A grounded theory of creating space for open safety communication between hospitalized patients and nurses.

BACKGROUND: There is evidence that fear of negative nurse response may prevent hospitalized patients from sharing safety concerns, adversely affecting patient safety. PURPOSE: The purpose of the present study was to describe the process by which bedside nurses recognize and respond to safety concerns expressed by patients or their families. METHODS: Twenty-five bedside nurses from 30 maternal-child, intensive, medical-surgical, and psychiatric inpatient units within an academic medical center participated in semi-structured interviews. Data were analyzed using grounded theory. FINDINGS: Nurses reported creating space for open safety communication to foster trust and maintain patient safety and sense of security. Nurses anticipated safety concerns, invited safety discussion, were accessible, recognized insecurity, reacted in a trustworthy way, shared a plan, and followed up with patient and family. DISCUSSION: This process involves multiple interacting components, yet was remarkably consistent across acute care settings, despite differences in nurses, patient populations, and unit cultures.

Nurse Sensemaking for Responding to Patient and Family Safety Concerns.

BACKGROUND: Hospitals need to prevent, respond to, and learn from safety risks and events perceived by patients and families, who in turn rely on nurses to respond to and report their safety concerns. OBJECTIVES: The aim of the study was to describe the process by which bedside nurses evaluate and determine the appropriate response to safety concerns expressed by patients or their families. METHODS: A qualitative design was employed. We recruited inpatient bedside nurses in an 811-bed Midwest academic medical center. Nurses provided demographic information and participated in semistructured interviews designed to elicit narratives related to evaluation and response to patient- or family-expressed safety concerns. Data analysis and interpretation were guided by grounded theory. RESULTS: We enrolled 25 nurses representing 22 units. Based on these nurses' experiences, we developed a grounded theory explaining how nurses evaluate a patient or family safety concern. Nurses make sense of the patient's or family's safety concern in order to take action. Achieving this goal requires evaluation of the meaningfulness and reasonableness of the concern, as well as the potential effect of the concern on the patient. Based on this nursing evaluation, nurses respond in ways designed to (a) manage emotions, (b) immediately resolve concerns, (c) involve other team members, and (d) address fear or uncertain grounding in reality. Nurses reported routinely handling safety concerns at the bedside without use of incident reporting. DISCUSSION: Safety requires an interpersonal and evaluative nursing process with actions responsive to patient and family concerns. Safety interventions designed to be used by nurses should be developed with the dynamic, cognitive, sensemaking nature of nurses' routine safety work in mind. Being sensitive to the vulnerability of patients, respecting patient and family input, and understanding the consequences of dismissing patient and family safety concerns are critical to making sense of the situation and taking appropriate action to maintain safety. Measuring patient safety or planning improvement based on patient or family expression of safety concerns would be a difficult undertaking using only standard approaches. A more complex approach incorporating direct patient engagement in data collection is necessary to gain a complete safety picture.