Moving on performance responsibility: an institutional ethnographic study of nurses’ experiences with quality indicators in the transforming healthcare system of Saudi Arabia

Abstract

Objective

To explore how nurses working in Saudi–affiliated health-care settings experience and negotiate quality indicators within the context of health system transformation in Saudi Arabia.

Methods

This qualitative institutional ethnographic study was conducted in tertiary teaching hospitals and primary health-care centres in Riyadh. Purposive sampling recruited 22 registered nurses from medical, surgical, critical care, emergency, oncology, obstetric, paediatric, and primary care units. Data were generated through semi-structured interviews, non-participant observations of quality-related activities, and collection of institutional texts, including policies, key performance indicator definitions, dashboards, and audit tools. Data were analysed using institutional ethnographic principles supported by NVivo 14 to map how nurses’ everyday work is coordinated by quality indicators and associated texts.

Results

Four interrelated themes were identified: “Caring Through Numbers: Making Quality Visible,” describing how nurses translate bedside care into indicator fields and documentation; “Carrying the Score: Performance Responsibility on Nurses’ Shoulders,” highlighting how unit-level indicator results are experienced as personal and collective judgments of nursing performance; “Working Around the System: Navigating Constraints and Contradictions,” capturing pragmatic adaptations and quiet resistance to indicator demands; and “Reclaiming Professional Voice in Quality Work,” showing how nurses use indicators as learning tools and call for shared responsibility and system support.

Conclusion

Quality indicators in Saudi university settings function as ruling texts that shape nurses’ priorities, accountability, and sense of professional agency. Transforming dashboards into instruments for quality improvement requires co-design with nurses, realistic targets, and organisational investment in staffing, education, and supportive digital infrastructure.

Clinical trial

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-04272-6.

Introduction

Nurses across the globe are increasingly positioned at the forefront of health-care quality agendas, as health systems adopt performance measurement and accountability frameworks to demonstrate value, efficiency, and patient-centred outcomes [1]. Quality indicators, typically expressed as standardized, quantifiable measures of structures, processes, and outcomes, have become central tools for governing health-care organizations, informing accreditation, benchmarking, and public reporting [2]. While these indicators are often presented as neutral, technical instruments that objectively capture “quality,” they are in fact socially organized practices embedded within complex institutional relations, power structures, and professional hierarchies [3].For nurses, who deliver much of the direct care that underpins these metrics, the growing emphasis on indicator performance has reshaped daily work, documentation practices, and professional responsibility in profound ways [4].

In many health systems, the rise of quality indicators is closely linked with broader trends in New Public Management, value-based care, and health-care marketization, which foreground measurement, transparency, and performance comparisons as mechanisms for improvement and control [5]. These approaches tend to translate multifaceted aspects of care, such as relational continuity, patient dignity, and teamwork, into discrete, countable units, often privileging what can be readily measured over what matters most to patients and professionals [6]. Empirical studies have shown that nurses frequently bear the burden of producing the data that drive these indicators, through extensive documentation, audits, and compliance checks, sometimes at the expense of direct patient care [7]. This shift has been described as a movement from “caring work” to “paper work,” and more recently to “screen work,” as electronic health records and dashboards proliferate at the bedside [8].

Saudi Arabia’s health-care system is undergoing an intensive period of transformation under the Vision 2030 and Health Sector Transformation Program, which seek to improve efficiency, quality, and population health outcomes, while expanding private sector participation and adopting value-based care models [9]. Within this reform landscape, quality indicators, key performance indicators (KPIs), and clinical quality dashboards are increasingly used to monitor hospital performance, drive accreditation, and align institutions with national strategic objectives [10]. National quality initiatives have emphasized patient safety, clinical effectiveness, and patient experience, supported by digital health platforms and standardized reporting mechanisms [11].These developments have important implications for nurses, who constitute the largest segment of the health-care workforce and are integral to achieving the quality and safety goals articulated in Vision 2030 [12].

Existing research in Saudi Arabia and comparable contexts has documented nurses’ involvement in quality improvement programmes, accreditation processes, and patient safety initiatives, highlighting both opportunities and challenges [13]. Studies point to issues such as workload, staffing shortages, documentation demands, and variable levels of education and training in quality methods, all of which may influence nurses’ engagement with quality indicators and their perceived ability to provide safe, person-centred care [14]. However, much of this literature approaches quality indicators as technical tools and focuses on knowledge, attitudes, or compliance, rather than examining how the indicator regime is socially organized and experienced in nurses’ everyday work. There is limited knowledge about how nurses in Saudi hospitals navigate, interpret, or negotiate performance expectations, and how these expectations interact with local workplace cultures, managerial priorities, and evolving governance structures in the transforming health system [15].

From a sociological perspective, quality indicators can be understood as ruling texts that coordinate and standardize work across settings, linking front-line practices to distant centres of decision making such as ministries, accreditation bodies, and corporate offices [16]. Institutional ethnography, developed by Dorothy Smith, offers a powerful lens for exploring these dynamics by starting from people’s everyday experiences and tracing how their activities are shaped by extra-local relations and textual infrastructures [17]. In the context of nursing, institutional ethnographic studies have revealed how documentation requirements, care pathways, and performance targets reorganize clinical work, redistribute responsibility, and produce tensions between professional values and institutional demands [18]. Applying institutional ethnography to the study of quality indicators in Saudi Arabia provides an opportunity to move beyond individual-level perspectives and to map how nurses’ experiences are coordinated by policies, dashboards, audits, and performance reports that originate outside the immediate clinical setting [19].

Understanding nurses’ standpoint in relation to quality indicators is particularly important at a time when the Saudi health-care system is moving toward corporatized service clusters, purchaser–provider separation, and performance-linked financing [20]. These reforms may intensify the visibility and perceived consequences of indicator performance, shaping how responsibility for quality is distributed among professionals and institutions. International literature suggests that performance regimes can generate unintended consequences, including gaming, tunnel vision, moral distress, and the displacement of responsibility onto front-line workers [21]. Yet the ways in which such dynamics manifest in the specific cultural, organizational, and policy context of Saudi Arabia remain underexplored.

