the patient]. Now I don’t have time. Here's your pills and if you’re lucky I will see you in an hour. I don’t think that's nursing at all. I don't know anybody's goals other than I want to get them out of here. (RN08)

RNs relied on the EMR when the patient was unable to communicate and share their history. A lack of time and access to accurate, readily available patient history information was a barrier. Bedside shift report allowed the RN to conduct a patient, environmental and safety assessment with input from the off‐going RN and involve the patient to create a shared understanding of the plan of care.

You check to see that safety things are in place before its noon and you’re like oh crap they don’t have a fall wristband or gripper socks on. Just laying eyes on your patient you can tell if they look weak or medically unstable and if they’re more of a safety risk. (RN03)

Bedside shift report was done inconsistently mostly because RNs didn’t want to wake the patient and get stuck in a room and pressure to leave the shift on time.

RNs also conducted bedside risk assessments which combined physical assessments and computerized risk assessments with nursing judgement to determine the patient's safety risks to guide nursing interventions.

You can look at the numbers all you want but, until you go see the patient with your eyes on that first assessment is what helps paint the picture. I have something I call the eyeball test [pointing to stomach area]. If you don't pass it, you’re in trouble. I might not know what's wrong with you but, that triggers me to look more into what could potentially be causing issues. (RN02)

Relying on risk scores without applying nursing judgement was a safety risk causing the under or the over‐use of nursing interventions and providing a false sense of security. ‘Risk screens completed on patients sometimes don’t match up with what I assess the expected intervention should be. That creates a barrier. Do I follow my instincts or the policy’ (RN04). Variation in and developing clinical judgement were barriers to this process. RNs lacked time to complete assessments.

RNs made frequent rounds throughout their shift, when time allowed, to ‘make sure the patient's breathing, the room is safe, alarms are on, you hear moaning, someone's in pain, you hear wrestling, and you prevent a fall’ (RN13). Continuity of care and time facilitated this process.

4.2. Using my gut and nursing interventions

RNs applied evidence‐based standards of care in conjunction with their nursing gut, or intuition based on experience, to keep patients safe. RNs’ sub‐themes described appropriate nursing interventions; checklists, alarms, warnings and safety checks; and workarounds to keep patients safe.

Policies, educational clinical skills, databases. That's my safety net at the point of care. I can't know everything all the time but I need to know where my resources are so that when an issue comes up I can get the answer I need quickly. (RN02)

Appropriate nursing interventions allowed guidance with sufficient autonomy for the RN to use their clinical judgement to make individualized patient care decisions. Nursing interventions weren’t always accessible, updated, lacked nursing input, conflicted with nursing judgement, lacked rationale, were subjected to variation in nursing judgement, and weren’t accepted or understood by the patient. Interventions weren’t always implemented because of time constraints. Lack of RN input into nursing interventions added extra work without added patient benefit or created safety risk when not applied using judgement. RN06 stated, ‘decisions are not made by people working on the floor. It's confusing and pure frustration. They are seeing the numbers and statistics, we are seeing real‐life what's going on and we don’t need all these extra steps’.

Checklists, alarms, warnings and safety checks were system design features within the environment or EMR that provided alerts, guides, or forcing functions to support safe decision making when RNs were too busy or when there was an increased patient safety risk. At times these features provided a false sense of security, were broken, faulty, not turned on or used because RNs were too busy or would forget, agitated the patient, or were bypassed by the RN.

Pretty much we put everyone on alarms. Think about alarm fatigue. They [nurses] will be sitting right outside their [patient] room and their bed alarm is going off and they’re not doing anything. I feel like some of the interventions may be overused to the point where nobody pays attention to them. (RN09)

Workarounds, or short cuts, were knowingly eliminating or not following steps in an established policy or protocol to allow RNs to provide safe care in a timely manner. RNs ‘always have the best intention of doing things to benefit the safety of the patient but, there are times when they [the patient] need something now and a 7‐step process for doing something won’t cut it’ (RN04). For example, a 17‐page fall prevention policy was required reading for the RNs; however, they shared it was too long and convoluted to be useful. Workarounds were caused by time pressure and nursing interventions that weren’t perceived by RNs to add benefit or increased risk for the patient.

