Investigate factors related to the patient safety competency among nurses working in emergency departments of public hospitals in Afghanistan

Abstract

BACKGROUND:

Providing safe and quality care is one of the fundamental principles and a primary goal in nursing. This study aimed to investigate factors related to patient safety competency among nurses working in the emergency departments of public hospitals.

MATERIALS AND METHODS:

This study was a correlational cross-sectional study conducted using the census method. A total of 113 nurses from the emergency departments of public hospitals in Afghanistan participated in 2023. Standardized questionnaires were used to examine three aspects of the study: patient safety competency, psychological safety, and teamwork. The data were analyzed using descriptive and inferential statistical tests in SPSS-21 software.

RESULTS:

All 113 nurses completed the study questionnaire, including 50 females (44.2%) and 63 males (55.8%). Except for age and experience, there was a significant correlation between other variables and patient safety competency (P < 0.05). A significant relationship was found between patient safety training courses and patient safety competency (P = 0.000). Additionally, there were significant relationships between psychological safety, team structure, team leadership, oversight, support, communication, and teamwork with patient safety competency (P < 0.05). Team structure was identified as the most important dimension among the workgroup factors related to patient safety competency (P < 0.05).

CONCLUSION:

Achieving safe and high-quality nursing care in emergency departments requires the design and implementation of multifaceted strategies, including structured team leadership, supportive supervision mechanisms, and both basic and advanced training courses to enhance patient safety competencies.

Introduction

Nurses spend more time with patients than other healthcare workers and play a critical role in managing patient treatment and enhancing safety. Therefore, identifying the patterns, prevalence, and factors contributing to Medical Errors (MEs) in Emergency Departments (EDs) can help nursing managers develop innovative, statistically robust, and evidence-based strategies to reduce MEs and their adverse effects.[1] The World Health Organization (WHO) defines adverse events (AEs) as incidents during nursing care that cause harm to patients but are unrelated to the patient’s underlying condition.[2,3] Harm from medical errors occurs at both individual and systemic levels and is a leading cause of disability, injury, and death worldwide. Unfortunately, medical errors are often not documented as the cause of death in patient records and are classified as unintentional practices.[4]

Nurses’ patient safety competency is essential for delivering high-quality healthcare.[5] Studies show a high prevalence of MEs and AEs in EDs, with global rates ranging from 4% to 68% and in Iran from 7% to 40%.[6] In the US, one in ten hospitalized patients is affected by AEs due to MEs, making MEs and AEs the third leading cause of death. The prevalence of AEs ranges from 2.9% to 16.6%, with 5% to 13% resulting in death, while 25% to 50% of AEs are significantly preventable.[4,7] Various studies have estimated ME rates in different countries. For example, a recent systematic review found that 2.9% to 21.9% of patients experience medical errors.[8] A study by Kang et al.[9] reported that 36% to 57% of nurses experienced at least one of four MEs in the past 12 months. In China, a study by Wang et al. found that 47.8% to 75.6% of nurses reported AEs due to MEs in the past year.[10] A 2021 national study in Iran revealed that 29.1% of nurses experienced MEs in the past six months.[2] According to a 2019 systematic review, ME rates in Iran ranged from 10% to 80%.[11] A systematic review of 48 studies by Hibbert et al.,[12] using the Global Trigger Tool, found ME rates ranging from 7% to 40%. Mistakes and errors are inevitable but are often caused by systemic barriers that can occur throughout the entire process. Punishing or blaming workers is ineffective in preventing errors; instead, the focus should be on developing systems to improve patient safety, which is critical.[13,14] Patient safety competency depends on the attitudes, skills, and knowledge of healthcare workers, who must protect patients from unnecessary risks and injuries. This is especially vital for nurses, who provide 24-hour patient care.[15,16,17] A 2019 study in Switzerland identified poor teamwork, failure to report AEs (MEs), and issues with patient transfers as key contributors to compromised patient safety in Eds.[18] Teamwork is essential in reducing MEs and AEs due to the critical condition of patients, high workload, large staff numbers, and the complexity of work in Eds.[19] According to Ajri-Khameslou et al.,[20] teamwork in EDs can enhance the efficiency and safety of patient care. Teamwork has been proposed as a solution to improve patient care quality and safety in Eds.[21] A 2022 study in Iran by Soola et al.[6] emphasized that, as frontline caregivers, ED nurses’ patient safety relies on teamwork and coordination with other clinical groups.

