1 INTRODUCTION

Preventable adverse events (AE) are a common global problem within all healthcare systems, and the healthcare system in Sweden is no exception. In Sweden, over 110.000 patients per year are affected by an AE of varying severity, and many of these injuries occur within surgical care settings. These avoidable injuries lead to suffering for the patient and their relatives and constitute a large cost for the healthcare system (Wigzell, 2020). Work on improving patient safety is therefore a high priority in the healthcare sector, and it is also governed by the Patient Safety Act (2010:659). In addition, there is an increased global interest in involving patients in such work, as it has been shown that patient involvement improves quality of care (Park & Giap, 2020). Therefore, it is important that healthcare professionals have knowledge on how to achieve patient participation, for example understanding the importance of informing and encouraging patients (and relatives when possible) continuously during their hospital stay on how they can participate in their own care. At Sahlgrenska University hospital in Sweden, the patient safety leaflet, “Your safety in hospital,” was implemented in 2017 as a supplement to oral information provided by healthcare professionals, with the aim to decrease preventable AE during inpatient care. Patient perception of the leaflets as well as their experiences of participation can provide new insights into how we can further improve patient safety during hospital stays.

2 BACKGROUND

Health care is a complex system, and errors and AE are well known in all healthcare settings. According to the World Health Organization (WHO), every tenth patient in Europe experience a preventable harm or AE during their hospital stay (WHO, 2020). Up to 15% of the Organization for Economic Co-operation and Development (OECD) countries' total hospital expenditures are due to AE, where blood clots, pressure ulcers and infections are the most burdensome (WHO, 2019). Research has shown that many of these injuries and AE could have been avoided (Nilsson et al., 2016; Schwendimann et al., 2018). In Sweden, a preventable harm is defined in the Patient Safety Act (2010:659) as, “suffering of bodily or mental injury or illness as well as death that could have been avoided if adequate measures had been taken in the patient's contact with health care” (SFS, 2010). In a Swedish review of surgical care, AE were identified in 15.4% of all patients studied and 62.5% of these were classified as preventable or probably preventable. Hospital-acquired infections were the most common AE, while urinary retention, pressure ulcers and falls were other examples. Patients with “probably preventable” AE had seven-day longer median hospital stays than patients without AE (Nilsson et al., 2016). Furthermore, being a patient and suffering from medical harm can result in both physical and psychosocial problems for the patient (Joelsson-Alm et al., 2014), financial hardship as well as loss of the patient's trust in the healthcare system and its providers (Southwick et al., 2015). An AE can additionally limit the patient's independence and autonomy due to resulting physical problems and an increased need for care (Hassel et al., 2016).

Research has shown that patient participation in their care has an important role in increasing patient safety in connection with hospital care (Park & Giap, 2020). In a recent review, it was concluded that patient are generally positive regarding engaging in their care and thereby improving overall patient safety. However, the review also concluded that gaps and barriers for patient engagement still exist (Park & Giap, 2020). The extent of patient safety involvement is influenced by several factors and personal characteristics such as health status, age, gender and motivation (Sahlström et al., 2016; Vaismoradi et al., 2015). Patients who have sufficient knowledge and are informed about patient safety are also more eager to participate in patient safety work (Vaismoradi et al., 2015).

It is the healthcare providers' responsibility to create an organizational environment and culture that enables the patient to participate in patient safety work (Wigzell, 2020). According to a concept analysis of patient participation, four attributes were identified as key factors for achieving patient participation: (1) an established relationship between the patient and nurse, (2) a rearrangement of power and control between patients and nurses, (3) meaningful sharing of information and (4) an active engagement from both parties (Sahlsten et al., 2008). Healthcare personnel also have a crucial role through education and support in promoting patient participation in issues related to patient safety (Davis et al., 2007), where nurses' knowledge, attitudes, encouragement and support affect patients' ability to participate (Vaismoradi et al., 2015). The healthcare system can employ various interventions to increase patient safety-relevant behaviours, for example patient information brochures, posters, videos and boards that inform patients and their relatives about how they can contribute to safer care for themselves.

Worldwide patient participation in their own care has been suggested as a strategy to reduce healthcare costs and medical errors, as well as improve patient satisfaction (Mavis et al., 2015; Wigzell, 2020). Therefore, there is interest both in Sweden and internationally, about how patient participation can be continuously improved and thereby promote safer care (Ringdal et al., 2017; Sahlström et al., 2016). This paper investigates patient perception of a patient safety intervention, using the leaflet, “Your safety in hospital,” from three perspectives: (1) information about the leaflet and patient safety, (2) participation in care and (3) feelings of being safe during the hospital stay.

3 METHODS

4 RESULTS

Eleven female and 9 male patients participated in the study. The mean age was 64 years (range: 51–82). The mean hospital stay at time of interview was 9 days (range: 2–26). Mean interview time was 14.08 min (range: 8.18–22.30).

Three categories emerged from the data: Positive and negative experiences of provided information, experiences of participation in own care and feelings of being safe arising from a perception of good quality care. These categories originated from nine subcategories; see Table 2 for a summary of categories and subcategories.

