RESEARCH ARTICLE Open Access

The long way ahead to achieve an effectivepatient safety culture: challenges perceivedby nursesJamileh Farokhzadian1, Nahid Dehghan Nayeri2* and Fariba Borhani3*

Abstract

Background: The safety culture has recently attracted the attention of healthcare organizations. Considering theimportance of the roles of nurses with regard to patient safety, their knowledge and experiences of the challengesthat influence patient safety culture can facilitate the development and implementation of better strategies. Theaim of this study was to explore the nurses’ experiences of the challenges influencing the implementation andintegration of safety culture in healthcare.

Methods: A qualitative study with deep and semi-structured individual interviews was carried out using apurposive sampling method to select 23 nurses from four hospitals affiliated with a large medical university inSoutheast Iran. Data were analysed using the conventional content analysis of Lundman and Graneheim.

Results: Data analysis reflected the main theme of the study, “A long way ahead of safety culture”. This themeincludes four categories: 1) inadequate organizational infrastructure, 2) insufficient leadership effectiveness, 3)inadequate efforts to keep pace with national and international standards, and 4) overshadowed values of teamparticipation.

Conclusion: While practical strategies for creating a safety culture may seem simple, their implementation is notnecessarily easy. There are several challenges ahead for cultivating an effective and positive safety culture inhealthcare organizations. To keep pace with international standards, healthcare managers must employ modernmethods of management in order to overcome the challenges faced by the institutionalization of safety cultureand to make a difference in the healthcare system.

Keywords: Quality improvement, Clinical risk management, Patient safety, Organizational culture, Qualitativecontent analysis

BackgroundWhile patient safety is a new and emerging phenomenon,historical evidence indicates that concerns for patientsafety have existed for a long time before modern health-care. More than 150 years ago, Florence Nightingale statedthat “the very first requirement in a hospital is to do noharm to patients” [1]. In 2001, the Institute of Medicine

(IOM) issued this concern in the form of “Crossing theQuality Chasm: A New Health System for the 21stCentury”. IOM emphasized the safety of healthcare andthat patients should be free of danger or risk caused bythe healthcare system [2].Nowadays, modern advances and the complexity of

healthcare have led to serious deficiencies in the qualityof care and patient safety. The high prevalence of clinicalrisks and safety incidents have increased concerns andchallenges for healthcare systems [3, 4]. Although esti-mates of the size of the problem are imprecise, it is likelythat millions of people suffer from disabling injuries ordeath in consequence of clinical risk and safety incidents[5]. It is estimated that, in the hospitals of developed

* Correspondence: Nahid.nayeri@gmail.com; faribaborhani@msn.com2School of Nursing and Midwifery, Tehran University of Medical Sciences,Nosrat St., Towhid Sq, Tehran 1419733171, Iran3Department of Nursing Ethics, Medical Ethics and Law Research Center,Shahid Beheshti University of Medical Sciences, Niyayesh Complex, NiyayeshCross-Section, Vali-e-Asr St, PO Box: 1985717443, Tehran, IranFull list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Farokhzadian et al. BMC Health Services Research (2018) 18:654 https://doi.org/10.1186/s12913-018-3467-1

countries, one in ten patients is harmed while receivingunsafe care. Moreover, the risk of damage is muchhigher in developing countries than developed countries.For example, the risk of healthcare-associated infectionin some developing countries is twenty times higherthan that in developed countries [6].However, the majority of injuries and safety-related

deaths are preventable by designing and planning safetyprocesses and techniques [5]. Therefore, to handle thesechallenges and to achieve quality and safety improve-ment, healthcare organizations are faced with increasingpressure to cultivate an effective safety culture [7]. Pa-tient safety culture is defined as a dimension oforganizational culture [8]. Specifically, it is the productof individual and group values, beliefs, attitudes, percep-tions, norms, procedures, competencies, and patterns ofbehaviour that determine the commitment of an healthorganization to patient safety management [7, 8].Safety experts have suggested the essential compo-

nents for safety culture such as teamwork, leadershipsupport, communication [7], and a just culture as well asa reporting and a learning culture [9]. Organizationswith a positive safety culture have communicationsbased on mutual trust, shared perceptions of the import-ance of safety, and confidence in the efficacy of prevent-ive measures and support for the workforce [1]. Safetyculture emphasizes preventive or predictive measures ofsafety more than retrospective ones [10]. In addition, thesafety culture emphasizes the system approach or “why”unsafe acts occurred rather than the person approach or“who” made the unsafe acts [1]. By developing a systemapproach, hospitals should foster a continuous learningenvironment by reporting and discussing clinical risksand safety incidents without fear of punishment [7].To promote a safety culture and to ensure safer health-

care systems, the IOM has emphasized the developmentof clear patient safety programs; use of non-punitive sys-tems for reporting and analysing safety incidents; incorp-oration of well-established safety principles such asstandardized and simplified equipment, supplies, andwork processes; and establishment of interdisciplinaryteam training safety programs. However, the IOM has an-nounced that the biggest challenge for moving towardsafety culture is changing the culture from one which laysthe blame on individuals to a system approach [11].Institutionalizing a safety culture is the shared respon-

sibility of all healthcare providers in the healthcare sys-tem [12]. Nevertheless, nurses have the central role inimproving patient safety culture. When facing the chal-lenges of healthcare systems, nurses are well positionedto protect the safety of patients or harm them with un-safe practices [13]. Therefore, both patients and nurseswill be protected, a safe milieu for nurses will be created,and distress caused by safety incidents will be decreased

by improving safety. Finally, these actions will reduce at-trition and alleviate chronic nursing shortages [14].However, creating a positive safety culture is challen-

ging for healthcare systems, and some studies suggestthat healthcare providers, especially nurses, give moreproblematic responses to patient safety culture [15, 16].An Iranian study indicated that hospitals did not meet aproper level of patient safety and a punitive culturedominated the workplace [17]. A systematic review onsix qualitative studies has demonstrated that hospitalsunderestimate organizational resources, and support isrequired for making patient safety initiatives and chan-ging the culture [18]. In another systematic review, re-searchers attempted to address the interventions used topromote safety culture in healthcare, but they did notassess the challenges of safety culture [8].World Health Organization (WHO) noted that, due to

the multidimensional nature of safety culture, a betterunderstanding of the factors influencing the patientsafety culture and addressing the interventions to im-prove patient safety are research priorities in developingcountries and countries with transition economies [5].Additionally, Vlayen et al. mentioned that safety culturevaries over time and this variation is linked withorganizational context such as hospital statute and sizeand human resource characteristics such as educationalbackground [19]. In this respect, the experiences ofnurses as the most important human resources can helpdevelop appropriate theories and provide specific guid-ance for healthcare professionals in facilitating safe prac-tice in both developed and developing countries [13].In-depth qualitative studies are required for a better

understanding of factors impacting the development ofpatient safety initiatives and challenges facing theinstitutionalization of those factors [20]. Although someeffort has been made to improve safety culture in Iranianhospitals, there is no comprehensive, qualitative studythat explores the challenges of implementing and inte-grating a positive safety culture in the Iranian healthcarefrom the nurses’ perspective. The aim of this study wasto explore and describe the nurses’ experiences of thechallenges facing the implementing a positive safety cul-ture within the culture and context of Iranian hospitals.

