An Exploration Into Patients' Experiences That Make Them Feel Safe During Hospitalization: A Qualitative Study.

BACKGROUND: Patient safety is a crucial indicator of health care quality. It is necessary to check the subjective perception of patient safety from the patient's point of view as a consumer of healthcare services. To identify patients' experiences of safety and the themes that constitute the patients' feeling of safety during hospitalization.
METHODS: A qualitative study, comprising five focus group discussions (seven people each), was conducted in South Korea between May and July 2018. Patients who were hospitalized for at least three days within one year were included. Researchers analyzed the transcribed script, and a content analysis was performed to describe patients' hospitalized experiences of safety.
RESULTS: A total of 35 patients with an average age of 45.4 years participated in the study, and had experience of hospitalization for up to 32 days. The findings revealed four core themes and 14 sub-themes. Patients wanted to take initiative in controlling his/her reception of information and wanted healthcare providers to make the patient feel safe. Patients felt safe when hospitals provided unstinted and generous support. Also, public sentiment about national healthcare and safety made an effect on patient safety sentiment.
CONCLUSION: Patients felt safe during hospitalization not only because of the explanation, attitude, and professionalism of the healthcare providers but also because of the support, system, and procedure of the medical institution. Healthcare providers and medical institutions should strive to narrow the gap in patient safety awareness factors through activities with patients. Furthermore, the government and society should make an effort to create a safe medical environment and social atmosphere.

INTRODUCTION

In the recent times, the paradigm of providing medical services has shifted from being provider- and disease-centered to patient-centered.12 To achieve patient-centered care, the Organisation for Economic Co-operation and Development (OECD) has emphasized and confirmed the importance of patient experience in the provision of medical services.3 Measuring patient satisfaction and experience is now an important factor in medical services.4 Patient experience is a concept that goes beyond the patient’s expected clinical outcome or health status, and is essential in providing patient- and family-centric care.56 However, patients’ expectations and experiences reported have been different, and related to overall patient satisfaction.7

Many countries, including the United States, Denmark, Norway, the United Kingdom and Canada, are investigating patient experiences to assess health system performance.89 The UK’s National Health Service (NHS) emphasizes the importance of patient-centered health care, focusing on a cultural shift that accepts patients as the pivotal facet, and the increasing value of patient experience feedback as an indicator for monitoring and improving health quality and safety.10 Similarly, the results of statistical analysis by the US Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) show that hospital profits were related to patient experience scores, and that reduction of physicians’ medical errors and provision of patient experience services were highly correlated.11 Since 2017, the Korean Health Insurance Review and Assessment Service has been evaluating patient experience.12 Twenty-four questions, including experience of physicians’ and nurses’ behavior during hospitalization, medication and treatment process, hospital environment, patient rights guarantee, and personal characteristics, have been employed for the survey.12

Patient safety is a crucial indicator of health care quality; adequate management of safety-related risks is the primary responsibility of medical service providers and healthcare systems. Treatment without patient safety does not guarantee patient-centeredness and can reflect disastrous health outcomes.13 Previous studies were aimed to some situations exploring the experiences of patients in a specific setting or elderly patients, or were focused on confirming the experiences of patients with anxiety or satisfaction.1415161718 Furthermore, although there is a study on physicians’ and nurses’ perception of patient safety culture,19 there have been few studies that specifically explored the experiences of factors that constitute patient safety. Qualitative research can offer the direction on how to identify and correct problems.2021 It is thus necessary to explore the subjective perception of patient safety from the patient's point of view as a consumer of healthcare services.

This qualitative study, thus, is aimed at understanding the patients’ experience of safety with hospitalization, and specifically, identifying the themes that constitute the patients’ feeling of safety during hospitalization.

METHODS

A qualitative study, with five focus group discussions (FGDs), was conducted, and a conventional content analysis was utilized. This qualitative study was performed according to the Consolidated Criteria for Reporting Qualitative Research (COREQ).22 The research team consisted of a physician, nurses, and national healthcare researchers. Nurses (SGJ, JEC, WL) with doctoral degrees and experience of conducting qualitative research several times and had been a modulator for FGD progression. While maintaining the anonymity of the participants, the interviews were recorded and transcribed. All researchers performed the content analysis together.

