Received: 14 September 2022 | Revised: 14 March 2023 | Accepted: 23 March 2023

DOI: 10.1111/hex.13758

ORIGINAL ARTICLE

A qualitative exploration of patient safety in a hospital setting

in Spain: Policy and practice recommendations on patients'
and companions' participation

Daniel G. Abiétar MD, MPH, Collaborating teaching staff1,2 | Laia Domingo PhD1,3 |
Laura Medina‐Perucha PhD, Lecturer3,4,5 | Nuria Saavedra BSN6 |
Anna Berenguera PhD, Associate Professor3,4,5 | Laia Lacueva MNSc7 |
Marta Hurtado MCRA8 | Xavier Castells PhD, Professor1,3 |
María Sala PhD, Associate Professor1,3

1
Servicio de Epidemiología y Evaluación,
Hospital del Mar, Barcelona, Spain Abstract
2
Facultad de Ciencias de la Salud y de la Vida, Introduction: Patients' and companions' participation in healthcare could help
Universidad Pompeu Fabra, Barcelona, Spain
prevent adverse events, which are a significant cause of disease and disability.
3
Red de Investigación en Cronicidad, Atención
Primaria y Promoción de la Salud (RICAPPS), Before designing interventions to increase participation, it is first necessary to
Madrid, Spain identify attitudes to patient safety. This study aimed to explore patients' and
4
Fundació Institut Universitari per a la recerca companions' perceptions, attitudes and experiences of patient safety, taking into
a l'Atenció Primària de Salut Jordi Gol i Gurina
(IDIAPJGol), Barcelona, Spain account contextual factors, such as cultural background, which are not usually
5
Universitat Autònoma de Barcelona, captured in the literature.
Barcelona, Spain
Methods: We conducted a qualitative study with a theoretical sampling of 13
6
Unidad de enfermería de Cirugía Ortopédica
inpatients and 3 companions in a university hospital in Barcelona, Spain. Information
y Traumatología, Hospital del Mar, Barcelona,
Spain was obtained from individual and triangular interviews. A descriptive thematic
7
Servicio de Metodología y Calidad en content analysis was conducted by four analysts and a consensus was reached
Cuidados Enfermeros, Hospital del Mar,
Barcelona, Spain
within the research team on the key categories that were identified. We also
8
Servicio de Atención a la Ciudadanía, conducted a card‐sorting exercise.
Hospital del Mar, Barcelona, Spain Results: All informants emphasized the role of good communication with health
professionals, a calm environment and the need for patient education. Discursive
Correspondence
María Sala, Hospital del Mar Medical Research positions differed by cultural background. Informants from a Pakistani–Bangladeshi
Institute (IMIM), Doctor Aiguader, 80, 08003
background emphasized language barriers, while those from European and Latin‐
Barcelona, Spain.
Email: [email protected] American backgrounds stressed health professionals' lack of time and the need for
more interdisciplinary teamwork. The card‐sorting exercise identified several
Funding information
Instituto de Salud Carlos III, opportunities to enhance participation: checking patient identification and medica-
Grant/Award Numbers: PI19/00056, RD21/ tion dispensation, and maintaining personal and environmental hygiene.
0016/0020
Conclusion: This exploration of informants' discourse on patient safety identified a
wide variety of categories not usually considered from institutional perspectives.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2023 The Authors. Health Expectations published by John Wiley & Sons Ltd.

1536 | wileyonlinelibrary.com/journal/hex Health Expectations. 2023;26:1536–1550.

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ABIÉTAR ET AL. | 1537

The findings of this study could enrich interventions in areas with diverse cultural
backgrounds, as well as current frameworks based exclusively on institutional
perspectives.
Patient or Public Contribution: The results of the study were communicated to
patients and accompanying persons via telephone or email. Similarly, a focus group
was held with a patient forum to comment on the results. In the design of
subsequent interventions to improve patient safety at the hospital, the proposals of
patients and companions for their participation will be included together with
healthcare professionals' opinions.

