The factors influencing patient safety management as perceived by emergency department nurses: A qualitative study

Abstract

Aim

One of the most important, unpredictable and stressful areas in hospitals is the emergency department (ED) where seconds are crucial for providing immediate care and saving the patients' lives. Therefore, the present study aimed to identify the factors which impact the patient safety management as perceived by the ED nurses in Southern Iran.

Design

This is a qualitative, descriptive study.

Methods

The participants were 23 ED nurses selected via purposeful sampling who were asked to take part in an interview. Data were collected using semi‐structured, individual, in‐depth interviews and analysed via content analysis.

Results

Analysis of the qualitative data yielded 4 themes and 12 subthemes. The four main themes were: negligence of safety standards and standard precautions, disregard of ethical principles, professional challenges and inefficient organizational management.

1. BACKGROUND

One of the most important and stressful units in hospitals where seconds count in giving emergency care and saving patients' lives is the emergency department (ED) (Amaniyan et al., 2020). Patient safety is an integral part of healthcare systems in different countries as the clinical risk caused by negligence of patient safety can lead to unwanted serious injuries to patients, including permanent disabilities and even death (Jani et al., 2016). Patient safety is defined by the World Health Organization (WHO, 2009) as ‘the prevention of errors and adverse effects to patients associated with health care’ and to do no harm to patients (WHO, 2009).

In other words, preservation of patient safety is one of the basic guiding principles of medical organizations, affecting all healthcare systems (Kakemam et al., 2021). Statistics on clinical risk and medical errors all over the world indicate that, despite the existence of a system for the management of clinical risk, the rate of injuries to patients in hospitals is still high (Alsabri et al., 2022). Because of the stressful nature of the ED, the personnel working in ED face a variety of safety challenges when they come into contact with patients and their companions: every year, millions of patients suffer injuries as a result of errors made by caregivers after their failure to provide safe care (Lecky et al., 2014; Savioli et al., 2022). Negligence in identifying the main factors in patient safety and their improvement not only causes injuries and disabilities but also increases the length of hospital stay, patients' dissatisfaction with healthcare services and high costs imposed on patients and the healthcare system. Thus, today, reducing medical errors and increasing patient safety have become global priorities (Bigham et al., 2012). The most effective way to avoid medical errors, which threaten patients' safety, and improve the management of patient safety is to identify the most significant barriers and challenges in preserving patient safety and deal with them by improving the healthcare system (Lt, 2000). According to a cross‐sectional study conducted by Alsabri, et al. (2022) in Saudi Arabia with the aim of identifying the effective factors in patients' safety in the ED as perceived by nurses, the most common threats to patient safety in the ED were found to be errors related to medical equipment and medication errors. The results of a systematic review by Çinarli et al. (2020) show that the factors which adversely affect management of patient safety in the ED include lack of effective teamwork, overcrowding in the ED, lack of experienced personnel and poor communication skills.

In a cross‐sectional study carried out by Ricklin et al. (2019) in Switzerland, it was shown that the lack of optimal reports of adverse events, lack of teamwork in the units and the transfer of patients accounted for the weakness in the emergency department in terms of patient safety.

The results of a study conducted by Habibi Soola et al. (2022) in Iran revealed that the patient safety competency of emergency department nurses was primarily related to the structure and leadership of the team and then to psychological safety and experience in patient safety activities. According to a systematic review conducted by Diz and Lucas (2022), the nurses' perceptions indicated that the work environment, teamwork and issues related to the leadership of hierarchical superiors were fundamental factors to improve the quality of care provided and patient safety.

For an in‐depth understanding of this concept and its different dimensions, a qualitative approach will prove helpful as qualitative studies investigate the concepts in cultural contexts from the perspective of individuals who have been engaged with the phenomenon in question for a long time period (Doyle et al., 2020). In addition, a qualitative approach to exploring the major barriers to management of patient safety in the ED will allow for an insight into in‐depth experiences of the ED personnel regarding the challenges in providing safe care. Without an understanding of the experiences and perceptions of the ED personnel of the existing difficulties in managing patient safety in the complex and unpredictable environment of the ED, it is not possible to determine effective strategies for dealing with those issues, which will contribute to the quality of care and patient safety. Accordingly, the present study aimed to identify the factors influencing patient safety management as perceived by the ED nurses in Southern Iran.