MethodsStudy designA qualitative and conventional content analysis with adescriptive-explorative approach was used for data col-lection and analysis. The qualitative content analysismethod is the process of understanding, interpreting,and conceptualizing the underlying meanings of qualita-tive data. Although this method can be implementedwith various degrees of interpretation including manifestmessages versus latent messages, both messages require

Farokhzadian et al. BMC Health Services Research (2018) 18:654 Page 2 of 13

interpretations which may vary in depth and level of ab-straction [21].

SettingsThe settings for this study were four teaching and refer-ral hospitals affiliated with Kerman University of Med-ical Sciences in southeast Iran. With the population ofabout 800,000, Kerman is the largest city in this part ofthe country. These hospitals have more than 1000 bedsin emergency, neonate, pediatric, surgery, and internalmedicine, dialysis wards; and CCU, ICU, NICU, etc. toprovide specialised care to patients with, among others,cardiac, endocrine, pulmonary, gastrointestinal, neuro-logical, and psychological disorders. They receivepatients from southeast of Iran, within the radius of500 km 24 h per day, 7 days per week. Differenthigh-tech medical and surgical interventions are con-ducted in these hospitals by nursing and medical staffwho collaborate with university-based medical scientistsin educating healthcare students.The implementation of healthcare policies is central-

ized in Iran, and Ministry of Health governs all the hos-pitals [22, 23]. The political agenda is currently payingmore attention to the reduction of patient harm, ensur-ing quality, and improvement of patient safety culture.To undertake this mission, all the hospitals are activelyimplementing “Clinical Governance” principles and“Hospital Accreditation Standards” [24]. In addition, thedistribution of healthcare providers is similar in all thehospitals all over the country. The majority of nurseshave Bachelor’s degrees and the recruitment of nursesfollows the same pattern in all the hospitals [22].

Participants and samplingPurposeful sampling was used to select participants whowere informed and experienced. In each hospital, anumber of eligible participants were selected by the firstresearcher and assistance from the nursing managers.Nurses were recruited by written invitation informingthem of the aims and methods of the study and askingthem to indicate their willingness to participate andorganize an interview session. The first interviews weredone with a key informed participant, who had enrichedexperiences regarding various roles of a clinical nurse.The sampling process continued based on the principlesof maximum variation to capture the rich and diverseperspectives and experience of nurses Therefore, 23nurses with different backgrounds in sex, age, years ofwork experience, degrees in nursing, position, and typeof ward were enrolled until data saturation. The nurseswere 15 women and 8 men aging 26–50 years with workexperiences ranging from 1.5 to 26 years. Six nurses hada master’s degree and the others had a bachelor’s degreein nursing. Seven participants came from hospital 1, six

from hospital 2, five from hospital 3 and five from hos-pital 4. The sample included a matron, three clinical su-pervisors, an educational supervisor, four head nurses, aquality improvement officer, and thirteen clinical nurses.Having at least bachelor’s degree in nursing, the workexperience for at least one year, and willingness to par-ticipate in this study were the main inclusion criteriaemployed for the selection of the participants.

Data collectionSemi-structured, individual, face-to-face, in-depth inter-views were carried out by one of the researchers whohad a background in clinical nursing and patient safetywork. Interviews were scheduled after explaining re-search objective to nurses. All interviews were initiatedwith an open question asking the participants to de-scribe their patient safety work. The interviews were di-rected towards the purpose of the study by topic guidequestions, e.g. “Would you please describe your experi-ence with integrating safety culture in organizationalculture?”, “To your experience, what requirements werenecessary for safety culture in your hospital?”, “What ac-tivities have been carried out in improving the safety cul-ture in your hospital?”, and “What barriers andchallenges have you experienced for implementing theseactivities?”. Then, probing questions were asked to ob-tain more elaborative answers and nurses’ experiences,e.g. “Would you explain the situation clearly?” We con-sidered patient safety in simple terms such as the pre-vention of errors and adverse effects to patientsassociated with healthcare.The interviews lasted for 50–75 min and took place in

a quiet room near the ward or in another location basedon the participants’ preference. All interviews wereaudio-recorded with the participants’ permission andtranscribed verbatim using Microsoft Office Word. Theinformation was saturated after twenty-one interviewsand two additional interviews were conducted to ensuredata saturation.

Data analysisData analysis was conducted according to the methodproposed by Graneheim and Lundman [25]. In this ap-proach, iterations consisted of the following: In the firststep, every interview was transcribed verbatim by thefirst researcher, the researchers read the transcriptionsseveral times to obtain an overall understanding of thecontent, and performed an initial coding individually.Second, the text was divided into meaning units thatwere then condensed. Each meaning unit comprisedwords and sentences containing aspects related to oneanother. Third, the condensed meaning units were ab-stracted and labelled using open codes. In the fourthstep, the codes were classified into subcategories and

Farokhzadian et al. BMC Health Services Research (2018) 18:654 Page 3 of 13

categories based on similarities and differences. A cat-egory consists of similar codes in the manifest level. Fi-nally, the underlying meaning and content of the datawere extracted, and themes were formulated as the ex-pression of the latent meaning of a text. All researchersdiscussed the content of the categories using triangulat-ing analysis. When the authors disagreed, discussionsand clarifications continued until achieving a consensus.

TrustworthinessThe trustworthiness of the data was determined usingLincoln and Guba’ criteria, including credibility, con-firmability, dependability, and transferability [25]. To en-hance credibility, the researcher established a friendlyrelationship with the participants and had prolonged en-gagements with the research settings and data analysis(in the 7-month period from April to October 2016).Moreover, the data were initially coded and categorizedindependently by the researchers and the developedthemes were compared. Where there was disagreement,discussions were held to reach consensus among allthree co-authors. For member checking, a summary ofthe interviews and results was presented in prescheduledmeetings with ten participants. They confirmed the con-tents as accurate and that the researchers were repre-senting their real experiences and perspective; only threeof them suggested minor changes to the situations andwording of codes. However the areas of disagreementwere discussed, and feedback loops were used to ensurerigour. New codes were added and some codes wereeliminated. The confirmability and dependability of datawere assessed through member checks by colleagues andparticipants. In addition, external checks were carried

out such that the first author met 5 nurses, 3 seniormanagers, 2 physicians who had not participated in thestudy and were informed of patient safety, and membersof the patient safety committee in hospitals who con-firmed the accuracy of our findings. In addition, researchand decision-making processes were accurately recordedand reported so that the follow-up by others and dataverification would be possible.

ResultsThe long way ahead of safety cultureTable 1 presents one main theme, four categories, and16 subcategories that were perceived by nurses as chal-lenges of implementing and integrating safety culture inhealthcare. According to the newly emerging safety cul-ture in Iranian hospitals, there are many challenges forestablishing a safety culture. Due to these challenges,there is a long way to integrate an effective safety culturein the organizational culture. They also have a negativeimpact on nurses in safety programs. Results are ex-plained in the following sections using the direct quota-tions of the participants.

Incompetent organizational infrastructureAccording to participants’ opinion, the risk of harm topatients, staff, and organizations has been increased bysome factors, including “shortage of resources”, “weak-ness of the staff ’s professional competence and em-powerment”, and “unfavourable work condition andunsafe environment”. These factors have also hinderedthe institutionalization of an effective safety culture.

