In the emergency department, patient safety relies on teamwork and coordination between clinical groups, as emergency nurses provide front-line care. Therefore, patient safety competency is crucial to ensure quality safe care. In our opinion, this is the first study that assesses the predictors of patient safety competency among Iranian emergency nurses using valid tools and, therefore, adds new knowledge in this field.
The patient safety competency level of emergency nurses in our study was 2.97, which was slightly lower (3.53) than the findings of Langari et al., . Also, this result was slightly higher (3.76) than the findings of the study of Han & Roh . These findings can be explained by cultural differences in patient safety education worldwide. The results of Han’s study showed that emergency nurses focus mainly on patient-related emergency activities and have a relatively small understanding of patient safety. Therefore, they need patient safety management activities, training, standardization, and measures to cope with problems . Langari et al., in their study, showed that European countries (Britain and Finland) have started patient safety and education activities for many years. Therefore, these results may be related to the initial integration of patient safety in the nursing curricula of these countries . These measures have led to improved nurses’ safety competency. Therefore, in the Iranian health system, it is necessary to integrate patient safety competence into nursing curricula. Also, nursing educators should strengthen the patient’s patient safety competency of emergency nurses by developing structured training programs. Nursing managers should adopt reliable tools to regularly assess patient safety competency that can guide safety policy development and training interventions. There is also a need to develop a specialized curriculum to strengthen evidence-based nursing performance and competencies for continuous quality improvement of nurses. Nurses should also learn to encourage patients to participate in patient safety. In addition, it is essential for hospital administrators to make patient safety education as common as possible.
The teamwork score among emergency nurses obtained in this study, was slightly lower than the study of Han & Roh  using similar tools. In another study in Iran, the score of teamwork among emergency nurses was slightly lower than our study . Nurses’ perception of teamwork is related to patient safety . Teamwork leads to more employee job satisfaction, increased patient safety, improved quality of care, and greater patient satisfaction . Effective teamwork in healthy environments also helps care for high-quality patients . Besides, safe and quality patient care can also result from effective teamwork . Teamwork is the cornerstone of quality care and patient safety . The results of our study show the need to improve the teamwork of emergency nurses. Emergency nurses can promote teamwork by facilitating communication, resolving disputes among team members, clarifying roles and responsibilities, and encouraging other team members. Nursing managers can promote teamwork by facilitating communication, managing conflict between team members, expanding the nursing team into other specialized areas, clarifying roles and responsibilities, and encouraging other team members. Nurses can also learn effective communication skills. They can also be the first to promote teamwork between themselves and other colleagues.
The psychological safety of emergency nurses was lower than the results of a similar study in South Korea . Psychological safety plays a special role in high-risk work areas such as health care . When health care teams are psychologically safe, they are likely to improve the quality and teamwork initiatives . Psychological safety supports patient safety by contributing to quality improvement and encouraging employees to talk about mistakes . Promoting psychological safety among health care workers increases patient safety and improves the quality of health care.
The results of stepwise regression revealed that team structure (β = 0.374, p < 0.001), leadership (β = 0.188, p = 0.012) and psychological safety (β = 0.125, 0.013). = p) were the organizational factors affecting patient safety competency. The emergency department is a potentially unique environment for teamwork and communication . The team structure is an integral part of the teamwork process. A properly structured patient care team is an enabler for and the result of effective communication, leadership, situation monitoring, and mutual support. Proper team structure can promote teamwork by including a clear leader, involving the patient, and ensuring that all team members commit to their roles in effective teamwork .
Organized and effective teamwork in the emergency department has extensive implications on patient safety, quality of care, employee and patient satisfaction. A team with a proper teamwork structure can predict the requirements of other team members. It is dynamically compatible with a changing environment including changing team members’ behavior and a common understanding of what should happen [9, 24]. The nurses who consider their managers as strong leaders can empower their working environment, which, in turn, leads to their use of professional practice behaviors. These practical professional behaviors, such as effective communication, cooperation, and mutual understanding with clinical leadership’s main characteristics, are compatible . The findings obtained by Boamah , showed that nurses often use clinical leader behaviors in their practice, which leads to the improvement of the patient’s adverse events. To ensure the patient’s safety, strong nursing leadership for implementation and continuity of effective management methods for training and continuous support for the environment is required to provide high-quality patient care. In our study, leadership has the largest teamwork score and is one of the predictors of patient safety competency. There are many factors, including leadership, communication, monitoring, and supporting behavior which helps create ideal teamwork in the emergency department . The findings of the study of Parr et al., show that leaders improve patients’ satisfaction with patient services and safety .
