Promoting Patient Safety through Patient Involvement: A Qualitative Study of Nurses' Experiences and Perceptions

Background: Spinal Cord Injury (SCI) presents a significant challenge to healthcare systems worldwide, often leading to severe physical disability and psychological distress, including depression. The rehabilitation process for SCI patients is complex, necessitating a multidimensional approach that addresses both the physical and psychological aspects of recovery. The interplay between occupational performance and mental health among individuals with SCI remains a critical area of investigation, particularly in regions like Peshawar, Pakistan, where such studies are scarce. Objective: The primary objective of this study was to explore the association between occupational performance and depression among individuals with SCI in Peshawar, with a secondary aim of comparing occupational performance levels and their relationship with depression in this demographic. Methods: A cross-sectional study was conducted at the Paraplegic Centre Peshawar over a six-month period, utilizing convenience sampling to recruit 120 participants. Depression and occupational performance were assessed using the Beck Depression Inventory and the Barthel Index Scale, respectively. Data analysis was performed using SPSS version 22, with statistical significance set at p<0.05. Results: The study found that 35.8% of participants experienced moderate depression, while mild mood disturbances and borderline clinical depression were reported by 21.7% and 12%, respectively. Severe and extreme depression were less common, observed in 9.8% and 1.1% of the sample. Regarding occupational performance, 37% were totally dependent, 50% were severely dependent, and 13% were moderately independent. Statistical analysis revealed a significant association between occupational performance and depression levels (Pearson Chi-Square = 17.986, p=.05; Likelihood Ratio = 18.683, p=.04; Fisher Exact Test = 9.214, p=.002). Conclusion: The study highlights a notable correlation between occupational performance and depression among SCI patients, emphasizing the need for integrated rehabilitation programs that address both physical disabilities and mental health concerns. Enhancing occupational performance through targeted interventions may reduce depression levels, thereby improving overall quality of life for SCI patients.


INTRODUCTION
Patient safety has increasingly become a pivotal component of healthcare delivery over the last decade and a half, transitioning from a peripheral concern to a paramount issue for healthcare professionals, managers, policymakers, and the general public alike.This shift was notably catalyzed by the publication of a significant national report in 2009, which shed light on the extent of avoidable adverse events occurring in Swedish hospitals (1)(2)(3).The findings of this report, indicating a considerable proportion of preventable mishaps during hospital treatment, spurred a national reckoning on patient safety within Sweden.In the wake of these revelations, the country undertook substantial legislative reforms, enacting new patient safety regulations in 2011 designed to rectify these issues.These regulations were not merely punitive but also incentivized county councils to adopt and implement patient safetyenhancing activities through financial rewards, marking a strategic approach to ameliorating healthcare safety standards (4).In conjunction with regulatory reforms, there has been an escalating interest in the integration of patients into safety enhancement projects (5)(6)(7).Recognizing patients as critical observers and participants in their care, due to their unique position and continuous presence throughout the treatment process, has been a key insight in this evolution.Patients frequently act as intermediaries, conveying information across different medical specialists and compensating for systemic shortcomings in healthcare delivery through covert efforts (8)(9)(10).This understanding has led to the endorsement of initiatives like the World Health Organization's "Patients for Patient Safety" program, which fosters collaboration between patients and healthcare stakeholders to fortify patient safety.By leveraging advocacy and partnership, such programs aim to cultivate a healthcare environment where patient engagement is not only encouraged but recognized as an essential element of safety and quality improvement strategies (2,3,7,11,12).The cumulative effect of these measures reflects a multifaceted strategy for enhancing patient safety, underscoring the necessity of regulatory adjustments, active patient participation, and collaborative endeavors among healthcare providers.This approach acknowledges the complexity of healthcare systems and the diverse factors that contribute to safety outcomes, advocating for a comprehensive and cooperative framework to tackle patient safety challenges (4,8).