Table 1 The main theme, categories, and subcategories

Main Theme Categories Subcategories

The long way ahead of safety culture 1. Incompetent organizational infrastructure - Shortage of resources- Weakness of the staff’s professional competence andempowerment

- Unfavourable work condition and unsafe environment

2. Insufficient leadership effectiveness - Lack of commitment- Non-supportive management- Non-participatory decision-making- Low efficiency of safety management rounds andclinical audit

3. Inadequate efforts to keep pace with nationaland international standards

- Failure to establish quality improvement and clinical riskmanagement systems

- Culture of resistance to change towards the systemapproach

- Culture of blame and punishment- Weakness in feedback to reporting errors- Weakness in the culture of organizational educationand learning

-Weakness in preventive (protective) culture

4. Overshadowed values of team participation - Failure to redefine and clarify roles- Gap in team coordination- Difficult dynamics of team interactions

Farokhzadian et al. BMC Health Services Research (2018) 18:654 Page 4 of 13

Shortage of resourcesSafety management programs and strategies of safetyimprovement have been affected by the shortage of fi-nancial and human resources, medical supplies, medica-tions, medical devices, and technology. Moreover, a lackof resources has led to failure in the innovation of safetyprograms. A quality improvement officer with 21 yearsof experience stated:

“Although the first action for an organization's safetyculture is to construct the organization infrastructure,the implementation of safety improvement strategieshas been blocked by insufficient funds, inadequatehuman resource, and unsafe physical environment.”

Weakness of the staff’s professional competence andempowermentAccording to the experiences of nurses, the institutionalizationof safety culture has been challenged by some factors,including a lack of creativity, inadequate professionaland moral competence, lack of ability in judgmentand clinical decision-making, lack of knowledge andability in care management, and lack of effort for im-proving professional competencies. An educationalsupervisor with a master’s degree and 19 years ofwork experience indicated:

“Although all our staff have to be safety managers,they are not capable because safety training courseshave failed to properly improve their safetycompetence. On the other hand, transferringresponsibility to employees without necessaryqualifications and competence increases the clinicalrisk.”Some nurses believed that newly graduatednurses do not develop adequate capability andcompetence for patient safety because there is nocoherent curriculum in the field of patient safety innursing education, especially in clinical training inuniversity. One of the newly hired nurses from thesurgery ward with 1.5 years of work experience said:

“Learning was not enough in the university. When Istarted working in the hospital, I realized that thetraining and courses on patient safety were highlyinadequate at university, and I came to know thesafety culture in the workplace.”

From another perspective, participants with more workexperience believed that even experienced nurses mightendanger the patients’ safety due to various reasons suchas false self-confidence, unwillingness toward change,and lack of up-to-date competencies. Therefore, all thestaff involved in healthcare should acquire up-to-date

competencies regarding their responsibilities in order tocreate an effective safety culture. Furthermore, theyshould receive effective, efficient, and specialized train-ing proportionate to their position and responsibilities.

Unfavourable work atmosphere and unsafe environmentNurses need to have proper conditions and environmentat the workplace in order to provide safe care for patients.The strengthening of safety culture is difficult to achieveat the workplace because of factors such as lack of time,hard and boring work, high level of patient admission anddischarge, poor communication with co-workers, environ-mental stress, emotional pressure after patients’ harm ordeath, and tension in the patients’ families. A headnursefrom the emergency ward with 16 years of work experi-ence stated:

“A crowded ward and a high number of patientsthreaten the safety of staff and patients. The staff areunder pressure and also at risk by agitation and highlevels of workload and tension. Therefore, their viewson the safety culture would be negative in suchstressful conditions.”

Insufficient leadership effectivenessThis category includes four challenges: “lack of commit-ment”, “non-supportive management”, “non-participatorydecision-making” and “low efficiency of safety manage-ment rounds and clinical audit”.

Lack of commitmentThe safety culture is established when the leaders havecommitted themselves to creating, shaping, and transfer-ring it to the workplace. The integration of safety cultureto organizational culture will never be successful withoutthoughtful, transformational, and committed leaders.According to the experiences of nurses, the leaders donot have commitment or creativity to strengthen thesafety culture due to a number of factors, e.g. ineffectivepolicies, poor-quality supervision, poor leadership prac-tices, absence of resource allocation, lack of appropriatemeasures for promotion and giving rewards to em-ployees, and lack of integrated management in the fieldof safety. A clinical nurse from the dialysis ward with23 years of work experience said:

“The managers’ supervision is based on their opinionsand they do not have a specified instruction formonitoring. For example, some managers are patient-centred and they walk round the ward with the viewof patient safety. On the other hand, some managersdo not have a clear recognition or intuition of thebasic principles, operational aspects, and requirements

Farokhzadian et al. BMC Health Services Research (2018) 18:654 Page 5 of 13

of safety culture. Consequently, we will be confused if ourmanagers are not committed to the guidelines of safety.”

The nursing managers also approved these challengesand considered continuous and precise supervision asone of the major managerial roles of managers commit-ted to the safety culture. A nursing manager with26 years of work experience expressed:

“Commitment of the managers to safety culture andprecise supervision is the fundamental principle ofcontinuousness of safety, but unfortunately some ofthe managers lack the sufficient commitment andeffective supervision.”

Non-supportive managementAccording to the experiences of nurses, the support of em-ployees is an important step for effective leadership in safetyculture. Managers should pay attention to psychological,mental, and emotional supports of their staff, and their sup-portive behaviour motivates the nurses to promote theircapabilities and implement safety programs. In addition,nurses mentioned a number of challenges, including man-agers’ lack of attention to workplace pressures and the heavyduties of nurses; managers’ discrimination, aggression, andviolence towards the staff; and the lack of support they hadexperienced in this field. A clinical nurse from the ortho-pedic ward with 5 years of work experience reported:

“In our ward, a patient had cardiac arrest immediatelyafter receiving an injection. The nurse tried to defendherself, but she was not successful. Thereafter, shewas not supported and was thus punished. In themeeting for root cause analysis of events, managersdid not allow the nurse to give a clear and precisereport about that event.”

However, some managers had an opposite view. Theybelieved that, in the event of errors, they would attemptto support their staff and even introduce them to thenursing system and nursing association. A clinical super-visor with 20 years of work experience stated:

“In case of system error, managers provide their staffwith emotional support. But in case of negligence inperforming duties, the managers don’t support thembecause such cases are often very complicated and itis impossible to support the staff.”

Non- participatory decision makingNurses believed that individuals who have to performsafety rules should participate in the development and

review of the rules. Nurses’ point of view on effective lead-ership has been changed negatively because of their dissat-isfaction with lack of participation in decision-making forsafety matters. Consequently, those conditions were a bar-rier to their active participation and movement towardsthe establishment of a safety culture. A nurse from theemergency ward with 10 years of work experience and amaster’s degree said:

“The physical space of the emergency department waschanged, but the opinions of nurses and supervisorswere not considered. Now, the beds are so close toeach other, and if a patient suffers from cardiac arrest,there will be no feasibility for cardiac and pulmonaryresuscitation and for taking the emergency trolleybeside the patient’s bed.”