A key component of effective teamwork is psychological safety. Donovan’s study found that psychological safety is a critical factor in improving teamwork quality and plays a significant role in healthcare teams.[22] Providing psychological safety to nurses enhances patient care safety and quality, while low levels of psychological safety increase psychological stress, absenteeism, patient safety risks, and reduce job satisfaction among nurses.[23,24] Greene et al.’s[24] study showed that psychological safety in healthcare settings impacts teamwork, participation in quality improvement, learning from failures, AE reporting, and patient safety competency. Numerous studies have explored the link between psychological safety and performance in healthcare teams, consistently showing that psychological safety enhances performance and, in one case, lowers risk-adjusted mortality rates.[24,25,26,27,28] Research on patient safety competency among ED nurses is limited.[15] Most studies on patient safety competency focus on nursing students and recent graduates.[29,30] To the best of the researcher’s knowledge, few studies in Afghanistan’s scientific literature address patient safety competency among ED nurses. By identifying key factors influencing patient safety, this study not only contributes to the global understanding of nursing competencies but also provides actionable insights tailored to the unique challenges in Afghanistan. These findings could inform the development of targeted training programs and policies to enhance patient safety and improve healthcare outcomes in similar settings worldwide. Given the high rates of patient harm and injuries due to MEs in EDs globally and the urgent need for comprehensive scientific support in Afghanistan’s health system, this research was conducted in all government hospitals in Kabul, the capital of Afghanistan.

Materials and Methods

Study design and setting

This quantitative study was a descriptive-analytical study conducted using a cross-sectional and correlational approach in 2023 in Afghanistan.

Study participants and sampling

This study was conducted in all government hospitals in Kabul City, each of which had an independent emergency department. The study population consisted of 113 nurses, both male and female, working in these emergency departments, selected using a census method.

Data collection tools and techniques

The questionnaire used for data collection in this study consisted of four parts: demographic information, patient safety competency, teamwork, and psychological safety.

Demographic information

This section included questions on age, years of service in the emergency department, retirement history, gender, marital status, type of emergency department, number of night Shifts, and patient safety training.

Patient safety competency

This section comprised 14 questions across three dimensions: knowledge (4 questions), skills (4 questions), and attitudes (6 questions). Responses were scored on a 4-point Likert scale (1 = completely disagree, 2 = disagree, 3 = agree, 4 = completely agree). Higher scores indicated greater patient safety competency (low: 1–2.5, medium: 2.5–3.25, high: 3.25–4). The maximum score was 56, and the minimum was 14. The validity and reliability of this questionnaire were confirmed in the study by Soola et al.[6]

Teamwork

The teamwork questionnaire, developed by Minoo et al., assessed attitudes toward teamwork. It included 30 questions across five dimensions: structure, leadership, situational awareness, mutual support, and communication, with six questions per dimension. Responses were scored on a 5-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = no opinion, 4 = agree, 5 = strongly agree). Higher scores indicated better teamwork understanding (low: 1–3, medium: 3–4, high: 4–5). Questions 41, 42, and 45 were scored under mutual support, and question 51 under communication. The maximum score was 150, and the minimum was 30. The validity and reliability were confirmed in Najafi’s study, with a Cronbach’s alpha of 0.80 and an intraclass correlation coefficient (ICC) of 0.8.[31]

Psychological safety

The Psychological Safety Instrument, designed by Edmondson, assessed psychological safety in teamwork. It included 7 questions scored on a 7-point Likert scale (1 = completely disagree, 2 = disagree, 3 = somewhat disagree, 4 = no opinion, 5 = somewhat agree, 6 = agree, 7 = completely agree). Higher scores indicated greater psychological safety (low: 1–4, medium: 4–5.5, high: 5.5–7). Questions 52, 54, and 56 were reverse-scored. Higher scores reflected a stronger perception of team psychological safety.[27] The validity and reliability of the Persian version were confirmed in Shams’ study.[32]