MATERIAL AND METHODS
In this qualitative study, the methodology encompassed in-depth interviews with registered nurses from various healthcare settings in Punjab, Pakistan, aiming to explore their experiences, practices, and attitudes towards patient participation in enhancing patient safety.Employing a purposive sampling strategy, the selection of participants was designed to achieve representation across a spectrum of experience levels and clinical specialties, ensuring a rich diversity of perspectives.This sampling method facilitated the inclusion of nurses working in environments ranging from primary healthcare to specialized surgical units, thus accommodating variations in patient demographics, including age, duration of hospital stay, and health status (6,10).The semi-structured nature of the interviews allowed for an explorative approach, enabling participants to offer detailed insights and personal narratives within the context of their professional environment.This was instrumental in facilitating a deeper understanding of the nuanced ways in which patient involvement could influence safety in healthcare settings.The interviews were structured around a guide developed by the researchers, which included questions aimed at eliciting both general and specific instances of patient participation relevant to safety, practices integrating patient feedback, and recommendations for improving patient involvement in safety protocols (5,9).To ensure a thorough exploration of the topic, the study employed thematic analysis following the framework suggested by Hsieh and Shannon (2005) for traditional content analysis.This method was chosen for its flexibility and applicability to the qualitative data gathered, allowing the researchers to identify, analyze, and report patterns within the data without being confined to a pre-existing theoretical framework.The analysis was conducted using SPSS version 25, where data were meticulously coded and categorized to uncover recurrent themes and insights.Investigator triangulation was a key aspect of the methodology, wherein multiple researchers independently analyzed the data to ensure the reliability and validity of the findings.Each transcript was thoroughly reviewed multiple times, with researchers taking extensive notes and employing coding techniques to capture the full breadth of the data.Initial impressions and insights were recorded to inform the subsequent in-depth analysis, emphasizing a rigorous and iterative approach to understanding the material.The study was conducted with strict adherence to ethical guidelines, including obtaining informed consent from all participants, who were provided with detailed information letters prior to the interviews.The consent process was designed to respect the autonomy of the participants, ensuring confidentiality and the right to withdraw at any time.The study's procedures were reviewed and approved by an ethical review board in accordance with the Declaration of Helsinki, ensuring that all research activities were conducted with the highest ethical standards.

RESULTS
The qualitative study exploring nurses' experiences and perceptions regarding patient involvement in healthcare safety illuminated critical themes that underscore the complexity and necessity of integrating patient engagement into care processes.These themes, ranging from the vital need for effective communication and patient education, the empowerment of shared decision-making and collaboration, the essential support of organizational structures and resources, to the challenges and barriers that impede patient involvement, provide a comprehensive overview of the multifaceted approach needed to enhance patient safety.Nurses play a pivotal role in this dynamic, serving as the linchpin between patients and the broader healthcare system, striving to bridge gaps in understanding, ensure patient-centered care, and navigate the myriad of obstacles that can hinder effective patient participation.
Through their insights, the study sheds light on the imperative of fostering an environment conducive to patient involvement, highlighting the potential for improved safety and care quality when patients are actively engaged in their healthcare journey.Effective Communication and Patient Education Under this theme, the crucial role of clear and open communication between nurses and patients is highlighted, along with the importance of educating patients about their health conditions, treatment options, and the implications of their care decisions.Nurses underscored the necessity of building trust and rapport with patients to empower them to voice their concerns and questions freely.Effective communication and patient education are foundational for enabling patients to make informed decisions and actively participate in their care, thereby enhancing patient safety and care quality.Shared Decision-Making and Collaboration This theme encapsulates the significance of involving patients in the decision-making process regarding their care.It underscores the collaborative effort required among healthcare team members to ensure that patient preferences and values are integrated into care planning.Shared decision-making is presented as a means to promote patient autonomy and engagement, contributing to safer and more personalized healthcare outcomes.Collaboration extends beyond the patient-provider dynamic to include the entire healthcare team, emphasizing the need for a cohesive approach to patient care.Organizational Support and Resource Allocation Nurses identified organizational support and the availability of resources as critical enablers of patient involvement in safety initiatives.This theme addresses the systemic factors that facilitate or hinder patient engagement, including the provision of adequate time for patient interactions, access to educational materials, and the creation of a supportive healthcare environment.The role of healthcare organizations in prioritizing patient safety and involvement through policy, culture, and practice adjustments is discussed, highlighting the need for a supportive infrastructure that enables effective patient participation.Challenges and Barriers to Patient Involvement This theme focuses on the various obstacles encountered in promoting patient involvement in healthcare safety, including time constraints, resource limitations, and the wide range of patient preferences and levels of health literacy.Nurses expressed concerns about the difficulties in communicating complex medical information and navigating the power dynamics that can inhibit patient participation.The challenges of ensuring meaningful patient involvement in a busy healthcare setting, along with strategies to overcome these barriers, are elaborately discussed.