Low efficiency of safety management rounds and clinicalauditParticipants believe that organized planning for targetedwalk rounds as well as observing and talking directlywith staff are the best ways for senior managers to be-come familiar with safety activities and discover thecauses of large safety problems. This method is muchmore effective than the inspection of statistics and re-ports in the office. Although the majority of managersbelieved that they underlined the necessary importanceof safety issues in walk rounds, the reaction of nursesshows that safety walk rounds did not have the requiredoutput. A clinical nurse from the surgery ward with13 years of work experience noted:

“Some managers believe that the commitment ofmanagement to safety only includes the preparation ofprotective equipment, installation of mottos, safetysigns, punishment, reward, and preparation ofstatistics. If managers listen closely to the problemsand concerns for employees in regular and targetedwalk rounds and track corrective actions, the staffswill be assured that managers have fulfilled theirpromises. But unfortunately this has not happenedand walk rounds have not been operational and hadno appropriate output yet.”

The nurses introduced clinical audit as an importantway to evaluate and enhance the safety culture usingstandard checklists. Nevertheless, they believed that theprocess of audit has failed for a number of reasons, suchas the lack of motivation of the audit team due to receiv-ing no reward, lack of expert team, and putting no im-portance on the audit by staffs and managers. A clinicalsupervisor with 23 years of work experience in differentwards stated:“Sometimes, individuals who perform the

Farokhzadian et al. BMC Health Services Research (2018) 18:654 Page 6 of 13

audit are not good or experts in auditing. Moreover,when the results of the audit are used in the safetypart, we see that no improvement has been made inthe next period of the audit.”

Inadequate efforts to keep pace with national andinternational standardsQuality improvement systems, e.g. accreditation, clinicalgovernance, and clinical risk management, are strategies forkeeping pace with national and international safety stand-ard. In addition, these strategies provide the convergenceand alignment of healthcare providers for reaching a safecare and establishing safety culture all over the world. Thedata showed that the efforts are not adequate for integra-tion and adjustment with these strategies. A number ofsubcategories were: “failure to establish quality improve-ment and clinical risk management systems”, “culture of re-sistance to change towards system approach”, “culture ofblame and punishment”, “weakness in feedback to report-ing errors”, “weakness in the culture of organizational edu-cation and learning”, and “weakness in protective culture”,reflecting the limited and disconnected efforts of all levelsof healthcare providers.

Failure to establish quality improvement and clinical riskmanagement systemsThe participants believed that quality improvement sys-tems have taken good measures to implement safetymanagement, such as infection control, but hospitals arefar from standards. Based on the perspective of nurses,challenges, e.g. lack of knowledge, problems of manage-ment and organizational culture, limited human and fi-nancial resources, high workload, lack of time, andweakness in team work, are the causes of staff ’s negativeattitude towards the approaches of quality and safety im-provement. A head nurse from the surgery ward with19 years of work experience said:

“Most of the staff oppose to clinical governance andaccreditation. They say that these issues havemultiplied the workload of nurses by a hundred times,because managers did not create an appropriatesubstructure and did not provide an infrastructure forthem. Rather, they just want the nurses to performthose tasks. Therefore, the communication of nurseswith patients has been lowered, and this is the causeof a drop in the quality and safety of services.”

The culture of resistance to change towards a systemapproachTo strengthen the safety culture, the system approachis required. The system approach helps managers to

comprehensively review safety events and prevent theaccidents arising from system’s problems by reformingthe system’s defects. Therefore, changes have to beapplied to the organizational culture, structures, sys-tems, procedures, environment, equipment, processes,and organizational behaviour. However, according tonurses’ experiences, there is resistance against culturechange. Even managers are not aware of the social,human, and economic benefits of the system ap-proach. A quality improvement officer with 21 yearsof experience stated:

“We need to change our vision from an individual toa system approach. Hence, when a hazardous accidenthappens, we should search for the defect in thesystem rather than the punishment of an individual.For example, when a high-risk medication wasprescribed by mistake, we noticed that there was noinstruction for the injection of the high-riskmedication in the ward and the nurse was not guilty.”

According to some participants, although the man-agers pretended that they had a systemic view of errors,that is, in fact, not the case. A clinical nurse with 10 yearsof work experience and contractual employment in themedical ward said:

“In meetings, managers tell us to brainstorm andreport the errors without fear, but in practice, they actin the opposite way because they do not yet have asystemic view. Once I reported a completely systemicerror, but they immediately warned and threatened tofire me and cancel my employment contract.”

Culture of blame and punishmentIn order to reduce safety incidents, special attentionshould be paid to the culture of errors and safetyevent reporting as a key component of safety culture.Furthermore, the culture of punishment andblame-seeking should be avoided. Nurses enumeratedthe following factors for the culture of blame; the fearof being blamed and punished, disregarding thenurses’ defence, reprimand and disciplinary measures.A clinical supervisor with 23 years of work experiencenoted:

“The statistics of safety incident reporting is lowin our hospital because employees are worriedabout the consequences of reporting, such asreproaching, rebuking, and jeopardizing their jobs.The failure to report the incidents mayunderestimate statistics of incidents. However, itdoes not enhance the safety culture.”

Farokhzadian et al. BMC Health Services Research (2018) 18:654 Page 7 of 13

Weakness in feedback to reporting errorsThe system of receiving data and reporting error isobliged to perform a radical analysis of safety events,analysis of findings, diffusion of corrective actions, andprovision of feedback for staff. Nurses believed that thelack of some actions, e.g. report delivery, feedback tostaff, and follow up of their feedbacks, indicates the lackof importance of reporting and weakness of safetyculture. A clinical nurse from NICU with 3 years ofwork experience and a master’s degree stated:

“We completed lots of error reporting forms and sentthem to the office of quality improvement, but we didnot receive any feedback or corrective action. Thus,we conclude that reporting has no benefit. Inaddition, actions without consequent monitoring,evaluation, and feedback would not create long-lastingchanges in safety.”

Although some of the managers believed that their goalof error reporting is to provide the staff with appropriatefeedback and learn from errors, some of the nursesbelieved that the managers’ viewpoint is one-sided.

Weakness in the culture of organizational education andlearningTeaching and learning individually, institutionally, or ingroup are stimulants for system approach and strength-ening the safety culture. The culture of learning frompast incidents will improve safety function and preventthe repetition of those incidents. According to the expe-riences of nurses, the staff has lost motivation fororganizational learning because of their passive presencein training courses, lack of appropriate training, lack oftime, and high workload. A clinical nurse form CCUwith 11 years of work experience mentioned:

“There is no appropriate planning for training, andthe intention of managers is to show that a class hasbeen held because it is mandatory for them to arrangerisk management and safety classes for receivingaccreditation. The classes are not efficient, and themanagers only fabricate documentation.”

Moreover, the participants with master’s degrees statedthat nurses who have attempted to promote theireducational degrees have never seen the outcome oftheir efforts appropriately. These nurses believed thatsome factors play a major role in reducing their mo-tivation for organizational learning, e.g. ignoring theirknowledge and capabilities as the major memberswhose activities influence the safety culture, as well asthe nursing managers’ deliberate efforts to preventthe nurses’ individual promotion.

Weakness in preventive (protective) cultureNurses believed that staff and managers should notexpect an incident to happen and then take correctiveactions. Sometimes this immoral approach is at the costof harming the patients and employees. Therefore, man-agers need to support the preventive approach tostrengthen the safety culture. They should also be a rolemodel for the staff. “Failure modes and effects analy-sis”)FMEA(is a preventive (protective) approach insafety, but no improvement has happened in this field inthe hospitals. Moreover, the preventive culture has notentered most processes yet. A clinical supervisor with19 years of experience said:

“When a fire happened due to system malfunction inour emergency room at midnight, it caused anaccident for patients and staff. Thus, if preventivemeasures had been taken, we would not have spentsubsequent costs. We should always have a strongpreventive insight, but we have considerable weaknessin this area.”