KEYWORDS
companions, hospital setting, patient participation, patient safety

1 | INTRODUCTION the patients' perspective. The aim of this study was to explore
patients' and their companions' perceptions of patient safety in a
According to the World Health Organization, adverse events due to hospital setting, and their recommendations for patient involvement
unsafe care are one of the 10 leading causes of death and disability aimed at improving patient safety. The results of this study could be
worldwide.1 In high‐income countries, it is estimated that 1 in 10 useful to design interventions to engage patients in safety during
2
patients experience an adverse event while receiving hospital care, direct care in other hospitals in the publicly funded health system in
of which almost 50% are preventable.3 This is also true of Spain.4 In Spain.
this regard, inequities in the safety of care and a higher risk of
adverse events have been found in ethnic minorities.5 Recommenda-
tions for hospital quality improvement, and especially for the 2 | METHODS
prevention of adverse events, usually originate from and are directed
towards healthcare teams.6,7 However, it is becoming increasingly This qualitative study is part of a larger project conducted in our
important to involve patients directly in interventions to enhance hospital aiming to design a set of interventions to improve patient
patient safety, which could reduce the burden of harm.6,8 safety in hospital care by involving patients and their companions.
Although data on the effectiveness of patient participation in The project is called ‘Improving patient safety through the active
patient safety can vary depending on the specific aims pursued,9 involvement of patients and companions’.
there is evidence that adverse events can be reduced by involving This study was conducted from design to analysis from the
patients and their companions in medication monitoring,10–12 and by perspective of critical theory and equity. This was essential because
preventing pressure ulcers, patient falls and surgical infections.6,13,14 the research team was aware that the area served by the hospital has
In contrast, studies assessing patient involvement in hand hygiene inequalities influencing participation and is more deprived than other
promotion among physicians show they are particularly reluctant to areas of the city.16
7
speak out when they observe poor hygiene practices.
Patient participation in safety during admission is a key element
of patient empowerment and a hospital culture that promotes a new, 2.1 | Study setting and design
more proactive patient role.15 Both could be achieved by simply
enquiring about patients' experiences during hospitalization.9 How- The Hospital del Mar is one of four public university hospitals in the
ever, before increasing patient participation, there is a need to city of Barcelona and attends medium‐ and high‐complexity diseases
identify patients' characteristics, such as cultural background, in a catchment area of more than 300,000 inhabitants. The hospital
socioeconomic position, gender and age,15 as they may influence has more than 400 conventional beds, and 12 operating rooms, and
attitudes towards participation. Indeed, specific mechanisms are annually assesses more than 95,000 patients in the Emergency
required to ensure participation among certain groups, such as ethnic Department.
minorities.5 To our knowledge, no other studies have investigated This exploratory and interpretative qualitative study used a
how patient safety is perceived, from different cultural perspectives, naturalist‐comprehensive paradigm. The perspective adopted was
and how patients can participate in designing patient participatory socioconstructionist: forms of participation are proposed from
processes in a hospital setting in southern Europe. The possibility of particular historical, social and individual contexts, and the aim of
codesign requires, among other things, exploring patient safety from researchers is to critically interpret the social positions underlying
 13697625, 2023, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13758 by Spanish Cochrane National Provision (Ministerio de Sanidad), Wiley Online Library on [29/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1538 | ABIÉTAR ET AL.

these proposals.17 Data collection techniques consisted of individual (European, Latin American, Indian–Pakistani–Bangladeshi and Magh-
and triangular semistructured interviews with patients and their rebi); educational attainment (none, primary education, secondary
companions. Triangular interviews (also known as triangular groups) education, vocational training and higher education); sex assigned at
are composed of a maximum of three people. They are intended to birth (male, female or intersex) and gender identity (feminine,
delve deeper into some topics, because, in a larger group, due to masculine or nonbinary*: nonbinary people are those who do not
group pressure, the discourse would be less rich. Our triangular identify with the male–female binomial). People from non‐Western
groups consisted of interviewing patients and companions cultural communities were specifically included to avoid under-
together.17 In accordance with the project's objective of proposing representation due to their lack of access to effective participation.
actions to improve patient safety in the hospital, the degree of data The cultural communities selected are the four most frequent in the
interpretation was high. health areas served by the hospital. Only one potential participant
An external company gave support in the transcription and refused to participate in the study because she felt dizzy due to her
coding stages. The external company is a strategic consultancy health status.
specializing both in innovation and qualitative studies. They have led
trend studies, ethnographic studies, digital ethnography and inter-
views with experts. A coding procedure was agreed upon before the 2.4 | Data collection
start of the study. Coding quality and control mechanisms were also
established, and the coding was finally reviewed by the research Individual interviews were conducted by the main researcher
team. A process of sharing the research objectives and the (D. G. A.) and another researcher from the external company in
methodological approach was necessary since the company was the patient's hospital room. We interviewed 16 participants
not involved in the process of designing the study protocol. Patients (13 hospitalized patients and 3 companions who were with patients
and companions were told they could ask to stop the interview if when they were first approached). Therefore, 10 were individual
they became tired or uncomfortable. Likewise, if interviewers interviews and 3 were triangular. A cultural mediator participated in
perceived any difficulty, they spontaneously asked if the informants interviews with a cultural and/or language barrier. The interviews
wanted to stop the interview. were conducted in Spanish (N = 10), Urdu (N = 2) and English (N = 1)
and lasted between 20 and 50 min.
Study participants were asked to describe the following in‐
2.2 | Study population depth: (a) the concept of patient safety, (b) their safe and unsafe
experiences during hospitalization and the possible causes and (c)
To guarantee appropriate health status for participation, eligible their proposals to improve patient participation in patient safety.
participants were hospitalized patients who were close to discharge We used a semistructured topic guide (Figure 1) to conduct the
and who belonged to European, Pakistani–Indian–Bangladeshi or interviews, based on findings from a nonsystematic review of
Latin‐American communities and were older than 18 years, irrespec- qualitative and quantitative studies examining patients' perspec-
tive of the reason for admission. Those selected were also able to tives and experiences of patient safety in hospitals, created by four
understand and provide consent to participate. Patients' companions members of our team. Because most previous studies have been
who were present at the time of the interview were approached after presented within frameworks consistently based on professional
the patient met the criteria and were invited to participate and to perspectives, in this study, we deliberately chose not to use a
provide consent. specific theoretical framework, as a means to explore how patients
and their companions conceptualized patient safety in their own
words. During the interviews, and after question 5, a card‐sorting
2.3 | Recruitment and sampling exercise was used to facilitate visualization of safety‐related
scenarios (Figure 2) and to try to overcome language and health
First, participants were identified a priori through hospital records in literacy barriers. The informants were asked to rank the images
November 2021, on the basis of general characteristics such as age, from those representing the least safe situation to that represent-
sex and place of birth. Among those patients who were expected to ing the safest situation and to explain their reasons as a way to
meet the heterogeneity criteria, potential participants were help them to think about these situations. All the information
approached by two investigators (D. G. A. and N. S.) and by a collected with this exercise was included in the textual corpus for
cultural interpreter (when necessary), face‐to‐face and a short survey the descriptive thematic content analysis.
was conducted to characterize their profile with the heterogeneity All interviews took place in December 2021 and January 2022
criteria described in the paragraph below. A convenience sample of and were audio recorded with the participants' permission. Data
participants was recruited in‐house (D. G. A.) after the short survey were collected until saturation criteria were reached. We con-
was conducted. Sample diversity and the equity perspective were sidered the discourse ‘saturated’ when discursive positions were
ensured by using the following heterogeneity criteria: age (18–34, clearly defined and no new elements were identified for any
35–64 and >65 years); a sense of belonging to a cultural community of them.
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ABIÉTAR ET AL. | 1539