At the end of the day, we need to get things done. As you create workarounds you are increasing the risks. People are weighing the balance of information. If you don’t understand the purpose, you’re going to bypass steps without understanding the reason or what you’re even trying to prevent. (RN02)

4.3. Getting extra eyes on the patient

RNs got extra eyes on the patient when they were in a situation that was outside of their expertise or when the patient's condition deteriorated requiring immediate assistance and additional resources. Leaning on others for their expertise and escalating to nursing leadership or by calling a rapid response team (RRT) to bring additional resources such as intensive care unit RNs, physicians and respiratory therapists to the patient's bedside were the sub‐themes describing how RNs got extra eyes on the patient.

RNs leaned on others for their expertise.

Our leads are very good. If we don’t know something we ask them, and they escalate up the ladder. Our manager is very good at helping and escalating as well. I never feel like I’m in a situation where I can’t ask anyone because I won’t do something that I’m not 100% comfortable with. (RN13)

Barriers were the charge nurse busy helping others, had an assignment, or wasn’t approachable; negative previous experience asking for help; and lack of experience to identify help was needed. ‘What we are used to doing is working together to exhaust all of our resources in our ability then, we run it by each other and decide if it is page‐worthy, so we don’t get the doctors angry’ (RN14). Collaborating with other disciplines facilitated safe care.

RNs escalated to nursing leadership when they couldn’t get what they needed for their patient or called an RRT when their patient needed something immediately due to a deteriorating condition. Escalation was generally due to a lack of or inadequate response from physicians. ‘The supervisors and the managers on the floors, they’re going to have your back. If you say I'm not getting this from a provider they will have your back and they will help get you what you need’ (RN06). The nurse leader wasn’t always available or able to remove barriers causing RNs to question escalating in the future. Previous negative experiences of getting scolded, pushback, or questioned when calling a RRT caused RNs to fear or delay calling a RRT; however, their role as a patient advocate facilitated escalating. ‘A provider actually scolded me in front of the patient for calling one [RRT]. That was definitely a barrier in providing safe care’ (RN01).

It's frustrating because I can’t put in orders, I don’t know how to intubate people, and I can't say what they need. The only thing I can do is push and try to get the help they [patients] need. (RN09)

4.4. Not always having what is needed to provide safe care

RNs didn’t always have resources or relationships they relied on to provide safe care. ‘There have been days where I was so overwhelmed walking out of here. I didn’t have enough help and had to stay an hour late to get things done. It's frustrating. It's overwhelming. There have been days I cried’ (RN13). This was described within the sub‐themes inadequate staffing contributes to unsafe care, supplies and working equipment are not always available, we don’t always work together as a team, and more respect from physicians would be appreciated.

It's going to be a good day when you don't have to run all over the unit to find these things [equipment and supplies]. They are already set up for you when you walk in. The correct amount of staff. I have the right support if there's a lot of difficult patients or a lot of impulsive patients. (RN03)

Staffing was identified as either the most frequently experienced challenge to providing safe care or the main contributor to the most unsafe shift. This was observed during safety huddles when over 50% of safety huddles described staffing shortages. ‘What we are seeing for patient to staff ratios, that's really where most of our burnout comes from and our concerns on the impact [staffing has] on safety’ (RN16).

