Iranian nurses’ attitudes towards the disclosure of patient safety incidents: a qualitative study

Abstract

Objective

Statistics suggests that patients and officials are unaware of a large number of patient safety incidents in healthcare centres. This study aimed to explore the concept of disclosure of patient safety incidents from the perspectives of Iranian nurses.

Design

Qualitative content analysis.

Setting

The study population was nurses working in hospitals affiliated with The Hormozgan University of Medical Sciences, military hospitals and private hospitals in Bandar Abbas, Iran. Sampling was done from January 2021 to September 2021.

Participants

11 female and 6 male nurses aged 27–59 years with a work experience of 3–34 years were included.

Primary and secondary outcome measures

This qualitative content analysis was to explore the experiences of Iranian nurses (n=17) using purposive sampling and semistructured, in-depth interviews. Maximum variation sampling (age, sex, work experience, education level, type of hospital and type of ward) was considered to obtain rich information. Guba and Lincoln criteria were used to increase the study’s trustworthiness and rigour, and the Graneheim and Lundman method and MAXQDA 2020 were used to analyse data.

Results

We extracted one theme, four categories and nine subcategories. The main theme was the mental schemas of disclosure of patient safety incidents with four categories: (1) misconceptions of harm to the organisation or self, (2) attributes of the disclosure process and its outcomes, (3) reactions to the disclosing incidents and (4) interpersonal conflicts.

Conclusion

Our study identified factors influencing the disclosure of patient safety incidents among nurses, including concerns about reputation, fear of consequences and perceptions of the disclosure process. Positive attitudes towards incident disclosure were associated with supportive organisational environments and transparent communication. Barriers to disclosure included patient and companion reactions, misinterpretation and anxiety. Healthcare organisations should foster a non-punitive reporting culture to enhance patient safety and accountability.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Rigorous qualitative content analysis approach employed.

• Purposive sampling and maximum variation sampling techniques used to ensure diverse perspectives and rich information.

• Identification of factors influencing disclosure of patient safety incidents among nurses, providing valuable insights for healthcare organisations.

• Limited generalisability due to the specific sample of nurses from hospitals affiliated with Hormozgan University of Medical Sciences, military hospitals and private hospitals in Bandar Abbas, Iran.

• Scope of the study focused on the perspectives of nurses, excluding other healthcare professionals and patients.

Introduction

Patient safety incidence is known as an inevitable event in the healthcare system.¹ Patient safety incidence increases the cost of hospitalisation and medical expenses in both developed and developing countries which lead to decrease the quality of healthcare systems and patient safety.^{1 2} In Iran, some documents demonstrate the possibility of high patient safety incidents rate in the healthcare system of Iran. Based on the reports, 1 of 150 patients dies due to outcomes of patient safety incidence in hospitals.^{1 3}

Reporting systems are essential in healthcare to improve patient safety by identifying potential risks and incidents. However, nurses often hesitate to report errors, influenced by various factors that impact the disclosure of patient safety incidents. Some reasons for their reluctance include fear of administrative sanctions, social and legal liability, and concerns about their professional competence being questioned. Additionally, the lack of a proper reporting structure, blame-oriented environments and punitive measures further discourage nurses from reporting incidents. Furthermore, nurses may perceive mandatory reporting systems as having negative effects on error reporting, such as increased likelihood of lawsuits and compromised overall patient safety. Attitudes, particularly those of leadership and management, play a crucial role in fostering a mature safety culture that promotes open communication and information sharing. By establishing a reporting culture that encourages cooperative behaviour, problem-solving, innovation and interdepartmental collaboration can be facilitated, leading to improved patient safety and a more informed healthcare system.

