Abstract
It is no surprise to readers of JRN that nurses play a central role in healthcare delivery, serving as the primary care providers who interact with patients on a daily basis. Their attitudes towards quality and safety significantly affect patient outcomes, clinical environments and the overall success of any healthcare system (Aiken et al., 2014). This paper builds on the overwhelming evidence that nurses and the care they provide are pivotal to patient outcomes and quality healthcare. It does so purely from a Saudi Arabian perspective, and the results are relatively consistent with the growing body of literature purporting nurses and nursing as gatekeepers to patient safety and quality care.
The World Health Organization (WHO) have been emphasising that the attitudes and behaviours of healthcare workers, particularly nurses, are central to ensuring patient safety and minimising errors for over a decade (World Health Organization, 2009). We also know that it is nurses’ attitudes that can either facilitate or hinder the successful implementation of safety initiatives. Negative attitudes, such as disregard for protocols or underestimation of risks, have been shown to increase incidents of medical errors, adversely affecting patient outcomes (Carayon et al., 2014). I know from my own early work that nurse’s attitudes can also affect the successful implementation of quality improvement initiatives (White et al., 2017). What is surprising and highlighted in this paper is what little inroads have been made positively influencing these attitudes in recent years. The authors found that nurses in this Saudi Arabian cohort had a less than positive attitude towards the safety of their patients. I think this merits further exploration and probing as I am left wondering what has influenced this less favourable attitude to patient safety and is it context specific, related to experience, contract or the international flavour of the Saudi Arabian nursing workforce. I really do hope there might be a qualitative exploratory phase to this study!
We do know from a growing body of literature that formal education plays a crucial role in shaping nurses’ attitudes. Nurses who have received comprehensive education on quality and safety standards, particularly during their academic training, are more likely to engage in best practices (Kim et al., 2019). This includes adherence to safety protocols, infection control practices and accurate reporting of incidents. However, this did not feature as a finding in this study or cohort.
The authors do report that a strong teamwork climate (working in a team), safety climate (the organisational commitment to safety), job satisfaction (experiences of work) and safety behaviour (collaborative working with nurses, physicians and pharmacists) were significantly associated with a decrease in all adverse events.
These findings align strongly with previous studies in other jurisdictions where culture or climate have been shown to significantly affect nurses’ attitudes. Positive climates (promoting transparency, accountability and learning from mistakes) influence positive attitudes towards safety and punitive climates or cultures influence the opposite – fear and reduced incident reporting (Ulrich et al., 2010). We know from previous studies the role that leadership plays in creating this positive climate and that nurse managers who provide clear guidance and resources for safety initiatives foster a proactive attitude among nurses (Flynn et al., 2016).
What is interesting in the authors findings is how collaborative working with other disciplines appeared to influence the safety behaviours of the nurses involved in the study. This warrants a little further exploration and may well be a strategy for overworked and understaffed nurses who are more likely to experience burnout, which negatively affects their commitment to quality care (Ball et al., 2014) resulting in higher incidences of adverse patient events (Griffiths et al. 2018). There is definitely something behind the sharing of concerns, experiences and learning with and across the multidisciplinary teams when it comes to safety. If peers and collaborative working heavily influence safety behaviour, we can start making inroads.
Finally, I believe the authors’ were prudent to highlight the need for supportive incident reporting and management systems in their recommendations for policy/practice. Nurses’ personal experiences (including previous involvement in medical errors) can shape their attitudes towards quality and safety and can be highly influenced by national, system and organisational cultures. Working in the Saudi Arabian health ecosystem is a unique experience and unlike any other. For international nurses (who make up most of the Saudi Arabian nursing workforce), contracts and job security are high ‘hygiene factor’ items in the decision to work and stay in the country. Those who have witnessed or been involved in incidents may be less likely to embrace error-reporting systems or safety measures that could possibly identify them and/or record their performance (for obvious reasons). Creating a culture that supports learning, improvement and ‘no blame’ is a key component to quality and safety and one that I am sure the Saudi Arabian health ministry embraces.