I had two critical patients, new staff members and float staff on our floor. I had to put catheters in four or five patients being the only urology trained nurse. My patient with an epidural just came up from surgery. There were confused patients and they kept trying to give me more admissions. I had to fight with staffing and patient flow. We can’t take anymore. It's not safe. (RN11)

Facilitators were proactive charge nurse planning, staffing algorithms, keeping extra support staff, right sizing teams, and distributing acuity. Barriers to staffing included high needs patients that were medically stable but required significant nursing time due to emotional or functional limitations that weren’t accounted for in a staffing algorithm, lack of support staff, and high acuity patients that prevented RNs from providing safe care to all of their patients and contributed to missed care.

We’re very busy and there's a lot of days that I go home and think about things that I could have done better. Did I remember to put the bed alarm on? Is the bed in [the] lowest position? Are there floor mats on the floor? Our workload is a huge barrier to safety. (RN16)

I feel bad when I walk into a patient's room and they’re like ‘I didn't even know you're still here, I haven’t seen you all day’ because you've been with a patient who is high needs for four or five hours. It makes you feel like crap because I haven't been there for you [patient] all day. When we don’t have enough staff falls happen, infections happen because you’re missing things. (RN06)

RNs got the supplies and equipment they needed however, they weren’t always readily available at the bedside, were broken, or delayed when they had to depend on other departments for delivery. Searching for working equipment and supplies took RNs away from patient care.

I know she [manager] got pretty upset when people didn’t do it [patient lifts] the right way and they got hurt. It's just one of those shortcuts to get it done. It's hard to find that staff member or to find supplies. (RN05)

We don’t always work together as a team was a situation when RNs didn’t receive the help they relied on and needed from their colleagues to assist in keeping patients safe. RNs depended on relationships with their coworkers to provide safe care. ‘The best safety culture is teamwork and working together’ (RN02). Having established, trusting relationships that developed over time facilitated teamwork. ‘If you get in a bind anybody will help you. If we didn’t have such great nurses and everybody pulling their weight it wouldn’t happen [safe care]. If I didn’t have good coworkers, then I wouldn’t work here’ (RN08). Attitudes and moods such as cranky, not open, negative and teammates that weren’t willing to help were barriers. RNs being too busy, tired, lacking competency to help, not trusting the quality of work of another teammate, alarm fatigue, trying to go on a break, not comfortable asking and negative previous experiences asking for help contributed to poor teamwork.

They’re [colleagues] tired. Twelve‐hour shifts can be a long time day after day, a couple in a row, it's exhausting. It's probably one of the biggest ones [reasons for not working together]. I feel like they’re just done. We say that around here. We are just done with today. (RN05)

When everyone leaves here everyone is absolutely exhausted mentally, emotionally, physically. I’m 32, I have a 45 min drive and some days when I got out of my car I can barely move. I have bursitis in my hips. My shoes are worn out. It's just physically demanding. (RN08)

RNs needed nurse leaders to hold people accountable for not working together as a team but, said that repeat poor behaviours were never addressed by leaders, ‘it's always the same people and it never changes’ (RN12).

Lastly, the sub‐theme more respect from physicians would be appreciated was defined as disrespectful interactions between RNs and physicians that inhibited RNs from providing safe care by increasing their workload or by not incorporating their perspective into the plan of care. ‘It's one of those intimidating things. They’re a doctor, I’m [puts up quotation signs and rolls eyes up] just a nurse’ (RN06).

It's always nice when the provider is readily available and responsive when you have a need. It's not always the amount of time it takes them to respond, it's actually listening to what I’m telling you and don't walk in like you know it all. To me responsiveness is relying on me as your eyes and ears because I spent 12 h with these people, not 10 min. (RN09)

Novice RNs in particular didn’t feel respected by physicians.

The ideal relationship would be being able to approach a physician and ask a question or express your concerns without feeling like you’re incompetent. It's frustrating but you just have to take it because there's not a whole lot you can do about it. I tell myself I have one more day to go then I’m off for 3 days. (RN16)

Physicians relied on RNs to double check and provide reminders to put in orders creating unsafe situations. ‘I can’t tell you the amount of times I have had patients that would have gotten anticoagulation before a procedure if I wouldn’t have just held it and said [to the physician] by the way you didn’t want to give this right’ (RN04). Physician behaviours were frequently not addressed; consequently, RNs ‘delay calling so they won’t get the doctors angry’ (RN14) creating an unsafe environment. RNs focused on their role as a patient advocate to cope with poor physician relationships.