Sampling and recruitment

Participants were recruited based on the following criteria: 1) adults aged 19 or more who have been hospitalized in a medical institution; 2) those who were hospitalized not more than one year ago from the date of participation; and 3) patients who were hospitalized for at least three days and provided sufficient information relating to the overall hospital facilities, tests, and treatments. Content such as disease was not considered as a selection criterion because the purpose of this study was to investigate patients’ overall experiences of safety with hospitalization, not the specific hospitalization experience. Patients who were hospitalized for symptom observation without undergoing an outpatient visit or receiving specific treatment even during hospitalization, were excluded.

Recruitment of participants was organized through: 1) the recruitment of research participants through 10 civic groups; and 2) purposive and convenience sampling using the researcher’s acquaintances.

Data collection

We conducted FGD with five groups (seven people per group) between May and July 2018. Since FGD could explore insights from active interactions within a group on a specific topic in a limited time, the method was selected for data collection. It was conducted according to a semi-structured interview guideline (Table 1) developed by the research team. It was developed based on factors affecting the patient safety sentiment through a literature review with keywords such as “patient safety,” “sentiment index,” and “patient experiences.” Each group discussion took approximately 120 to 150 minutes.

Table 1

Focus group discussion progress guideline

Step/Topic	Question
Introduction	1. What do you think about the topic that has brought us here today (patient safety)?
Common perception of experience of patient safety during hospitalization	2. Have you ever experienced or thought that the hospital was not safe during your hospitalization?
Attitudes of healthcare provider and importance of patient engagement	3. Did the healthcare provider tend to listen to the patient during the treatment process?
	4. To what extent does the patient want to participate in the treatment process?
	5. How do you feel about the patient's role in making decisions about treatment?
	6. What difficulties do you have in participating in the treatment process?
Awareness of health literacy	7. Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions.
	8. To what extent do you think patients are aware of the need for health information?
	9. Do you feel that you have received sufficient education regarding your disease and treatment?
	10. Where and how do you get information about your medical treatment/disease during the hospital stay? (face-to-face education, manual, text message, etc.)
Awareness of disease treatment, medical accident and patient's privacy	11. Have you ever experienced unexpected results during hospitalization, such as failure to achieve treatment goals or medical accidents?
	12. If you have experience, how did you find out?
	13. Did the healthcare provider personally provide a patient safety incident disclosure to you?
Attitude toward the hospital environment and the social system	14. What environmental aspects of the hospital made you feel safe?
	15. Do you feel that patient safety is your number one priority during the treatment process?
Finish the discussions	16. Let's summarize some of the key points from our discussion. Is there anything else?
	17. Do you have any questions?

Data analysis and validity evaluation

We analyzed the descriptions in two phases. The first phase was a conventional content analysis, which generally has the purpose of describing particular phenomena. This type of research design was used when existing theories or research literature were limited.23

In the first phase, a semantic unit analysis was conducted to understand the opinions of the participants revealed in the transcription data. One researcher led the analysis, and two others reviewed it. Thereafter, the final semantic unit was derived by agreeing on the additional and revised parts. In the process of categorizing the derived semantic units, the three researchers divided the upper categories and proceeded individually, before cross-reviewing several times for each category, to arrive at a consensus. Throughout the entire process of data analysis, the researchers met several times and continuously contacted each other to compare, discuss, and agree on the data analyzed. Additionally, the process of reconfirming and revising the derived code, subcategory, and category was repeated by going through the data. After the final agreement on the categories, the three researchers received a review of the category table by one preventive medicine specialist and one nurse, and judged data saturation so that no new semantic units appeared further.

In the second phase, confirmations of the research result were received from two participants via e-mail to increase the factual value. Furthermore, two individuals who met the criteria for the selection of participants, but did not participate in this study, were shown the results of the study and confirmed whether they had similar experiences and felt safe at a hospital. To increase consistency, three researchers reviewed and confirmed the contents of the data analysis and tried to reduce misunderstandings in interpretation.

Ethics statement

The research was approved by the Institutional Review Board (No: NECAIRB18-005) of the National Evidence-based healthcare Collaborating Agency at Seoul, Korea. Before beginning the FGD, researchers explained to the participants the purpose of the study, the guarantee of anonymity, and the possibility of withdrawal from the study at any time, and written informed consents were submitted by all participants.