The WHO provides a definition for the disclosure of patient safety incidents, which refers to events that may result in avoidable harm to the patient.⁴ However, there is a lack of comprehensive information regarding the disclosure of patient safety incidents in developing countries such as Iran. This gap exists because healthcare workers in these countries tend to avoid reporting such incidents.^{5 6} According to some Iranian studies, the reporting rate of patient safety incidents varies from one hospital to another in Iran, but 60% of the physicians and 55% of the nurses avoided reporting the incidents to the patients and authorities.^{7 8}

A quantitative study on 20 hospitals in northern Iran showed that only 186 out of 317 966 admitted patients (0.06%) received incident reports; the most reasons were no attitude towards the disclosure of safety incidents and discloser’s punishment.⁹ Several studies indicated that the attitude of healthcare workers, especially nurses, is one of the factors influencing the disclosure of patient safety incidents.^{10 11}

Attitude is one’s positive or negative orientation towards a social or personal thing based on mental schemas, and individual’s knowledge, experiences, perception, personal culture, social culture, organisational culture and religion can have an effect on these schemas. Hashemi et al studied the perception of nursing error reports among 115 nurses working in hospitals affiliated to Tehran University of Medical Sciences. They found that Iranian nurses avoided disclosing patient safety incidents due to lack of knowledge and proper attitude towards the disclosure of incidents and lack of support from the managers.¹² Bifftu et al ¹³ studied management of nursing errors in the USA and considered the lack of attitude towards the disclosure of patient safety incidents as one of the most important reasons why nurses avoided reporting incidents.¹³ The findings of Almansour¹⁴ add to existing knowledge regarding the barriers preventing the reporting of incidents and near misses among healthcare professionals, emphasising the importance for health leaders to ensure a non-punitive reporting process and assess middle-level managers’ knowledge regarding quality of care and patient safety practices.¹⁴ The review of literature shows that lack of attitude towards the disclosure of patient safety incidents has an effective role in not reporting incidents and Disclosure errors is fundamental to error prevention.^11–13

We used a qualitative research method to explore nurses’ attitudes towards disclosing patient safety incidents. This approach was chosen because qualitative research allows for a more in-depth understanding of complex phenomena, such as attitudes. It provides detailed information about nurses’ perspectives, beliefs and experiences related to disclosure.⁴ The qualitative method also helps capture the contextual factors that influence attitudes, such as fear of sanctions, legal liability and organisational culture. It focuses on individual experiences and the decision-making process involved in reporting incidents.¹⁵ From this research, we can learn about the specific factors influencing nurses’ attitudes, the barriers to disclosure and gain contextual insights into the healthcare system. This information is valuable for developing interventions, policies and practices that promote a culture of transparency and patient safety. We decided to conduct qualitative research to explore nurses’ attitudes towards the disclosure of patient safety incidents to better manage safety incidents.

Methods

Study design and setting

This descriptive-explorative study was conducted using conventional content analysis, which purpose is to search in documents and information collected through interviews or field observations.¹⁶ Limitations available in quantitative analysis can be settled by qualitative content analysis; therefore, qualitative content analysis categorises or codes words and themes and focuses on interpreting and understanding texts.¹⁷

Sampling, participants and data collection

We tried to discover the latent and manifest content. The study population was nurses working in hospitals affiliated to Hormozgan University of Medical Sciences (HUMS), military hospitals and private hospitals in Bandar Abbas. Participant recruitment last using purposive sampling from January 2021 to September 2021. 11 female and 6 male nurses aged 27–59 years with a work experience of 3–34 years (table 1) were included based on the inclusion criteria. Semistructured, in-depth face-to-face interviews were conducted. The first participant was chosen because of she had a good ability in speaking and 10 years of work experience. The first researcher (a PhD candidate) conducted the interviews. We conducted a total of 21 interviews, including 4 reinterviews with the participants to regain new insights and 1 additional interview to address some misconceptions. The inclusion criteria were participants with a diploma or bachelor’s/higher degrees in nursing, at least 6 months of clinical experience and direct or indirect involvement in patient care. Data saturation was achieved after 21 interviews with 17 participants. To maintain the maximum variation sampling, all nurses with different ages, education levels, work experiences and job positions were used (committed nurse, experienced nurse, head nurse, matron, supervisor). We required interviewing with nurses working in patient safety unit as well as in military and private hospitals. All interviews were conducted in the hospitals affiliated to HUMS in Bandar Abbas.

Table 1.

Participants’ characteristics (N=17)

Variables		Count
sex	Female	11
	Male	6
Age (year)	Minimum	27
	Maximum	59
Marital status	Single	8
	Married	9
Work experience (year)	Minimum	3
	Maximum	34
Education level	Diploma	2
	Bachelor’s degree	10
	Master’s degree	4
	PhD	1

We conducted interviews using the guidelines of Charmaz 2014: opening questions, intermediate questions and ending questions.^{18 19} An example of opening questions was as follows: would you please express your experience of patient safety incidents? Intermediate questions were: how did you feel about disclosing the incident? What was your reaction after finding the patient safety incident? Why did you avoid disclosing the incident? What was your feeling for not disclosing the incident? What were your concerns about disclosure or non-disclosure of the incident? The ending question was: If you feel like you missed a key word or phrase during the interview, please express it. Each interview lasted 45–90 min.