Method

Design

This study adopted a qualitative institutional ethnographic design to explore how nurses experience, negotiate, and “move on” performance responsibility in relation to quality indicators within a transforming university-based health-care system. Institutional ethnography, originally developed by Smith, shifts the analytic focus from individual attitudes to the social relations that organize everyday work, beginning from people’s standpoint and tracing how their activities are coordinated by texts, policies, and managerial discourses across sites [22]. This approach was selected for its strength in revealing how seemingly neutral instruments, such as quality dashboards, key performance indicators (KPIs), and audit tools, enter into nurses’ daily practices and reorganize their responsibilities and accountabilities [23]. Rather than treating quality indicators as purely technical measures, institutional ethnography examines how they operate as “ruling texts” that link bedside care to extra-local governance structures, including university leadership, hospital administration, and national regulatory bodies. Consistent with the study aim, to understand how nurses’ work is shaped by quality indicators within King Saud University health-care settings, the design prioritized detailed accounts of work processes, institutional texts, and the relations between them. The research process adhered to the Standards for Reporting Qualitative Research (SRQR) to enhance transparency, reflexivity, and analytic rigour.

Study setting and recruitment

The study was conducted in multiple health-care settings in Riyadh. These institutions operate within a rapidly transforming Saudi health-care landscape characterized by Vision 2030 reforms, increasing corporatization, and growing emphasis on performance-based governance and accreditation. Nurses in these settings are routinely exposed to quality indicators such as falls, pressure injuries, medication errors, documentation completeness, pain reassessment, and patient satisfaction metrics, which are monitored through electronic dashboards, monthly performance reports, and accreditation audits. Recruitment targeted registered nurses working in adult and paediatric inpatient units, intensive care units, emergency departments, and primary care clinics to capture variation in how indicators are operationalized across service lines.

Participants were recruited using purposive and maximum variation sampling to include nurses with different roles (staff nurses, charge nurses, and unit-based quality link nurses), years of experience, and contractual arrangements (Saudi nationals and expatriates).⁵⁵ Recruitment was facilitated through collaboration with nursing directors and quality departments, who disseminated study information to eligible nurses via email, staff meetings, and ward noticeboards. Interested nurses contacted the research team directly to maintain confidentiality and reduce perceived managerial pressure. Socio-cultural norms, hierarchical structures, and workload patterns within the university hospitals were considered when scheduling interviews to minimize disruption to patient care and to facilitate safe spaces for open discussion.

Inclusion and exclusion criteria

Inclusion Criteria:

• Registered nurse employed in a King Saud University–affiliated hospital or primary health-care setting.

• Minimum of 1 year of continuous experience in the current unit.

• Direct involvement in clinical care and/or documentation related to quality indicators (e.g., falls, pressure ulcers, pain assessment, medication errors, patient experience).

• Able to participate in a 60–90 min interview in Arabic or English.

• Willing to provide informed consent and reflect on experiences with quality indicators and performance responsibility.

Exclusion Criteria:

• Nurses in exclusively administrative, non-clinical positions with no recent direct involvement in indicator-related work.

• Individuals on probation, under formal disciplinary investigation, or on extended leave at the time of recruitment.

• Nurses with documented cognitive impairment or severe psychiatric illness that might limit participation.

• Staff unable to provide informed consent due to legal or medical incapacitation.

Data collection

Data were collected through in-depth, semi-structured interviews complemented by observational field notes and the examination of key institutional texts. Semi-structured interviews were chosen for their appropriateness in exploring complex and potentially sensitive issues around accountability, performance monitoring, and perceived fairness of quality systems [24]. Interviews were conducted in private offices, meeting rooms, or quiet staff areas within the university hospitals and primary care centres, depending on participants’ preference and shift patterns. A purposive sample of approximately 20–25 nurses was planned to achieve diversity in unit type and role, with final sample size determined by the richness of accounts and saturation of institutional processes rather than numeric thresholds [25].

In addition to interviews, the first author conducted non-participant observations of selected quality-related activities such as ward-based audits, indicator feedback meetings, and quality rounds when access was granted. Brief field notes captured how dashboards were presented, how results were discussed, and how responsibility was allocated in interactions between nurses, unit managers, and quality officers. Policy documents, KPI definitions, audit forms, and selected extracts from electronic dashboards were collected as “texts” in the institutional ethnographic sense, providing insight into how nurses’ work was discursively organized.

Interview structure and conduct

The interview guide was developed iteratively, drawing on institutional ethnographic principles and preliminary discussions with nurse leaders and quality specialists. It was piloted with two nurses from non-participating units to refine wording and flow (pilot data were not included in the final analysis). The guide used open-ended prompts to elicit descriptions of everyday work, rather than abstract opinions, such as:

• “Can you walk me through a typical shift, and show me where quality indicators appear in your work?”

• “Tell me about a time when indicator results were shared with your unit, what happened, and how did it affect you?”

• “When a quality indicator does not meet the target, how is responsibility discussed or assigned?”

• “How do dashboards, emails, or forms shape what you prioritize during your shift?”

Probing questions and requests for examples (“Can you give me a specific situation?”) were used to move from general statements to concrete descriptions of work processes and institutional expectations. Interviews lasted between 45 and 95 min (mean duration approximately 70 min), depending on participants’ availability and depth of discussion. All interviews were conducted by the first author, a nurse academic with experience in qualitative research and no direct line-management role in the participating units, to minimize power imbalances and social desirability bias. Immediately after each interview, field notes were completed to capture contextual features, emotions, and reflections relevant to the analysis.

The interview guide was developed iteratively, drawing on institutional ethnographic principles and preliminary discussions with nurse leaders and quality specialists. It was piloted with two nurses from non-participating units to refine wording and flow (pilot data were not included in the final analysis). The semi-structured interview guide was developed specifically for this study and was not adapted from any previously published instrument. An English-language version of the full interview guide is provided as Supplementary File 1.

Recording and transcription

With participants’ written consent, all interviews were digitally audio-recorded using encrypted devices. Recordings were transferred to a secure, password-protected university server within 24 h and deleted from portable devices. Interviews conducted in Arabic, or in a mix of Arabic and English, were transcribed verbatim in the original language by a professional transcriptionist and subsequently translated into English by a bilingual member of the research team. Back-translation of a subset of transcripts was undertaken to ensure semantic accuracy and preservation of key idioms related to responsibility, blame, and quality.⁵⁷ Each transcript was checked against the original audio by the interviewer to verify accuracy, correct transcription errors, and anonymize names of people, wards, and hospitals. All identifiable information was removed or generalized (e.g., “surgical ward” instead of specific unit names).