Due to differences between Iranian and Afghan Persian, the questionnaire was translated into Afghan Persian by a fluent translator, then back-translated into Iranian Persian by another translator to ensure alignment with the original version. In order to examine the content validity of the questionnaire, a qualitative method was used. For this purpose, the questionnaire was presented to six experts in the field of health services management and they were asked to review the questions in the questionnaire and express their opinions about their quality and relevance to the research topic. To ensure the reliability of the questionnaire, Cronbach’s alpha test was used. For this purpose, the questionnaire was completed by 30 members of the research community. The Cronbach’s alpha values obtained for the patient safety competency, teamwork, and psychological safety questionnaires were 0.93, 0.87, and 0.89, respectively, which are higher than 0.70, so the questionnaire in this study has internal consistency.

After obtaining permission from hospital authorities, questionnaires were distributed to the targeted nurses by a trained team and collected following established guidelines. Data were entered into the analytical system by a coresearcher, and statistical analysis was conducted at a 95% confidence interval using SPSS version 21. Ethical considerations were strictly followed during data collection.

Statistical analysis methods

Data were initially described using central and dispersion indices. Independent t-tests and Mann-Whitney tests were used to compare quantitative variables for binary variables, depending on data normality. For variables with more than two levels, ANOVA and Kruskal-Wallis tests were applied. Pearson and Spearman correlation coefficients were used to examine relationships between quantitative variables, based on data distribution. Finally, an appropriate regression model was used to assess the simultaneous effects of demographic, teamwork, and psychological variables on nurses’ patient safety competency, considering data characteristics.

The significance level for all tests was set at 0.05. All analyses were performed using SPSS version 21.

Ethical considerations

To ensure ethical compliance, the study obtained an ethics code from the Ethics Committee of Mashhad University of Medical Sciences. Written informed consent was obtained from participants, and data collection proceeded only after voluntary, informed consent. All procedures involving human participants adhered to the ethical standards of the institutional and national research committees and complied with the 1975 Helsinki Declaration and its amendments or comparable ethical standards. The study was approved by the Biomedical Research Ethics Committee of Mashhad University of Medical Sciences (ethics code: IR.MUMS.FHMPM.REC.1401.077).

AI policy

During the preparation of this work, the authors used ChatGPT in order to check the grammar and improve readability. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

Results

The demographic characteristics of the study participants are shown in Table 1. The response rate for this study was 92.6%. Of the 113 participants, 50 (44.2%) were female and 63 (55.8%) were male. The majority were married (57.5%). According to the study findings, 70 participants (61.9%) had more than six-night shifts per month, while 43 (38.1%) had six or fewer night shifts. Nearly 70% of the participants had attended patient safety training. Fifty-three participants (46.9%) were from the internal emergency department, representing the largest group, while twelve (10.6%) were from the pediatric emergency department, the smallest group. Additionally, 32 (28.3%) and 16 (14.2%) were from the trauma and gynecology/obstetrics emergency departments, respectively. The mean age of the nurses was 27.09 ± 5.4 years. Their mean work experience in the emergency department and general hospital wards was 2.74 ± 2.57 years and 4.77 ± 3.88 years, respectively.

Table 1.

The demographic characteristics of the study’s target group

Variables				Numbers (%)		Mean±S. D
Age				–		27.09±5.4
Retirement history				–		4.77±3.88
Years of service in the emergency department				–		2.74±2.57
Gender		Female		50 (44.2)		–
		Male		63 (55.8)		–
Marital status		Single		48 (42.5)		–
		Married		65 (57.5)		–
Type of emergency department		Trauma		32 (28.3)		–
		Internal		53 (46.9)		–
		Gyn/Obstetric		16 (14.2)		–
		Pediatric		12 (10.6)		–
Number of night shifts		≤6 nights		43 (38.1)		–
		>6 nights		70 (61.9)		–
Patient safety training		Yes		79 (69.9)		–
		No		34 (30.1)		–

Distribution normality of quantitative variables

Before data analysis, the normality of quantitative variables was assessed using the Kolmogorov-Smirnov test, which was rejected at a significance level of 0.05.

Univariate analysis

As shown in Table 2, the correlation between each variable and patient safety competency was examined. Based on Spearman’s correlation coefficient results, except for age, work experience in general hospital wards, and work experience in the emergency department, all other variables showed a significant correlation with patient safety competency (P < 0.05).

