Introduction
Patient safety, with the principal of “do no harm”, has become an escalating global public health concern, with its prevalence and gravity on the rise [1]. In recent years, there has been an increasing acknowledgment of the significance of patient engagement in enhancing patient safety and augmenting health outcomes. Patient engagement (PE) refers to the process by which an individual patient communicates, influences, and actively engages or participates in the clinical process [2], which harnesses the patient’s experience, authority and opportunities to synergize with the expertise of healthcare professionals [3], positing the patient as a vital human resource within the medical process. It is crucial for ensuring patient safety. The World Health Organization (WHO) advocates for actively including families and patients in the medical process to mitigate preventable harm in healthcare, as outlined in the Global Patient Safety Action Plan for 2021–2030 [4].
The concept of engaging patients as active participants in their healthcare management is both clinically advantageous and inherently complex, contrasting markedly with the experiences of healthy individuals or those managing a single health issue. As patients, there are limitations on their energy and physical abilities. The responsibility of PE may impose an additional physical or mental burden [5] to them, and mastering complex medical knowledge presents an even greater challenge. Although PE behaviors offer theoretical benefits for patient safety, the quality of evidence supporting their effectiveness in improving patient safety is currently relatively low [6]. The effects of PE in some studies for the medical process were uncertain [7, 8]. The absence of a unified standard for PE models results in diverse behaviors and patterns of PE. Ineffective or erroneous engaging behaviors may pose certain clinical risks, and clinical staff expressed some concerns regarding the uncertain risks associated with PE [5, 9, 10]. In this process, the balance between the responsibilities and rights of medical staff and patients has become an important factor troubling both clinical practitioners and patients. For patients, excessive responsibility for their safety can become a source of pressure and challenge [11]. Patients may question their competencies to engage effectively. On the other hand, in the context of PE, medical personnel still bear the vast majority of the responsibility for maintaining patient safety. Due to patients’ limited knowledge, attitudes, or differences in values [12], safety risks that may arise from patients’ improper participation behaviors. This implies a certain degree of contradictory relationship between patients’ participation behaviors and responsibilities. Therefore, many studies promoting PE have emphasized the term “effective” [7, 13]. Some medical staffs believe that only patients with higher competence, such as healthy literacy, safety awareness, would and could engage effectively and serve as good partner [14, 15]. With adequate resources and support, it is feasible to moderately enhance the competency levels of the patient population, thereby improving their involvement in their own safety [15‐19]. To facilitate more effective and reasonable patient engagement in their safety, healthcare providers must conduct a comprehensive assessment of patients’ competence to engage and the resources at their disposal [6]. Based on this assessment, targeted empowerment strategies can be implemented. Simultaneously, compensatory strategies should be adopted to address areas of deficiency. This approach ensures that patients are better equipped to make informed decisions regarding their health, thereby promoting a safer and more inclusive healthcare environment. Although the competence of patients has been a concern, particularly in decision-making and self-care processes [15, 20‐22], there is no clear description of the patient competencies needed throughout the process of engagement. Furthermore, due to the absence of comprehensive literacy assessment methods, the effectiveness of intervention measures remains questionable. Patient safety is a multidimensional issue that involves the interaction between healthcare providers and patients. To improve patient safety, both must work together to ensure that healthcare providers can provide appropriate support and education, while ensuring that patients are empowered to actively engage in their own treatment process.
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Therefore, when exploring the necessary competencies required for patients to engage in their own safety, it is necessary to consider the perspectives of both healthcare providers and patients. This article conducted semi-structured interviews with nurses, nursing managers, and patients at a Grade A hospital in Wuhan, China, inquiring about their understanding, experience and feelings about PE during work or medical treatment, and explores the necessary competence that patients need to possess to engage in their safety, in order to clarify the goal of further promoting PE in patient safety in the future.
Method
Study design
Our research team employed a phenomenological approach [23] to investigate the competence of PE in their safety from the perspectives of nurses and patients with semi-structural interviewing method. Different from structural interview, semi-structural interview is more flexible but not going off-topic. By semi-structural interview, we can learn about the nurse’s and patients’ experience with patient safety issues as well as their perspectives about patient competence for PE by their words.
Data collection
The study was conducted from Sep. 15th 2023 to Apr. 30th 2024 at a Tier-A tertiary hospital in Wuhan, China. The inclusion and exclusion criteria for participants were showed in Table 1. A nursing graduate student (YL) who had experience in conducting interviews and received training interviewed the participants. To ensure the consistency of the interview quality, all participants were interviewed by this researcher. Another researcher (XL) recorded the conversation between the interviewer and the participant by recorder and notebook. The two interviewers conducted a nursing internship for several days in the department before the interview, and established a good relationship with the nursing staff, nursing managers and interviewed patients to gain trust. After getting familiar with the participants, the two interviewers invited the interviewees and explained the content and purpose of the study in detail. After obtaining the consent of the interviewees, the two researchers agreed on the time, place and format of the interview according to the preferences of the interviewees. In order to prevent the interview from delaying the patient’s treatment plan, the interview with the patient was conducted in the ward at the end of the daily treatment or during the period of little treatment. The interview with the nursing staff was conducted during the rest time of the nursing staff or nursing managers, in a quiet meeting room, office or online video call according to the preferences of the nursing staff. The number of interviewees was determined based on data saturation, and the interview was terminated after interviewing two more interviewees to ensure that no new opinions emerged.