Data analysis

Data were analysed using an institutional ethnographic approach supported by NVivo 14 software. Analysis began with repeated readings of transcripts and field notes to gain familiarity with participants’ language, work routines, and descriptions of indicator-related activities. Initial coding focused on segments of text where nurses described “what they do” in relation to quality indicators (e.g., documenting, auditing, explaining results, responding to targets), as well as references to specific texts (dashboards, emails, policies). Codes were grouped into categories representing sequences of work, institutional expectations, and experiences of accountability.

Subsequently, analytic attention shifted to mapping how these local work processes were coordinated by extra-local relations, including hospital and university quality structures and national performance frameworks. This involved linking interview data to policy documents, KPI definitions, and observation notes to construct “work-process maps” that depicted how quality indicators travelled across levels of the organization. The research team held iterative analytic meetings to refine categories, identify patterns of “performance responsibility,” and examine contradictions or tensions (for example, between patient-centred values and indicator targets). Throughout, the analysis remained grounded in participants’ accounts while tracing how institutional texts organized their experiences, in line with institutional ethnographic logic.

Ethical considerations

Ethical approval was obtained from the Institutional Review Board of King Saud University. All participants received a detailed information sheet explaining the study purpose, voluntary nature of participation, data handling procedures, and potential risks and benefits. Written informed consent was obtained before each interview, and participants were reminded of their right to refuse to answer any question or to withdraw from the study at any time without consequences for their employment or appraisal. Particular attention was paid to confidentiality given the sensitivity of discussing performance, errors, and accountability within a hierarchical organization.

To reduce perceived risk, no unit-level performance data were reported, and quotations were anonymized using codes (e.g., N03, N14) that did not reveal unit type when this could risk identification. Findings were presented in aggregate form, and care was taken to avoid language that could be interpreted as evaluative of individual nurses or specific units. Audio files, transcripts, and documents were stored on encrypted, access-controlled systems in accordance with institutional policies and national data protection regulations.

Rigour and reflexivity

Trustworthiness was supported using Lincoln and Guba’s criteria of credibility, dependability, confirmability, and transferability. Credibility was enhanced through prolonged engagement in the field, triangulation of data sources (interviews, observations, and documents), and member checking with a subset of participants who reviewed preliminary thematic and process maps and confirmed that these resonated with their experiences. Dependability was promoted by maintaining an audit trail of methodological decisions, sampling rationale, coding schemes, and revisions to analytic frameworks, all documented in project logs and memos.

Confirmability was addressed through regular peer debriefing with qualitative researchers experienced in institutional ethnography, who critically examined emerging interpretations and their grounding in the data. Transferability was supported by providing thick description of the organizational context, types of units, and features of the Saudi university hospital setting, allowing readers to judge relevance to other contexts. The first author maintained a reflexive journal throughout the study, documenting positionality as a nurse academic working within the Saudi health system, assumptions about quality and performance, and potential influences of professional identity on data collection and interpretation. Reflexive entries were revisited during analysis to surface and bracket taken-for-granted understandings, in order to foreground nurses’ standpoint and the institutional relations shaping their work.

Results

Characteristics of participants

Twenty-two registered nurses employed across King Saud University–affiliated hospitals and primary health-care centres in Riyadh participated in the study (Table 1). Participants’ ages ranged from 26 to 47 years, with a mean age of 35.3 years (SD = 6.0). The sample was predominantly female (n = 20), with two male nurses. Just over half of the participants were Saudi nationals (n = 12), while the remainder were expatriate nurses from diverse countries, reflecting the multicultural composition of the nursing workforce in the university sector.

Table 1.

Demographic and professional characteristics of participants (n = 22)

Participant ID	Age range (years)	Nationality	Role/Position	Primary unit/setting	Years in current unit	Total nursing experience (years)	Highest qualification
N01	26–29	Saudi	Staff nurse	Adult medical ward	2	4	BSN
N02	30–34	Expatriate	Staff nurse	Adult surgical ward	4	8	BSN
N03	26–29	Saudi	Staff nurse	Emergency department	3	5	BSN
N04	40–44	Saudi	Charge nurse	Medical ICU	7	15	BSN
N05	35–39	Expatriate	Staff nurse	Cardiac step-down unit	5	10	BSN
N06	35–39	Saudi	Quality link nurse	Adult oncology ward	6	12	BSN
N07	30–34	Expatriate	Staff nurse	Primary health-care centre	2	6	BSN
N08	30–34	Saudi	Staff nurse	Adult surgical ward	3	7	BSN
N09	45–49	Expatriate	Charge nurse	Adult medical ward	9	18	BSN
N10	35–39	Saudi	Staff nurse	Obstetrics and gynaecology ward	5	11	BSN
N11	26–29	Expatriate	Staff nurse	Paediatric ward	3	3	BSN
N12	30–34	Saudi	Staff nurse	Adult medical ward	2	6	BSN
N13	40–44	Expatriate	Quality link nurse	Medical ICU	8	14	BSN
N14	35–39	Saudi	Charge nurse	Emergency department	6	9	BSN
N15	30–34	Saudi	Staff nurse	Adult surgical ward	4	8	BSN
N16	35–39	Expatriate	Staff nurse	Primary health-care centre	7	13	BSN
N17	40–44	Saudi	Quality link nurse	Adult oncology ward	9	16	MSN
N18	26–29	Expatriate	Staff nurse	Paediatric ICU	2	4	BSN
N19	26–29	Saudi	Staff nurse	Adult medical ward	3	5	BSN
N20	45–49	Expatriate	Charge nurse	Surgical ICU	10	20	MSN
N21	40–44	Saudi	Staff nurse	Cardiac step-down unit	8	22	BSN
N22	30–34	Expatriate	Staff nurse	Primary health-care centre	3	7	BSN

Most nurses occupied direct care roles as staff nurses (n = 15), complemented by charge nurses (n = 4) and unit-based quality link nurses (n = 3). Participants were drawn from a range of clinical areas, including adult medical and surgical wards, intensive care units (medical, paediatric, and surgical), emergency departments, obstetrics and gynaecology, paediatrics, oncology, cardiac step-down units, and primary health-care centres. This spread across inpatient and outpatient services ensured that quality indicators related to safety, clinical effectiveness, and patient experience were represented in different organizational contexts.

Total nursing experience ranged from 3 to 22 years (median ≈ 9 years), while time in the current unit varied between 2 and 10 years (median ≈ 5 years). The majority of participants held a Bachelor of Science in Nursing (BSN), with two nurses holding a Master of Science in Nursing (MSN). Taken together, the demographic and professional diversity of the sample supported an in-depth institutional ethnographic mapping of how quality indicators and performance responsibility are experienced and negotiated across multiple King Saud University health-care settings.

