Facilitators and barriers influencing patient safety in Swedish hospitals: a qualitative study of nurses’ perceptions

The Institute of Medicine report To Err is Human in 1999 [1] generated tremendous public and media attention, setting the stage for unprecedented efforts and activities to improve patient safety. Sweden has undertaken many national, regional, and local initiatives to improve patient safety since the mid-2000s, with increased activity over the last few years. A national study from 2008 showed that the incidence (8.6%) of adverse events in Swedish hospitals was not lower than international comparisons [2]. This brought increased focus to patient safety in Swedish health care. The Swedish Association of Local Authorities and Region (SALAR), representing the county councils (health care regions) and municipalities, has played a leading role in efforts for improved patient safety. They have organized patient safety conferences, set up networks of experts and policy-makers and published widely distributed handbooks and evidence-based guidelines for health issues such as falls, pressure ulcers, medication errors in health care transitions and health care-associated infections.

In 2011, a new law on patient safety was introduced and a government-supported financial incentive plan was initiated by SALAR ), which has allocated over 2 billion SEK for 2011–2014 to county councils that carry out certain patient safety-enhancing actions and meet established requirements for specific patient safety indicators. A vision of zero tolerance for adverse events has been discussed in Swedish health care [3, 4].

How can the high ambition for improved patient safety in Sweden be achieved? There are few evidence-based patient safety practices that ensure improved patient safety, if implemented with fidelity. Rather, much patient safety work tends to be pragmatic and experience-based instead of relying on solid evidence of effectiveness [5]. Walshe and Boaden (p. 224) [6] complain that many interventions are simply based on “a hunch that they may work” and Vincent [7] (p. 374) believes that the urge to “get on and change things” often takes precedence over carefully planned and evaluated interventions. Thus, it is important to investigate perceived facilitators and barriers to improved patient safety among those who are involved in the direct provision of health care.

Nurses are critical to patient safety. They often have an important role as the coordinator of multidisciplinary care and are involved in many aspects of patient care, from providing comfort and hygiene to administering drugs, updating medical records, as well as handling some therapeutic and diagnostic procedures. Nurse staffing levels, workload, and education levels having been linked to various patient safety outcomes [8‐10]. Furthermore, nurses constitute the largest professional group in Swedish health care; 43% of health care professionals are registered nurses and 28% are nurse assistants [11].

Considering the importance of nurses with regard to patient safety, knowledge about their perceptions of the factors that influence patient safety could facilitate the development and implementation of better solutions. It is also possible that their perceptions could help identify less-known patient safety issues. Moreover, solutions based on nurses’ views are likely to be more effective. Based on interviews, the aim of this study was to explore important factors influencing patient safety, as perceived by registered nurses in general hospital care in Sweden.

Table 2 presents a summary of the categories and the factors associated with influencing patient safety, as perceived by the nurses.

This study sought to explore important factors for patient safety, as perceived by registered nurses in general hospital care in Sweden. The nurses identified 22 factors that influenced patient safety, of which 12 functioned as both facilitators and barriers, six constituted barriers, and four were facilitators. These 22 factors belonged to many different levels, ranging from patient interaction and individual staff to institutional context. There were no specific patterns in which barriers or facilitators were not more common at any level. They were quite evenly distributed at the different levels.

Our findings indicate that the nurses had a multilevel perspective of patient safety, viewing facilitators and barriers to patient safety in terms of several system levels. Nurses often have an important role as coordinators of multidisciplinary care and are involved in many aspects of patient care. Their role facilitates systems thinking because they are able to see interrelationships, patterns, and underlying structures that reveal the dynamic interplay among system components. The importance of systems thinking in understanding the dynamics of the big picture and the multiple levels of interacting influences on patient safety has been emphasized since the publication of the Institute of Medicine report To Err is Human in 1999 [21‐23].

The multifaceted systemic nature of patient safety facilitators and barriers suggests that solutions will need to be as complex as the problem, targeting different levels such as individual health care practitioners, teams, departments, and organizations [24]. In Sweden, the Swedish Association of Local Authorities and Regions (SALAR) has taken a multifaceted approach to patient safety by promoting a multitude of initiatives [25]. Although many of these efforts and activities have considerable face validity, solid evidence of effectiveness is lacking for many patient safety solutions because they are often too complex to study under rigorous controlled conditions. There is debate among patient safety researchers and policy makers regarding the degree to which various solutions should or could be studied scientifically before dissemination and implementation [5, 7, 15].