Table 1
Inclusion criteria
Participants | Inclusion criteria |
|---|---|
Nurse | (1) a clinical nursing tenure exceeding 5 years |
(2) middle or higher professional title | |
(3) Working in adult wards | |
(4) voluntarily participated in this study | |
Patient | (1) aged 18 years or older |
(2) understand the objectives of the study and voluntarily engaged in this study | |
(3) conscious and without mental disorder | |
(4) physical condition is stable | |
(5) not in acute stage or advanced stage of tumor | |
(6) have communication ability, can speak Chinese and understand Mandarin. |
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Outline of the interview
Prior to initiating the interviews, we crafted an interview protocol and modified the content of the interview outline with counsel of two experts experienced in qualitative research studies in our research group. The outline’s content is bifurcated: the first part gathers general information regarding the nurses and patient. The interview outline showed in Table 2.
Table 2
Interview outline
Participants | Interview outline | |
|---|---|---|
Nurse | 1. General information | Gender |
Highest Education | ||
Professional Title | ||
Length of work | ||
Department | ||
2. Key questions for interview | (1) Could you elaborate on your comprehension of patient engagement in patient safety and your perspectives on this subject? | |
(2) Please share your clinical practice and experiences regarding the facilitation of patient engagement in patient safety. | ||
(3) What benefits do you perceive arising from patient engagement in patient safety? | ||
(4) Does patient engagement in patient safety present any challenges for you or your colleagues? Please share your experiences. | ||
(5) What attributes, competencies, or criteria do you believe patients should possess or fulfill to be actively involved in their own safety? | ||
(6) What kind of support do you think is necessary to further promote patient engagement for patient safety? | ||
(7) Do you have any additional insights to contribute? | ||
Patient | 1. General information | Age |
Gender | ||
Medical Insurance Type | ||
Education Background | ||
Inpatient Department | ||
2. Key questions for interview | (1) How do you interpret the concept of patient engagement in patient safety? | |
(2) Have you or anyone you know experienced adverse safety events during medical treatment? Can you detail the experience? | ||
(3) What types of health or safety information do you usually pay attention to while hospitalized? | ||
(4) What actions have you taken to protect your own safety during medical treatment? Why did you take these actions? Please share your experience. | ||
(5) How do you perceive your responsibilities concerning personal safety? | ||
(6) Have you encountered obstacles in engaging in or maintaining your own security? If so, what were they, and how did you overcome them? | ||
(7) Do you think you possess the requisite qualities or abilities to engage in the maintenance of your own security? Can you provide some examples? | ||
(8) What additional support do you think is necessary for you to effectively maintain your safety as a patient? | ||
(9) Do you have any further suggestions or opinions on how hospitals can better support patients’ engagement in patient safety? | ||
(10) Is there any other information or perspective you would like to add? |
Throughout the interviewing process, the line of questioning may be adapted in response to the participants’ contributions or their behavior that interviewer observed. Questions already answered in the patient’s response would not be repeated.
The conversations during the interview were recorded by the recorder and notebook, the length of each interview is between 26 min and 68 min, and were transferred into literature in 24 h after the interview.
Data analysis
Colaizzi’s analysis method [24] was employed to examine the aggregated data. The research team transcribed the audio recordings and notes into electronic text formats within 24 h, constituting the raw data. The researcher meticulously reviewed the raw data multiple times to attain a profound comprehension of its contents, proceeding with initial coding. Based on the initial coding, the researcher categorized the coded content by looking for commonalities, and extracted and summarized themes from it. The analyzed themes were then reviewed by the researcher, who revisited all the coded data to review whether the codes could be generalized to the themes that had been proposed, and if there were codes for which themes could not be found, the themes were re-grouped. And then, we reviewed the raw data to check whether all the data segments could truly reflect the content of the themes. Subsequently, we reviewed the theme content to check whether there were themes with broad content and unclear pointers, and if so, they were categorized into more clearly defined sub-themes and the above steps were repeated. After the initial identification of themes, we then conducted a review of the relationships between different themes, checking whether there were themes that were similar and could be merged, and whether there were themes whose logical relationship was one of containment. The themes were finally confirmed through continuous review and adjustment of the content and themes over and over again.