Data analysis

We performed the following steps based on the five steps proposed by Graneheim and Lundman²⁰:

1. Transcribe interviews immediately.

2. Read the entire text of the interview to get a general understanding of the content.

3. Determine meaning units and primary codes.

4. Categorise similar primary codes into more comprehensive categories and subcategories based on similarities and differences.

5. Determine the latent content.²⁰

First, all interviews were transcribed verbatim and then were read several times. Meaning unites were determined using words, phrases or paragraphs that contained important points about nurses’ attitudes towards the disclosure of patient safety incidents; condensed meaning units were labelled and coded. The codes were compared in terms of similarities and differences, and then the similar codes were merged. Subcategories were developed based on appropriateness and similarity. Then, categories, the main characteristic of qualitative content analysis, were developed. Backward-forward comparison was used to ensure the strength of the codes; categories and subcategories were compared several times and then the main theme was obtained. MAXQ2020 was used for data analysis. Table 2 summarises the analytical procedure used for each text.

Table 2.

Example of qualitative content analysis process

Theme	Categories	Subcategories	Code	Condensation	Meaning unit
Schema of the disclosure of patient safety incidents	Misconceptions of harm to the organisation or self	Misconceptions regarding potential harm to the nurse’s position	Lack of job promotion	The nurse thinks that disclosure will prevent her from being promoted	If I report the incident, it may affect my job promotion and management positions.
		Concerns regarding potential harm to the organisation’s reputation	Reduced social acceptability of the hospital	The nurse thinks that disclosure damages the hospital’s reputation.	If I disclosed an insignificant incident, the reputation of the hospital would be damaged.
	Attributes of the disclosure process and its outcomes	Nurse’s insights regarding the disclosure process	Disclosure only by the offender	The nurse believes that disclosure must be made by the offender	I did not report the incident because I did not commit it. Reporting is the duty of the person who committed it.
		Considerations regarding the disclosure outcome	Ineffective disclosure	The nurse believes that disclosure will not correct the incident.	I did not disclose the incident because the root cause of the incident will not be corrected.
	Reactions to the disclosing incidents	Negative and punitive reaction of system	Belief in the punitive treatment of the organisation	Organisational punishment prevented the disclosure of the incident	If I had reported the incident, the committee would have punished us.
		Positive and supportive reactions of system	Belief in the incentive approach of the organisation	Organisational incentive induced disclosure behaviour	I will not disclose because there is no incentive for the discloser as well as no difference between the person who discloses and the person who hides the incident.
		Negative feedback by patients and companions	Disclosure makes the patient anxious	Prevention of patient anxiety was a cause of non-disclosure	I do not report the incident because the patient gets anxious and worried, which is harmful for his/her heart.
	Interpersonal conflicts	Shame and embarrassment	Feeling ashamed of being blamed by the patient.	Feeling ashamed of being blamed by the doctor.	I felt ashamed of being blamed by the doctor.
		Internal motivations	Considering God as the observer of everything.	Religious beliefs caused the nurse to disclose the incident	Sometimes feeling religious makes you report the incident. We believe God sees everything and we cannot hide anything. It is harm to God’s creation.

Trustworthiness

Guba and Lincoln criteria were used in this study: credibility, dependability, confirmability, transferability and authenticity.²¹ Triangulation, unstructured interview, prolonged engagement, member checking, peer debriefing, maximum variation sampling and constract were used for data credibility.²² In order to ensure the researcher’s credibility, the research team members experienced in conducting qualitative research were used. Credibility in this study was determined through the triangulation (semistructured, in-depth interview, observation, memoing, filed notes) and audit trail (correct interview technique, careful copying and analysis of the authors). The data confirmability was extracted from the participants’ conversations and the authors set aside their views and motivations. Transferability was determined through description of the research method, the characteristics of the participants, the data collection and analysis, and examples of the participants’ statements.²³ The researcher observed the principle of authenticity by obtaining participants’ informed consent, respecting their statements, discovering interpersonal relationships and explaining the research method to the participants.²⁴

Results

After reviewing, removing and merging duplicate or similar codes, we determined one theme, four categories and nine sub categories. The theme was schemas of the disclosure of patient safety incidents with four categories: (1) misconception of harm to the organisation or a person; (2) opinions about the disclosure process and outcome, (3) opinions about behaviours and (4) inner conflict between feelings. Each of the categories consisted of a number of subcategories.