Thematic findings

Institutional ethnographic analysis traced how quality indicators entered nurses’ everyday work and coordinated their actions across King Saud University–affiliated settings. Four interwoven themes were identified that illuminate how nurses understand, carry, and sometimes contest performance responsibility within a transforming, indicator-driven system. Together, these themes show how quality indicators reconfigure the boundaries between “good nursing,” managerial expectations, and accountability, while highlighting nurses’ creative strategies to protect patient care and professional integrity. Table 2 summarizes the themes, sub-themes, and brief descriptions.

Table 2.

Themes, sub-themes, and descriptions

Theme	Sub-Theme	Description
1. Caring Through Numbers: Making Quality Visible	1.1 Translating Care into Indicators	Nurses described how routine care activities, pain assessment, fall prevention, pressure injury surveillance, medication checks, were continuously translated into indicator fields, checklists, and electronic prompts, turning everyday nursing work into measurable items. Documentation was framed as “evidence” that care had occurred, even when nurses felt the indicators only captured a fraction of what they actually did.
	1.2 Chasing Targets, Losing Nuance	Participants reported working to meet unit and hospital targets (e.g., “zero falls,” “100% documentation”) while feeling that the nuances of complex patients, staff shortages, and fluctuating acuity were largely invisible in the dashboards. The pressure to “be green” sometimes overshadowed discussions of context and clinical judgement, contributing to a sense that indicators simplified the realities of practice.
2. Carrying the Score: Performance Responsibility on Nurses’ Shoulders	2.1 Feeling Personally Accountable for the Dashboard	Many nurses spoke of indicator results as a personal and collective “score” for the unit, with poor performance experienced as a reflection on their competence and commitment. When monthly reports were shared, nurses felt they were “under the microscope,” even when incidents involved multiple professionals or system-level gaps.
	2.2 Between Blame and Ownership	While some participants expressed pride in achieving high-quality scores and embraced indicators as part of professional responsibility, others described a thin line between accountability and blame. When targets were not met, nurses reported feeling singled out in meetings, experiencing implicit or explicit blame, and absorbing pressure that they felt should be shared across the multidisciplinary team and organizational leadership.
3. Working Around the System: Navigating Constraints and Contradictions	3.1 Bending Routines to Fit Indicators	Nurses described adjusting workflows and priorities in order to align with indicator requirements, for example, clustering documentation near audit times, prioritizing tasks that were measured, or re-sequencing care to satisfy time-stamped prompts. These adaptations were often pragmatic responses to high workload and staffing constraints but sometimes led to tension between “what the system wants” and what nurses felt patients needed first.
	3.2 Quiet Resistance and Ethical Workarounds	In response to perceived unfairness or impracticality of certain measures, some nurses engaged in subtle forms of resistance, such as questioning indicator definitions, challenging how incidents were categorized, or informally negotiating with quality staff about what counted as a “failure.” Others described ethical workarounds, trying to meet indicator demands while informally redistributing tasks among colleagues, to protect both patient care and one another from punitive interpretations of data.
4. Reclaiming Professional Voice in Quality Work	4.1 Turning Indicators into Learning Opportunities	Despite frustrations, several participants described efforts to reframe indicator discussions as learning rather than blame. In units where managers facilitated reflective debriefings, nurses reported using indicator data to identify patterns, share practical solutions, and celebrate small improvements, which made quality work feel more collaborative and meaningful.
	4.2 Calling for Shared Responsibility and System Support	Nurses consistently voiced a desire for quality indicators to reflect shared, system-level responsibility rather than being positioned solely as nursing outcomes. Participants called for more involvement in indicator design, realistic target-setting, and better resourcing (staffing, education, and digital support) to align expectations with actual capacity. These calls highlighted nurses’ aspiration to be recognized as partners, and not just data producers, in shaping quality within the transforming Saudi health-care system.

Caring through numbers: making quality visible

This theme captures how nurses came to understand quality largely through what could be counted, checked, or displayed on a dashboard. Participants described a daily process of “turning care into numbers,” where fundamental nursing activities, pain assessment, fall prevention, patient education, pressure injury checks, were continually translated into indicator fields, time stamps, and audit forms.

Translating care into indicators

Across settings, nurses described a continuous, almost automatic process of translating their daily care into the language of indicators. Routine tasks, such as repositioning a patient, reassessing pain, or educating families about fall precautions, were framed not only as good practice but as items that must be documented correctly to appear in monthly statistics.

The moment I enter the room, I am already thinking, ‘Did I document pain? Did I click falls risk? Did I sign the education form?’ It’s like my mind is split between the patient and the checklist.

(N03, staff nurse, medical ward, 5 years)

Nurses noted that indicator fields in the electronic record functioned as prompts and boundaries for what “counts” as quality. If a task was not attached to a designated field or time stamp, it was easily perceived as invisible to the system, even when it was clinically important. One primary care nurse explained how this shaped her priorities:

There are many things we discuss with patients, but if it doesn’t have a box in the system, it feels like it disappears. The things with indicators, like patient education on medication or pain score, those we make sure to document perfectly.

(N07, staff nurse, PHC, 6 years)

For some participants, the ability to show indicator data was empowering. It allowed them to demonstrate workload, defend their practice, and counter assumptions that “nurses are not doing enough”:

Before, people would say, ‘Why is this happening?’ Now we can open the dashboard and show: falls assessments done, pain reassessed, education given. It gives us evidence that we are not just sitting.

(N14, charge nurse, emergency, 9 years)

Yet, this translation also introduced a more transactional feeling into care. Several nurses described how interactions with patients were sometimes structured around the need to complete certain fields, asking about pain or explaining fall precautions in a way that matched the form, rather than fully engaging with patients’ broader concerns. One ICU nurse reflected:

Sometimes I feel I am talking in bullet points: ‘Did you understand the risk of…? Do you have pain from 0 to 10?’ I know it’s important, but humans don’t speak like that. We adapt our conversation to fit the documentation.

(N04, charge nurse, ICU, 15 years)

The work of translating care into indicators therefore functioned as both a protective strategy, making nursing visible, and a source of subtle distortion, where rich, relational aspects of care were squeezed into predefined categories and time frames.