Triangulation
In order to substantiate the credibility of our findings, researcher triangulation was adopted. Data gleaned from the semi-structured interviews were recorded, followed by thematic analyses post-initial coding to identify the themes. In the process of thematic analysis, two researchers (YL, JJZ) independently read and initially analyzed the original data, and then discussed the results of the analysis with other members of the research team, summarizing similar or identical themes, discussing themes with differences, and re-analyzing the corresponding raw data. Through multiple consensus meetings and iterative reviews of thematic content, a unified agreement was established, affirming the final themes.
Result
General information of interview participants
A total of 27 participants accepted the interview and contributed their perspectives, comprising 14 clinical nurses and 13 patients, with 4 of nurses are nursing managers. The general information of participants were showed in Tables 3 and 4.
Table 3
General information of patients(n = 13)
Patient(n = 13) | n(%) |
|---|---|
Gender | |
Male | 6(46.15%) |
Female | 7(53.85%) |
Age(M ± SD) | 54.07 ± 11.67 |
Medical Insurance Type | |
Insurance for urban residents | 4(30.77%) |
Insurance for urban workers | 7(53.85%) |
The new rural cooperative medical insurance | 1(7.69%) |
self-financing | 1(7.69%) |
Highest Education | |
High school | 5(38.46%) |
Middle school | 4(30.77%) |
College | 1(7.69%) |
Bachelor degree | 3(23.08%) |
Inpatient Department | |
Thoracic surgery department | 3(23.08%) |
Cardiovascular department | 3(23.08%) |
Neurology department | 2(15.38%) |
Gastrointestinal surgery department | 2(15.38%) |
Gynecology department | 2(15.38%) |
Department of Hepatobiliary surgery | 1(7.69%) |
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Table 4
General information of clinical nurses and nursing managers (n = 14)
Nurse(n = 10) n(%) | Nursing Manager(n = 4) n(%) | |
|---|---|---|
Gender | ||
Female | 10(100%) | 4(100%) |
male | 0 | 0 |
Highest Education | ||
Bachelor degree | 9(90%) | 2(50%) |
Master degree | 1(10%) | 2(50%) |
Working years(M ± SD) | 10.80 ± 2.49 | 19.75 ± 3.59 |
Title of Professional Position | ||
Supervisor nurse | 10(100%) | 0 |
Chief nurse | 0 | 4(100%) |
Department | ||
Department of cardiology | 3(30%) | 0 |
Department of neurology | 1(10%) | 1(25%) |
Department of Gynecological tumor | 1(10%) | 0 |
Department of Gastroenterology | 1(10%) | 0 |
Department of Pancreatic surgery | 1(10%) | 0 |
Department of Gynecology | 1(10%) | 0 |
Department of Maxillofacial surgery | 1(10%) | 0 |
Department of Gastrointestinal surgery | 1(10%) | 0 |
Day surgery ward | 0 | 1(25%) |
Department of Stomatology | 0 | 1(25%) |
Department of Hepatobiliary surgery | 0 | 1(25%) |
Major themes
Competence of information sharing
There existed both consensus and divergence in the understanding of PE for patient safety when we queried patients and nurses.
For patient safety, some of nursing staffs specifically described their understanding of patient safety through case examples, focusing on the prevention of adverse events regulated by the nursing department, such as falls, pressure ulcers, medication errors, misidentification, accidental tube removal, and so on. Some of them also mentioned unavoidable safety risks related to the patient’s disease or treatment, things like sudden death due to cardiovascular causes, surgical risks, which require the patient to be fully informed and to sign an informed consent form. In addition, some nursing staff pointed out the potential adverse outcomes due to the lack of self-care ability after patient discharge. Nursing staff particularly emphasized avoiding preventable physical harm to patients. In contrast, patients’ understanding of patient safety is more subjective. When talking about patient safety, they focus more on their personal feelings and experiences, such as comfort, pain relief, and sense of security.
N7: Patient safety? You mean things like preventing pressure ulcer, medication error, falling down? …Staffs in nursing department check frequently on adverse events so our colleagues will pay more attention on risks of these security incidents.
N2: For instance, if a person is at high risk of falling, I would certainly provide safety education to the him and his family to prevent such incidents, which is also part of patient safety management by hospital. And we also explain matters like adverse effect of medication or treatment, knowledge about their disease, and how to handle emergencies, such as patients with heart attacks, to the patients and their families, which are certainly part of patient safety. We educate patients and their families extensively, and if they can comply, for example, by taking medication on time and quitting smoking and alcohol, I believe that’s their active engagement.
P11: For matters like surgery, I feel it’s necessary to find a good hospital and a proficient professor to put my trust in.
P4: Anyway, by following the doctors’ and nurses’ instructions I feel like I’m recovering quite well. I do what they tell me to do, if they ask me to take medicine, I take it. There’s a (health education) video at the nurse station, and when I’m free, I go there to learn rehabilitation exercises by myself. I think I’m safe here.