Theme: schemas of the disclosure of patient safety incidents

We concluded that attitudes were schemas that acted as a hidden mechanism in a person when he/she was disclosing incidents. Schemas are based on reality or experience and shape individuals’ responses and behaviours. According to the participants, the schema of disclosure of patient safety incidents consisted of four categories including: misconception of harm to the organisation or self, opinions about the disclosure process and outcome, opinions about behaviours and the inner conflict between feelings.

Misconceptions of harm to the organisation or self

The participants expressed a strong belief that disclosing incidents would negatively impact the hospital’s reputation and their own personal standing within the hospital and society. As a result, they did not hold a positive attitude towards incident disclosure. This category can be further divided into two subcategories: the misconceptions regarding potential harm to the nurse’s position and the misconceptions regarding potential harm to the organisation’s reputation.

Misconceptions regarding potential harm to the nurse’s position

The participants contended that revealing patient safety incidents posed a threat to the offender’s position within the organisation and the job security of the individual disclosing the incidents. They believed that such disclosures would lead to diminished acceptance, hindered career advancement, perceived professional incompetence and tarnished reputation in the eyes of patients. These factors acted as barriers to the disclosure of patient safety incidents.

If we disclosed the incident, the head nurse and nurse would be fired. (Participant No. 3, a 34-year-old female nurse with 12 years of work experience in the ICU)

I avoided disclosing the incident because I would lose the trust of others. (Participant No. 17, a 29-year-old female nurse with 7 years of work experience in the internal medicine department)

Concerns regarding potential harm to the organisation’s reputation

The participants held the belief that revealing patient safety incidents would have detrimental effects on the reputation and prestige of the hospital. They expressed concerns that healthcare workers associated with the hospital would experience a loss of social acceptability. Additionally, participants highlighted the potential negative consequences, such as diminished social acceptability of the hospital itself, compromised professional dignity of nurses and potential harm to the hospital’s accreditation status.

If the patient becomes aware of the incident immediately, he or she will lose his/her trust in the healthcare team. (Participant No. 7, a 36-year-old male nurse with 17 years of work experience in the emergency ward)

Too much disclosure of patient safety incidents will drop the department’s performance indicators, so, we avoid reporting many incidents. (Participant No. 3, a 34-year-old female nurse, with 12 years of work experience in the ICU)

The presence of a competitive environment in Iranian private hospitals, aimed at attracting patients, emerged as a significant factor influencing the disclosure of patient safety incidents.

We avoid disclosing the incidents in private hospitals because patients lose their trust in the hospital. (Participant No. 9, a 28-year-old male nurse with six years of work experience in the burn emergency department)

Attributes of the disclosure process and its outcomes

The participants discussed their perspectives on the process and outcome of disclosing patient safety incidents. This category can be further divided into two subcategories: beliefs regarding the disclosure process and beliefs regarding the disclosure outcome.

Nurse’s insights regarding the disclosure process

Nurses described certain attributes related to the process of disclosing safety incidents. They believed that the handling of non-disclosure of non-harmful incidents, disclosure of harmful incidents, non-disclosure of compensated incidents, the offender’s disclosure and non-disclosure of frequent incidents by the system influenced participants' attitudes and behaviours towards the disclosure of patient safety incidents. These attributes were considered significant factors in shaping how individuals approached incident disclosure.