RESULTS

There was a total of 35 participants (10 males and 25 females), with an average age of 45.4 years (range, 19–65), and an average hospitalization period of 9.8 days (range, 3–32). The general characteristics of the participants in this study are shown in Table 2. There were four themes and 14 sub-themes of patients’ feeling of safety during hospitalization (Table 3).

Table 2

General characteristics of participants (N = 35)

Group	Sex	Age	Admission days	Type of hospital	Hospitalized department
1	Female	19	5	Tertiary hospital	Hemato-oncology
1	Male	43	6	Tertiary hospital	Hemato-oncology
1	Female	45	13	General hospital	Cardiology
1	Male	22	4	Hospital	Orthopedic surgery
1	Female	45	6	General hospital	General Surgery
1	Female	37	19	Tertiary hospital	General Surgery
1	Female	32	5	General hospital	Obstetrics & Gynecology
2	Male	56	8	Tertiary hospital	Orthopedic surgery
2	Female	53	12	Tertiary hospital	Gastroenterology
2	Female	53	8	General hospital	Hemato-oncology
2	Female	51	6	General hospital	Cardiology
2	Female	51	4	General hospital	General Surgery
2	Female	50	21	General hospital	Orthopedic surgery
2	Female	65	27	General hospital	Orthopedic surgery
3	Male	50	7	Tertiary hospital	Hemato-oncology
3	Female	30	7	General hospital	Orthopedic surgery
3	Female	56	7	Tertiary hospital	Obstetrics & Gynecology
3	Female	43	5	General hospital	Obstetrics & Gynecology
3	Female	59	23	General hospital	General Surgery
3	Male	22	8	General hospital	Hemato-oncology
3	Female	52	32	Tertiary hospital	Gastroenterology
4	Female	54	10	Tertiary hospital	Obstetrics & Gynecology
4	Female	55	10	General hospital	Obstetrics & Gynecology
4	Male	50	6	Tertiary hospital	Orthopedic surgery
4	Female	51	4	Tertiary hospital	Obstetrics & Gynecology
4	Female	43	5	General hospital	Obstetrics & Gynecology
4	Female	39	11	General hospital	Pulmonology
4	Male	55	5	General hospital	Gastroenterology
5	Male	50	10	General hospital	Orthopedic surgery
5	Female	53	5	Tertiary hospital	Obstetrics & Gynecology
5	Male	41	3	Tertiary hospital	Urology
5	Female	41	21	General hospital	General Surgery
5	Female	50	11	General hospital	Obstetrics & Gynecology
5	Male	21	5	General hospital	Pulmonology
5	Female	51	4	Tertiary hospital	Gastroenterology

Table 3

Themes for patients’ feeling of safety during hospitalization

Themes	Sub-themes
Patients who want to take initiative in controlling his/her reception of information	Direct or indirect experience by others or media
	Effort to access and understand the medical information
	Hope to take a proactive role in decision-making based on active communication
Healthcare providers who make the patient feel safe	Physician's professionalism and positive clinical outcome
	Attitude to fulfill the patients' desire to know
	Treatment of patients with the highest priority
	Respecting patients' information and privacy
Hospital's unstinted and generous support	An organized communication system
	Sufficient arrangement of employees
	Efficient working process for healthcare provider
	Management of hospital facility and medical devices
Public sentiment about national healthcare and safety	Distrust of governmental programs to evaluate the level of institutional quality
	Trust and preference to a big private hospital
	Insensitivity towards safety that is prevalent in our society

Patients who want to take initiative in controlling his/her reception of information

Patients wanted to obtain information directly or indirectly related to their disease through all channels. As they stated, they gauged the safety of the medical environment that they will experience by collecting their own past experiences and indirect experiences, such as other people’s experiences or information through media.

“I actually felt that other people’s hospital experiences are not different” (G1, Participant 3)

Due to the requirement of expertise and specificity of medical information, there exists a gap in knowledge between patients and the healthcare providers. The participants sought to acquire knowledge to narrow this gap, and hoped to communicate equally with physicians. Surgery patients wanted to receive more detailed explanations about the surgical procedure, progress, and so on when they received explanations and informed consent forms. They believed they should acquire an insight and information about the disease to minimize risk. In order to communicate on an equal footing, patients tried to acquire and understand knowledge, sometimes pretending to know in front of the physician.