2. METHODS

This study used a descriptive qualitative design which is an effective method used to find the answer to a research question and determine the subjects' perception of the phenomenon under study (Bradshaw et al., 2017). When little is known about a population's perception of a concept, a descriptive qualitative design allows the researchers to gain insight into human experiences in their unique context (Lewis, 2015).

2.1. Participants

The participants consisted of 23 ED nurses selected using purposeful sampling in Fars Province in southern Iran. Sampling continued until the data reached saturation. The inclusion criteria were having at least 1 year of experience in practice in the ED and being willing to participate in the study. The subjects who were not prepared physically or mentally to be interviewed or were not willing to continue their participation in the study were excluded. The study was carried out from May to December 2022.

2.2. Data collection

Data were collected from 23 semi‐structured, individual, in‐depth interviews. All the interviews were conducted in the conference hall of the ED of the hospital by prior arrangement with the director of the hospital, the head nurse of the ED and the participants.

After consultation with the head nurse of the ED, we chose one of the personnel who could help us gather rich information for the first interview. Then, he was asked to introduce a colleague with sufficient knowledge and experience of the subject we were investigating. Thus, we selected the subsequent participants with a good understanding of the study subject based on the information which was provided by the participants selected earlier.

The first author conducted the interviews. Each interview lasted about 45–60 min and began with some general questions, including ‘How long is your work experience?’ and ‘What is your typical workday like in the ED?’ Next, more specific questions related to the objectives of the study were asked, for example, ‘Based on your experience, what are the major barriers and challenges in management of patient safety in the ED?’, ‘What strategies do you suggest for management of patient safety?’ and ‘What skills do you require to manage patient safety well?’ We focused on the main objective of the study in the interviews. We also asked some follow‐up questions to add to the clarity of the information given by the participants, for example: ‘Can you explain that point further?’, ‘What do you mean by that?’ and ‘Can you give an example or tell me about your experience?’ After we interviewed21 participants, we found that no new information had been extracted from the interview. After 2 more interviews, no new information related to the research was obtained. When we collected sufficient data and achieved data saturation, the interviews were stopped.

2.3. Data analysis

In the present study, Graneheim and Lundman's method of content analysis (2004) was used to analyse the data (Cypress, 2017). First, to immerse in the data and obtain a general idea of the concept under study, the researchers read and reread the transcript of each interview several times. Next, the words, sentences or paragraphs signifying the major barriers and challenges in management of patient safety in the ED were selected as meaning units. Then, we classified the meaning units by making a link to a summary of the meanings of the units and coded the texts. Subsequently, the codes were studied in terms of their similarities and differences, and the similar codes were merged. In this manner, we developed different categories. To confirm the reliability of the codes, the researchers re‐examined the categories and compared them to the codes. After we deeply reflected on the categories, the themes were identified. Immediately after each interview, the first author transcribed the recorded content and marked the significant paragraphs. After we to assigned codes the meaning units were, the corresponding author checked the transcripts and identified the similar codes which were then merged to form categories. The researchers examined the categories and compared them to the initial data. Finally, after several joined meetings, the research team extracted the themes from the categories. The collected data were analysed in MAXQDA 2007 (Table 1 shows example of the process of data analysis).

TABLE 1.

An example of coding and development of subthemes and themes.

Meaning units	Coding	Subtheme	Theme
‘Sometimes, when the emergency room is too crowded and there are many accident victims, my colleagues ignore the principles of hygienic bandaging and dressing in caring for wounds and controlling bleeding. The fact that there are a lot of accident victims who need immediate care does not mean we can stop working systematically and professionally and risk the patients' health. On many occasions, I've seen unprofessional behaviours by my colleagues who don't observe the principles of sterile bandaging on the excuse that the patients must receive care right away’ (participant 12)	Non‐use the principles of sterile in bandaging and dressing	Non‐hygienic bandaging and dressing in wound care	Negligence of safety standards and standard precautions
‘Not everyone is qualified to work in the emergency room. The slightest mistake or negligence can put a patient's life at risk. Unfortunately, because there aren't enough human resources, the managers sometimes use inexperienced nurses who lack the necessary professional capabilities and clinical competence, which threatens the patients' safety’ (participant 15)	Use of inexperienced nurses who lack the professional capabilities and clinical competence	Lack of experienced expert personnel in emergency rooms	Professional challenges

2.4. Rigour

The accuracy and trustworthiness of the data which were collected were examined using the criteria suggested by Guba and Lincoln (1982). Prolonged engagement, member checking and peer review were used by the researchers to verify the credibility of the results. As to member‐checking, seven emergency room nurses were provided with a copy of the coded interviews; then, they were asked to confirm the accuracy of the content. For peer‐checking, six experts observed the process of data analysis and confirmed the codes and categories. The researchers produced an audit trail, including the use of precise interview techniques, accurate transcription and peer review to ensure dependability and confirmability. Transferability was increased by providing thorough and accurate descriptions of the concept under study, participants' characteristics, method of data collection, method of data analysis and samples of the participants' quotes (Graneheim & Lundman, 2004).