We reported the incident because it was serious and we could not ignore it. (Participant No.1, a 33-year-old female nurse with a 10-year work experience in the emergency ward)

We did not report the incident because the patient was fine and had no problem. (Participant No. 10, a 35-year-old female nurse with 10 years of work experience in the surgery ward)

I quickly reported the incident and the anesthetist intubated the patient again. I reported it because I had no idea how to compensate for it, but I did not report previous incidents because I could solve them. (Participant No. 11, a 38-year-old female nurse with 13 years of work experience in the CCU & Cath lab)

Considerations regarding the disclosure outcome

They held the belief that the likelihood of reporting an incident depended on the expectation of a positive outcome resulting from the disclosure. In other words, they were more inclined to report an incident when they anticipated a positive consequence or outcome from doing so. This perception influenced their decision-making process regarding incident disclosure. As a result, they maintained a positive attitude towards the potential positive outcomes associated with disclosing patient safety incidents. However, their attitude turned negative when contemplating the potential negative outcomes of such disclosures. Various factors influenced their attitudes, including the goal of preventing further harm, fostering learning from the incident, respecting the patient’s right to be informed and evaluating the effectiveness of the disclosure outcome. These factors played a significant role in shaping the participants’ perspectives on incident disclosure.

I reported the incident because I did not want to cause more harm to the patient. (Participant No. 17, a 29-year-old female nurse with seven years of work experience in the internal ward)

We reported the incident to learn and prevent it from happening again. (Participant No. 2, a 32-year-old male nurse with 14 years of work experience in the military hospital)

Reactions to the disclosing incidents

The study participants mentioned three factors: negative beliefs in punitive behaviours, beliefs in supportive behaviours of the organisation and negative beliefs in patients’ behaviours.

Negative and punitive reaction of system

The participants in the study exhibited a negative attitude towards disclosing patient safety incidents due to their fear of facing repercussions from organisational authorities. This subcategory encompassed several beliefs, including the perception that it was difficult to predict how authorities would react, the presence of an authoritarian and harsh management style and the belief that organisational punishment would be imposed. These beliefs collectively contributed to the participants’ apprehension and reluctance to disclose incidents.

I think disclosure is the right thing to do, but I regretted reporting the incident when I saw that the management mechanism was tyrannical. (Participant No. 8, a 27-year-old male nurse, with four years of work experience in the CCU ward)

My colleague administered the wrong medication for which she was reprimanded and severely punished. Based on this experience, I have chosen not to report the incident. (Participant No. 12, a 30-year-old female nurse with 6 years of work experience in the postpartum & pediatric ward)

Positive and supportive reactions of system

According to the nurses who participated in the study, several factors were identified as having positive impacts on the disclosure of patient safety incidents. These factors included organisational incentives, supportive reactions and the experience of receiving support from the organisation following the disclosure. The participants highlighted these elements as influential in promoting a culture of openness and encouraging healthcare professionals to disclose incidents without fear of negative consequences.

I reported an incident because the hospital gave incentives and increased the monthly salary of those who reported incidents. (Participant No. 10, a 35-year-old female nurse with 10 years of work experience in the nursing management office)

We always report errors because we are sure that the authorities will support us and there will be no problems for us. (Participant No. 4, a 37-year-old female nurse with 15 years of work experience in the surgery ward)

Negative feedback by patients and companions

The study participants shared negative feedback that contributed to a reduced likelihood of incident disclosure. These included instances where disclosure resulted in the patient filing a legal complaint, the patient’s companion engaging in physical assault, the patient misinterpreting the incident and the patient experiencing heightened anxiety as a result of the disclosure. These negative outcomes highlighted the potential risks and adverse consequences associated with disclosing patient safety incidents, which in turn influenced the participants’ decision-making process regarding incident disclosure.

I was replaced by someone who had been fired for a patient safety incident and heavily fined by the court, so I was afraid to report my mistakes and tried not to report them. (Participant No. 7, a 36-year-old male nurse with 17 years of work experience in the emergency ward)

Unfortunately, in all experiences I have had or witnessed, when an incident occurs, patient companions do not behave appropriately, and this inappropriate behavior by physicians and patients led us not to report the incidents. (Participant No. 6, a 27-year-old male nurse with three years of work experience in the ICU & internal ward)

Interpersonal conflicts

Nurses provided insights into the interpersonal conflicts they experienced when it came to reporting incidents. These conflicts arose from conflicting desires, moral beliefs, mental struggles, feelings of insecurity, confusion and doubts, all of which were associated with the reporting process. The study findings revealed that these conflicts significantly influenced nurses’ attitudes towards disclosing patient safety incidents. This category can be further divided into two subcategories: shame and embarrassment and internal motivations.