“I just searched the internet and found ‘Oh, this is the way to operate during a surgery.’ Search engines are extremely useful these days for obtaining information.” (G4, Participant 5)

“When I talk to my physician, if I use medical terms and pretend to know, the physician's attitude toward me changes a bit.” (G2, Participant 1)

Patients felt relieved when they actively participated in the medical process and made decisions based on their own judgment. They believed that by acquiring information about their own health from the healthcare provider, they prepared a countermeasure for any safety-related issue. Patients hoped to play a proactive role in decision-making based on active communication.

“When I meet with my physician and talk about my ailment, I repeatedly ask my physician to confirm what I understand and know.” (G3 Participant 7)

Healthcare providers who make the patient feel safe

Most of the respondents observed the physicians’ compliance with principles and hygiene through their explanation and behavioral observation. The professionalism of physicians was judged based on occupational consciousness, responsibility, and positive treatment results.

“I like physicians who are kind and do explain well, but I think a competent physician is the best.” (G5, Participant 4)

Also, patients considered attitude to fulfill the patients’ desire to know important. Just as the patients themselves wanted to acquire medical information, they felt safe depending on how the healthcare provider provided the information. The healthcare provider’s empathy for patients, kind words and actions, and sincere explanations tailored to the patient’s level, made the patient believe they were being treated properly.

“I think I met a good physician when he (she) explained in detail the reason of delayed operation time and comforted me.” (G2, Participant 7)

“The role of a physician is, of course, to treat a patient accurately, but I think a physician should be adept at putting people’s minds at ease.” (G4, Participant 1)

Patients trust the medical personnel when the staff explains issues in a patient-friendly manner from the patient’s point of view. A patient reported feeling left out by a professor who cares about the understanding of residents or medical students, rather than the patients during treatment; it made the patient feel alienated. Patients felt respected based on how the healthcare provider listened to their opinions, and whether they see the patient not as an educational tool or an experimental object.

“It is important for healthcare providers to look and understand from the perspective of the patient rather than the national framework or the position of the hospital.” (G2, Participant 1)

Patients particularly value privacy, and hope that the healthcare provider would respect this from the patient’s point of view. Patients said that they did not want other patients to hear their information on the same level as their body exposure in a shared room. Contrarily, a small group of patients were of the positive opinion that medical information could be obtained naturally from other patient’s disease information, as it is difficult to obtain medical information from one’s own physician.

“The physician just pulled out the foley catheter without closing the curtain. I thought I wasn’t being treated personally. I felt like I was being tested.” (G2, Participant 3)

“I hate other patients in the same room hearing my personal information and disease.” (G2, Participant 4)

Hospital’s unstinted and generous support

The miscommunication of information due to the changing shift of nurses was recognized as the institution’s procedural problem, not a problem of nurses. Additionally, incorrect communication between medical interns, residents, and professors in charge made the patients feel unstable. It was recognized that the inconsistency of communication between the patient and the healthcare provider was not a problem of individual healthcare provider but a systematic problem at the institutional level.

“Because my attending nurse changes so often (shift work), I think my information cannot be delivered efficiently. I would skip the meals because of getting an injection, but the information was not applied promptly, so the meal continued to come out.” (G2, Participant 6)

Patients thought that the lack of healthcare providers makes it difficult to provide dedicated service to patients. It was considered important for patient safety that physicians and nurses work without haste and with sufficient personnel. In particular, the shortage of nurses was emphasized by patients who frequently met nurses during hospitalization. The guidance of appropriate nursing care personnel was important for patient safety.

“When nurses work at night, there is too little manpower. (omitted) Patients often call a nurse, but the nurse alone can’t handle it.” (G3, Participant 2)

Hospitals generally carry out various activities for safety, such as patient identification, surgical site identification, and fire drills. Patients reported that they felt safe through repetitive procedures rather than feeling uncomfortable with ongoing safety activities.