Due to the difference in understanding and needs for patient safety, both nurses and patients think the key element in PE and PE competence is information sharing. However, their concerns are not same. Nurses prioritize the provision of information by patients during clinical practice, they focus more on patients’ conditions and treatment needs for a better caring plan as professionals, whereas patients emphasize their opportunities to receive more information from healthcare providers and concern more about their own rights which will enhance their sense of security. Clearly, the competence of providing, receiving and understanding information of patient is of paramount importance for both patient and nurses.
N1: Only the patient knows their true desires and needs, as well as the types of safety measures they prefer. Engagement is the process make patients have opportunity to provide us more information about themselves or their requirement.
P8: I believe engagement entails asking more questions, which is within my capacity and should be met by healthcare providers. I need to know all about myself.
Competence of taking PE as responsibility and right
Responsibility and right for security is one of the key concerns of PE for both sides. All nurses believe that patients should fulfill responsibilities and obligations to maintain their own safety in some case. Nursing professionals hold the view that patients must be fully informed about their conditions, treatment and caring plans as well as associated risks, and should be required to provide informed consent. In instances where the patient needs protective concealment, family members should also undertake the corresponding responsibility, acting as the patient’s proxy. Certain nursing personnel posit that a patient’s lack of awareness regarding risks does not foster greater trust in medical staff but rather escalates the potential for discord between doctor and patient. When patients’ expectations are too high and the risk is not fully known or expected, the responsibility will be fully imposed on medical staff. When there is an inevitable safety risk under normal circumstances, the huge gap between reality and expectation will cause patients and their families to fall into bad emotions, which will lead to unnecessary conflicts between doctors and patients.
N10: For example, for cancer chemotherapy patients, we now have a variety of chemotherapy programs, with each presenting its own set of pros and cons, of course. It is imperative for medical staff to conduct evaluations based on individual patient circumstances, thereby facilitating informed decision-making. Yet the unpredictability of cancer means that we cannot assure the effectiveness of any given program, it is a step by step, each program in the individual effect is different. Consequently, our role is limited to presenting potential outcomes alongside risk information, among which the possible risks and benefits also include treatment costs, so patients need to consider and make choices among them. At present, there are many clinical trial programs available for cancer patients, with risks and benefits still being evaluated during the trial phase, and some patients are not in good economic condition. Some patients, facing economic hardships, may opt to engage in these studies if they fulfill the trial’s eligibility criteria. Therefore, it is imperative that patients thoroughly read and sign the informed consent form acknowledging the risks, including those that are unknown and uncertain. It is essential for patients to possess a strong sense of responsibility.
At the same time, most nurses recognized that, even when adhering to established procedures in clinical practice, mistakes are inevitable, and leading to safety risks. Medical personnel have the responsibility to ensure the safety of patients, but they also hope that patients can consciously engage in a role of verification and oversight. Several nurses shared with us the safety incidents they have experienced or heard about in the course of their work that highlighting instances where PE averted serious adverse outcomes. They believe that the proper PE behavior of patients has great value and significance in promoting patient safety.
N3: Of course, we have to operate in accordance with the procedures in clinical practice, but it is really very difficult to ensure that we can ensure a complete absence of errors, isn’t it? No one is perfect. What we hope is that upon a patient’s arrival at the hospital, they retain a strong sense of personal responsibility, not to completely rely on the medical staff, but to cooperate with the medical staff to ensure their own safety, such as to assist the medical staff to verify information, monitoring the operation of medical staff, and ensuring adherence to hand hygiene protocols of the medical staff.
N5 Once, a student nurse went to hang an IV drip for a patient in the morning. Because the morning shift was very busy, she helped out with the task. Likely overwhelmed by the multitude of medications in her possession, an error occurred—the IV designated for patient 33 was mistakenly set up for patient 32. When I went to remove the needle for another patient in the room, before I even reached the bedside, the patient in bed 32 promptly noticed the information on the medication packaging and said, “Hey, this isn’t my name on it.” He immediately told me, and upon checking, I found that indeed one bag of medication had been mistakenly hung at bed 32. I quickly apologized to the patient and told him that his action was very good, as it prevented an accident.
Some nurses have reported that patients lacking a sense of responsibility, their engaging behaviors, such as providing false information, not only fail to promote safety, but may also escalate safety risks. A nurse shared her perspective, stating:
N8: Despite being instructed to fast and refrain from drinking before surgery, some patients still consume food in the mistaken belief that it poses no safety risks. In reality, this is extremely hazardous, especially when patients, despite being informed of the risks, persist in their actions and deceive caregivers by falsely claiming, for instance, that they have not eaten, therefore providing us with incorrect information that can severely mislead clinical judgment. Often, the truth comes to light only through our repeated questioning and observation of subtle clues. Such actions are very dangerous, and there have been many medical incidents have arisen as a consequence. Even though we have emphasized the dangers of such behavior to patients multiple times, they fail to take a responsible attitude towards their own safety and neglect their well-being.