FIGURE 1 Topic guide used in the interviews (16 participants) taking place in Hospital del Mar (Barcelona) between November and January
2021–2022.

2.5 | Data analysis following steps: (i) identification of the relevant subjects and texts;
(ii) fragmentation of the text; (iii) text codification with emerging
The audio recordings were transcribed verbatim by an external codes; (iv) creation of subcategories and categories; (v) analysis of
professional. Two sessions were held between the external each category and (vi) interpretation of the emerging findings. The
professional and two researchers (D. G. A. and M. S.) to check results were subsequently discussed among the research team
the coding process and carry out the handover for the rest of the (D. G. A., L. D., M. S. and L. M.‐P.) until reaching a consensus on the
analysis. Then, a descriptive thematic analysis was carried out by key categories.
three researchers (D. G. A., L. D. and L. M.‐P.).18,19 They began by Because the discourse of the selected cultural communities had
reading the transcripts to identify the range of data in the data set, not been previously explored in our setting, we did not decide on a
and then first independently, and then jointly, performed the specific conceptual framework beforehand for the data analysis.
 13697625, 2023, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13758 by Spanish Cochrane National Provision (Ministerio de Sanidad), Wiley Online Library on [29/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1540 | ABIÉTAR ET AL.

F I G U R E 2 Card‐sorting exercise. ‘Here are some situations in which a patient like you may feel unsafe. Rank them according to your
perception from least safe to most safe and explain why’.

3 | F I ND I NG S and internal medicine. Patient characteristics are shown in

Table 1.
Of the 16 participants, 11 (69%) were aged between 35 and 64 We identified three major categories: (i) conceptualization of
(range: 21–80) years. Seven informants (44%) had elementary patient safety and key moments of safety and insecurity; (ii) factors
education or no schooling. Community belonging was heteroge- related to the institution, health professionals and informants
neous (five European, six South Asian and five South American). influencing informants' participation and (iii) informants' proposals
Nine informants (66%) were men and 7 (44%) were women. None for their participation in patient safety. The latter two points were
of the participants identified as nonbinary or trans (gender dominated by two axes: cultural community and educational level,
identity) or reported being intersex (sex at birth). Patients were which determined patient‐professional interaction, and the degree of
from different hospital services: general surgery, gastroenterol- acculturation (Figure 3). The three major categories are presented
ogy, neurology, neurosurgery, urology, oncology, traumatology below, together with participant quotes.
 ABIÉTAR
ET AL.

TABLE 1 Patient characteristics.

Participanta Age category Reasons for admission Cultural community belonging Educational level Sex assigned at birth Gender identity

(1) Patient A >65 Colostomy Spanish Primary school Woman Feminine

(2) Patient B 35–64 Epilepsy Latin‐American (Argentina) Primary school Man Masculine

(3) Patient C 35–64 Hernia Spanish Vocational training Woman Feminine

(4) Companion A (patient D's 35–64 Patient D had multiple pathologies (COVID‐19 Pakistani None Man Masculine
companion) and cancer)

(5) Patient E >65 Spondylodiscitis Spanish Higher education Man Masculine

(6) Patient F 35–64 Septic arthritis Pakistani Don't know Man Masculine

(7) Patient G 35–64 Lithiasis Latin‐American (Brazil) Secondary school Woman Feminine

(8) Patient H 18–34 Appendicitis Pakistani Higher education Man Masculine

(9) Patient I 18–34 Femur fracture Pakistani Secondary school Woman Feminine

(10) Patient J 35–64 Anaemia Latin‐American (Ecuador) Primary school Man Masculine

(11) Patient K 35–64 Pneumonia Bangladeshi Primary school Man Masculine

(12) Patient L 35–64 Subarachnoid haemorrhage Latin‐American (Brazil) Secondary school Woman Feminine

(13) Patient M 35–64 Hernia Spanish Primary studies Woman Feminine

(14) Patient N 35–64 Postgastrectomy haematoma Latin‐American (Argentina‐ Secondary studies Man Masculine
Paraguay)

(15) Companion B (patient M's 35–64 – Spanish Primary studies Woman Feminine
companion)

(16) Companion C (patient I's 18–34 – Pakistani Higher education Woman Feminine
companion)
a
Names have been anonymized fictional to protect participant's identities.
| 1541

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 13697625, 2023, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13758 by Spanish Cochrane National Provision (Ministerio de Sanidad), Wiley Online Library on [29/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1542 | ABIÉTAR ET AL.