2.5. Ethical considerations

The informed consent was signed by all participants before they participated in the study. They were assured of the anonymity and confidentiality of their information. Furthermore, the study was approved by the Institutional Research Ethics Committee of Fasa University of Medical Sciences, Fasa, Iran (ethical code: IR.FUMS.REC.1401.028). All methods were performed based on the guidelines and regulations, meeting the ethical guidelines described in the Declaration of Helsinki.

3. RESULTS

The participants' mean age and work experience were 36.26 ± 6.15 and11.34 ± 5.47 years respectively. Table 2 displays the other demographic characteristics of the participants. Analysis of the qualitative data yielded 4 themes and 12 subthemes. The four main themes were negligence of safety standards and standard precautions, disregard of ethical principles, professional challenges and inefficient organizational management (Table 3).

TABLE 2.

Individual characteristics of the participants.

Participants	Gender	Age (year)	Educational level	Work experience (years)
P1	Female	27	Bachelor's degree in nursing	3
P2	Male	31	Bachelor's degree in nursing	7
P3	Male	33	Bachelor's degree in nursing	9
P4	Female	29	Bachelor's degree in nursing	5
P5	Female	35	Master degree in nursing	10
P6	Male	41	Bachelor's degree in nursing	15
P7	Male	39	Bachelor's degree in nursing	13
98	Male	43	Master degree in nursing	17
P9	Male	37	Bachelor's degree in nursing	11
P10	Female	36	Master's degree in nursing	9
P11	Male	29	Bachelor's degree in nursing	5
P12	Female	33	Bachelor's degree in nursing	9
P13	Female	28	Bachelor's degree in nursing	3
P14	Male	30	Bachelor's degree in nursing	5
P15	Male	44	Master's degree in nursing	19
P16	Female	39	Master's degree in nursing	15
P17	Male	46	Bachelor's degree in nursing	17
P18	Female	31	Bachelor's degree in nursing	8
P19	Male	33	Master's degree in nursing	10
P20	Male	40	Bachelor's degree in nursing	16
P21	Male	47	Bachelor's degree in nursing	20
P22	Male	38	Bachelor's degree in nursing	14
P23	Female	45	Master degree in nursing	21

TABLE 3.

Themes and subthemes extracted from content analysis.

Themes	Subthemes
Negligence of safety standards and standard precautions	Medication errors Non‐hygienic bandaging and dressing in wound care Negligence of safety rules Incorrect transfer of patients to other wards
Disregard of ethical principles	Disrespect for patients' human dignity and personal identity Disrespect for patients' privacy
Professional challenges	Lack of experienced expert personnel in emergency rooms Work fatigue and stress due to work overload Poor communication skills and lack of effective teamwork
Inefficient organizational management	Lack of a mechanism for continuous monitoring and evaluation of the personnel's professional performance Lack of clinical guidelines on patient safety management Lack of standard equipment and physical space

3.1. Negligence of safety standards and standard precautions

The participants' experiences and views revealed that negligence of safety standards and standard precautions is one of the major barriers to management of patient safety in the ED. The subthemes of medication errors, non‐hygienic bandaging, negligence of safety rules and incorrect transfer of patients were the components of this theme.