All nurses advocate for patient involvement, believing that patients have the right to ensure their safety throughout medical treatment, a right that all healthcare professionals should respect. Even if patients do not possess adequate knowledge or competencies, and despite the potential for increased workload on medical staff, hospitals and healthcare providers should still encourage patients to fully engage in the maintenance of their own safety and provide them with sufficient support.
N3: PE is meaningful and deserves vigorous promotion. In fact, regardless of the level of literacy, we support it. It’s not just about the patients; clinical medical staff and hospital management must enhance their awareness, possess relevant knowledge, and take actions to optimize the entire medical environment.
N2: Even when we encounter challenges in communication with certain patients or find them troublesome amidst our busy work schedules, they still serve a crucial role in providing us with information on potential concerns. If a patient reports any discomfort, I would be more vigilant and cautious, and our observations would be more closely monitored. There might be times when it turns out to be false alarms, and it might increase the workload, but we are more relieved that the patient is unharmed and safe.
The majority of patients believe they should be responsible for their own safety, and as a result, some patients will engage in proactive behaviors. However, a minority of patients, despite agreeing that they are the primarily responsible for their own safety, remain disengaged from the medical process, under the assumption that hospitals are safe places and medical staffs will ensure their well-being. A small subset of patients dissents from the PE model, thinking that ensuring safety of patients should be the sole responsibility of medical professionals.
P5: I take my health and safety very seriously. The family and social education I’ve received, although I didn’t study medicine, still made me aware of the importance of health and safety.
P2: Most hospitals, especially those of higher levels, are generally safe environments. Of course, you are certainly responsible for your own safety, but within the hospital, it’s relatively safe. Doctors and nurses are readily available to address any issues, so there’s no need to worry too much.
P11: Since I’m hospitalized, I just need to follow the doctor’s advice; the doctor will take responsibility for my safety, so I don’t need to worry about it myself.
Competence of maintaining trust relationship with health personnels
All nurses and nursing managers assert that trust is an essential prerequisite for PE to yield positive outcomes. They believe that PE in their own safety is a collaborative process between the doctor and the patient, rather than a task to be completed by the patient alone. When asked about the troubles or adverse outcomes caused by incorrect PE and the underlying reasons, almost all nurses mentioned “distrust” in the process of summarizing.
N2 Ultimately, patients lack a medical background, and our criteria for judgment differ from theirs. Even if we have explained, we cannot fully make him understand the significance of treatments like dialysis. Therefore, popular traditional impressions and some incorrect views may still be a major factor in the patient’s decision-making. Hence, we will try our best to enhance the patient’s understanding but, more importantly, to earn their trust.
Trust plays a dual role in PE behaviors. In certain instance reported among nurses and patients, trust has a positive effect, promoting correct PE and fostering a good cooperative relationship between doctors and patients. In other cases, an over-reliance on medical staff due to trust is the primary cause of reduced PE levels.
N6: When patients trust medical staff, they can cooperate better. For example, after we have provided health education on ankle pump exercises, some patients are able to follow our instructions diligently, performing each movement accurately and fully, for the required duration, not only in the hospital but also consciously at home. They often give us feedback, and the results are very good. However, some patients may harbor some hostility towards medical staff for various reasons, such as cost or negative emotions brought on by illness. Others may only trust their professors and distrust other doctors and nurses. They may not listen to the precautions and health education we provide, resulting in poor cooperation.
P7: I think the doctors and nurses here are very good. I don’t understand medical professional knowledge, nor do I want to ask too many questions. However, I believe that following their advice is always the right thing to do, and cooperating with them is enough. I feel the outcome is very good.
Regardless of the role trust plays in PE in safety, it has led to better outcomes, with patients exhibiting higher compliance. Many nursing staff have indicated that gaining the trust of patients is a key step in ensuring patient safety in medical work. Some medical personnel believe that the mass media should play a role in this process.
M3: At present, some news outlets frequently report negative conflicts between doctors and patients, which has led to a decrease in trust among many patients towards medical staff. Especially in the current era of rampant self-media, if patients or their families are dissatisfied with the treatment outcomes or have other grievances, they may publicize online what they perceive as improperly conduct by doctors, nurses, or hospitals, which can sometimes be just misunderstandings. Under such public opinion circumstances, the doctor-patient relationship becomes even more strained, and the trust of patients in medical staff is greatly affected. However, in reality, the negative incidents publicized online are only a small minority. The vast majority of healthcare providers administer treatment for patients in compliance with established regulations and standards, always prioritizing the patients’ interests and life safety. I believe that the online public opinion environment needs to be improved, and the mass media should also promote more positive cases, help the public establish the correct safety concepts, and work together to create a harmonious doctor-patient environment.