Chasing targets, losing nuance

Once care was translated into numbers, these numbers became targets. Nurses across units were acutely aware of monthly thresholds,100% documentation, zero falls, 95% pain reassessment, and many described “chasing” these targets as part of their everyday work. Indicator performance was displayed on dashboards, shared in staff meetings, and referenced in managerial feedback, turning unit scores into a constant backdrop for practice.

We get the email every month: green, yellow, red. If it’s red, everyone feels it. We know exactly which indicator pulled us down and we start running after it the next month.

(N09, charge nurse, medical ward, 18 years)

While some participants felt motivated and even proud when targets were met, others described this environment as narrowing the conversation about quality. Complex clinical situations, high-acuity patients, families in crisis, understaffing, were rarely visible in reports that showed only percentages and colours.

If we are short-staffed and have two unstable patients, of course some documentation will be late. But the dashboard just says ‘90%, target not met.’ It doesn’t say ‘they were saving a patient’s life.’

(N05, staff nurse, cardiac step-down, 10 years)

Nurses also reported that the pressure to keep indicators “green” sometimes led to the prioritization of tasks that were measured over those that were not, even when the latter were clinically or emotionally important. One primary care nurse recalled:

On busy days, I focus first on what will be audited, pain score, vital signs, education sheet. I still try to listen to patients’ other worries, but honestly, if time is short, the system’s priorities win.

(N22, staff nurse, PHC, 7 years)

Several participants worried that this target-driven focus created a distorted picture of quality: units could appear successful on paper while nurses felt they were constantly compromising in less visible areas, such as emotional support, in-depth teaching, or collaborative decision-making.

We can have all green indicators and still feel that we didn’t give patients the full care they deserved. The numbers don’t show when you had to rush, when you couldn’t sit and explain properly.

(N10, staff nurse, obstetrics and gynaecology, 11 years)

In this sense, “chasing targets” was experienced as a necessary but incomplete version of quality work. Nurses engaged with indicators because they shaped appraisal, reputation, and accreditation, yet many felt that the relentless focus on meeting numeric thresholds risked erasing the nuance of clinical judgement and the contextual realities of Saudi university hospitals in transition.

Carrying the score: performance responsibility on nurses’ shoulders

This theme highlights how quality indicator results, summarized in dashboards, scorecards, and monthly reports, were experienced not as abstract organizational measures, but as a “score” carried on nurses’ shoulders. Participants spoke about indicator performance in highly personal and emotional terms, describing pride when their unit was “all green” and embarrassment, stress, or even guilt when results slipped into yellow or red.

Feeling personally accountable for the dashboard

Many participants described a powerful emotional connection to their unit’s dashboard, speaking of monthly reports as if they were personal report cards. Even when results reflected multiple disciplines and system-level processes, nurses narrated them in the first person: “we failed,” “we dropped,” “we improved.”

When we see the dashboard, it’s like looking at our own exam result. If falls are high or documentation is low, I feel it in my stomach. Even if I know I did my part, I still feel I’m part of that red colour.

(N02, staff nurse, surgical ward, 8 years)

Some nurses checked performance reports as soon as they were released, anticipating how scores might be discussed in meetings or used in informal ward comparisons. Units with consistently high scores were talked about with pride, and nurses used this language to reinforce professional identity:

When we are all green for three months, we feel proud. We say, ‘Our unit is strong, our nursing is strong.’ It’s like a badge we wear, even if nobody outside understands what it took to get there.

(N21, staff nurse, cardiac step-down, 22 years)

At the same time, nurses were acutely aware that a single incident or a small documentation gap could pull a unit’s percentage below the target. This magnified the emotional impact of indicator performance, particularly in high-acuity areas where risk was inherently higher:

In ICU, one pressure injury or one missed reassessment can change the whole month’s score. Even if we worked day and night to prevent ten others, we will be remembered for that one.

(N04, charge nurse, ICU, 15 years)

Several participants noted that indicator discussions were often framed in managerial or disciplinary language,“Why did this happen?”, “Who was on shift?”,which reinforced a sense of personal accountability, even when multiple structural and contextual factors were involved. For junior nurses especially, this climate could be intimidating:

As a new nurse, when they show the report and ask, ‘Who was responsible for this patient?’ you feel exposed. You are afraid your name will be linked to the red bar.

(N01, staff nurse, medical ward, 4 years)

Despite this pressure, many nurses internalized dashboard performance as part of their ethical commitment to safe care. They did not reject responsibility for quality; rather, they struggled with the mismatch between what they could realistically control and what the indicators seemed to demand.

Between blame and ownership

Within this climate of personal accountability, nurses navigated a fine line between feeling blamed and feeling a sense of constructive ownership over quality. Participants differentiated sharply between performance conversations that were supportive and improvement-focused, and those that felt punitive or one-sided.

When the nurse manager says, ‘Let’s see what went wrong and how we can support you,’ it feels like we own the problem together. But when they ask, ‘Who did this?’ it becomes blame, not learning.

(N14, charge nurse, emergency, 9 years)

Several nurses described situations where adverse events or missed targets were discussed in ways that implicitly located failure in nursing alone, even when the issue spanned physician practice, bed availability, or equipment shortages. This one-directional attribution was experienced as unfair and demoralizing:

If the doctor delays the order, if the porter is late, if there is no bed, still the indicator will say ‘nursing delay.’ We are the final step, so the system writes our name on the problem.

(N06, quality link nurse, oncology, 12 years)

In response, some nurses developed strategies to push back gently against oversimplified narratives of blame. They began bringing contextual information to meetings, workload data, staffing levels, acuity changes, to show that indicator performance was a shared, system-level outcome:

Now, when we discuss a fall or a documentation delay, I come with the full picture: number of nurses, number of patients, how many admissions that shift. Not to excuse, but to show that it’s bigger than one nurse.

(N17, quality link nurse, oncology, 16 years)

Despite these tensions, many participants still described a strong sense of ownership over quality indicators when they felt respected as partners in interpretation and solution-building. In units where managers invited nurses to co-analyse trends and design changes, indicator work became a shared project rather than a burden:

When they sit with us and say, ‘This is our result, what do we think we can change?’ then I feel motivated. It’s not about ‘catching’ us; it’s about improving care together.

(N09, charge nurse, medical ward, 18 years)

Conversely, when indicators were used primarily to highlight deficits or to compare units competitively without context, nurses withdrew emotionally from the data, seeing them as an external pressure rather than a meaningful tool:

After some time, you stop listening. You know they will just show the red and say, ‘You must fix it,’ without asking what support we need. Then indicators become something you fear, not something you own.