Strategies for Encouraging Patient Participation
Within this theme, specific strategies employed by nurses to encourage patient participation are detailed.These include creating an inviting environment for questions and dialogue, utilizing patient education as a tool for engagement, and acknowledging patient contributions to their care.The strategies reflect a proactive approach to fostering patient involvement, with a focus on enhancing patient understanding, comfort, and willingness to engage in their healthcare processes.Importance of Patient Participation for Safer Care Highlighting the critical role of patient involvement in improving healthcare safety, this theme presents evidence and nurse testimonies on how patient participation has led to the identification and prevention of potential safety issues.From medication errors to infection risks, patient insights and active engagement are shown to be invaluable in safeguarding their health.The theme reinforces the concept that patients, as active participants in their care, can contribute significantly to the detection of errors and the implementation of safer care practices.

DISCUSSION
The study illuminated the pivotal role of nurses in enhancing patient safety through active patient involvement, a concept that has garnered increasing attention within the healthcare domain.Through fostering open lines of communication, providing comprehensive education, and building collaborative partnerships, nurses empower patients to take an active stance in managing their health and safety.This endeavor, however, necessitates substantial organizational support and adequate resources to surmount existing barriers and facilitate a culture shift within healthcare systems towards more patient-centered care (11,12).The findings resonate with existing literature, affirming that nurses view patient participation not only as beneficial but essential for improving patient safety (2,13,14).Nurses recognize the dual responsibility in ensuring safer treatment outcomes, necessitating engagement from both healthcare professionals and patients (1,15,16).This collaborative approach aligns with the study by Joseph-Williams, Elwyn, and Edwards (6), which highlighted the influence of perceived power and knowledge on patients' willingness to engage in their care.It further underscores the significance of the healthcare provider's role in mitigating power imbalances, enhancing patient comprehension, and fostering a conducive environment for patient participation.The challenges to patient involvement identified in this study, such as communication barriers and limited healthcare resources, echo the concerns raised in earlier research (8,9).These challenges highlight the necessity for healthcare providers to actively encourage patient involvement, emphasizing the importance of personalized information delivery as a facilitator for patient safety, a finding supported by a Swedish study (13,(16)(17)(18)(19).Despite these insights, the study is not without limitations.Its focus on nurses' perspectives, while invaluable, suggests the need for further research encompassing a broader range of healthcare professionals and patient experiences to provide a more comprehensive understanding of patient involvement in safety.Additionally, the study's qualitative nature limits its generalizability, pointing to the necessity of larger-scale quantitative studies to validate and expand upon these findings (14,20,21).Future research should aim to explore effective strategies for enhancing patient engagement initiatives and evaluate their impact on patient outcomes and healthcare quality.Investigating the integration of technological solutions, such as digital health platforms, could offer innovative avenues for promoting patient participation and overcoming existing barriers.Moreover, studies should examine the organizational and policy-level changes required to support a culture of patient-centered care that prioritizes safety and quality.

CONCLUSION
In conclusion, this study contributes to the growing body of literature on patient safety by underscoring the critical role of nurses and the collaborative nature of patient involvement.It highlights the necessity of addressing systemic challenges and leveraging organizational support to foster a healthcare environment conducive to patient participation.By doing so, healthcare providers can significantly enhance the safety and quality of care, ensuring that patient-centered models of care become a cornerstone of healthcare delivery.References

Figure 1
Figure 1 Perceived importance as per respective theme