Competence of making equal communication
To address the challenges in PE and foster correct and effective engagement, all nursing staff have identified communication as crucial. They believe that thorough communication with patients is the most effective approach. Through such communication, medical personnel can understand the patient’s concerns and needs, while patients can gain the information they require and be aware of their safety risks. Additionally, nursing staff have highlighted the importance of equal communication, where medical staff and patients must respect each other and collaborate to achieve health and safety objectives.
M2: If the relationship between medical staffs and patients is asymmetrical, or if communication is impeded, it may be difficult to reach a consensus with the patient on health management, and it may also be hard to achieve the purpose of our service. Although medical staff are more professional, the individual needs of patients vary. Therefore, there must be equal mutual communication between both parties, so that we can understand their needs, and they can understand the purpose and benefits of our recommendations. Only in this way can we achieve the goal of their health, which is also the goal of our service; otherwise, it is difficult. Moreover, I believe that only by respecting the patient’s decision-making rights, fully involving them, and allowing them to fully understand our practices can they better cooperate with our various treatments and nursing, and thus better serve the patient’s health.
Competence of accepting non-punitive safety culture
A safety culture that avoidspunitive measures is vital for both medical staff and patients. While all the nurses interviewed expressed their approval of patient involvement, some expressed concerns when discussing the supervisory role of patients. They worry that medical staff might be reluctant to involve patients in the process for fear that patients will discover their mistakes.
N7: Despite our rigorous compliance with legal and regulatory standards, errors can occasionally occur, particularly for novice medical personnel who may not have enough experience. The dissatisfaction and criticism from patients, even in the absence of adverse outcomes, can undermine the confidence of medical staff. To prevent accusations or complaints, some practitioners may opt to reduce the information they share with patients or limit their involvement in the process.
Additionally, patients have expressed analogous apprehensions, fearing that their perceived lack of competence might result in erroneous reports or misguided suggestions, which could provoke discontent from healthcare professionals.
P12: They are all very busy, and I don’t understand professional medical knowledge. They must have their reasons for doing things in a certain way. I might not be right, and I’m afraid that asking too many questions might make them think I’m a troublesome person.
Need of resource support
Need of human resources
Both patients and healthcare professionals have highlighted the issue of inadequate human resources, which impedes the advancement of patient involvement in clinical processes. Nursing staff, in particular, have shared their concerns about the additional workload associated with fostering PE, a burden that could potentially exacerbate tensions between healthcare providers and patients.
N8: Naturally, we endorse patient participation; however, it demands additional exertions from clinical staff. For instance, there is a need for more meticulous and targeted health education, coupled with positive promotion through mass media. Undoubtedly, there is a continuous need to resolve a variety of patient issues in the course of work. Current clinical tasks are already overwhelming, and medical staff can only take on these additional responsibilities at the expense of their own rest time, leading to excessively burdens and also challenges the maintenance of quality care. It is unrealistic to expect this degree of commitment from everyone; there is an urgent need for hospitals and departments to provide additional human resource support to alleviate the workload for each staff member.
N7 In our routine nursing practice, if we are not busy, we can address patient inquiries patiently. However, during extremely busy times, especially when I am interrupted during the administration of nursing treatments or medication preparation, it becomes quite troubling. These interruptions can easily lead to mistakes in my work and could potentially cause accidents. Yet, ignoring patients’ concerns can breed dissatisfaction, with some even lodging complaints. Moreover, when I am too busy to explain things thoroughly to patients due to lack of time and faced with a multitude of pending tasks, I can only briefly outline the essentials to patients, which may also lead to misunderstandings and can easily spark disputes.
Some patients have also complained that the busy work of medical staff prevents them from obtaining a comprehensive understanding of their own conditions. When patients seek for additional information from medical staff, they find it difficult to get support, and thus cannot engage effectively.
P 10: When I try to consult with the professor, I can never find him; his colleagues tell me he’s either engaged in surgery, attending to clinic patients, or in a meeting. The morning rounds are always rushed, and I can’t ask more questions.
Need of channels to provide accurate health information
Many nurses have pointed out that in today’s era of advanced artificial intelligence and the internet, the online spaces have become one of the primary sources for patients seeking information. The abundant information resources available online can serve as a valuable supplement to the busy clinical workload. However, given that most patients have not received formal medical education and lack the ability to discern accurate information, they are prone to being deceived by false information or misleading advertisements, which can lead to adverse outcomes.
N8: Actually, in promoting patient involvement, improving patients’ health literacy is essential, but it cannot be solely reliant on hospitals. After all, the time patients have for medical visits is limited, and our work is very busy. As an individual caregiver, I sometimes have to manage more than a dozen patients, and the time I can allocate for educating each patient is very limited. Patients are required to seek relevant information by themselves, but the online information is often cluttered. Ideally, medical professionals or organizations should establish their own media or public platforms to provide scientific health education to the general public.