5 DISCUSSION

Overall, patients were satisfied when describing their experience of information about their overall care and they viewed receiving information (such as surgery outcome and care plans) as participating in their own care. Almost all participants said that they expected to be involved in their care and that it was important to them. Being well informed about ongoing care and treatment was described as the major component in patient participation, findings that also have been described by others (Larnebratt et al., 2019). In contrast, relatively few patients described the meaning of being involved in their care from a broader perspective, although some expressed involvement to a greater extent, for example when it came to being involved in decision-making about further care. These results are interesting because they show that participation as a concept can have different meanings and that the expectation of participation can differ between patients, healthcare personnel and policymakers. For example, in the May 2020 European Standard, Patient involvement in health care – Minimum requirements for person-centred care, it is stated that shared decision-making is a key factor in patient involvement and when building a partnership with the patient. It is further written that healthcare personnel should provide favourable conditions to establish this partnership (SiS, 2020). Based on the patients' narratives, it became clear that there was a lack of communication between healthcare personnel and the patients regarding the safety leaflet. The information material in most cases was lying on the bedside table without a verbal introduction by the personnel. Some patients reported that several days had passed before they read it. Participants explained that, in addition to the leaflet, they also wanted verbal information from the personnel, including an opportunity to discuss and ask questions about participation to reduce the risk for AE. This indicates that health professionals, such as registered nurses and nursing assistants, failed to involve patients fully in this patient safety work.

Why information from healthcare personnel varied and sometimes was lacking is not investigated in this study, but one possible explanation may have been some organizational ambiguity in connection with the introduction and ongoing work with the patient safety leaflet at the wards. Inadequate organizational structure and its negative effect on safety culture have previously been reported by Farokhzadian et al. (2018). In their qualitative interview study with 23 nurses, they found that lack of knowledge and ability in care management, lack of time, poor communication with team members and insufficient efforts for improving professional competence can be barriers for implementation of safety improvement strategies. Lack of competence, influence of significant others as well as organization and work environment were described hindrances for patient participation already in 2005, by Sahlsten, Larsson, Plos and Lindencrona. The authors suggested that in order to increase this knowledge and to best support the patient's ability and willingness to participate, nurses needed organizational and collegial support as well as time for reflection and that more experienced nurses needed to support more novice nurses or nursing students regarding patient participation.

For those who received information about how to avoid AE according to the patient safety leaflet, the extent to which the information was individualized for the participant's specific needs and resources varied. For example, having pain and fatigue were described as barriers to participation and patients in such situations experienced an uncertainty as to how they could be involved, being so affected by their condition particularly in the beginning of their care episode. This indicates that the information may not have been sufficiently individualized, which further highlights the importance of nurses having the time, willingness and competence to provide adapted information to each patient continuously under the care period. If a patient at one point is unable or unwilling to receive information about participation, his or her ability and willingness to be engaged in their safety might change over time (Burrows Walters & Duthie, 2017). One way of overcoming barriers, such as lack of participation, is a genuine partnership with the patients. This also shows that, although patient participation in patient safety work is a priority for health care, it is not a central part of the work in the care departments. Similar results have been found by Martin et al. (2013), whose study demonstrated that patient participation in patient safety work did not appear in the daily clinical work and there was a lack of a systematic approach towards patient involvement in their own safety.

Another aspect that emerged was that most participants stated that even though they performed several activities in the leaflet, for example being active and taking measures to avoid falls, they had not reflected on these activities as being part of participating in a safer care environment. Patient safety as a concept and action was something with which patients were not familiar, a phenomenon that also has been described by others (Burrows Walters & Duthie, 2017; Martin et al., 2013). Not being aware of the role of these important actions in avoiding AE, might reduce patient motivation and involvement in their own care and thus also patient safety.

6 CONCLUSION

Many patients experienced that the verbal information about the patient safety leaflet was limited. Nonetheless, participants described performing several of the activities defined in the leaflet, despite having not received oral information nor the opportunity to ask questions. This indicates that this accessible leaflet is a valuable tool for providing information on this topic. However, the structure of the information transfer between patients and healthcare professionals could be further improved to optimize its usefulness. Although the results revealed several factors that hinder the patients' ability to participate in the safety work, most participants were satisfied with their participation during the care period and did not have a desire to be further involved. Still, we believe that the ongoing implementation of a person-centred care in Sweden can contribute to an even higher level of patient participation and thus a safer care environment. Moreover, participants also stated that they felt safe and secure during their hospital stay, which indicates that the lack of communication regarding participation and patient safety did not negatively affect their experience of safety.

AUTHOR CONTRIBUTIONS

BT, CF and ME: Idea for the study. AZK and PL: Data collection. AZK, PL and ME: data analysis, interpretation and formulation of the manuscript. Finally, all authors (BT, CF, AZK, PL and ME) revised the manuscript and approved the final version and contributed to the design and concept.

FUNDING INFORMATION

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

CONFLICT OF INTEREST

None.