Overshadowed values of team participationSafety culture requires teamwork at all levels oforganization and at every level of education and skill,and it will not be possible without team participationand intellect. The values of team participation in the es-tablishment of a safety culture are overshadowed by anumber of challenges, including “failure to redefine andclarify roles”, “gap in team coordination”, and “difficultdynamics of team interactions.”

Failure to redefine and clarify rolesAccording to nurses, clarity in the roles of healthcareteam is very important to the promotion of patientsafety. However, factors such as lack of clarity in dutiesand roles in the team, resistance to the implementationof roles and responsibilities, lack of education about theroles, and lack of understanding of one’s place in team-work inhibit the effective roles in the team, therebythreatening safety. A head nurse from the surgery wardwith 19 years of work experience stated:

“Some members of the healthcare team do not agreewith their responsibilities in risk and safetymanagement (e.g. identifying risks and reportingincidents). According to them, these responsibilitiesare not parts of their duties. Therefore, risk and safetymanagement should be clarified in the job descriptionof each member of the healthcare team.”

The participants with a master’s degree believed thatdespite the improvement of their academic level, their

Farokhzadian et al. BMC Health Services Research (2018) 18:654 Page 8 of 13

duties and roles have not been changed, so that they stillhave to continue to work in their former job position.Therefore, continuing education at higher levels is notan advantage or a guarantee to obtain an appropriate jobposition. It might even lead to more duties and responsi-bilities for nurses with a Master’s degrees.

Gap in team coordinationFrom the viewpoint of nurses, coordination is an im-portant aspect of team participation. They believe thatphysicians are the most important group that imposerisk on the patients. On the other hand, physicians resistwhen they are invited to participate in safety team pro-grams, such as root cause analysis, or they do not havecoordination with therapy and management teams inmany care and treatment programs. A nursing managerwith 26 years of work experience said:

“The physicians’ coordination and participation insafety programs is very low. The committee of rootcause analysis of events invited a resident for theradical analysis of an error, and the resident opposedthe committee and refused to attend the meeting.”

Difficult dynamics of team interactionsParticipants acknowledged that positive interactions andprofessional relationships between them and their col-leagues, nurse leaders, and physicians working as a teamwould promote the safety culture. They emphasized thatappropriate relationships create a favorable emotional,psychological, and social atmosphere and reduce theirstress in the work environment. Nevertheless, factorssuch as unprofessional and inappropriate communica-tions and lack of knowledge of communication princi-ples have created difficult dynamics of team interactions.In such situations, nurses would have unfriendly feelingsthat negatively affect their performance and decrease pa-tient safety. A clinical nurse from the emergency wardwith 7 years of work experience indicated:

“Some of my colleagues have forgotten the purpose ofreporting safety events. They complain about thereports given by other colleagues. These behaviorsspoil professional communication and show nohonesty between nurses.”

According to nurses, nurse leaders in a multidisciplinaryteam have a vital position to improve the dynamics ofteam interactions. Therefore, the nurses expected fromnurse leaders to facilitate professional relationships, en-courage multidisciplinary collaboration, and resolvecommunication difficulties between nurses and otherhealthcare providers. However, some leaders do not have

appropriate communication with nurses and do notunderstand their concerns about patient safety. Such in-effective communication discourages nurses from takingpatient safety measures such as reporting their errors.In terms of emphasizing the influence of all healthcare

team members, the nurse–physician communication wasan important factor which influenced patient safety. Thenurses believed ineffective communication between phy-sicians and nurses could act as an obstacle to improvedpatient safety culture due to perceived hierarchical dif-ferences. In addition, physicians’ individualism and theirattitudes have prevented them from accepting nurses’opinions and ideas or using their knowledge and experi-ence in decision-making. Such conditions have hadnegative impacts on the performance of nurses andcaused stress, lack of motivation, and lack of sense ofmental security among the nurses. A clinical nurse fromICU with 13 years of work experience and a Master’s de-gree stated:

“The relationship between physicians and nurses isnot desirable. Some physicians act individually and donot examine nursing reports. They seldom ask nursesabout patients conditions or whether patients haveimproved with the previous day’s prescription.Furthermore, physicians hardly accept oursuggestions.”

DiscussionThe present study attempted to attain an insight into thechallenges of establishing an effective safety cultureusing the experiences of nurses. These challenges haveaffected the performance, conception, and attitude ofnurses to involve in safety culture and have slowed themovement towards an effective safety culture. The maintheme of this study indicates that the healthcare systemhas a long way ahead to achieve an effective and positivesafety culture.One of the categories of this study was incompetent

organizational infrastructure along with a number ofsubcategories, including the shortage of resources, un-favourable work condition and unsafe environment, andweakness of the staff ’s professional competence and em-powerment. These results were in agreement with previ-ous studies [26–28] which reported that lack of humanresources, financial, time, equipment, and informationtechnology was the main obstacle to implementing qual-ity improvement and patient safety programs. In a quali-tative study in the UK, human resources wereconsidered as having a key role in the process of chan-ging the culture. On the other hand, it was reported thatthe implementation of safety programs will be difficultdue to limitations in financial resources for human

Farokhzadian et al. BMC Health Services Research (2018) 18:654 Page 9 of 13

resource management (i.e. training, recruitment, andempowerment) and the lack of qualified, skilled, andtrained personnel [29]. According to the results, nursesin general and newly graduated nurses in particular be-lieved that nurses do not develop an adequate capabilityand competence for patient safety in university. In agree-ment with these results, Vaismoradi et al. [30] confirmedthat new graduates experience stress as they becomehealthcare professionals, and that nursing educationdoes not seem to prepare nurses for complex and chal-lenging work environments.This study is consistent with other studies showing

that the work condition and environment, e.g. mentaland emotional setting, profession attrition [31], workingin shifts and fatigue [32], lack of control over complexand unsafe working conditions [33], high workload,crowded and irregular environment, and inadequatespace [27] affect patient safety and quality improvement.Mahmood et al. [34] emphasized that inappropriate andunsafe work environment cause physical and mentalpressure and stress for nurses, increasing the risk of ac-cidents. They also indicated that factors, including com-prehensive understanding of environmental factors,considering interventions and appropriate strategies formanaging the challenges of physical environment, andmental and emotional settings, are prerequisites formanaging the safety culture.In the present study, insufficient leadership effectiveness

along with some challenges, such as lack of commitment,non-supportive management, non-participatory decision-making, and low efficiency of safety management roundsand clinical audit, were significant challenges for theinstitutionalization of the safety culture. These findingsare in agreement with the results of other studies showingthat the programs of quality improvement have facedsome challenges, including a lack of leadership commit-ment and inefficient management [35], flaws in involvingemployees in safety programs, and lack of autonomy anda supportive setting [36]. In another study, researchers ac-knowledged that when nurse leaders welcomed nurses’participation in decision-making, asked for their perspec-tives, devolved the responsibility and authority of man-agerial duties, and administered appropriate supervision,nurses responded to the leaders’ trust by becoming morecommitted to patient safety [37].Low efficiency of safety management rounds and clin-