“I tell the ID number, the nurse checks the name and administers the medication. Before carrying out medical treatment, they always asked me to say my name and ID number. So, I was relieved that the medicine would not be wrong.” (G3, Participant 4)

Patients felt anxious about the nurses sharing medical devices, such as sphygmomanometers and thermometers with many patients, and felt unsafe as broken medical devices were not repaired. Although the uncleanliness of the toilets used by multiple individuals was not directly related to treatment, it was a factor that made patients feel unsafe. As for the various materials, such as pamphlets and posters, attached to the wall, although initially the patients thought they were tacky and unsanitary, they realized after being hospitalized, that they were promotional materials, stuck for safety awareness.

“I thought the old interior and the signposts on the wall were tacky, but after the hospitalization experience, it was good that such an environment helped feel safe.” (G1, Participant 7)

Public sentiment about national healthcare and safety

Although the exact name of the government-provided evaluation results, such as accreditation system for healthcare organization and evaluation of medical benefits, was unknown, all participants were aware of their contents. However, they thought the government-supplied evaluation result was the minimum standard that a medical institution must meet, and thus, they did not trust medical institutions based on the evaluation result.

“The certification of accreditation seems to be placed anywhere.” (G1, Participant 3)

“The certification of accreditation is considered as the minimum standard that patients do not die due to medical accidents at least in this hospital.” (G1, Participant 4)

There are various sized public health centers run by the government; however, most are not preferred by the patients as they believed that the size of a hospital is directly related to its efficiency and safety.

“I believe only a huge university hospital. If I get cancer or serious illness, of course I will go to such a big sized hospital.” (G5, Participant 3)

Based on the response at the time of participation, the respondents answered that the low sensitivity to safety has an effect on the sentiment of patient safety. When medical accidents such as infections become a big social issue, the attention of the entire nation is concentrated for a short period of time; however, people quickly forget it, and they seem to repeat their actions.

“Patients seem to be vulnerable to hygiene and infection. (omitted) The thought of ‘I do this because I’ve been doing in this way’ remains in consciousness not only for the healthcare providers but also for the majority of the people.” (G3, Participant 3)

DISCUSSION

A qualitative study was conducted through FGDs to identify the themes that influenced patient safety sentiment during hospitalization. Patients want to take initiative in controlling their reception of information and want healthcare providers to make the patient feel safe. Patients felt safe when hospitals do unstinted and generous support. Also, public sentiment about national healthcare and safety made an effect on patient safety sentiment.

First, participants of this study mentioned that they obtained information from the media, and through direct or indirect ways, such as listening to others’ experiences similar to how patients obtain health information from the internet, publications, friends, acquaintances, and relatives.2425 The participants tried to secure safety by communicating actively with healthcare providers based on information collected through various channels, but they did not utilize reliable information provided by healthcare providers or the nation. When it comes to communication with healthcare providers, if patients have low trust in their physicians, their safety may be jeopardized by intentionally failing to provide medical information that may be important to them.26 On the other hand, patients' active efforts to obtain information can improve the patient-physician relationship and help patients participate in the decision-making process.27 Healthcare providers not only provide accurate medical information to patients, but also establish a trusting relationship with patients through patient-centered decision-making methods such as SDM,28 which ultimately protects patient safety. Also, patients are aware of the existence of information provided by the nation, such as the accreditation system, but are unable to use it. It is necessary to secure patients’ trust in information through active publicity and education at the government level.

Second, interpersonal care quality such as kindness, sympathy, and sincerity, was an important factor in determining patient satisfaction.29 In this study, participants emphasized the efforts of the healthcare provider as a response to their requests, such as detailed explanations of treatment and resolving questions, rather than any unconditional kindness by them. Participants also said that they felt safe upon observing the efforts of the healthcare provider in making patients feel safe. To improve patient satisfaction, medical institutions have begun making service-oriented efforts, such as shortening waiting times,30 and conducting customer service training.31 These efforts should not only improve for patient-centeredness, but also patient safety, which is the ultimate goal. Participants also considered not only physical privacy but also privacy of their own information within the scope of patient safety. Medical institutions conduct anonymizing patient information to protect patients. Furthermore, guidelines for protecting medical photographs are also being developed.32 However, measures to protect patients, such as single-room use, teamwork, surveillance, monitoring and keeping patients safe, may backfire and threaten patient safety.33 It is thus, necessary to strike an appropriate balance between patient privacy and safety.