Table 2.

The relationship between quantitative variables with patient safety competency

Variables		Spearman’s Correlation		P-value
Age		−0.022		0.816
Work experience in general wards		0.106		0.262
Work experience in emergency departments		−0.026		0.783
Psychological security		0.483		<0.001
Team structure		0.614		<0.001
Team leadership		0.570		<0.001
Oversight		0.664		<0.001
Support		0.547		<0.001
Communication		0.551		<0.001
Team working		0.710		<0.001
Patient safety competency		1		–

As shown in Table 3, the results of the Mann-Whitney and Kruskal-Wallis tests indicated a significant relationship between patient safety training courses and patient safety competency. Participants who attended patient safety training courses achieved higher patient safety competency scores compared to those who did not attend (P = 0.000).

Table 3.

The relationship between quantitative variables with patient safety competency

Variables				Std.D±Mean		Test results*
Gender		Female		46.5±7.4		Z=−0.982 P=0.326
		Male		47.5±7.8
Marriage status		Single		45.4±7.9		Z=−1.882 P=0.060
		Married		48.1±7.1
Occupation		Nurses		46.6±7.4		Z=−1.195 P=0.232
		Midwives		48.1±8.1
Night duty		Equal/less than six nights		46.5±8.4		Z=−0.228 P=0.820
		More than six nights		47.2±7.0
Patient safety training		Yes		49.1±5.3		Z=−3.875 P=0.000
		No		41.9±9.3
Emergency departments		Trauma		47.5±6.9		KS$=1.079 P=0.777
		Internal		45.8±8.6
		Gyn/Obstetric		48.5±6.0
		Pediatric		48.5±5.4

*Mann-Whitney U test. ^$Kruskal-Wallis test

Similarly, variables with P < 0.1 in the univariate phase were analyzed using a multiple linear regression model to simultaneously examine their relationship with patient safety competency.

Based on the results from the multiple linear regression model in Table 4, there was a statistically significant positive relationship between team structure, team leadership, and oversight with patient safety competency. For each one-point increase in team structure, team leadership, and oversight, patient safety competency scores increased by 0.575, 0.232, and 0.246, respectively. Notably, while controlling for other variables, the safety competency score of single nurses was, on average, 2.11 points lower than that of married nurses. Among the teamwork dimensions significantly associated with patient safety competency, team structure was identified as the second most important factor.

Table 4.

Results of simultaneous investigation by the multiple linear regression model

Variables		Regression coefficient (B)		Std. error of regression coefficient		P
Team structure		0.575		0.117		<0.001
Team leadership		0.232		0.094		0.015
Oversight		0.246		0.114		0.033
Support		0.030		0.134		0.823
Communication		0.019		0.095		0.845
Psychological security		0.137		0.077		0.079
Marriage status
Single		−2.11		0.795		0.009
Married (Reference)		–		–		–
Patient safety training course
Yes		1.67		0.987		0.093
No (Reference)		–		–		–

Discussion

The present study aimed to investigate factors related to patient safety competency among nurses working in emergency departments of public hospitals in Afghanistan. The findings revealed no significant relationship between age, retirement work experience, or nurses’ emergency department experience and patient safety competency. This suggests that patient safety and its culture are not solely tied to nurses’ personal or professional status. Instead, the results indicate that policymakers and hospital nursing managers should focus on improving team structure and leadership through training programs on patient safety and enhancing psychological safety at the nursing unit level to boost patient safety competencies. Consistent with this finding, Jang et al.[33] found no significant relationship between nurses’ demographic variables and patient safety competency. Similarly, El-Azzab and El-Aziz[34] reported no significant association between nurses’ demographic characteristics and patient safety competency scores. However, Biresaw et al.[35] found a significant relationship between nurses’ attitudes toward patient safety and their demographic characteristics, and Chenot et al.[36] showed that nursing students’ age, race, and ethnicity influenced their knowledge, skills, and attitudes regarding patient safety. These discrepancies may be attributed to differences in geographical settings, cultural contexts, and social conditions across studies.