ical audit was mentioned as one of the challenges in thepresent study. In a study in Iran, numerous obstacleswere reported for the effectiveness of clinical audit andsafety walk rounds. These obstacles were insufficient al-locations of resources, inadequate standards for theaudit, lack of trained personnel, shortage of personnelfor follow-up safety measures, incomplete documenta-tion, and low collaboration of clinicians in the audit

process [38]. Contrary to this study, however, safetymanagement rounds were introduced as an effective toolin promoting risk management activities and safety cul-ture in a mixed method study. These visits increased thecommitment and accountability of senior managementto the safety of patients, employees, and the society [39].In addition, clinical audit and feedbacks of the auditwere mentioned as an important strategy for the con-tinuation of quality and safety improvement activities ina systematic review [40]. This difference is probably dueto the inadequate organizational infrastructure of thehospitals mentioned in this study.Failure to establish quality improvement and clinical

risk management systems was another challenge for theeffective safety culture. In this regard, a study in Iran re-ported similar challenges and obstacles, including lim-ited financial resources and equipment, human resourceconstraints (e.g. lack of skilled workers and low motiv-ation), management problems, weakness in training pro-grams, failure in communications, cultural issues (e.g.feeling no need to change and lack of team participa-tion), and laws and policies (e.g. the absence of harmo-nized rules and poor assessment of the Ministry anduniversities) [35]. These suggest that progress in patientsafety and quality improvement systems is still far fromideal in Iran. One of the important roots of this situationmight be the failure to address the patient safety systemin scientific, academic, and research gatherings, as wellas the failure to provide proper infrastructure to imple-ment them.The culture of resistance to change towards a system

approach was mentioned as one of the safety culturechallenges. In a study, the political context of healthcare,lack of required skills among managers and the pressureto deliver quick and measurable changes were reportedas barriers to changing the culture of quality and safetyprograms in [41]. Another study reported that, with re-spect to the complexity of organizational factors such asculture, structures, and processes, change in theorganizational fundament would not be easy but wouldbe possible. Therefore, it is necessary to identify poten-tial strategies for change [26]. This study highlights thatchange in the organization, creation, and promotion ofsafety culture and quality improvement is impossiblewithout the support and involvement of different levelsof management and leadership or without providingorganizational infrastructure.Regarding challenge of the culture of blame and pun-

ishment, in agreement with present study, a study inIran reported that non-punitive response to errors isweak in hospitals. The Iranian healthcare context mustavoid the culture of “name, shame, and blame” and im-plement the system approach [15]. In another study, fac-tors related to the organization, e.g. the absence or lack

Farokhzadian et al. BMC Health Services Research (2018) 18:654 Page 10 of 13

of a safety culture, a culture of blame and reprimand,lack of support of the staff in the event of an error, aninappropriate function and reaction of managers, havebeen considered as barriers to error reporting [42]. Theculture of blame is a barrier to reporting the errors andlearning from mistakes. It also restrains the nurses frompatient protection [43].Weakness in feedback to reporting errors and weak-

ness in the culture of organizational education andlearning were the other challenges presented in thisstudy. In agreement with this results a qualitative studyin Australia which introduced the lack of receiving feed-back from an error report, culture of blame, lack ofvalue in the process, and failure to receive legal privi-leges as barriers to reporting the errors by nurses anddoctors [44]. In organizational learning, the emphasis ison learning from errors and mistakes, providing an op-portunity to learn later. One method to improve patientsafety is to lead the organization towards organizationallearning by enforcing the appropriate setting for learningfrom errors and their proper management [45]. Perhapsthe reasons of weakness in organizational learning couldbe lack of learning conditions. For example, in a qualita-tive study by Heidari et al. [46], the lack of a sense of at-tachment, confidence, and satisfaction with professionalposition were identified as the main concerns of nurses,especially those with a master’s degree, in the process oforganizational learning. Also, the nurses highlightedissues such as lack of confidence at the obtainedcompetencies, deficiency in work autonomy, lack ofdecision-making power, absence of autonomy to usetheir knowledge, and predominance of physicians’ opin-ions which had deterrent effects on the efforts of nursesto achieve personal and organizational promotion. Theinteresting point about the experiences of nurses wasthat, in the current system, higher knowledge and skillswere not considered as benefits for nurses, even creatingmore duties and responsibilities for them.The participants believed that the weakness in pre-

ventive culture was another challenge for the safety cul-ture. This study was consistent with a study whichconcluded that the errors receive attention by a morepassive and retrospective (reactive) approach and peopleare considered as the cause of errors in Iran. In addition,the researchers in that study reduced the incidence oferrors in the processes of emergency department byusing the prospective method of “failure modes and ef-fects analysis”)FMEA). They introduced the FMEA as anefficient and effective technique for the advancement ofsystem thinking and access to safe processes of patientcare [47].Based on the results, challenges such as failure to re-

define and clarify roles, gap in team coordination, and dif-ficult dynamics of team interactions have overshadowed

the values of team participation in the establishment of asafety culture. Castro-Sánchez et al. [30] highlighted thatthe consequences of lacking awareness about professionalresponsibilities (own and others’) could threaten patientsafety. Various studies have reported similar challengesand obstacles to team participation in patient safety pro-grams, risk management, and quality improvement. Thosechallenges were inconsistency in team communication,negative attitude to teamwork, unwillingness to performduties in the team [48], lack of job descriptions [13], gapin team engagement and coordination [49], inadequacy inteam communication and interaction [50], and lack of aculture of teamwork [42].The participants in our study commented that an as-

pect of difficult dynamics of team interactions was theunfavorable relationship between nurses and physicians,leading to dissatisfaction among nurses and reduced pa-tient safety. In consistent with the results other studiesconcluded that ineffective relationships affected nurses’performance negatively and reduced care quality. Nursesreported that unfavorable relationships among somephysicians and nurses disappointed the nursing staff,making them lose their motivation. In addition, lack ofattention to nurses’ knowledge and capabilities by somephysicians caused stress and unpleasant feelings regard-ing the work atmosphere, acting as a barrier to theproper delivery of nursing care [51]. Disharmony in theinteraction between physicians and nurses will causeconflicts among the members of healthcare team, result-ing in error and disruptions in patient safety. Therefore,improving the interactions between nurses and physi-cians should be considered as one of the effective strat-egies to improve patient safety.

LimitationsThis study explored merely a part of the challenges ofinstitutionalization of an effective and positive safety cul-ture based on the experiences of one professional group(nurses) in cultural and social fields in the hospitals ofIran. Therefore, the transferability of findings should beconsidered with caution and critiqued and comparedwith those of similar studies conducted in other con-texts. In addition, others challenges may be recognizedin different cultural and organizational contexts, withother groups of healthcare system, e.g. physicians, andeven from a multidisciplinary perspective. Thus, morequalitative and quantitative studies must be performedto adopt the strategies and processes of the managementof safety challenges proportionate to diverse cultural andorganizational contexts. The results of such comprehen-sive research could pave the way for creating and institu-tionalizing a growing safety culture, leading to highquality and safe care in the unique cultural context.