4.5. Organization prioritizes patient safety

The organization prioritized patient safety through a directive from the top executive of the organization that patient safety and striving for zero harm was the overarching goal for everyone in the organization as described by the sub‐themes sharing the numbers and keeping us updated and giving nurses a voice in making improvements.

Every open‐heart patient had a triple lumen in from when they got into the OR to when they went home and we just drew right off it. No one was trying to create harm but when we were having CLABSI's [central‐line associated bloodstream infections], hey maybe we should get these lines out earlier. That question wasn’t asked because quality and safety wasn’t in the forefront at that time. (RN02)

The organization provided transparency of patient safety data and new safety interventions through emails, newsletters, the website, meetings, videos, safety huddles and executive rounds.

We do huddles with our manager and sometimes the higher‐ups come like the CEO. We discuss our goals and what we’ve accomplished so they are aware of the progress we made. They are willing to listen to our needs, hear what's going on, and support you. If you feel comfortable to voice concerns, it gets somewhere. (RN13).

Huddles lasting too long, lack of leader follow‐up, lack of huddles on night shift, frequently changing, inconsistent messaging by managers, and ‘ineffective delivery so we don’t know the whys’ (RN04) were barriers.

RNs were invited to proactively design interventions that kept patients safe through nursing governance councils and improvement teams. However, RNs didn’t have time to participate in councils, councils didn’t prioritize important things, and they didn’t have enough staff nurse input. ‘There's a disconnect with upper management. You have to bring it back to nursing and there's not a lot of connection to our opinions and thoughts, so things are implemented quickly without discussion’ (RN12).

4.6. Learning: have our backs

RNs needed to learn in a non‐judgemental, non‐punitive environment where the organization would support their decisions. The sub‐themes were described as time to teach and learn from experience, learning from mistakes, and we don’t always learn from audits.

A lot of the judgment for me comes from experience and talking to other nurses. I might see something and yeah I’ve seen this before let's do this. Other times I’m like this is kind of murky what should we do and that's when I lean on someone, when I’ve never seen it before. Everyone is always just willing to jump in and help me make that safe decision. (RN10)

RNs needed time to teach and learn from experience through experienced RNs teaching new RNs, sharing experiences, debriefing and reflecting. ‘The best safety culture is gathering experiences from other nurses and talking through situations. We don’t have real time feedback or debriefing. It gets lost on nurses just trying to stay alive in their workflow’ (RN02).

Learning from mistakes occurred when nurse leaders provided timely, non‐judgemental, non‐punitive follow through and shared learnings from reported safety events. ‘Being able to have a conversation and not feel like it's going to come back and hurt me. She's not judging me. She's listening, active listening, and going to do something about it’ (RN03).

RNs were more willing to report safety incidents when they believed nurse leaders would ‘have our backs’ (RN09), listen, maintain confidentiality, follow up and provide friendly feedback, focus on fixing the problem and not blaming the person and didn’t write it down.

When I was fairly new I programmed the pump [PCA] incorrectly. I came in the next day and I found out it was programmed incorrectly and the patient's respirations were down. I almost killed her and it scared me. I beat myself up about it but this organization didn’t. This organization made me feel like they were going after the process and the equipment. They changed the settings on the PCA. Good things came of it. (RN09)

Lack of time, stress, poor leader follow up, negative experiences reporting and learning, fear of repercussions, jeopardizing relationships, and getting into trouble based on stories heard were barriers to reporting and learning.