A portion of elderly patients have expressed their frustration with the difficulty of discerning authentic from false information online. This has led them to refrain from seeking information through the internet and instead, they place their trust exclusively in the expertise and guidance provided by healthcare professionals.
P7: I’m hesitant to search online because I’m afraid of being deceived; there’s a lot of false information on the internet.
Discussion
From the viewpoints of both nurses and patients, the sharing of information is important, and both parties prefer to have more information in order to better achieve safety goals. However, it should be noted that patients’ desire to share information may be affected by their level of knowledge and trust. Although patients possessing higher levels of education and extensive medical knowledge may be capable of supplying more information and attaining a profound understanding of it, nursing staffs do not believe this ensures that patients’ engagement behaviors will invariably result in safer treatment outcomes. Nevertheless, it is imperative to acknowledge that a reservoir of medical knowledge may significantly influence the extent of patient engagement and their perceived self-efficacy [20, 25]. Due to insufficient knowledge reserves, some patients may hesitate to raise their doubts to medical staff. However, a more thorough understanding of information can enhance the patient’s sense of security, such as knowing the hospital, the areas of expertise of the attending physician, and being aware of the treatment, care, and rehabilitation plans and measures for the disease. This requires medical staffs to take the initiative to invite, guide, and inquire to promote active PE. At the same time, if patients lack the necessary knowledge reserves, they may ignore some abnormal situations or potential risk factors, and find it difficult to identify or be aware of the risks and adverse events that have occurred. Previous studies have indicated that access to information can enhance patients’ self-efficacy and risk perception of participation, thereby increasing their willingness to engage in their care [12]. In this study, when discussing the support needs and directions for future improvement, almost all nursing staff emphasized the need to enhance health education for patients based on their specific needs, in order to fostering a deeper understanding of their own conditions and augmenting their knowledge of safety and health. Therefore, compared with the improvement of health knowledge, it is more important to build a correct concept of safety and awareness of participation among the public.
In addition, compared with the improvement of health knowledge, it is more important to build a correct concept of safety and awareness of engagement among the public. In the opinion of most interviewed nurses, PE holds the potential to enhance patient safety. However, ensuring proper and effective engagement of patients is contingent upon patients possessing a sense of responsibility for their own safety. When patients possess a sense of safety and have a responsible attitude toward their own safety, they become more active in the process of clinical treatment process, cooperating with healthcare providers to maintain their own safety behaviors. It requires ongoing education and development.
However, limited human resources restrict the implementation of further health education within clinical practice. The inadequacy of human resources is an important factor impeding the further participation of patients. In the case of lack of information, medical staff, being the primary information providers for patients, may not have sufficient time and energy to share more adequate information with patients, which causes patients’ dissatisfaction and also becomes a potential risk of doctor-patient conflicts.
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The abundance of online information resources offers the possibility to overcome limitations. With the development of network media, online health information has become one of the main sources of patient health information. However, in this study, many patients and nursing staff have expressed concerns regarding the overwhelming amount of health information online. Many nursing professionals stated that it is the responsibility of the state, government, and medical institutions to disseminate accurate medical knowledge and filter out erroneous information, rather than imposing the difficult task of discerning reliable information on patients, which is too demanding for them. Medical and health institutions should establish professional information channels on online platforms and take responsibility for spreading accurate and reliable medical knowledge. Many studies also leverage information sharing on network platforms to enhance patients’ comprehensive understanding of their own conditions, promote PE, and improve patient safety maintenance competence [26, 27]. On the other hand, the government and the public media must also assume the responsibility of instilling the correct safety concept of patients, cultivating public awareness of safety participation, encouraging appropriate PE during medical treatment, protecting their own rights and interests, and sharing the maintenance responsibilities of safety with medical staffs.