The current study also found a significant relationship between psychological safety, team structure, team leadership, supervision, support, communication, and teamwork with patient safety competency. These factors are interconnected and collectively influence nurses’ ability to provide safe, high-quality care.[37] The findings underscore the importance of psychological safety, teamwork, and management principles in nursing to ensure patient safety. Consistent with these results, Dietl et al.[38] highlighted the need for a supportive work environment, effective management, stress reduction, and improved job satisfaction to enhance patient safety outcomes. Other studies have shown that effective teamwork among healthcare professionals significantly contributes to patient safety, emphasizing clear communication, mutual respect, and shared goals.[39] Effective leadership is also critical, with leaders needing to foster a safety culture, promote open communication, and encourage reporting of safety concerns.[3,40] Additionally, a balance between supervision and autonomy is essential for effective patient care and improving patient safety.[41] The findings emphasize the interconnected roles of teamwork, leadership, psychological safety, and communication in ensuring patient safety. These factors collectively shape nurses’ ability to safeguard patients, highlighting the need for a comprehensive approach that balances these elements to achieve optimal safety outcomes. Nursing managers can promote teamwork by facilitating communication, resolving conflicts, expanding nursing expertise, clarifying roles, and encouraging collaboration. Nurses can also develop effective communication skills and lead efforts to enhance teamwork with colleagues. The study also found a statistically significant relationship between patient safety training courses and patient safety competency, with participants who completed training scoring higher than those who did not. This suggests that patient safety training positively impacts nurses’ knowledge, skills, and attitudes, enabling them to identify and mitigate risks, prevent adverse events, and ensure safe care. Such training should be a mandatory part of nurses’ professional development. Consistent with this, Najafi et al.[42] found that trained nurses had significantly higher patient safety competency than untrained nurses, and Jang et al.[33] linked safety knowledge to patient safety training history. These findings suggest that regular, periodic safety training can enhance nurses’ safety knowledge.

The study also identified a statistically significant positive relationship between team structure, team leadership, and supervision with patient safety competency. Nurses who perceive themselves as strong leaders can empower their work environment, fostering professional behaviors such as effective communication, collaboration, and mutual understanding, which align with clinical leadership traits.[43] Boamah’s[44] findings support this, showing that nurses’ clinical leadership behaviors improve patient outcomes. Strong nursing leadership is essential to implement and sustain effective management practices, education, and continuous support for high-quality patient care. In this study, leadership had the highest teamwork score and was a predictor of patient safety competency. Factors such as leadership, communication, supervision, and supportive behavior are crucial for ideal teamwork in emergency departments.[20] Parr et al.[45] found that leaders enhance patient satisfaction and safety, while Yodang et al.[46] showed that nurses with strong team leadership are more likely to report adverse events and foster a culture of safety and innovation. Labrague et al.[47] highlighted the role of nursing leadership in strengthening safety measures, reducing adverse patient outcomes, and improving care quality. Leadership indirectly impacts patient safety outcomes, requiring empowered work environments and effective leader-nurse relationships.[48] Teamwork and leadership are critical in addressing adverse events, and improving team education can enhance patient safety and strengthen nontechnical skills like prioritization, leadership, and decision-making. The study found that single nurses had lower safety competency scores than married nurses. Kim et al.[49] similarly reported higher patient safety competency among married nurses. Additionally, team structure was identified as the most critical dimension among teamwork factors related to patient safety competency. A well-structured team facilitates effective communication, leadership, situational monitoring, and mutual support, promoting teamwork through clear leadership, patient involvement, and role commitment.[50] Soola et al. and other studies confirm that team structure is a key organizational factor in patient safety competency, with organized teamwork significantly impacting care quality and safety.[6,44]

Limitations and recommendations

This study faced several limitations. First, some nurses were excluded due to incomplete questionnaires, which lacked necessary information. Additionally, the study was limited to nurses working in emergency departments of public hospitals in Afghanistan, necessitating caution when generalizing the findings. To enhance precision and accuracy, comprehensive and longitudinal studies are recommended. Given these limitations, future research should involve larger sample sizes and be conducted in different countries to ensure more reliable results.