I would identify safety things and nothing was done so you stop saying stuff. It's exhausting to be trying to make a difference and feeling like you’re not being heard. (RN02)

Nursing interventions were audited to facilitate learning and compliance. Experienced RNs didn’t find value in audits; however, less experienced RNs appreciated the validation audits offered. RNs believed audits were a waste of time because nurse leaders didn’t follow through with findings.

Leadership has us do all these audits but, they don’t do anything with them. Today the missing ID bands I talked about is very dangerous and it frequently comes up on our audits but, why does it keep happening? People need to be held accountable. (RN04)

5. CONCLUSIONS

This study described medical‐surgical RNs safety culture experiences. Safety culture was being able to provide safe care however, many barriers were described providing context to what is influencing years of less than favourable safety culture perceptions. High organizational expectations of nursing care were set by sharing a vision of zero harm but, the inability for RNs to provide safe care to achieve the vision due to lack or organizational support and unhealthy work environments left them feeling physically and emotionally exhausted.

RNs spent their shift making sure their patients were safe. This study corroborated a substantive, making sure theory described as a RN process of knowing what's going on, being close, watching and not taking anything for granted, taking action and protecting patients from harm and negative events (Schmidt, 2010). Lack of time and excessive time spent advocating for patient safety prevented RNs from making sure patients were safe. Not having time to know their patients not only imposed a patient safety risk but contributed to RN physical and emotional exhaustion. Understanding the patient status to make safe decisions is facilitated through physical time the RN spends with the patient (Nibbelink & Brewer, 2018). Nurses experience compassion satisfaction by forming relationships with patients and being able to help them which buffers the impact of burnout (Ryu & Shim, 2021). Nurse leaders must understand what is contributing to time barriers and remove those barriers or consider a redesign in the RN role that would support them having the time to build relationships with their patients and provide safe care.

RNs shared unfavourable attitudes of nursing interventions that were developed without their input and conflicted with nursing judgement. This placed RNs in a precarious position to follow interventions they didn’t believe improved safety patient care and due to a lack of time resulted in missed care (Hessels et al., 2019; Mohamed & Mohamed, 2018). Although RNs could provide input into nursing interventions, they didn’t have time. This study further informed the impact that perceived non‐value added work caused by nursing interventions that didn’t influence safer care including increased time pressure, frustration, increased patient risk by performing workarounds and role dissatisfaction. Barriers to developing and implementing appropriate nursing interventions must be addressed through further research organization attention and policy. Organizations must create time and space that would engage and support RNs to provide input.

Previously described safety culture barriers including a shortage of resources, lack of empowerment, unfavourable work environment, leader ineffectiveness, weakness in learning, lack of teamwork, staffing and disruptive behaviours were described (Farokhzadian et al., 2018; Oliveira et al., 2015). Professional work environment components including nurse manager ability, leadership and support; RN participation in hospital affairs; staffing and resource adequacy; and collegial nurse–physician relationships were described barriers (NQF, 2019). An unhealthy work environment contributed to the inability of RNs to provide safe care contributing to a lack of perception of safety culture, role dissatisfaction and burnout (Aiken et al., 2018). This study added the emotional and physical impact this has on RNs. This suggests further research and prioritization of improving the professional environment is needed to influence safety culture in nursing.

RNs were comfortable sharing errors as they trusted their nurse leaders and said that they had their backs; they described a need for feedback and follow through. They also described nurse leaders as ineffective in ensuring accountability and obtaining needed resources. Promoting a non‐punitive response to errors and effective teamwork and communication contributes to a positive safety culture (Alanazi et al., 2022). RNs also shared a desire to learn from each other but, lack of time prevented this. System change is needed for organizations to expect, empower and support nurse leaders to influence and make changes within the healthcare system to support safe patient care. Nurse leaders must continue to advocate for and cultivate a non‐punitive learning environment while providing feedback and following up on concerns. Organizations must also create time and space for RNs to learn from each other.