(N03, staff nurse, medical ward, 5 years)

Thus, nurses’ experiences of performance responsibility oscillated between blame and ownership, shaped not only by the numbers themselves but by how those numbers were framed, discussed, and acted upon within King Saud University health-care settings.

Working around the system: navigating constraints and contradictions

This theme captures how nurses actively negotiated the gaps between indicator expectations and the realities of everyday practice. Faced with high patient acuity, staffing shortages, overlapping initiatives, and rigid audit schedules, participants described a constant need to “work around” the system to keep both patients and performance scores safe. Rather than passively implementing indicator requirements, nurses selectively adapted, re-sequenced, or redistributed tasks to survive competing demands.

Bending routines to fit indicators

Across units, nurses described “bending” their routines so that they could meet indicator requirements without completely abandoning clinical priorities. One common strategy involved clustering documentation around known audit times or at the end of shifts when patient care demands were relatively lower.

We know when the quality team usually comes, so we make sure everything is updated before that. Sometimes we delay less urgent tasks until after documentation is complete, just to avoid a red mark.

(N01, staff nurse, medical ward, 4 years)

Participants also reported re-sequencing care to match time-stamped prompts in the electronic record. For example, pain reassessments or fall-risk checks might be documented slightly earlier or later than the textbook schedule to fit with medication rounds, physician visits, or family discussions:

The system wants pain reassessment exactly 30 min after medication. But if I have two critical patients and a new admission, I will check pain when I can, then adjust the time so it doesn’t show as a failure. The patient is still cared for, but not according to the computer’s perfect timing.

(N13, quality link nurse, ICU, 14 years)

In primary care and outpatient settings, nurses described adjusting patient flow to comply with education or screening indicators. At busy times, they would prioritize indicator-linked counselling (e.g., falls or medication safety) over broader, holistic discussions:

If the clinic is full, I go straight to the topics that are monitored. I still listen to other concerns, but the sequence is changed, first what the system will ask me later, then what the patient wants to talk about.

(N07, staff nurse, PHC, 6 years)

For many nurses, these adjustments were framed as necessary compromises rather than deliberate rule-breaking. They saw themselves as trying to satisfy the logic of indicators while still protecting patient safety and managing an often unrealistic workload. Yet, participants also worried that such bending of routines risked normalising a gap between “recorded” and “real” care:

On paper everything looks perfect, timing, signatures, education. In reality, we are constantly negotiating: who can wait, who cannot, what can be done now, what must be done later. The record doesn’t show this negotiation.

(N19, staff nurse, medical ward, 5 years)

Quiet resistance and ethical workarounds

Alongside pragmatic adaptations, nurses also described more intentional, quiet forms of resistance when they perceived indicators or audit practices as unfair, unrealistic, or misaligned with clinical judgement. This resistance did not usually take the form of open confrontation; instead, it appeared as subtle questioning, re-interpretation, or collective shielding of colleagues.

When a fall happens with a very confused patient, sometimes the first reaction from management is, ‘Why didn’t you prevent it?’ We push back gently, explaining the situation, asking them to consider the whole context, not just the checkbox. It’s our way of resisting the idea that everything is under our control.

(N09, charge nurse, medical ward, 18 years)

Some participants described negotiating, informally, how incidents were categorised or reported, especially when they felt the indicator definition did not match the clinical reality or would unfairly stigmatise a unit:

There are cases where technically it could be reported as a medication error, but clinically it was a safe adjustment agreed with the doctor. In those situations, we discuss with the quality officer how to document it so it reflects reality and doesn’t show as ‘nursing error’.

(N05, staff nurse, cardiac step-down, 10 years)

Ethical workarounds also emerged in how nurses redistributed indicator-related tasks to protect colleagues and maintain team cohesion. For example, more experienced nurses or quality link nurses sometimes took on additional documentation or follow-up duties to prevent individual staff from being singled out in reports:

If we see one nurse is struggling with the documentation, we help complete some of the missing parts before the audit. It’s not about hiding things; it’s about not letting one person be ‘the problem’ when actually the whole system is overloaded.

(N17, quality link nurse, oncology, 16 years)

In other instances, nurses purposefully prioritised patient-centred actions over strict indicator compliance, accepting the risk of a “red” score as the ethical cost of doing what they believed was right:

One night I had a patient deteriorating and the family was very distressed. I spent a long time with them, explaining, supporting. I knew some documentation would be late, but in that moment, my responsibility was to them, not the dashboard. If it shows red, it shows red.

(N04, charge nurse, ICU, 15 years)

These narratives of quiet resistance and ethical workaround highlight nurses’ active moral reasoning within an indicator-driven environment. Rather than simply complying or rejecting the system, nurses continually weighed the demands of performance metrics against the lived needs of patients and teams. In doing so, they exposed the contradictions of a system that asks for both perfect numbers and humane, context-sensitive care, and showed how, in practice, they tried to hold both together, even when the system did not fully recognise this work.

Reclaiming professional voice in quality work

This theme reflects how nurses actively sought to move beyond a passive, target-driven relationship with quality indicators and instead reclaim a sense of professional agency in how quality work is understood, discussed, and acted upon. While participants described feeling burdened by indicator demands, many also articulated a desire to use data in ways that supported learning, teamwork, and safer care rather than blame and fear.

Turning indicators into learning opportunities

Nurses reported that the tone and structure of indicator feedback meetings made a crucial difference in whether data were experienced as punitive or as a genuine opportunity to learn. In units where managers framed indicators as tools for reflection, participants described feeling more able to speak openly, analyse underlying causes, and collaboratively design improvements.

When my head nurse presents the indicator, she doesn’t say, ‘You failed.’ She asks, ‘What is behind this? What was happening that week?’ Then we all talk about it. It becomes a learning moment, not a judgment.

(N14, charge nurse, emergency, 9 years)

In these settings, dashboards and monthly reports were treated as starting points for problem-solving rather than endpoints. Nurses discussed specific cases, staffing patterns, or workflow issues that might explain a spike in falls or late pain reassessments, and together identified practical changes, such as adjusting rounding times, pairing junior and senior staff, or clarifying roles during busy shifts.

The numbers show us where to look, but the real answer comes when we sit together and break down the situation. Otherwise, we are just chasing percentages without understanding.