FIGURE 3 Discursive positions on patient participation, depending on two different axes (sense of community belonging and educational
level).

3.1 | Conceptualization of patient safety and its professionals' behaviour (e.g., ‘humane manners, professionalism,
key moments sincerity and honesty’ and coordination as a team), as well as a
comfortable hospital environment (e.g., ‘clean and quiet space’,
For all informants—independently of cultural background, age, sex and ‘being supported’). They reported that both items protected
assigned at birth and educational level—their conceptualization of them from errors and made them feel safe. Perceptions were
patient safety during hospitalization was broader and more ambigu- closely linked to the discursive positions shown in Figure 3. As
ous than the concept commonly used by preventive medicine stated by patient B:
services (‘absence of errors in healthcare’) and was specifically
defined in subjective, relational terms. Good doctors, good nurses […]. For example, the
doctors express themselves very well, the nurses are
nice. The beds are good… sometimes they give beds
3.1.1 | Subjective factors that break your back, and here they don't, for example.
And more things, I don't know how to explain it, the
When asked for a definition of patient safety, informants reported, socialization between patient and nurse or between
on the one hand, positive experiences of trust and well‐being patient and doctor and so on
between patients and health professionals, mostly with nurses and,
on the other hand, also negative experiences, such as shame during For the informants, calm and cordial relationships among all the
wound care or a lack of communication by physicians. Therefore, hospital staff were important, not simply relationships among the
they emphasized the value of the subjective component of safety. In healthcare staff or patient‐professional communication. This idea was
their discourse, they assigned little importance to the usual definition expressed by patient L:
of patient safety, understood as an awareness of errors and
experiences of adverse events, because in one patient's words, ‘we In the hospital there are people living together: the
trust the professionals, otherwise we wouldn't be here’. In other cleaning team, the cook, the doctors, the nurses. It is a
words, if informants trusted professionals, they trusted them not to family and these people are like ants, they walk around
make mistakes. and do their work. From the moment they say ‘Good
morning′ to me, or the cleaning lady works happily, or
the person who brings the food is friendly and happy…
3.1.2 | Safety understood as quality I know that everything is going well. From the moment
people are bitter, shouting, swearing, the doctor
To a certain extent, the informants' conceptualization of safety humiliating the staff… it's bad for us [patients]. There
was similar to the concept of ‘quality’, and they had both positive are hospitals where that happens, I haven't seen it
and negative perceptions during hospitalization. For participants, here, but there are. There are places where you work
patient safety was mostly related to two dimensions: but you are oppressed. And this influences the
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ABIÉTAR ET AL. | 1543

patient's treatment. However, when the team works 3.2.1 | Patient and companion factors
together, the result is felt by the patient
Informants identified several factors that could influence patient
participation, most of which were related to patients' attitudes to
professionals (seen as empathy, although only some used this
3.1.3 | Key moments for safety word), their knowledge of the institution and the disease (health
literacy) and their disease status. Lack of knowledge of the field
Based on the participants' accounts during the card‐sorting exercise, of patient safety was one of the first barriers mentioned by
most participants perceived that some phases were safer than others. patients, most of whom felt that they had ‘no legitimacy to
For all of them, the safest part of the admission was the stay in the say what should be done’. Participation was seen as an ad hoc
hospital ward, and the most unsafe and critical moments were and management issue, rather than a cooperative and longitudinal
waiting for admission and transfers, especially among those with one. The issue of health literacy was clearly expressed by
language barriers and with no formal education, or only primary patient C:
schooling or vocational training (Figure 3). Several needs were
identified during these periods. Some informants mentioned commu- I've received three interventions, not one. This could
nication barriers during transfers around the hospital—both a lack of have happened to anyone. Could it have been a
signage/signaletics and interpreters for Pakistani/Bangladeshi com- mistake? Possibly. I can't blame anyone if I don't know
munities. As stated by patient F's interpreter: [what happened]

He is happy now, he says that the worst was on Some patients, especially those with no education or with
Monday in the emergency room, when he was left primary education only (but not those with vocational training) and
alone. He says he was in a wheelchair and waiting for a those from Pakistani‐Bangladeshi cultural backgrounds, seemed to
long time, but no one could help consider their participation as passive (‘just to take heed of the
recommendations’). This was expressed clearly by patient J:
Other informants, like patient C, mentioned the need for more
information at discharge: [He was asked about proposals for participation] It's all
good, for my part it's all good. I must listen. If you
When I get out of here I want to know what I have to don't listen…once doesn't usually hurt but…I have to
do, what my life is going to be more or less like now, listen to what she says [his nurse]
because of course I'm not supposed to be able to
make any effort or anything. Maybe they explain it to This view contrasts with participation as active and mediated by
me and I say ‘ok, yes’, but I don't understand. I need technological tools, as mentioned by people with higher educational
help from someone else levels and Spanish backgrounds and exemplified by patient E:

Staff check‐in and check‐out [of the room] could be

improved. Here I think it is an improvement that
3.2 | Factors influencing patients' and companions' affects people's rights a little bit, but that could be
participation solved with the new software programs