3.1.1. Medication errors

According to the experiences and views of the ED nurses, one of the most common threats to patients' safety in the ED is medication errors. Fatigue due to work overload, inadequate knowledge about drugs, and lack of clinical guidelines on medication administration safety caused the ED nurses to make medication errors. Also, negligence of safety rules and standard precautions lead to the recurrence of medication errors. One of the participants stated:

Very often, I've witnessed my colleagues put the patients' lives at risk by not taking the medication safety rules seriously. I've even seen patients lose their lives because of medication errors on the part of the emergency department personnel. These incidents are truly harrowing. (participant 9)

Another participant stated that:

The core of nursing care is preserving the patients' safety and health, and risking the patients' safety and lives is the red line in nursing. We must never let medication errors, which I think are rooted in lack of attention to the principles of medication safety and put the safety and lives of patients at risk. It's really upsetting to see a patient lose his or her life because of a medication error which could have been prevented. (participant 7)

3.1.2. Non‐hygienic bandaging and dressing in wound care

Another subtheme of negligence of safety standards and standard precautions is non‐hygienic bandaging. In the ED, sometimes the staff must provide care to a large number of patients in trauma, those who have suffered serious injuries and are bleeding profusely. At such times, adherence to safety guidelines and standard professional precautions is essential as it directly affects the patients' health and safety. According to one of the participants:

Sometimes, when the emergency room is too crowded and there are many accident victims, my colleagues ignore the principles of hygienic bandaging and dressing in caring for wounds and controlling bleeding. The fact that there are a lot of accident victims who need immediate care does not mean we can stop working systematically and professionally and risk the patients' health. On many occasions, I've seen unprofessional behaviors by my colleagues who don't observe the principles of sterile bandaging on the excuse that the patients must receive care right away. (participant 12)

3.1.3. Negligence of safety rules

Another subtheme of negligence of safety standards and standard precautions is the negligence of safety rules and principles. The participants' experiences showed that one of the major threats to patient safety in the ED is negligence and disregard for patient care principles. The ED nurses must often provide care to a crowd of patients, each of whom needs a specific type of care depending on their illness or injury. Some patients may carry dangerous viral infections, including HIV and hepatitis, which can put the health of the ED nurses and other patients at risk. Therefore, it is essential that the principles of hygiene, especially hands washing and sanitary disposal of waste, be observed. One of the participants stated that:

On some occasions, we've had 30 to 40 patients with different kinds of issues who attend the emergency department in one shift. We don't even know what illness each patient has. The best thing to do is taking the rules of sanitation seriously to protect our own and the patients' lives. How long does it take to wash one's hands? I don't see why some of the personnel don't care about this rule of hygiene to protect themselves and their patients. Very often I've seen some of my colleagues not wash their hands even once during a shift despite their contact with many patients. (participant 11)

According to another participant:

The nature of care in the ED is such that many things are unpredictable and at the same time there is a host of patients to care for. Thus, following the rules of sanitation about segregating waste is very important. Sometimes, the doctors or nurses don't comply with the rules of safety and hygiene when they're performing wound care or diagnostic procedures and let contaminated dressings, blood or infected discharge from patients fall on the floor or put them in waste bins which are for non‐infected waste. This can spread an infection and threaten the safety of the personnel and patients. (participant 17)

3.1.4. Incorrect transfer of patients to other wards

Another instance of disregard for safety standards and standard precautions is incorrect and unsafe transfer of patients to other hospital wards. One of the participants stated that:

Unfortunately, when the ED is very busy and things are complicated, and the patients should be triaged quickly and sent to other wards, like the operating rooms and the surgical unit, in patient transfer, due to the personnel's negligence of safety standards, the patients sometimes fall and suffer concussions. In a few cases, I saw patients who fell and suffered serious brain injury and then lost their lives. (participant 16)

3.2. Disregard of ethical principles

Disregard of patients' ethical principles, another main theme in the present study, consists of the subthemes of disrespect for patients' human dignity and personal identity and disrespect for patients' privacy. The participants' experiences showed that patient dignity was not limited to protecting the physical safety of the patients but encompassed their psychological safety as well.

3.2.1. Disrespect for patients' human dignity and personal identity

In patient care, care providers must respect their patients' dignity, values and religious beliefs. Disregard of patients' personal identity can threaten their psychological safety. According to one of the participants:

It doesn't make a difference to me, as the ED nurse, what personal or religious beliefs my patients hold. Showing respect for patients' dignity and values will guarantee their psychological safety and security. If patients feel that their values and beliefs are ignored or disrespected or think that the doctors and nurses are treating them differently from others or pity them, then they will feel that their personal identity and psychological safety are not important. (participant 19)

3.2.2. Disrespect for patients' privacy

Another subtheme of disrespect for patient dignity is disrespect for patients' privacy. Maintaining patients' privacy is one of the most important aspects of their psychological safety, which care providers must consider in all hospital units, especially in the ED. According to one of the participants:

Sadly, some the ED nurses and doctors have no respect for patient privacy; when patients are naked, they start to insert a catheter without even using a folding screen, or, sometimes, for burn patients, when there is lack of workforce, a male nurse does the dressing for a female patient. This is very inconvenient to patients and makes them feel that their dignity does not matter; this causes frustration. (participant 18)

3.3. Professional challenges

As another main theme in the present study, professional challenges consist of the subthemes of lack of experienced expert personnel in the ED, work fatigue and stress due to work overload poor communication skills, and lack of effective teamwork.