Shame and embarrassment

The study participants admitted that shame and embarrassment affected their attitudes towards the disclosure of patient safety incidents. This subcategory consisted of feeling ashamed of being blamed by patients, feeling ashamed of being blamed by colleagues, feeling ashamed of being mocked by colleagues, feeling ashamed of being blamed by doctors.

We avoid reporting incidents because patients blame us, which makes us feel guilty. (Participant No. 1, a 33-year-old female nurse, with 10 years of work experience)

I was a new nurse, so I was afraid that my colleagues would make fun of me; I did not want my colleagues to point their fingers at me. (Participant No. 5, a 49-year-old female nurse with 22 years of work experience in the general surgical & psychiatric)

Internal motivations

Some internal factors rooted in religion, beliefs and personality characteristics of people and affected nurses’ attitudes towards the disclosure of patient safety incidents. This subcategory included feeling guilty, feeling responsible, seeing God as an observer, having an obligatory sense to disclose oneself.

I will report incidents in order not to feel guilty; if I had caused a patient death, I would not have had a comfortable life. (Participant No. 15, a 32-year-old female nurse with nine years of work experience in the postpartum)

I reported an incident because my religion and the moral principles are more preferable to me. Nothing is hidden from Almighty God. (Participant No. 3, a 34-year-old female nurse with 12 years of work experience in the ICU)

Discussion

The aim of our study was to explore the concept of disclosure of patient safety incidents from the perspectives of Iranian nurses. Through our research, we discovered that nurses’ behaviours concerning the disclosure of security incidents were influenced by their past experiences, as well as several related factors. We identified various factors that influence the process and outcomes of disclosure. The findings highlighted the complex nature of incident disclosure, with participants expressing both positive and negative attitudes towards the process and outcomes. Factors such as concerns about personal and organisational reputation, fear of professional and legal consequences, and perceptions of the disclosure process and its potential outcomes played significant roles in shaping nurses’ attitudes and behaviours. The study also revealed the importance of supportive organisational environments and positive incentives in promoting incident disclosure. Nurses emphasised the need for transparent communication, accountability and learning from incidents to improve patient safety. However, there were also identified barriers, including concerns about patient and companion reactions, misinterpretation of incidents and increased anxiety.

Previous studies have also identified factors that influence the disclosure of patient safety incidents. For example, a study by Polisena et al ²⁵ found that fear of punishment, uncertainty of what should be reported and how incident reports will be used and time constraints were factors that influenced the recognition, reporting and resolution of patient safety incidents. Another study by Kim and Lee⁴ found that patients can understand the situation better, accept it and develop greater trust in healthcare when nurses disclose patient safety incidents.

The studies also emphasised the importance of supportive organisational environments and positive incentives in promoting incident disclosure. For example, a study by Goekcimen et al ²⁶ found that lack of organisational support and lack of knowledge on incident reporting system and what constitutes an error were reasons why healthcare professionals did not always report errors. Another study by Lee and Kim²⁷ found that nurses emphasised the need for transparent communication, accountability and learning from incidents to improve patient safety. The study by Konlan and Shin²⁸ identified attributes that were associated with patient safety, such as participation in a patient safety programme, reporting of adverse events, communication openness, teamwork within the hospital, organisational learning and exchange of feedback about the error.

The barriers identified in our study, including concerns about patient and companion reactions, misinterpretation of incidents and increased anxiety, are also consistent with previous research that has identified fear of blame and retribution, lack of trust in the organisation and concerns about professional reputation as barriers to incident reporting. A study by Schwappach and Niederhauser²⁹ found that healthcare workers’ fear of blame and retribution was a significant barrier to incident reporting. The study also identified the importance of creating a non-punitive reporting culture and providing feedback to healthcare workers who report incidents. Another study by Geerligs et al ³⁰ found that healthcare workers’ concerns about professional reputation were a significant barrier to incident reporting. The study recommended creating a culture of openness and transparency, providing education and training on incident reporting, and involving healthcare workers in the development of incident reporting policies. A study by Hamed and Konstantinidis³¹ found that healthcare workers’ lack of trust in the organisation was a significant barrier to incident reporting. The study recommended creating a culture of trust and transparency, involving healthcare workers in the development of incident reporting policies and providing feedback to healthcare workers who report incidents. A study by Ali et al ³² found that healthcare workers’ concerns about patient and companion reactions were a significant barrier to incident reporting. The study recommended creating a culture of safety and trust, providing education and training on incident reporting, and involving patients and families in the development of incident reporting policies. A study by Lee et al ³³ found that healthcare workers’ anxiety related to incident disclosure was a significant barrier to incident reporting. The study recommended providing emotional support and counselling to healthcare workers who report incidents, creating a non-punitive reporting culture and involving healthcare workers in the development of incident reporting policies.