Informants felt that patient participation was mainly influenced by Among patients from non‐European cultural backgrounds, the
the following subcategories (i) patient and companion factors factors seen as heavily influencing their participation were language
(‘knowledge’ or ‘cultural background’); (ii) infrastructures and institu- barriers (and the presence or absence of a cultural interpreter) and
tional factors (‘patient spaces beyond rooms’, time for patient the cultural gap between them and health professionals. This was
feedback face‐to‐face and ‘professional's working conditions’) and explained by patient F through his interpreter:
iii) professionals' factors (‘communication, emotional management’).
Although informants were not specifically asked about factors that Intr: He told me it's difficult [to participate] because he
might influence patient involvement in safety, these factors is a foreigner and they don't know the language
spontaneously emerged when proposals were made for involvement, [Urdu]. But he says he has been well looked after. He
mostly as resistance to the possibilities for patient and companions' says sometimes there are little things that can happen,
participation, rather than as facilitators. Participants often justified because if they are busy and you need them, you must
their lack of participation by citing structural issues influencing wait a bit, but he says these are little things that don't
professionals' attitudes towards participation (i.e., lack of staff time to really bother him. […] He says he's had constipation
become involved in proposals). and he hasn't been able to explain it
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1544 | ABIÉTAR ET AL.

Paradoxically, some informants associated this cultural gap with words, a person working here cannot earn a miserable
better, rather than worse care, as stated by companion A: salary. Some of them. If that doesn't improve, we are
taking health care backwards. […] We are human
[companion A explained that some exceptions were beings and, even if you have a vocation… forgive me
made in visiting restrictions for Urdu‐speakers because it brings tears to my eyes to talk about this…
patients during the COVID‐19 pandemic due to even though it's a vocational job, if a person who
language barriers with healthcare professionals] works here doesn't earn a living wage, it affects their
Sometimes we [patients and companions] have work. The essential work of the country has been
thought that they treat you better if you are a neglected. […]
foreigner. It's not like something is missing, it's not
80 out of 100. Out of 100 I would say it's 100 or more

3.2.4 | Professional factors

3.2.2 | Institutional and professional factors related Latin‐American patients in particular identified emotional manage-
to patient participation ment skills as a crucial professional‐related factor and believed that
they determined how professionals requested their participation.
In terms of infrastructure, all informants believed that to facilitate Professionals' reactions to patients' and their companions' doubts
patients' participation during admission, hospital spaces should be and questions made a difference in their attitudes towards participa-
comfortable (even with background music in the case of a Cuban tion in different situations and to their perceptions of safety. As
woman), clean, and safe… with the aim of making them feel ‘at home’ mentioned by patient G, both patients and their companions find
and promote the relationship between patients. In this sense, patient themselves in very difficult emotional situations:
G commented:
For me it is very important that health professionals
Ask him [the patient] what he likes to listen to, have true vocation, so that patients don't feel
because I stopped playing my music to play music for mistreated. Because when you're on your hospital
my partner and he was very relaxed, much better. The bed, you are nervous, and it's easy to break into
thing is that, in here, with the coexistence in this little tears. […] Health professionals can never lose their
piece that you see here […] that is very important, temper. Because I depend on them, I am in their
patients should talk [with their companions]. This hands
curtain only closes when the nurse comes in, but once
she leaves it is open and here we are a family, which is
better than fighting
3.3 | Patients' and companions' proposals for their
participation in patient safety

3.2.3 | Institutional factors From the descriptive thematic content analysis, various activities and
moments were considered appropriate for participation.
The informants' discourse revealed that professionals are embedded
in institutional dynamics, which concern human resources manage-
ment. In the measures proposed, closely related to time as a resource, 3.3.1 | Checking correct identification
two further and relatedideas always were identified: Professionals
needed more time to improve patient involvement, but the lack of The informants believed that the identities of both patients and
human resources and their difficult working conditions (salary and professionals should be checked, whenever the latter establish
schedules) made it ‘practically impossible’ to implement these contact with them or with accompanying persons, as mentioned by
measures, especially among nursing and auxiliary teams, as health patient C:
professionals ‘couldn't be more dedicated to their work’. In this
regard, the ‘system’ (ambiguity) was criticized for not giving health Now, if they call me Pepita, I'll say ‘excuse me, my
professionals the opportunity to work as well as possible. The idea name is not Pepita’. But when they call you by your
was illustrated by patient E: name from the beginning, and they describe what's
wrong with you, it's because they know who you are.
Now, it's a pain in the ass because of the health care […] Patients must give clear and correct information
cuts. If there are cuts, everything is shaken. In other about themselves
 13697625, 2023, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13758 by Spanish Cochrane National Provision (Ministerio de Sanidad), Wiley Online Library on [29/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ABIÉTAR ET AL. | 1545

3.3.2 | Ensuring that the medication dispensed is entirely orally and face‐to‐face so that patients would have a real
correct opportunity to express doubts. They also believed their experience
would be substantially improved if they knew the approximate time
The participants believed that patients or their companions should of the nurse's appointment during the admission process.
check that the medication is correct before taking it and should write
down its indication and dosage. This was expressed clearly by
patient G: 3.3.6 | The importance of companions as mediators