Unsafe staffing contributed to the most unsafe day (Lee & Dahinten, 2020; Oliveira et al., 2015) and reason for nurse burnout (Garcia et al., 2019). Safety policies that added extra work without added benefits, lack of teamwork, poor relationships with physicians, resources not readily available and patient factors contributed to staffing barriers. Safety initiatives such as increased safety assessments and procedures, frequent rounding, additional documentation, safety checks, use of safety equipment and safety policies have been identified as an additional, invisible, impact on workload (Ross et al., 2018). Lack of time, long shifts, working multiple days in a row and often not getting a break also prevented RNs from participating in councils and committees which resulted in the development of policies without perceived appropriate input from RNs. To support safe care and to reduce burnout, the identified inefficiencies in workflows must be removed as this study informed the physical and emotional impact this had on RNs and the impact on safety culture. If safe patient care is to be realized, nurse leaders must advocate for safer staffing and realistic resources to support the demands placed on RNs.

Relationships and working together as a team were the most significant facilitators to address lack of time and unsafe staffing, previously reported (Upadhyay et al., 2021). The power of relationships must be understood and cultivated within teams as this study informed the impact of relationships on safety culture and safer patient care. Providing time and space for RNs to discuss patient care and learn from one another can help build professional nurses, cultivate professional relationships and promote safe care. Nurse leaders must teach, expect and hold their staff accountable for teamwork behaviours. Relationship development and impact requires further empirical support.

Finally, lack of a collegial nurse–physician relationships resulted in unsafe care, frustration and emotional exhaustion among RNs. Escalating patient concerns was necessary to keep patients safe; however, delays caused by fear created by previous negative physician experiences, hierarchies and power dynamics were all experienced and consistent with the literature (Morrow et al., 2016). A literature review identified an alarming existence of disruptive physician behaviour as perceived by RNs and was associated with increased RN intent to leave the organization, a reported increase in patient errors by RNs and RN inability to concentrate or engage in critical thinking (Saxton et al., 2009). Differing perceptions of nurse–physician collaboration has been reported (House & Havens, 2017). Further empirical understanding of the differing perceptions and the lack of respectful, professional RN‐physician relationships is warranted as this study supported the long‐standing impact of these poor relationships on safety culture and nurse burnout. Professional, collaborative relationships must be cultivated and expected by organizations. A zero tolerance of disruptive behaviours by anyone must become an organizational imperative.

5.1. Limitations

This study intended to isolate the unique experience of RNs; however, improving safety culture will require understanding and describing the experiences of all members of the healthcare team. A pandemic was experienced during the interviews however, the hospital didn’t experience a surge of patients until the final validation of results. The researcher served in a leadership role at the organization without any formal or matrixed authority over the participants. Although these results are not intended to be generalizable, the rich description will support the reader in determining the transferability of the results within their own practice.

5.2. Conclusion

This study provided a richer understanding of what is contributing to long standing unfavourable safety culture perceptions in nursing. RNs described daily challenges in the professional work environment that limited their ability to provide safe care. Tension between a desire to provide safe care and achieve zero harm and appropriate organizational support and a professional work environment led to unsafe care, role dissatisfaction and burnout. Systems must understand, expect and support a professional work environment if there is to be any impact on safety culture, safer patient care and keeping RNs working at the bedside in a fulfilling role.

FUNDING INFORMATION

There are no sources of support.

CONFLICT OF INTEREST STATEMENT

The authors disclose that there are no conflicts of interest.

ETHICAL APPROVAL

This study was approved by the Loyola University, Chicago Research Ethics Committee (approval number 212782). Informed consent was obtained from all participants in the study.

Supporting information

Data S1.

Data S2.

Harton, L. , & Skemp, L. (2024). Have our backs‐medical‐surgical nurses’ safety culture experiences: An inductive qualitative descriptive study. Nursing Open, 11, e2095. 10.1002/nop2.2095

DATA AVAILABILITY STATEMENT

Author elects to not share data.