3.3.1. Lack of experienced expert personnel in emergency rooms

The participants' experiences showed that a significant contributory factor in the quality of care provided to patients, and, by extension, patient safety is the presence of experienced nurses who possess clinical competence. Given the complicated nature of patient care in the ED, it is essential that the ED nurses have enough clinical knowledge, skill and experience to provide quality care to patients as quickly as possible. One of the participants maintained:

Not everyone is qualified to work in the emergency room. The slightest mistake or negligence can put a patient's life at risk. Unfortunately, because there aren't enough human resources, the managers sometimes use inexperienced nurses who lack the necessary professional capabilities and clinical competence, which threatens the patients' safety. (participant 15)

Another participant stated that:

When some of my colleagues don't have the required clinical competence for practice in the emergency department, are not familiar with high‐risk emergencies and life‐threatening conditions, and can't assess and manage the clinical status of a patient in need of urgent care, how can we expect them to preserve patient safety and not harm the patients? (participant 6)

3.3.2. Work fatigue and stress due to work overload

The work environment in the ED is very stressful and the hard work conditions and excessive workload can cause fatigue, burnout and severe psychological tension in the ED nurses, with adverse effects on the quality of nursing care and patient safety. According to one of the participants:

Working in the ED is really exhausting. Sometimes, there is so much work to do that I don't even get the chance to drink a glass of water; I don't even notice when my shift is over. I'm a human and there is a limit to what I can take. They put so much pressure on the emergency room nurses that some of them get burned out in the first few years and quit the emergency department. (participant 10)

According to another participant:

The work overload and burnout caused by the emotional and psychological tension of working in the ED not only threaten the nurses' occupational health but also have a negative impact on the quality of the services. When the work shifts are extended and the nurses in the ED get fatigued, they can't concentrate and make the right clinical decision in an emergency, which puts the patients' safety at risk. (participant 14)

3.3.3. Poor communication skills and lack of effective teamwork

The participants' experiences showed that good communication skills and effective teamwork are essential in the complicated working conditions of the ED. According to one of the participants:

Unfortunately, most of the doctors and nurses in the ED don't have the necessary communication and teamwork skills and, in some cases, poor communication skills result in quarrels and conflicts between the personnel. At times like this, those who suffer most are the patients. When I, as a nurse, can't have a good relationship with my colleagues and patients, how can the patients be expected to trust the medical team? (participant 21)

3.4. Inefficient organizational management

Another main theme extracted from the data is inefficient organizational management, which is comprised of lack of a mechanism for continuous monitoring and evaluation of the personnel's professional performance, lack of clinical guidelines on patient safety management and lack of standard equipment and physical space. Based on the participants' experiences, hospital managers must see patient safety as a top priority and take measures to remove the barriers to effective management of patient safety.

3.4.1. Lack of a mechanism for continuous monitoring and evaluation of the personnel's professional performance

For the quality of patient care and, by extension, patient safety to improve, it is necessary that the professional performance of emergency room nurses should be monitored and evaluated continuously so that their weaknesses can be identified and dealt with. According to one of the participants:

Unfortunately, the ED managers and head nurses do not monitor the emergency room nurses' performance in a precise and regular manner, and we witness nurses make mistakes in caring for patients every day. (participant 18)

3.4.2. Lack of clinical guidelines on patient safety management

Up‐to‐date clinical guidelines on hazard and patient safety management play a key part in improving the nurses' clinical knowledge and the quality of nursing care. One of the participants stated that:

There are times when we really don't know what is right and what is wrong. If there was an accurate and clear set of guidelines for the emergency room nurses, we wouldn't get confused or feel hesitant about the interventions. (participant 13)

3.4.3. Lack of standard equipment and physical space

Providing quality care in the ED depends on access to standard equipment and physical space. As the work environment in the ED is unpredictable and the personnel should provide care to a large number of patients with different clinical issues, shortage of standard medical equipment and physical space can hamper the provision of safe care. One of the participants said:

Many times, because the ED is overcrowded, there aren't enough beds or physical space for the patients, or we don't have the equipment for heart monitoring for high‐risk patients with cardiac disorders. As the ED nurse, I must do something for my patients, so I administer a high‐risk heart medication without any heart monitoring. (participant 5)

Another participant stated that:

The physical space of the ED must be standard, so when there is a large crowd of patients, there is enough room for everyone. Also, the physical space of the ED must be specialized, so that every patient can receive the specific specialized emergency care that he or she needs. For instance, the ED for trauma patients should be separate from the area for patients with poisoning or burns. If all the patients who need immediate medical attention are sent to a single area in the emergency department, the result is overcrowding and risk to patient safety (participant 8)

4. DISCUSSION

This qualitative study was carried out to identify the factors influencing patient safety management from the perspective of the ED nurses in the south of Iran. Analysis of the qualitative data resulted in four themes, namely negligence of safety standards and standard precautions, disregard of ethical principles, professional challenges and inefficient organizational management. The findings of the present study revealed that one of the main challenges in the management of patient safety in the emergency department is negligence of safety rules and standard precautions. Institutionalizing adherence to safety standards and standard precautions in emergency departments is the key to effective and efficient safety management. In the participants' experience, medication errors, incorrect and non‐hygienic bandaging, negligence of rules of hygiene, especially hand hygiene, and unsafe transfer of patients from the ED to other hospital units are caused by the personnel's disregard for safety standards and precautions. According to a study, observance of standard precautions, including hand hygiene, by the medical personnel in the ED during diagnostic and treatment procedures is essential to preventing the spread of infections and, consequently, protecting the health and safety of the personnel and patients. Therefore, it is important that emergency department managers continuously monitor the personnel's compliance with safety rules and standard precautions and evaluate their performance (Chen et al., 2019). A study by Issa et al. (2023) found that observance of hand hygiene by emergency department doctors and nurses was not satisfactory. In view of the spread of various viral infections and the unknown nature of some diseases caused by them, it is necessary that continuing educational programmes should be organized to enhance care providers' awareness of safety rules towards protecting the safety of the personnel and patients.

Another aspect of negligence of safety rules is incorrect and unsafe transfer of patients from the ED to other hospital units. The participants' experiences showed that patients' falling during transfer is a common incident which threatens the patients' safety and health. According to a study carried out by Choi et al. (2019), one of the hazards which threatens the safety of patients, especially elderly patients in the ED, is falling, which can lead to a concussion or serious femoral and pelvic fractures. It is important that the ED managers develop and implement standard protocols on safe patient transfer to prevent injuries to patients while they are being transferred to other hospital units and regularly evaluate the personnel's compliance with the safety rules in this area.

Another subtheme of negligence of safety standards and standard precautions is medication errors. A study by Shitu et al. (2020) indicated that the rate of medication errors committed by emergency room nurses was 30.5%. Also, a study conducted by Di Simone et al. (2018) showed that the main causes of medication errors in emergency rooms are fatigue due to work overload, inadequate knowledge of medications and lack of specific guidelines on medication administration safety, which is consistent with the findings of the present study. However, a study conducted by Hosseini Marznaki et al. (2020) found that the incidence rate of medication errors made by the ED nurses in Iran was high (46.2%). This study reported that extended shifts and inadequate knowledge of drugs were the main causes of these errors, which agrees with the findings of the present study. According to the high prevalence of medication errors made by the ED nurses, it is essential that senior ED managers take measures to remove the existing professional barriers, increase the nurses' medication knowledge, develop specific guidelines on medication administration safety and continuously monitor and evaluate the ED nurses' performance with regard to medication errors.

Another theme extracted from the data in the present study is disregard of ethical principles, which encompasses disrespect for patients' human dignity and personal identity and disrespect for patient privacy. According to a study by Bijani and Mohammadi (2021), maintaining patient autonomy, patient dignity and patient privacy was the most important ethical consideration from the perspective of emergency burn care nurses. Also, the results of a study by Bijani et al. (2021) showed that the emergency care personnel regarded respecting and maintaining patient privacy as an important ethical dimension of patient care. It is necessary that nurses follow the ethical principles of patient care; therefore, the nursing managers in the ED should monitor the nurses' adherence to codes of ethics and stress the importance of providing care according to these codes.