Conclusion

The quality of healthcare services delivered in emergency departments is critical for reducing medical errors and enhancing patient safety. Nurses’ professional competencies in patient safety are among the key factors for an effective emergency care system. According to the findings, team structure, team leadership, oversight, and marital status significantly impact patient safety, which can enhance nurses’ competency in this area. Notably, married nurses demonstrate higher competency levels compared to their single counterparts. The competency of nurses in patient safety is a crucial factor that hospital managers must prioritize. Based on the study findings, greater emphasis should be placed on team structure and leadership, supportive supervision, continuous learning, and psychological safety to improve the quality of emergency services. Hospital managers are recommended to design and implement multifaceted strategies, including structured team leadership, supportive supervision mechanisms, and basic and advanced training courses, to improve nurses’ competency. Additionally, policies promoting organizational culture, personnel commitment, team leadership and management, staff self-assessment mechanisms, and prioritizing the recruitment of married nurses over single ones in emergency departments can significantly enhance the quality of emergency services and drastically reduce medical errors during the provision of healthcare services to patients.

These strategies should include structured team leadership, supportive supervision mechanisms, and comprehensive training programs (both basic and advanced) to enhance patient safety competencies. To ensure sustainability and scalability, these interventions should be embedded within broader health policy frameworks, such as the WHO Patient Safety Framework and the Institute of Medicine (IOM) recommendations for improving healthcare quality. Policymakers should prioritize workforce development by investing in continuous professional education and training, as outlined in the Global Strategy on Human Resources for Health. Furthermore, fostering a culture of safety through psychological safety and teamwork, as recommended by the Agency for Healthcare Research and Quality (AHRQ), can significantly reduce medical errors and adverse events. By integrating these evidence-based policy benchmarks, healthcare systems can create resilient emergency care environments that not only improve patient safety outcomes but also enhance the overall quality of care.

Study suggestions for further research

1. Conduct longitudinal studies to examine the long-term impact of patient safety training programs on nurses’ patient safety competency in emergency departments, particularly in Afghanistan, to assess sustainability and changes over time.

2. Expand the study to include nurses from private hospitals and other healthcare settings in Afghanistan to compare patient safety competency across different healthcare systems and identify contextual differences.

3. Investigate the role of cultural and organizational factors specific to Afghanistan in shaping nurses’ patient safety competency, focusing on how cultural norms and workplace dynamics influence teamwork and psychological safety.

4. Explore the impact of advanced simulation-based training on patient safety competency among emergency department nurses, assessing its effectiveness in improving teamwork, communication, and clinical decision-making skills.

5. Examine the relationship between nurses’ workload, shift patterns, and patient safety competency in emergency departments, particularly focusing on how night shifts and overtime affect psychological safety and teamwork.

6. Investigate the influence of interprofessional collaboration on patient safety competency, including the roles of physicians, paramedics, and other healthcare workers in emergency departments, to identify strategies for enhancing team dynamics.

7. Conduct comparative studies across different countries with similar healthcare challenges to Afghanistan to identify global best practices for improving patient safety competency among emergency department nurses.

8. Explore the development and validation of context-specific tools for assessing patient safety competency in Afghanistan, considering linguistic, cultural, and resource-related factors unique to the region.

9. Investigate the impact of leadership styles (e.g., transformational vs. transactional) on nurses’ patient safety competency, focusing on how leadership influences team structure, oversight, and psychological safety in emergency departments.

10. Examine the role of technology, such as electronic health records and decision-support systems, in enhancing patient safety competency among emergency department nurses, assessing barriers and facilitators to adoption in Afghanistan.

Disclosure

The funding agency had no role in the study design, data analysis, interpretation of results, writing of the report, and the decision to submit the article for publication.

Abbreviations

MEs: Medical Errors; EDs: Emergency Departments; AEs:Adverse Events; WHO: World Health Organization; ICC: Intraclass Correlation Coefficient; IOM: Institute of Medicine; AHRQ: Agency for Healthcare Research and Quality.

Author’s contributions

AS and SST designed the study. RR, VGH and SST participated in the conception of the study. AS participated in the data collection. VGh managed and conducted the statistical analyses and interpreted the data. RR, AS and SST wrote the first draft, and RR and SST revised it to make the final manuscript. All authors have read and approved the final manuscript.

Data availability statement

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

Conflicts of interest

The authors declare no conflict of interest, financial or otherwise.

Funding Statement

Nil.