Third, lack of physician-nurse and patient-staff interactions, and lack of effective nurse handover are major factors influencing patient outcomes, and effective communication and teamwork improve patient safety.3435 We found that patients felt that it was safe to be supported not only by the competence of individual medical personnel, but also by systematic support from medical institutions, such as communication systems, personnel, procedures, and facilities. Thus, patients become aware of the absence of a system or procedure, such as the lack of communication between healthcare providers, which subsequently affects their feeling of safety during hospitalization. Accordingly, a systematic approach should be used to ensure that patients feel safe during hospitalization. Organizations recommend and support the use of communication tools such as Situation, Background, Assessment, Recommendation (SBAR), Acknowledge, Introduce, Duration, Explain and Thank (AIDET), and I-PASS Nursing Handoff Bundle.3637 Additionally, the participants experienced anxiety and believed that their own safety was not guaranteed in situations where manpower was scarce. According to the OECD, the number of active nurses per 1,000 patients exceeds 17 in Norway and Switzerland; however, in Korea, it was less than half, at 7.2.38 Shortage of manpower is related to burnout of medical personnel.3940 Previous research shows that clinicians maintain patient safety despite overwork.41 This is a problem that cannot be solved by single medical personnel; it is, thus, necessary to secure and deploy sufficient personnel at the institution and national level.

Lastly, the overall public consciousness about healthcare was at the base of the patient safety sentiment factor experienced by patients. Rather than trusting the safety indicators of hospitals, the worse the health of a patient, the higher their distrust of the national health care system.42 Participants were not fully trusted the factors used internationally as patient safety indicators: adequacy indicators, medical institution certification, hospital infection rate, re-admission rate, and number of reported medical accidents, among others. According to Dean et al.,43 the physician’s recommendation and health insurance program were the main factors in choosing a hospital, demonstrating high confidence in objective indicators in Iran. However, patients in this study had a negative perception that they did not trust even if they had heard particular information. By providing education to the public to improve health literacy, we can expect to restore confidence in the healthcare system.44 In addition, adequate patient literacy should be thus provided so that the patients can judge medical institutions based on national safety indicators.

Insensitivity to safety indicates that people are unaware of safety-related accidents or have become accustomed to those, and do not think much of the dangers of accidents. In general, healthcare providers’ failure to follow safety guidelines leads to accidents. Conversely, patients’ exaggerated concerns regarding safety make the healthcare provider tired. For example, immediately after experiencing the Middle East Respiratory Syndrome in 2015, people were very alert about infectious diseases; however, they soon forgot and returned to their daily lives. As they re-experience the pandemic of coronavirus disease 2019 (COVID-19), recent changes in patients’ perceptions prioritize patient safety without making them uncomfortable.45

This study limited the participants’ regions to Seoul and Gyeonggi-do, and identified only patients with a history of hospitalization. Therefore, it was difficult to provide a broad view of the patients’ feeling safe during hospitalization because inpatients outside of Seoul and Gyeonggi-do regions and outpatient patients were excluded. In addition, the average age of the study participants was 45.4 years, and only three were in their twenties. People in their over 50s are more likely than those in their 20s to be admitted to hospital in general.46 There are inevitable differences between generations in terms of views on the subject. It seems necessary to discuss what patients in their 20s and 30s think about patient safety. For follow-up studies, it is necessary to use methods such as online video calls to collect data beyond regional limitations, and include many types of patients according to classifications such as age, admission days, type of hospital, treatment option, and hospitalized department. Nevertheless, we tried to collect diverse and rich experiences by recruiting patients who have been hospitalized for at least three days, and this study is meaningful in that it qualitatively explored whether the patient experienced safety, an unfamiliar concept to the patient.

This study confirmed the overall experience of hospitalization, including hospital facilities and systems. Patients wished to have an active communication and objective information exchange with healthcare provider consistently and felt safe when they acquired all the relevant information. However, as much sufficient and accurate information as they wanted was not delivered to patients, and information regarding patient safety activities of medical institutions and healthcare providers was not provided adequately. Public consciousness and the social atmosphere about healthcare also may affect the patient safety sentiment. Healthcare providers, medical institutions, and government should make efforts to narrow the gap in factors of safety perception between each position, through patient safety activities with patients. This study can be used as basic data to understand the perception and feeling of safety from the patient's point of view. In addition, it should be utilized to create a safe medical environment along with objective numerical values such as surveys, a patient reported outcome measurement.