When they are giving the medicine, ask what this pill is Informants reported that companions were important to mediate
for, to be informed. ‘This one you have to take every between the patient and professionals when needed by the patient
day, this one every eight hours’ or when misunderstandings occur, but also when patients cannot
deal with some responsibilities (hygiene, being communicative…).
This was perfectly explained by patient L:

3.3.3 | Proactively helping as much as possible with With the family, communication and diagnostic proce-
nursing care, whenever possible dures are important. […] I think communication must
be the same with them, with sincerity and in a simple
As stated by patient N and patient C, respectively: way. […] I am good at taking medication. If you tell me
that I have to take a medicine at 8 o'clock, I will take it
I know that to lift a patient up, nurses are small, at 8 o'clock. But there are people who don't, who want
sometimes they cannot. And if you can help with this to take it at 10 o'clock. For example, if a patient
and push up… doesn't want to take a shower, but has a cut, if he
doesn't clean it, he gets infected. There are people
The first thing when you meet the professional at the who don't have hygienic habits and for their wounds
visit is to create this bond between professional and to heal well, they have to keep them clean and dress
patient. And ask how things are going and try to be as the wound. The family has to mediate in these cases
communicative as possible. I think that builds trust

3.3.7 | The importance of patient groups

3.3.4 | Always expressing doubts, giving feedback of
safety and being empathetic with health professionals, From a collective point of view, patient participation was mainly
especially when they perceive errors conceived as interaction with other inpatients. As exemplified by
patient N, informants suggested the need for physical spaces
Some of these ideas were expressed by patient B designed for patients and their companions, so that they could share
experiences during admission and create self‐help links.
The fact that I am always very affectionate. I am
always friendly with people, I think that also helps. […] I think that patient groups are important. For example,
I also hear that the nurses and assistants are caring, when I started this whole process for the operation,
and that also encourages the patient, for example, and there were patients who formed groups and they are
lifts his or her spirits. […] The patient should be kind to always in contact. I think they are good to be in
the doctor and the nurse. And try to understand what communication, to know how other patients are doing,
they are going to do to you, you are here for a reason how their operations went, to keep this link…

To facilitate patient relations, informants believed that appropri-

ate spaces should be created. This was described by patient L:
3.3.5 | Changes to patient evaluation surveys and
the informed consent process An open area in the hospital for people to walk
around. Because here [in the rooms] it is closed, there
Despite not being mentioned in the card‐sorting exercise, most is nothing open, very closed. We could have an area
participants believed that both quality/patient safety evaluation with trees, tables, chairs to sit and talk. So that people
surveys and the informed consent process should change to improve can have a life closer to the reality that they have
participation. The informants suggested that both should be done at home
 13697625, 2023, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13758 by Spanish Cochrane National Provision (Ministerio de Sanidad), Wiley Online Library on [29/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1546 | ABIÉTAR ET AL.

TABLE 2 Most relevant proposals for participation by study informants and equivalent proposals are discussed in the literature reviewed.

Proposals for patient and companions' participation in this study Equivalent proposals and their rationale in other studies

Checking correct identification of patients and professionals, whenever − Also mentioned in Vaismoriadi20 and Park.6
the latter establishes contact with them or with accompanying
persons.

Ensuring the medication dispensed is correct before taking it, writing − To engage both patients and companions in treatment surveillance,
down notes about its indication and dosage. de Jong10.
− Examples of medication management have been described by Gabe
et al.21 and Jordan et al.22
− Successful interventions to encourage patient participation in the
monitoring and self‐management of medication in hospitals have
been described by Hall et al.23

Proactively helping with nursing care whenever possible. − This proposal could be considered together with patients’ and
companions' roles in preventing pressure ulcers.4

Always expressing doubts and being communicative with professionals, − Patient participation relies on patients being encouraged to raise
especially when patients or their companions perceive errors. doubts without fear of offending healthcare staff. Agreement on how
patients should ask these questions would encourage patient‐
provider trust.24
− To encourage patient participation, the management system must be
supportive and continuously identify and correct all the weaknesses
and failures that arise in the system.25 Management should also be
committed to supporting and empowering patient involvement and
challenging power inequities.24

Maintaining personal and environmental hygiene. − Most concerns are about environmental factors such as noise at night
and poor bathroom facilities.5
− This was also considered important for surgical infections.4

The informed consent process should be communicated entirely orally and − Communication and cooperation between patients and healthcare
face‐to‐face to allow patients to express doubts. professionals are important resources for patient participation in
quality improvement projects.7

Professionals ask for patients' safety perceptions at discharge to improve − Successful quality improvement interventions can be simple. Direct
the processes. patient feedback can pinpoint areas of harm not previously noticed
and can embolden healthcare professionals' to report harm, leading
to changes at the microsystem level.7
− For this type of intervention, professionals might need training.24
− Active intervention is required, whether at the individual or collective
level, to create an environment where patients are listened to, and
their views are taken seriously and acted on. Productive
communication does not occur by itself.5
− Many problems and interventions in healthcare are complicated or
complex, but effective safety interventions can also be
straightforward. For example, to encourage patients and their
families to report harm, the introduction of a simple, real‐time
bedside questionnaire enhanced the ward's overall safety culture.7