Farokhzadian et al. BMC Health Services Research (2018) 18:654 Page 11 of 13

ConclusionDespite the numerous efforts of healthcare system, there isstill a long way towards the institutionalization of an effect-ive and positive safety culture. Several challenges have slo-wed the realization of safety culture in the organizationalculture. The patient safety culture is an internationalphenomenon and the challenges detected in this study aresomewhat similar to other studies. However, adopting strat-egies and processes for the integration of safety culture inthe cultural and organizational field should be consistentwith underlying conditions which are unique in each hos-pital. More efforts are required in order to have an effectiveand positive safety culture in all parts of the organization,including management and healthcare staff. Quality im-provement systems, such as accreditation, are useful toolsfor improving the safety culture. Healthcare managersshould allocate the necessary resources to keep pace withthese systems and to draw the participation of all membersof the healthcare team. Moreover, they should employ so-cial and cultural beliefs and capabilities to achieve an effect-ive safety culture. It is also essential that they use modernmanagement styles, such as change management and par-ticipative management, in order to make a difference inhealthcare, overcome challenges, and establish the safetyculture. It is suggested that more quantitative and qualita-tive studies be conducted to evaluate the strategies of over-coming barriers to the establishment of the safety culture.

AbbreviationsCCU: Coronary care unit; FMEA: Failure modes and effects analysis;ICU: Intensive care unit; IOM: Institute of Medicine

AcknowledgementsThe researchers appreciate all nursing staff who generously offered theirtime in order to participate in the study.

FundingThis study received no specific grant from any funding agency, commercial,or non-profit sectors.

Availability of data and materialsThe datasets generated and analysed in the present study are not publiclyavailable, as another paper will be written based on the dataset. The data,however, are available upon request to the corresponding author aftersigning appropriate documents in line with ethical application and thedecision of the Ethics Committee.

Authors’ contributionsJF, ND, and FB contributed to conceiving and designing the research. Thedata were collected, analysed, and interpreted by JF, FB and ND. JF, ND andFB contributed equally to writing and revising the manuscript and approvedthe final manuscript.

Ethics approval and consent to participateThe ethical principles were transparent throughout the study. First, the studywas approved by the Ethics Committee affiliated with Kerman University ofMedical Sciences)IR.KMU.REC.1395.374). Then, oral and written informedconsent was obtained from the nurses before recording the interviews. Thenurses were informed that participation in the study was voluntary and theycould withdraw at any time, confidentiality would be maintained, and thatno personal information would be identified in any publications arising fromthe study. The researchers allowed the nurses to call or e-mail regarding anyquestions or information.

Consent for publicationNot applicable.

Competing interestsThe authors declare that they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Author details1Nursing Research Center, Kerman University of Medical Sciences, Kerman,Iran. 2School of Nursing and Midwifery, Tehran University of MedicalSciences, Nosrat St., Towhid Sq, Tehran 1419733171, Iran. 3Department ofNursing Ethics, Medical Ethics and Law Research Center, Shahid BeheshtiUniversity of Medical Sciences, Niyayesh Complex, Niyayesh Cross-Section,Vali-e-Asr St, PO Box: 1985717443, Tehran, Iran.

Received: 13 May 2017 Accepted: 13 August 2018

References1. Friesen MA, Farquhar MB, Hughes R: The nurse's role in promoting a culture

of patient safety: Center for American Nurses; 2005. Available from: ana.nursingworld.org/mods/archive/mod780/cerole full.htm. Accessed 20 May2016.

2. Baker A. Crossing the quality chasm: a new health system for the 21stcentury. BMJ: British Medical Journal. 2001 17;323(7322):1192.

3. Farokhzadian J, Nayeri ND, Borhani F. Assessment of clinical riskmanagement system in hospitals: an approach for quality improvement.Glob J Health Sci. 2015;7(5):294.

4. Farokhzadian J, Nayeri ND, Borhani F. Rocky milieu: challenges of effectiveintegration of clinical risk management into hospitals in Iran. Int J Qual StudHealth Well-being. 2015;10(1):27040.

5. World Health Organization. 10 facts on patient safety. Available from: http://www.who.int/features/factfiles/patient_safety/en/. Accessed 23 Feb 2016.

6. World Health Organization. 10 facts on patient safety. Available from: WHOwebsite: http://www.who.int/features/factfiles/patient_safety/patient_safety_facts/en/index8.html. Accessed 23 Feb 2016.

7. Croll ZT, Coburn AF, Pearson KB: Promoting a culture of safety: use of thehospital survey on patient safety culture in critical access hospitals. FlexMonitoring Team Briefing 2012(30). Available from: digitalcommons.usm.maine.edu. Accessed 23 Feb 2016.

8. Weaver SJ, Lubomksi LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM.Promoting a culture of safety as a patient safety strategy: a systematicreview. Ann Intern Med. 2013;158(5_Part_2):369–74. https://doi.org/10.7326/0003-4819-158-5-201303051-00002.

9. Reason J, Hobbs A. Managing maintenance error: a practical guide. CRCPress; 2003. Available from: https://www.amazon.com/Managing-Maintenance-Error-Practical-Guide/dp/075461591X. Accessed 23 Feb 2016.

10. Colla J, Bracken A, Kinney L, Weeks W: Measuring patient safety climate: areview of surveys. Qual Saf Health Care 20052005, 14(5):364–366.

11. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a saferhealth system. National Academy of Science, Institute of Medicine. 2002.Available from: citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1 .531.9961& reprep1.pdf. Accessed 23 Feb 2016.

12. Attree M. Factors influencing nurses’ decisions to raise concerns about carequality. J Nurs Manag. 2007;15(4):392–402.

13. Vaismoradi M, Salsali M, Turunen H, Bondas T. A qualitative study on Iraniannurses’ experiences and perspectives on how to provide safe care in clinicalpractice. J Res Nurs. 2013;18(4):351–65.

14. Warburton RN. Improving patient safety: an economic perspective on therole of nurses. J Nurs Manag. 2009;17(2):223–9.

15. Bahrami MA, Chalak M, Montazeralfaraj R, Tafti AD: Iranian nurses’perception of patient safety culture. Iran Red Crescent Med J 2014, 16(4).https://doi.org/10.5812/ircmj.11894.

16. Singer SJ, Gaba D, Geppert J, Sinaiko A. Howard SKs, park K: the culture ofsafety: results of an organization-wide survey in 15 California hospitals. QualSaf Health Care. 2003;12(2):112–8.

17. Moussavi F, Moghri J, Gholizadeh Y, Karami A, Najjari S, Mehmandust R,Asghari M, Asghari H. Assessment of patient safety culture among

Farokhzadian et al. BMC Health Services Research (2018) 18:654 Page 12 of 13

personnel in the hospitals associated with Islamic Azad University in Tehranin 2013. Electronic physician. 2013;5(3):664. https://doi.org/10.14661/2013.664-671.

18. Morello RT, Lowthian JA, Barker AL, McGinnes R, Dunt D, Brand C. Strategiesfor improving patient safety culture in hospitals: a systematic review. BMJQual Saf. 2013;22(1):11–8.

19. Vlayen A, Hellings J, Barrado LG, Haelterman M, Peleman H, Schrooten W,Claes N. Evolution of patient safety culture in Belgian acute, psychiatric andlong-term care hospitals. Safety in Health. 2015;1(1):1.

20. Donaldson C. Is safety safe in the market’s hands? Qual Saf Health Care.2009;18(2):87–8.

21. Thyme KE, Wiberg B, Lundman B, Graneheim UH. Qualitative contentanalysis in art psychotherapy research: concepts, procedures, and measuresto reveal the latent meaning in pictures and the words attached to thepictures. Arts Psychother. 2013;40(1):101–7.