The nurses mentioned several factors that are associated with patient safety culture, including collaboration in multiprofessional teams, communication with colleagues, leadership, and structures and forums for learning from errors. Patient safety culture, which is one aspect of the wider culture of the organization, has been defined as the shared assumptions, values, and norms among members of an organization or group concerning practices that directly or indirectly influence patient safety [26, 27]. The Institute of Medicine report recommended that health care organizations create an environment in which safety culture is an explicit organizational goal and a leadership-driven top priority [1]. There is emerging evidence to support the potential effectiveness of solutions to promote improved safety culture. The best evidence to date seems to include solutions comprising multiple components that incorporate team training and mechanisms to support team communication, and include management engagement in front-line safety work [28‐31].

The culture of an organization is often studied as an organization-wide issue, but researchers have increasingly shown that subcultures should be studied to develop an in-depth understanding of an organization’s culture [32, 33]. A subculture in an organization is “a group or unit in an organization that is in frequent interaction perceives itself to be distinct from other groups in the organization, and that shares similar problems as well as in-group understanding of ways of solving such problems” [34]. An important issue is the extent to which the nurses’ views on facilitators and barriers to patient safety overlap with factors identified by other professions. Studies have shown that the perception of patient safety and how it can be improved differs depending on the position in the health care system [35‐37] and the profession [38, 39]. There is a need for studies of other professions to investigate whether the subcultures are aligned with the organization-wide safety goals and the extent to which there are interprofessional communication and collaboration difficulties that affect patient safety.

Communication is closely linked with hierarchy, with research showing that the authority gradient, i.e. the psychological distance between individuals and professional groups, can lead to withheld information or information being adapted to suit the recipient. Commercial airline crews have learned to speak up and raise concerns, contributing to a remarkable safety record in commercial aviation over the past 50 years [15]. While some nurses in our study perceived hierarchical difference between nurses and physicians as a barrier to patient safety, research by Berbyuk et al. [40] suggests that the professional hierarchy in Swedish health care is rather flat and that the authority gradient is relatively low [40]. The lack of steep hierarchies could mean that most nurses feel comfortable raising their concerns with physicians, but it could lead to unclear professional roles which would cause other difficulties. Learning is widely considered to be a critical aspect of a beneficial safety culture [7, 41]. The nurses in our study pointed to several issues related to learning, including the importance of having time and structures for discussions on patient safety issues and the skills, abilities, and interest that may affect patient safety. Organizations learn through their individual members, yet organizational learning is not simply the sum of the learning of each of its members. Organizational learning is usually conceived as a process that results in relatively lasting changes in organizational practices due to changes in routines, rules, norms, strategies, and technologies that are assumed to guide the behavior of the organization’s members [42, 43]. A learning organization is competent in creating, acquiring and transferring knowledge, and modifying its behavior to reflect new knowledge [44]. However, the nurses in our study mentioned disturbances in communications with their colleagues and with patients, and they noted that all incidents were not reported and that feedback was not always given for reported incidents, thus suggesting that organizational learning was difficult.

Feedback is also imperative to achieve continuous high rates of incident reports [45, 46]. Incident reporting was mentioned by the nurses as important for patient safety, which was expected considering that local reporting systems have been given a dominant role in efforts to improve patient safety in Sweden [47]. However, the reliance on incident reporting systems in many countries has been criticized because these systems are insufficient on their own to identify incidents [48, 49]. The systems have also been described as being too outcome oriented, resulting in an incomplete picture of the event [50]. The nurses in our study group emphasized the importance of having meetings where they can discuss and reflect on the events for increased learning.