This study also found that the medical-patient relationship profoundly affects the effectiveness of PE. A good doctor-patient relationship is the foundation for promoting proper PE behaviors, with trust in healthcare providers being an essential precondition for patients to undertake appropriate participatory actions. Although some patients in this study exhibited over-reliance on medical personnel due to excessive trust and thus diminished their active participation, trust in medical personnel remains the basis for ensuring effective communication between doctors and patients and improving the level of patient cooperation. In the absence of trust in medical personnel, patients may withhold true information, exhibit hostility, and engage in non-compliant behavior, which will cause difficulties and unsafe consequences for medical personnel. Patients’ reliance on medical personnel depends on their sense of responsibility for their own safety, a sentiment that aligns with, rather than conflicts with, their trust in medical personnel. Patients who possess a strong sense of safety and responsibility are better equipped to cooperate with medical personnel in the process of medical treatment. Through effective verification and oversight, to make up for the omissions of medical personnel in busy clinical work, and identify potential medical errors to ensure their own safety. It is noteworthy that previous study [5] has also indicated that a decline in relationship between patient and medical professionals may be one of the negative effects brought about by PE. This deterioration can be attributed to differences in decision-making between doctors and patients, as well as the anxiety that arises from an overload of information. Establishing equal communication between doctors and patients is an effective way to foster meaningful PE and achieve positive health outcomes. This finding aligns with prior studies which suggest that when patients perceive their role and status as subordinate to that of healthcare providers, their engagement in error reduction is significantly diminished [28]. In this study, patients demonstrate hesitancy in expressing their confusion to medical staff due to a deficient grasp of the concept of relationship equivalence. Meanwhile, this study also revealed that disparities in power between patients and medical staffs can lead to communication barriers. Patients may be reluctant to ask questions or challenge the authority of medical staffs, or refuse to follow the advice of medical staffs, resulting in non-compliant behaviors. This, in turn, escalates security risks. When patients exhibit a negative attitude and contempt for medical staff, it can induce fear among medical personnel of becoming subjects of patient complaints or conflict, thereby diminishing PE. Therefore, establishing an equal communication relationship is imperative for promoting effective PE and ensuring safety.
In the process of PE in reducing errors, the construction of a safety culture without punishment can increase the willingness of medical staff to support and promote PE. Previous qualitative studies of health care workers have found that [29, 30] one of the main reasons medical staff do not support PEis the fear of becoming the target of patient complaints or causing conflict. In the cases mentioned by the nurse, the medical staff strongly support the behavior of the patient which identify safety risk and put forward the stop in time. Conversely, the medical staff would feel panic for the behavior such as accusations and complaints. At the same time, it is worth noting that patients are also afraid to present potentially misguided advice or questions to medical staff because of similar concerns. Therefore, we need to cultivate a more inclusive culture of PE, wherein both medical professionals and patients mut engage in mutual understanding, tolerance and collaboration to collectively advance patient safety.
In the future, it is essential to publicize PE in patient safety through public media in China and even in a larger scope, establish a proper safety concept for the public, and assist patients in developing their own awareness of safety responsibility in the process of medical treatment. Meanwhile, medical institutions should invest more human resources for clinical practice, thereby offering enhanced support for PE. More medical institutions, particularly government health institutions, should establish official health information platforms, providing patients with diverse ways and channels for assessing accurate and reliable health and safety information, and assist the national government and online platforms to combat health rumors and promote citizens’ health. In the future, healthcare providers should implement more individualized and targeted health education for patients. Meanwhile, tools designed to systematically evaluate patients’ participation competence or literacy or conditions are needed. By measurement and facilitate the resolution of these issues, health providers can more comprehensively understand the obstacles that patients may encounter in the process of engagement Relevant guidelines and systems regarding PE in patient safety warrant further research to provide sufficient reference for clinical practice. At the same time, there is a critical need to strengthen the development of a proper safety culture, not for the purpose of punishment or blame, but rather for the goal of enhancing safety. In this study, we found that there are some differences in the understanding and requirements of patient safety between patients and caregivers, but we did not conduct a more in-depth study on this. In the future, a more in-depth study and discussion should be conducted on the different needs of both health providers and patients for patient safety and the specific scope of patient safety.
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Strengths and limitations
This study adopts a phenomenological approach, from the perspectives of two roles in the clinical, the nurses and patients, who experience more PE [30], to ascertain the specific competencies patients must possess to effectively engage in their safety processes. By digging deep into the experience and true feelings of both parties in the participation process, more abundant information is obtained, and the similarities and differences in the opinions of both parties on the attributes of competence required by patients in the safety process of participation are explained.
However, certain limitations exist.To achieve a richer sharing of experiences, this study invited only experienced senior nurses for interviews, and did not interview newly hired or less experienced nurses. The findings are predicated solely on the recollections of the nursing staff regarding their own sentiments from earlier in their careers or on their retelling of the feelings of other less experienced staff, which may have a certain degree of recall bias.
Conclusion
From the dual perspectives of nurses and patients, this study describes the necessary competence for correct participation of patients, encompassing information sharing, patient’s safety awareness and sense of responsibility, trust between medical staff and patients, and equitable communication, construction of medical-patient participation safety culture without punishment, as well as the provision of adequate human resources and robust network information platform support. Achieving these competence improvements requires not only the efforts of patients, but also the concerted efforts of medical staff, healthcare institutions, national governmental bodies and social media platforms. At the same time, there is a future need to develop clearer measurement tools for gauging PE in patient safety competencies, offering medical staff and patients themselves with clear references for enhancement strategies.
Acknowledgements
Not applicable.
Declarations
Ethics approval and consent to participate
Ethical approval for this study was obtained from the Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Ethics No: UHCT-IEC-SOP-016-03-01. Informed consent to participate was obtained from all participants prior to the enrollment of this study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Clinical trial number
Not applicable.
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