22. Farokhzadian J, Khajouei R, Ahmadian L. Information seeking and retrievalskills of nurses: nurses readiness for evidence based practice in hospitals ofa medical university in Iran. Int J Med Inform. 2015;84(8):570-77.

23. Karami A, Farokhzadian J, Foroughameri G. Nurses’ professional competencyand organizational commitment: is it important for human resourcemanagement? PLoS One. 2017;12(11):e0187863.

24. Hashjin AA, Kringos DS, Manoochehri J, Ravaghi H, Klazinga NS.Implementation of patient safety and patient-centeredness strategies inIranian hospitals. PLoS One. 2014;9(9):e108831.

25. Graneheim UH, Lundman B. Qualitative content analysis in nursing research:concepts, procedures and measures to achieve trustworthiness. Nurse EducToday. 2004;24(2):105–12.

26. Krein SL, Damschroder LJ, Kowalski CP, Forman J, Hofer TP, Saint S. Theinfluence of organizational context on quality improvement and patientsafety efforts in infection prevention: a multi-center qualitative study. SocSci Med. 2010;71(9):1692–701.

27. Ravaghi H, Heidarpour P, Mohseni M, Rafiei S. Senior managers’ viewpointstoward challenges of implementing clinical governance: a national study inIran. Int J Health Policy Manag. 2013;1(4):295.

28. Michel P, Roberts T, Porro Z, Es-seddiqi H, Saillour F. What are the Barriersand Facilitators to the Implementation and/or Success of QualityImprovement and Risk Management in Hospitals: A Systematic LiteratureReview. J Epidemiol Public Health Rev. 2016;1:(4).

29. Som CV. Exploring the human resource implications of clinical governance.Health policy. 2007;80(2):281–96.

30. Vaismoradi M, Salsali M, Ahmadi F. Perspectives of Iranian male nursingstudents regarding the role of nursing education in developing aprofessional identity: a content analysis study. Jpn J Nurs Sci.2011;8(2):174–83.

31. Laschinger HKS, Almost J, Tuer-Hodes D. Workplace empowerment andmagnet hospital characteristics: making the link. J Nurs Adm. 2003;33(7/8):410–22.

32. Rassouli M, Zandiye S, Noorian M, Zayeri F. Fatigue and its related factors inpediatric and adult oncology nurses. Iran Journal of Nursing 2011, 24(72):37–47. Available from: ijn.iums.ac.ir/article-1-1024-en.pdf. Accessed 21 may2016. [in Persian].

33. GHolam Nejad H, Nikpeyma N. Occupational stressors in nursing. IranOccupational Health Journal 2009, 6(1):22–27. Available from: ioh.iums.ac.ir/browse.php?a_code=A-10-3-37&sid=1&slc_lang=en. Accessed 21 May 2016.[in Persian].

34. Mahmood A, Chaudhury H, Valente M. Nurses' perceptions of how physicalenvironment affects medication errors in acute care settings. Appl Nurs Res.2011;24(4):229–37.

35. Dehnavieh R, Ebrahimipour H, Jafari Zadeh M, Dianat M, Noori Hekmat S,Mehrolhassani MH. Clinical governance: the challenges of implementationin Iran. International Journal of Hospital Research. 2013;2(1):1–10.

36. Briner M, Manser T, Kessler O. Clinical risk management in hospitals:strategy, central coordination and dialogue as key enablers. J Eval Clin Pract.2013;19(2):363–9.

37. Vaismoradi M, Bondas T, Salsali M, Jasper M, Turunen H. Facilitating safecare: a qualitative study of Iranian nurse leaders. J Nurs Manag. 2014;22(1):106–16.

38. Ataollahi F: Clinical Governance Implementation Challenges in TeachingHospitals Affiliated to Yazd University of Medical Sciences, Iran, Based onthe Experts' Viewpoint. Journal of Management and Medical Information

School 2012. Available from: jms.kmu.ac.ir/browse.php?a_id=37&sid=1&slc_lang=en. Accessed 10 May 2016.

39. Jannati A, Moltajaie Farid MS, Saadati M, Yahyaie SM, Asadi P, Narimani MR,Dadsetan M, Piry H, Nouri M. An evaluation of Patient Safety LeadershipWalkrounds, Shahid Mahalati Hospital. Depiction of Health 2013, 20(20):20–25 Available from: hmrc.tbzmed.ac.ir/uploads/174/CMS/user/file/2692/.../D4-sh4-s92/Abstract4.pdf. Accessed 10 May 2016.

40. Scott I. What are the most effective strategies for improving quality andsafety of health care? Intern Med. 2009;39(6):389–400.

41. Marshall M, Sheaff R, Rogers A, Campbell S, Halliwell S, Pickard S, Sibbald B,Roland M: A qualitative study of the cultural changes in primary careorganisations needed to implement clinical governance. Br J Gen Pract2002, 52(481):641–645: 641–5. PMCID: PMC1314382.

42. Hashemi F, Nasrabadi AN, Asghari F. Factors associated with reportingnursing errors in Iran: a qualitative study. BMC Nurs. 2012 Oct 18;11(1):20.

43. Brady A, Malone A, Fleming S. A literature review of the individual andsystems factors that contribute to medication errors in nursing practice. JNurs Manag. 2009;17(6):679–97.

44. Kingston MJ, Evans SM, Smith BJ, Berry JG. Attitudes of doctors and nursestowards incident reporting: a qualitative analysis. Med J Aust.2004;181(1):36–9.

45. Heidari S, Nayeri ND, Ravari A, Sabzevari S. How organizational learning isassociated with patient rights: a qualitative content analysis. Glob HealthAction. 2016;9

46. Heidari S, Ravari A, Dehgan Nayeri N, Sabzevari S. Exploration ofOrgnizational learning Process in clinical Nursing. Kerman: KermanUniversity of Medical Sciences; 2016 (dissertation of PhD in nursing).Available from: eprints.kmu.ac.ir/25480/. Accessed 12 June 2016

47. Attar Jannesar N, Tofighi S, Hafezimoghadam P, Maleki M, Goharinezhad S.Risk Assessment of Processes of Rasoule Akram Emergency Departmentbythe Failure Mode and Effects Analysis (FMEA) Methodology. Hakim ResearchJournal 2010. 2010;13(3):165–76. Available from: hakim.hbi.ir/browse.php?a_id=7 13&sid=1&slc_ lang=en.

48. Sujan MA. A novel tool for organisational learning and its impact on safetyculture in a hospital dispensary. Reliab Eng & Syst Safe. 2012;101:21–34.

49. Wæhle HV, Haugen AS, Søfteland E, Hjälmhult E. Adjusting teaminvolvement: a grounded theory study of challenges in utilizing a surgicalsafety checklist as experienced by nurses in the operating room. BMC Nurs.2012;11(1):16.

50. Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, BohnenJ, Whyte S. Evaluation of a preoperative checklist and team briefing amongsurgeons, nurses, and anesthesiologists to reduce failures incommunication. Arch Surg. 2008;143(1):12–7.

51. Molazem Z, Ahmadi F, Mohammadi E, Bolandparvaz S. Improvement in thenursing care quality in general surgery wards: Iranian nurses’ perceptions.Scand J Caring Sci. 2011;25(2):350–6.

Farokhzadian et al. BMC Health Services Research (2018) 18:654 Page 13 of 13