(N06, quality link nurse, oncology, 12 years)

Some nurses described using indicators to advocate for patients and for themselves. By tracking patterns over time, they could argue for more realistic staffing, targeted education, or equipment (e.g., pressure-relieving mattresses, bed alarms) that directly impacted outcomes:

When we showed that pressure injuries were higher in rooms without special mattresses, it helped us get more equipment approved. That was one time the indicator truly worked for the patient and for us.

(N04, charge nurse, ICU, 15 years)

In this way, indicators became tools that could amplify nurses’ experiential knowledge instead of silencing it. Participants emphasized that when data were discussed in a non-punitive, inquiry-oriented way, they felt more confident to share concerns, suggest changes, and connect “the numbers” back to real patients and real work. This transformed quality meetings from stressful reporting sessions into spaces for collective sense-making and professional growth.

Calling for shared responsibility and system support

Alongside efforts to reframe indicators as learning tools, nurses voiced a strong, consistent call for quality to be recognized as a shared, system-level responsibility rather than something located primarily on nurses’ shoulders. Participants repeatedly highlighted how indicator results are influenced by factors beyond nursing control, medical decisions, bed availability, documentation by other disciplines, and institutional resource constraints, yet are still often presented as “nursing scores.”

When there is a medication error, there is a prescriber, a pharmacist, the system itself. But in the report it’s ‘nursing medication error.’ We are not denying our part, but the whole chain must be visible.

(N05, staff nurse, cardiac step-down, 10 years)

Nurses expressed a desire to be involved earlier and more meaningfully in the design and revision of indicators, including definitions, thresholds, and data collection processes. They argued that without their input, measures could be unrealistic or misaligned with the realities of patient care in busy university hospitals.

Targets are sometimes decided in offices far from the ward. If they sat with us when they design these KPIs, they would see what is possible and what support we need. Quality should be built with nurses, not just monitored on them.

(N21, staff nurse, cardiac step-down, 22 years)

Participants also called for concrete system supports to match performance expectations: adequate staffing, protected time for documentation, user-friendly electronic systems, and ongoing training that went beyond one-off sessions. Several nurses described feeling that they were asked to “do more with less” while still being held to absolute thresholds:

We can accept high standards, we also want that. But if you want zero falls and 100% documentation, then give us the tools: enough staff, working equipment, a system that doesn’t crash. Responsibility must come with support.

(N16, staff nurse, PHC, 13 years)

These narratives reveal a deeper aspiration: nurses wanted to be recognized not only as implementers of quality policies but as partners in shaping how quality is defined, measured, and improved within the transforming Saudi health system. By calling for shared responsibility and system support, participants were not rejecting indicators outright; rather, they were advocating for a more just and realistic quality culture, where data are interpreted in context, accountability is distributed across the care continuum, and nurses’ professional voices help steer quality work toward genuinely safer, more person-centred care.

Discussion

This institutional ethnographic study examined how nurses working in King Saud University–affiliated hospitals and primary health-care centres experience and negotiate quality indicators within a rapidly transforming Saudi health system. The findings show that quality indicators are not neutral technical tools but active “organizing forces” that shape how nurses understand quality, prioritize tasks, and experience responsibility and accountability in their everyday work. In line with previous work on performance measurement in health care, indicators functioned as ruling texts that coordinate local practices with distant managerial, regulatory, and policy agendas [26]. The four themes,Caring Through Numbers, Carrying the Score, Working Around the System, and Reclaiming Professional Voice,together illustrate a dynamic, often ambivalent relationship between nurses and quality indicators, marked by both alignment with and resistance to a target-driven culture [27].

The first theme, Caring Through Numbers: Making Quality Visible, highlights how nurses continually translate relational, hands-on care into documentation fields, time-stamped entries, and audit forms. This resonates with literature describing the drift from “bedside work” to “paper work” and “screen work,” where clinical practice is increasingly mediated by electronic records and performance metrics [8]. Participants recognized that indicators made some aspects of their labour visible to managers and accreditation bodies, allowing them to “prove” that care had been delivered and defend themselves against assumptions of poor performance. Similar to findings in other contexts, documentation was perceived as both protection and burden: essential for demonstrating quality and legal compliance, yet insufficient to capture the richness and complexity of nursing work [28]. The study adds nuance by showing how this translation process is lived in a Vision 2030 reform environment, where quality dashboards and KPIs are tightly linked to institutional reputation and strategic targets [29].

However, the subtheme Chasing Targets, Losing Nuance reveals how the visibility gained through indicators comes at a cost. Nurses described an intense focus on “being green” on dashboards, sometimes at the expense of unmeasured but clinically and emotionally important aspects of care. This echoes critiques of New Public Management and metric-driven governance, where what is counted tends to displace what is not, leading to tunnel vision, gaming, and distortions of practice [30]. Consistent with prior research on nursing and performance regimes, participants reported reorganizing workflows to satisfy time-bound prompts or audit schedules, prioritizing tasks that “count” over those that are harder to measure [31]. The present study extends this evidence by illustrating how such dynamics unfold in Saudi university hospitals, where high patient acuity, staff shortages, and cultural expectations around family involvement interact with indicator demands, making target achievement both morally and practically challenging.

The second theme, Carrying the Score: Performance Responsibility on Nurses’ Shoulders, shows that indicator results are experienced as a collective “score” for the unit, but one that nurses feel disproportionately responsible for. When indicators fell below target, they reported feeling scrutinized and sometimes blamed, even when incidents involved multidisciplinary teams or structural constraints beyond their control. Previous studies have similarly documented the individualization of responsibility in quality and safety work, where front-line nurses become the focal point for system-level failures [32]. Our findings align with this but also show how this individualization is intensified in a context of rapid health-sector transformation and corporatization, where KPIs are closely tied to institutional competitiveness, accreditation, and, increasingly, financing models [33]. Nurses’ accounts of “carrying the dashboard on their backs” suggest a risk of moral distress and burnout when they are held accountable for outcomes shaped by inadequate staffing, limited equipment, or decisions made elsewhere in the system [34].