Based on the findings obtained by Kakemam et al. , nurses with stronger team leadership tend to report adverse events. Moreover, the result obtained by Kakemam showed that reducing medical errors can be achieved by effective leadership. Effective leadership can develop and strengthen the patient’s safety and innovation culture in the health care environment. Accordingly, leaders are recommended to use educational strategies for reducing adverse events . The results obtained by Labrague et al., indicate the importance of the advancement of nurses’ management in strengthening nurses’ safety measures reducing the results of the patient and promoting the quality of nursing care . The results show that nursing leadership has a significant indirect effect on patient safety outcomes. From a person-centered perspective, the care environment requires workplace empowerment and effective relationships between leaders and nurses . Effective teamwork and leadership are recognized as important factors in many adverse events. Thus, a greater understanding of team dynamism and effectiveness and helping improve group training can lead to patient safety development and strengthen individual and team competencies in non-technical aspects of care, such as prioritization, leadership, and decision-making.
Having safe teams psychologically can improve learning, creativity, and performance in organizations. In the framework of healthcare, psychological safety supports patient safety by creating the ability to promote quality and encourage employees to talk about medical errors . Psychological safety has been recently a critical factor in understanding phenomena such as teamwork, team learning, and organizational learning [23, 29]. Effective teamwork depends on the psychological safety of the team members, which are defined as their ability to trust each other and feel sufficient safety in the team to accept the fault, ask questions, and present new data. Higher psychological safety leads to better reports of adverse events . Adopt strategies for improving the psychological safety of emergency nurses are required. When the employees are assured that the organization considers their welfare as the priority, they feel psychological safety and this makes improving the patient’s safety in everyday clinical performance . Providing psychological safety to emergency nurses increases patient safety and the quality of care. Therefore, nursing managers should always strive to develop effective methods to improve the psychological safety of their employees.
Our findings indicated that high age (β = 0.177, p = 0.003) was the predictor of the patient safety competency of emergency nurses, such that the safety competency increases with rising age. This finding was consistent with the results obtained by Alquwez and Chen [31, 32]. This finding is probably due to the more professional and responsible behavior of the nurses with increasing age.
Experience in patient safety activities (β = 0.128, p = 0.014) was another factor that affected the patient safety competency of emergency nurses. Nurses play a key role in coordinating patient safety activities because they are in close contact with patients and are involved in health care teams’ decisions about patient safety . Having previous information and activities about patient safety can improve nurses’ level of safety knowledge and affect their performance in patient safety [34, 35]. Therefore, nurses the more experience in patient safety activities are in the emergency department, the more committed they will be to patient safety and compliance, and the more competent they will be in terms of patient safety.
Gender (β = 0.105, p = 0.037) was also one of the work-related factors predictors of the safety competency of emergency nurses. Hence, the mean score in women was significantly higher than men. These findings were consistent with results obtained by Chen and Jabarkhil [32, 36] and were not consistent with those obtained by Alquwez . One reason for such a difference in outcome can be attributed to the participation of male and female nurses. Nursing is a majority female-dominated profession. In this study, 43.3% of the nurses were male. However, women are generally more sensitive than men to safety, quality of patient care, and the use of safety principles. These results suggest that women pay more attention to patient safety than men.
Emergency nurses with non-permanent employment status (β = −0.135, p = 0.022) perceive patient safety competency more than those with permanent employment, which was not consistent with the study by Chegini et al. . It Can be concluded that permanent employees are in the ultimate employment status, and non-permanent employees are more efforts to improve and upgrade their employment status. Therefore, it is necessary to provide in-service patient safety training for this group of employees.
In our opinion, this is the first study that evaluates the predictors of patient safety competency of Iranian emergency nurses. However, there are some limitations to our research that may affect the results and should be addressed when interpreting our findings. First, the discussion of safety in a health institution dos not complete without considering factors such as workplace violence, accreditation status, workload, and disease severity in patients, which may affect nurses’ patient safety competency scores. Therefore, further studies are needed to assess other factors affecting patient safety competency. Second, our sample consisted only of nurses working in the emergency departments of Ardabil teaching hospitals, Iran. Hence, our results should be generalized with caution. Third, as we measured all variables using our reports, our results may include responsive response bias. Finally, the current study was performed using a cross-sectional design that makes it impossible to resolve causal relationships between variables.