Another theme in the present study is professional challenges, consisting of lack of experienced expert personnel in the ED, work fatigue and stress due to work overload and poor communication skills and lack of effective teamwork. Studies by Levis‐Elmelech et al. (2022) and Aloyce et al. (2014) found that most the ED nurses made mistakes in triage because they lacked clinical experience and expertise in this area. A study by Duko et al. (2019) showed that having knowledge of triage protocols and good clinical knowledge of pathology and emergencies was the key to nurses' successful execution of triage. According to a study by Barasteh et al. (2021), lack of specialized nurses was a major nursing challenge in the Iranian healthcare system. Similarly, studies conducted by Bijani and Khaleghi (2019) and Najafi et al. (2021) indicate that lack of experienced and expert personnel who possess the required professional capabilities, and work burnout and stress caused by work overload were serious challenges which adversely affect the quality of triage by the ED nurses. On a similar note, Caulfield et al. (2022) reported that excessive workload in emergency departments led to job distress in emergency nurses, with a negative impact on the quality of patient care and patient safety. According to the sensitive nature of emergency care, senior emergency department managers should take measures to recruit nurses who have the necessary professional capabilities. Measures should also be taken to reduce the ED nurses' exposure to work stress and burnout, which adversely affect the nurses' professional performance and patient safety.

Another subcategory of professional challenges in the present study is poor communication skills and lack of effective teamwork. The participants' experiences showed that disagreements and conflicts between doctors and nurses in the ED, which are caused by lack of communication and teamwork skills, have an adverse effect on the quality of care, and the patients are the ones who suffer the most. A study by Henry et al. (2016) showed that, from the patients' perspective, good teamwork between the ED doctors and nurses increased the patients' trust in the medical team and assured the patients that they were at the centre of care. Similarly, according to a study by Muntlin Athlin et al. (2013), effective teamwork in the emergency department not only enhances the quality of emergency care but is essential to safe patient care. Similarly, according to a study carried out by Ricklin et al. (2019) and Diz and Lucas (2022), the lack of optimal teamwork is the reason for weakness in the emergency department as to patient safety.

Thus, in view of the significance of communication skills and teamwork in improving the quality of patient care, emergency department managers should design continuing educational programmes to enhance the medical teams' communication and teamwork skills.

The last theme extracted from the data in the present study was inefficient organizational management, which consists of lack of continuous monitoring and evaluation of the personnel's professional performance, lack of clinical guidelines on patient safety management and lack of standard equipment and physical space. Bijani and Khaleghi (2019) in their study indicated that lack of clinical guidelines, standard medical equipment and physical space which adversely affect the safety and quality of nursing care were seen by the ED nurses as the main challenges in triage. Likewise, Mohammadi et al. (2021) found that, from the perspective of the emergency care personnel, lack of clinical guidelines had an adverse effect on the quality of patient triage. Moreover, in their study, Najafi et al. (2021) concluded that a mechanism for continuous monitoring and evaluation of the personnel's performance, evidence‐based care, clinical guidelines, specialized equipment and a standard physical space were the primary indexes of a standard emergency department as perceived by ED nurses.

4.1. Limitations

The participants of the present study consisted of ED nurses only; therefore, it is suggested that future research should investigate both the ED doctors and patients' views. Also, the present study was conducted in Fars Province, the south of Iran, so the results are not generalizable to other parts of the country. There are economic, cultural and social differences between Iran and other countries, so it is recommended that a similar study should be conducted in other countries.

4.2. Strengths

This is the first qualitative study on the major barriers and challenges in the management of patient safety as perceived by the ED nurses in Iran, which makes it an innovative work.

5. CONCLUSION

Negligence of safety standards and standard precautions, disregard for ethical principles, professional challenges and inefficient organizational management impact the quality of nursing care adversely and, as a result, patient safety. Senior emergency nursing managers can use the findings of the present study to identify and eliminate the factors influencing patient safety management in the ED, and, consequently, facilitate the provision of safe, comprehensive and quality nursing care.

AUTHOR CONTRIBUTIONS

FM and MB were involved in the conception and organization of the study and participated in statistical analysis design and/or execution. MB and SR were involved in the execution and data collection of the study. All authors contributed to the preparation, critical review and all of them approved the final manuscript.

FUNDING INFORMATION

This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no competing interests.

Mohammadi, F. , Rustaee, S. , & Bijani, M. (2024). The factors influencing patient safety management as perceived by emergency department nurses: A qualitative study. Nursing Open, 11, e2135. 10.1002/nop2.2135

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.