The third theme, Working Around the System: Navigating Constraints and Contradictions, illustrates nurses’ pragmatic and sometimes resistant responses to indicator-driven pressures. They described bending routines to fit indicator requirements, clustering documentation, re-sequencing tasks, or informally redistributing work, to cope with constraints while still trying to safeguard patient care. These “workarounds” mirror broader evidence that front-line workers creatively adapt formal protocols to make systems function under real-world conditions [35]. The study contributes by framing these adaptations not simply as deviations or compliance failures, but as ethical negotiations in which nurses attempt to reconcile institutional expectations with professional values of holistic, person-centred care. The subtheme on quiet resistance, questioning indicator definitions, contesting what counts as “failure,” and negotiating with quality staff, also suggests that nurses are not passive recipients of performance policies, but active interpreters and sometimes critics of them. This aligns with institutional ethnographic accounts showing how workers push back against ruling texts that misrepresent or constrain their work [36].

The final theme, Reclaiming Professional Voice in Quality Work, offers an important counterpoint to narratives of burden and control. In units where managers framed indicators as starting points for inquiry rather than tools for blame, nurses described using data to identify patterns, advocate for resources, and co-design changes. This supports evidence that when performance information is embedded in a learning-oriented culture, it can foster reflective practice and team-based problem solving rather than fear and defensiveness [37]. Participants’ examples, using pressure injury data to secure adequate equipment or fall trends to adjust rounding practices, show that indicators can be mobilized to amplify, rather than silence, nurses’ experiential knowledge.

At the same time, the subtheme Calling for Shared Responsibility and System Support underscores that meaningful engagement with quality data requires fair distribution of responsibility and adequate structural support. Nurses’ appeals to be involved in indicator design, to have realistic targets, and to receive staffing, training, and functional IT systems highlight the conditions under which performance regimes can become more just and effective. Similar calls for co-production of quality measures and shared accountability across professions have been made in international literature on patient safety and value-based care [38]. The present study strengthens these arguments by grounding them in the voices of nurses working within Saudi Arabia’s reform agenda, emphasizing that high expectations for quality must be matched with investments in workforce wellbeing and infrastructure [39].

Implications of the study

This study has several important implications for nursing practice, leadership, education, and policy within the transforming Saudi health-care system. At the practice level, the findings highlight the need to rebalance quality work so that indicators support, rather than overshadow, person-centred care. Nurses require protected time, supportive documentation systems, and realistic targets so that “caring through numbers” does not crowd out relational, emotional, and family-inclusive aspects of care that are harder to quantify but central to nursing in the Saudi context. At the leadership and organizational level, the study suggests that how indicator data are framed and discussed is critical. Moving from blame-oriented feedback to learning-focused, team-based debriefings can help transform dashboards into tools for reflection and improvement rather than sources of anxiety or silent resistance. Involving nurses in the co-design of indicators, definitions, and targets may enhance the clinical relevance and feasibility of quality measures and improve ownership of quality initiatives. For nursing education, curricula and in-service training should address not only the technical aspects of quality indicators but also their ethical, sociocultural, and organizational dimensions, preparing nurses to critically interpret data, advocate for system support, and participate in quality governance. At the policy level, the findings underscore that successful implementation of Vision 2030 and the Health Sector Transformation Program depends on recognizing nurses as partners in shaping quality frameworks and ensuring that performance expectations are matched with investments in workforce wellbeing, staffing, and digital infrastructure.

Limitations of the study

Several limitations should be considered when interpreting these findings. First, the study was conducted within health-care settings affiliated with a single academic institution, King Saud University in Riyadh, which may limit transferability to other regions, private hospitals, or non-university facilities with different governance structures, resources, or workforce profiles. Second, the sample, although diverse in terms of unit type, nationality, and role, included only nurses; perspectives of physicians, allied health professionals, quality officers, and senior managers were not directly explored, which may have constrained the ability to fully map the multi-professional and organizational dynamics surrounding indicator design and use. Third, institutional ethnography relies on in-depth interviews, observations, and textual analysis rather than large, representative samples; as such, the goal is to elucidate social relations and processes, not to generalize prevalence or quantify the extent of particular experiences. Fourth, social desirability bias cannot be ruled out: despite assurances of confidentiality and the researcher’s non-managerial role, some participants may have moderated criticism of quality systems or leadership. Finally, time-limited access to certain meetings or documents may have resulted in partial visibility of how indicator data are negotiated at higher administrative levels. These limitations point to the need for complementary research using additional methods and samples.

Conclusion

This institutional ethnographic study shows that quality indicators, as implemented in King Saud University–affiliated health-care settings, are deeply woven into nurses’ everyday work, shaping what counts as quality, how care is organized, and who feels responsible when targets are not met. Nurses “care through numbers” by continually translating bedside work into measurable items, while at the same time “carrying the score” of unit performance, often absorbing responsibility for outcomes shaped by broader system constraints. They respond with a mix of adaptation, workaround, and quiet resistance, striving to protect patient care and professional integrity in a target-driven environment. Yet the findings also reveal a strong aspiration among nurses to reclaim their professional voice in quality work: to use indicators as tools for learning, to participate in indicator design, and to situate responsibility at system as well as individual levels. For the Saudi health system in transition, these insights suggest that achieving high-quality, value-based care will require more than sophisticated dashboards; it will require governance approaches that recognize nurses as knowledgeable partners, align performance expectations with structural support, and ensure that what is measured does not eclipse what matters most to patients and those who care for them.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

WMA, TE, FFA and AMA contributed to the conception and design of the study. WMA and TE coordinated data collection and conducted the fieldwork. WMA and AMA led the data analysis, with critical input from TE and FFA. WMA drafted the initial manuscript. TE, FFA and AMA critically reviewed and revised the manuscript for important intellectual content. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work.

Funding

The authors would like to thank Ongoing Research Funding Program, (ORFFT-2025-156-1), King Saud University, Riyadh, Saudi Arabia for financial support.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to the sensitive and identifiable nature of qualitative interview data but are available from the corresponding author on reasonable request, subject to institutional and ethical approvals.

Declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of King Saud University, College of Medicine, Riyadh, Saudi Arabia (IRB reference: KSU-HE-25-934, approval date: 1-9-2025. The study was conducted in accordance with the ethical standards of the institutional and national research committees and with the 1964 Helsinki Declaration and its later amendments. All eligible nurses received written and verbal information about the study aims, procedures, potential risks and benefits, and their rights as participants, including the right to refuse participation or withdraw at any time without any impact on their employment, evaluation, or professional relationships. Written informed consent to participate was obtained from all participants prior to data collection.

Consent for publication

No identifying personal or clinical details, images or videos of participants are included in this manuscript. Consent for publication of anonymised quotations from interviews was obtained from all participants at the time of data collection.

Competing interests

The authors declare no competing interests.