Participation requires resources (especially time) for professionals. − Healthcare managers are responsible for providing an appropriate
Knowing the approximate time of the nurse's appointment time during and positive environment for nurses to engage patients in patient
the admission process could help and their companions. safety.24
− Research has identified multiple barriers that need to be identified
and considered by organizations when managing quality
improvement efforts. Such barriers include healthcare system
financing, competing organizational changes and the work
environment, for example, time constraints, staffing, routines,
educational skills and the existing attitudes and culture.7
 13697625, 2023, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13758 by Spanish Cochrane National Provision (Ministerio de Sanidad), Wiley Online Library on [29/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ABIÉTAR ET AL. | 1547

TABLE 2 (Continued)

Proposals for patient and companions' participation in this study Equivalent proposals and their rationale in other studies

The role of companions' is conceived as acting as mediators with − This role has been previously conceived, especially when a patient's
professionals when misunderstandings occur or when patients must ability to participate is reduced by illness.24
responsibility. − Companions are expected to speak up at a time when patients
themselves are too vulnerable or unwell to act as their own
advocates.5

Interaction with other inpatients in physical spaces designed for patients − It is important to generate a participation culture.13
and companions, so that they can share experiences during admission − It is also important to consider patient participation from a collective
and generate self‐help links. Patient associations raise doubts about perspective.5 Well‐designed collective forums for the patient and
their usefulness and possible hidden interests. public participation can be a motor for change. The power of the
collective contrasts with the inequalities between patient‐
professional communication at the point of care, when patients are
particularly vulnerable. In collective forums, patients could potentially
work together to achieve stronger influence than is possible in
individual‐level interventions, which are inherently asymmetrical.5
− An easy way to improve quality would be to facilitate face‐to‐face
meetings, encourage participants to listen to each other and to
reflect, and encourage the development of these relationships and
cooperation methods.7

Finally, informants were asked to propose specific measures to 4.2 | Comparison with existing literature
be considered for our context, to avoid ambiguity over how patients
should participate in patient safety and to prioritize areas of action, To a lesser extent, the perception of patient safety for patients and
which is in agreement with other studies.6,20 The proposals are companions was defined more on the basis of care structures or
summarized and compared with those in similar studies in Table 2. In outcomes of care than on the healthcare process, which is consistent
these proposals, the effect of the card‐sorting exercise should be with the existing systematic reviews on quality.24 As in other studies,
considered, as the informants' collective beliefs have been fuelled by informants were aware of the existence of errors but did not consider
the images proposed as moments when patient safety is important. them as the main issue in patient safety and, when they did occur,
they mostly blamed poor communication before and after the error
(as did health professionals).6,24 From our study, this patient's logical
4 | DISC US SION reasoning could be interpreted as if communication regulates patient
safety conceptualization and perceptions, making errors visible and
4.1 | Summary more important for patients when bad communication is happening,
probably because trust in health professionals become deteriorated.
In this study, we explored patients' and companions' knowledge, In this regard, several factors that encouraged patients and their
perceptions and attitudes regarding patient safety in a hospital companions to develop trust in healthcare teams have been reported
setting, and their recommendations for patient participation aimed in other studies.7,25 In our consideration, these factors may include
at improving patient safety from an equity perspective and the historically passive role of patients in healthcare, their blind trust
different discourse positions. Independently of informants' char- in healthcare professionals and the perception of comfort and good
acteristics, the factors important for patient safety were transpar- quality of care compared with less well‐equipped healthcare services
ent, easy‐to‐understand and respectful communication by health in low‐income countries. As it could be interpreted by patient C's
professionals and a calm environment. Errors did not emerge as second statement, the development of trust can also be influenced by
relevant. Informants' conceptions of participation differed, mainly a lack of knowledge about the disease itself and its clinical
according to their cultural background and educational level. When management.26 Regardless of its causes, in the absence of errors
these last two characteristics could hamper communication with perceptible by the informants, trust was a sufficient reason to feel
professionals, the discourse was limited to communication barriers safe. This process could be interpreted as an act of handing over
and their consequences for participation. When there were no collective responsibility to protect patient safety to the institution
communication problems (European and Latin‐American back- and its professionals. Therefore, these elements could be key in
grounds, and secondary and university education), informants promoting a shift to a more proactive attitude of informants to
added that participation was mainly influenced by a lack of clinical participate.
knowledge, the feeling that health professionals worked in One of the most notable results of this study is that there was
suboptimal conditions and were overly busy, and their lack of agreement that transfers were key unsafe moments during hospital-
emotional skills. ization. However, informants expressed different needs according to
 13697625, 2023, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13758 by Spanish Cochrane National Provision (Ministerio de Sanidad), Wiley Online Library on [29/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1548 | ABIÉTAR ET AL.