The nurses believed patient interaction and engagement were important for patient safety. There is an international trend towards greater patient involvement in health care delivery. Government policies in many countries aim for patients to be generally more involved in their health care [51]. However, despite increased international emphasis on patient involvement in safety, there is a paucity of research findings on the acceptability to patients of a new patient role and the extent to which such involvement actually leads to safety improvements [52]. Research has identified numerous barriers to enlisting patients in efforts to improve patient safety, including limited acceptance of a more active patient role [53] and insufficient health literacy, that is, the capacity to obtain, process, and understand basic health information and the services needed to make appropriate health decisions [54]. One facilitator, as our nurses also emphasized, is that the patient’s relatives should be included and involved in the care, if acceptable to the patient [55, 56]. There have been calls for more research for better understanding of how patients can be involved in their own care [51, 52].

We have found few comparable studies on hospital nurses’ perception of factors of relevance for patient safety. Other studies within this field have either been set in a specific setting such as the operating theatre or intensive care [57‐59], examined quality improvement work [22, 60, 61], been limited to one factor such as communication or medical errors [45, 46, 62], or investigated the perspectives of other professional groups [13]. However, two studies are broadly similar to our study. A study by Currie and Watterson [60] set in the United Kingdom focused mainly on barriers and quality improvement, identifying training and education in patient safety-related issues as essential to achieve improved patient safety. They also mentioned organizational context and organization and management of care as important factors, which were also mentioned by nurses in our study. A Canadian study by Nicklin and McVeety [63] emphasized the importance of work environment–related factors, including issues related to workload, nursing shortages, and the physical environment. These somewhat overlapping results might suggest that other health care systems in other countries present similar challenges as those in Swedish health care. Further research on patient safety perceptions of nurses and other professional groups is warranted. It is also important to analyze these perceptions in relation to the existing evidence base for various solutions.

The researchers behind this study have previously undertaken a survey of patient safety officers in the county councils, i.e. the meso level of Swedish health care, to identify factors they believed to be of relevance for improved patient safety [13]. There was some overlap with the findings of this micro-level study, including the importance attributed to patient safety culture and communication. The previous study also pointed to the importance of education and training in patient safety issues. Considering the paucity of evidence-based patient safety practices, it is important to investigate perceived facilitators and barriers for improved patient safety at different levels of health care since the “patient safety determinants” do not necessarily correspond.

This study has a number of shortcomings that must be considered when interpreting the results. The sample size was relatively small (12 nurses) although the data analysis confirmed that data saturation was reached before cessation of the interviews. The voluntary nature of participation in the study means that the nurses interviewed may differ from the broader population of nurses. These nurses were recommended by patient safety officers in their county council and almost half of them have an explicit patient safety responsibility in their duty. This could bias the results to some extent since they are likely to be interested in patient safety issues and might have more insights into factors that contribute to or detract from improved patient safety. However, knowledgeable interviewees have probably given us a fuller interview material, and there is little evidence that imply other, less interested, nurses would mention other factors.

The factors associated with patient safety are not intended as an exhaustive list of all possible facilitators and barriers to patient safety as perceived by nurses; other studies may yield partially different factors or give different priorities to various factors. The interviews were mostly conducted by telephone. Although face-to-face interviews have the advantage of eliciting non-verbal information, telephone interviews allow the researcher to follow and respond to the interviewee through language and reflection, which has the potential of making the interviewee’s descriptions richer [64]. Telephone interviews were also practical as the participants were from different areas in Sweden. They were suitable for the descriptive aim of the study [60]. Further, research suggests that transcriptions of telephone and face-to-face interviews do not differ much [14]. The telephone interviews were shorter in duration, but we did not notice any differences with regard to the richness of the interview material.

The study also has strengths. The decision to conduct interviews instead of undertaking a survey was based on the belief that the interviews would lead to a more in-depth understanding of the factors concerning patient safety that are important to front-line nurses. The multidisciplinary research team may also be considered a strength, permitting different perspectives on the issues under study. The team consisted of a nurse (MR) with experience from clinical patient work and work with safety issues such as conducting risk- and root cause analyses, a researcher (KR) with a background in implementation science, innovation research and medical technology research and a researcher (PN) with experience from implementation science and injury prevention research. We believe the study has provided unique information on factors contributing to improved patient safety according to nurses in Sweden.

A broad range of factors are important for patient safety according to registered nurses in general hospital care in Sweden. The nurses identified facilitators and barriers to improved patient safety at multiple system levels, indicating that complex multifaceted initiatives are required to address patient safety issues. This study encourages further research to achieve a more explicit understanding of the problems and solutions to patient safety.