The significance of supportive organisational environments and positive incentives in promoting incident disclosure was also emphasised in the current study as well as in previous research. Lack of organisational support, inadequate knowledge of incident reporting systems and unclear understanding of what constitutes an error have been identified as reasons for under-reporting incidents. Conversely, transparent communication, accountability and learning from incidents were highlighted as crucial for improving patient safety, as mentioned by both nurses in the current study and in the study by Lee and Kim.

The barriers to incident reporting identified in the study align with previous research on the topic. Fear of blame and retribution, lack of trust in the organisation, concerns about professional reputation and anxiety have consistently been identified as barriers to reporting incidents. Establishing a non-punitive reporting culture, providing feedback and emotional support to healthcare workers, involving them in the development of incident reporting policies, and fostering trust and transparency within the organisation have been recommended as strategies to overcome these barriers.

Based on our findings, it is crucial to provide comprehensive education and training programmes for nurses, highlighting the significance of disclosing incidents, the benefits it brings in terms of patient safety, incident learning and harm prevention. Healthcare organisations should establish a supportive environment that encourages nurses to disclose patient safety incidents without fear of punishment or intimidation. Clear policies, procedures and guidelines should be developed to facilitate the disclosure process. A patient-centred approach must be emphasised, emphasising the importance of patient-centred care and respecting patients’ rights during the disclosure process. Addressing misconceptions and fears surrounding disclosure by providing evidence-based information that dispels myths about negative consequences, highlighting the positive outcomes such as improved patient safety and learning from incidents. Recognising and addressing the emotional and psychological impact on nurses when disclosing incidents by offering resources for emotional support, counselling services and peer support programmes. Cultivating a culture of support and understanding is essential. Evaluating and enhancing the disclosure process based on feedback from nurses and patients. Regularly reviewing and updating disclosure guidelines and policies ensures their effectiveness and alignment with best practices. Future studies should explore these differences and tailor interventions accordingly. By implementing these recommendations, healthcare organisations can foster a culture of transparency and openness, leading to improved patient outcomes and a stronger commitment to quality healthcare.

Limitations

One of the limitations of this study was the spread of the COVID-19 and less access to samples, which increased the duration of sampling. We conducted this study in southeastern Iran, but there are many cultural and ethnic differences in Iran, so future studies should take into account these differences.

Conclusion

Our study results shed light on various factors influencing the disclosure of patient safety incidents among nurses. The findings highlighted the complex nature of incident disclosure, with participants expressing both positive and negative attitudes towards the process and outcomes. Factors such as concerns about personal and organisational reputation, fear of professional and legal consequences, and perceptions of the disclosure process and its potential outcomes played significant roles in shaping nurses’ attitudes and behaviours. The study also revealed the importance of supportive organisational environments and positive incentives in promoting incident disclosure. Nurses emphasised the need for transparent communication, accountability and learning from incidents to improve patient safety. However, there were also identified barriers, including concerns about patient and companion reactions, misinterpretation of incidents and increased anxiety. Overall, the study underscores the need for healthcare organisations to foster a culture of safety and non-punitive reporting, where nurses feel supported and encouraged to disclose incidents without fear of negative repercussions. By addressing the identified barriers and implementing strategies to promote open communication, healthcare organisations can enhance patient safety, facilitate learning and promote a culture of transparency and accountability.

Data availability statement

Data are available on reasonable request.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).

Ethics approval

The studies involving human participants were reviewed and approved by IR.KMU.REC.1399.574. This study was conducted following the ethical guidelines outlined in the Declaration of Helsinki. The ethics committee of KUMS approved all procedures used in the. The study objectives, data collection and recording, the roles of the researcher and participants, data privacy and confidentiality were explained orally. Participants were assured that they could withdraw from the study at any time. The researcher received written consent from all the study participants.