their profiles. Older people signalled a need to improve the hospital's studies,24 patients (independent of their educational level or gender
signalectics to help with admission, visits and discharge, as reported identity) identified the importance of emotional management and
7
by the systematic review by Sutton et al., whereas the Pakistani and communication skills in both health professionals and patients for
Bangladeshi communities perceived language barriers as hampering patient safety. As reported by studies conducted in Australia,32 this
transfers during admission, although they also stressed the useful- might also ameliorate the negative effects of carers' involvement, by
ness of the permanent availability of a cultural interpreter. However, assigning a higher value to their contributions. In our study, Latin‐
6,12,15,27,28
in the existing literature, patients' characteristics are American informants, who placed special emphasis on having warm
usually not reported, hindering identification of the discursive relationships with health professionals, were especially sensitive to a
positions behind the expression of this need. lack of emotional management and communication skills. Patient
For some patients, particularly those with a university, high empowerment depends on feeling valued, safe and motivated to
school or vocational education, trust in professional teams was participate.20,33
independent of whether they engaged in checking and verifying
behaviours (e.g., of medication). Underlying this idea, as proposed in
other studies with heterogeneous patient profiles, there is a belief 4.3 | Strengths and limitations
that patients should be able to trust they are receiving competent
care, as opposed to assuming a leadership role in their safety.6,20,29 This study has some strengths and limitations. First, we did not
Much has been written about factors influencing patient include any inpatients from Maghreb, which is the third largest
participation, but studies performed in other hospital contexts such non‐Spanish cultural community in the hospital healthcare area.
as Switzerland, the United Kingdom, the United States and Asia, do However, we were able to include informants from Asia Minor,
not describe patient characteristics.20 This hampers comparisons, as Latin America and Europe, and we ensured a diversity of profiles
it does not answer the question of ‘who says what?’. Patients' with different educational levels, cultures and gender. There was
knowledge of their disease has previously been noted to be an also a lack of younger participants, given that inpatients are usually
6,7,20,26,30,31
important factor in participation, especially in long‐term elderly people. No exclusions were due to language barriers. Broad
diseases, and patient education has been proposed as a plausible characterization of the informants allowed for a richer interpreta-
solution that could even reduce adverse events.15 This entails tion of the units of analysis, without neglecting the position of the
viewing patient participation as a learning process.20 Although informants, and enhanced the issuing of recommendations for
experiences and beliefs have been proposed as key factors for participatory practices in patient safety.24 Despite the presence of
20
participation, our informants assigned them little importance when a cultural mediator, the cultural gap between the research team
they asked about them. Moreover, patients' health conditions are and participants from Asia Minor, hampered the detection of
also important and must be taken into account to adapt expectations variations in cultural practices and could have impaired data
and proposals for participation.20,26 In this respect, it is also obvious collection in this group. This could explain why no differences
but important to remember that some patients may not wish to be were found between the countries included in this group and also
actively involved for legitimate reasons.6,20 Indeed, as described in limits the conclusions of the study in this population. In any case,
Section 2, one woman refused to participate due to dizziness. studies of patient participation in patient safety so far have usually
Although improving patients' knowledgeand experiences and neglected to characterize informants' profiles and have not been
deconstructing beliefs would improve patients' willingness to partici- inclusive.7,24 In addition, for the first time in our setting, we
pate, it might be insufficient. On the one hand, from an equity included the role of companions in participation, which, based on
perspective, health professionals in our setting probably lack cultural fieldwork observations, seems to have facilitated participants'
competency, in addition to the existence of language barriers, which expression of their views. Nevertheless, because of COVID‐19
may explain the discourse of Pakistani and Bangladeshi informants restrictions, visits were strictly limited, which hampered our ability
concerning participation, and echoes the reflections in a systematic to interview more companions.
review.26 Information from different cultural contexts is valuable to Second, we conducted the interviews during hospital admission,
15,20
achieve patient involvement. However, some of the studies in which may have limited participants' responses to more positive
this area limited participation to persons with no language problems, opinions about professionals and the healthcare process in general.
which is an ethical problem of the first magnitude. On the other hand, Moreover, as previously mentioned, limits on visits made it difficult to
the informants themselves identified institutional and professional interview more companions. The inpatient setting could also have led
factors preventing participation: both the lack of specific resources to to some processes and structures emerging more frequently than
allow professionals to devote time directly to talking to patients and outcomes as indicators of patient safety.
their high‐stress working environment. Previous studies have Finally, it was difficult to find quiet spaces for the interviews,
reported that the impact of participation could be limited unless although, as previously mentioned, informants could stop the
steps are taken to ameliorate cultural, structural and organizational interview at any time. However, performing the interview during
barriers7,20,24,30 and, as discussed, patients and their companions are the admission facilitated the participation of all patient profiles and
able to recognize them. In this regard, in agreement with other avoided the loss of information due to memory bias.
 13697625, 2023, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13758 by Spanish Cochrane National Provision (Ministerio de Sanidad), Wiley Online Library on [29/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ABIÉTAR ET AL. | 1549

5 | C ONC LUS I ON DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on
The results of this study indicate that identifying patients' and request from the corresponding author, María Sala. The data are not
companions' perspectives on patient' safety and their participation is publicly available due to ethical issues and if they are asked,
needed before beginning to design an intervention. Examples shared containing information that could compromise the privacy of
in our paper show the need for a broader conceptualization of patient research participants would be deleted before.
safety in hospitals, an explicit description of the cultural character-
istics of the communities served and a particular focus on ETHIC S S TATEM ENT
communication between patients, companions and professionals. All participants signed an informed consent form. No identifying
Both patients and companions are able to identify needs particular to names or other details that could have compromised anonymity were
their diverse profiles and key aspects for their involvement in hospital used. The study was approved by CEICm‐PSMar (2021/10070/I).
safety.
ORC I D
Daniel G. Abiétar http://orcid.org/0000-0002-5268-3574
6 | I M PL I C A T I O N S F O R PO L I C Y AN D María Sala http://orcid.org/0000-0002-9955-8746
PR AC TI C E
RE F ER EN CES
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