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  • v.4(4); 2017 Oct

Patient involvement for improved patient safety: A qualitative study of nurses’ perceptions and experiences

Janna skagerström.

1 Research and Development Unit in Region Östergötland and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden

Carin Ericsson

2 Centre of Heart and Medicine, Region Östergötland, Linköping, Sweden

3 Department of Medical and Health Sciences, Linköping University, Linköping, Sweden

Mirjam Ekstedt

4 Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden

5 Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden

Kristina Schildmeijer

To explore nurses’ perceptions and experiences of patient involvement relevant to patient safety.

Qualitative design using individual semi‐structured interviews.

Interviews with registered nurses ( n  =   11) and nurse assistants ( n  =   8) were conducted in 2015–2016. Nurses were recruited from five different healthcare units in Sweden. The material was analysed using conventional content analysis.

The analysis resulted in four categories: healthcare professionals’ ways of influencing patient involvement for safer care; patients’ ways of influencing patient involvement for safer care; barriers to patient involvement for safer care; and relevance of patient involvement for safer care. The nurses expressed that patient involvement is a shared responsibility. They also emphasized that healthcare provider has a responsibility to create opportunities for the patient to participate. According to the nurses, involvement can be hindered by factors related to the patient, the healthcare provider and the healthcare system. However, respondents expressed that patient involvement can lead to safer care and benefits for individual patients.

Why is this research needed?

  • The patient has an overall perspective of their care and observes the whole care process.
  • Most research on patient involvement concern the patient perspective and there is limited knowledge about the healthcare professionals’ views on patient participation for patient safety.

What are the key findings?

  • The nurses believed that healthcare professionals and patients had a shared responsibility for patient participation to occur.
  • The nurses emphasized the importance of their own initiatives to achieve patient involvement for enhanced patient safety by initiating dialogue and inviting the patients to ask questions.
  • The nurses expressed that barriers to achieve patient participation for safer care were seen both within patients, healthcare professionals and the healthcare system.

How should the findings be used to influence policy/practice/research/education?

  • The healthcare system should allocate time and supportive environments to facilitate open dialogue between healthcare professionals and patients.
  • Healthcare professionals should be offered training in how to encourage the patients to be involved in their health care.


Patient safety has progressed over the last 15 years from being a relatively insignificant issue to a position high on the agenda for healthcare professionals, managers and policy makers as well as the public. Sweden has seen increased patient safety efforts since 2009 when a national study on adverse events in Swedish hospital care was published (Soop, Fyksmark, Köster, & Haglund, 2009 ). The study estimated the percentage of preventable adverse events as high as 8.6% in hospital care, demonstrating that the magnitude of the patient safety problem was not smaller in Sweden than elsewhere. Efforts for improved patient safety in Sweden were further enhanced in 2011 with the introduction of a new law on patient safety and a financial incentive for county councils (responsible for providing health care in Sweden) that performed certain patient safety‐enhancing activities (Ridelberg, Roback, Nilsen, & Carlfjord, 2016 ).

There is increasing interest in involving patients in safety‐related initiatives, premised on the assumption that their interaction with healthcare professionals can improve the safety of health care in many ways (Berger, Flickinger, Pfoh, Martinez, & Dy, 2014 , World Health Organization, 2013a a). The importance of eliciting and acting on patients’ concerns has been emphasized. The patients are privileged witnesses of health care because they are at the centre of the process of care and observe the whole process (Schwappach & Wernli, 2010 ). Patients also carry out hidden work to compensate for inefficiencies of the healthcare system, such as relaying information between healthcare professionals (Vincent & Davis, 2012 ). Various policy initiatives have been undertaken aimed at encouraging patients in a range of safety‐relevant behaviours. The World Health Organization (WHO) promotes the program “Patients for Patient Safety” to bring together patients and various stakeholders to improve patient safety through advocacy, collaboration and partnership (WHO, 2013 ). In Sweden, the National Board of Health and Welfare and Swedish Association of Local Authorities and Region (SALAR), representing the county councils and municipalities, have emphasized the importance of a new perspective on the patient for improved quality and effectiveness of health care (National Board of Health and Welfare, 2015 , SALAR, 2011 ). Healthcare professionals are also obliged by the law to give patients an opportunity to take part in patient safety work (SFS, 2010 ).

1.1. Background

Research indicates that there is a potential for patients to improve safety (Davis, Jacklin, Sevdalis, & Vincent, 2007 ; Vincent & Coulter, 2002 ) and that patients are willing and able to be involved in safety‐related work (Waterman et al., 2006 Wright et al., 2016 ). However, several barriers to involving patients in improving patient safety has been identified and organized into three key barriers: (i) patients are not always willing or prepared to commit their time and energy to improve their care because they have enough to worry about being ill; (ii) healthcare professionals represent traditional medical authority and questioning or advising professionals about what they do is unacceptable for many patients; and (iii) patients may be apprehensive about reporting problems in their care when providers’ responses are unappreciative or when the patients believe that their feedback may jeopardize the providers’ goodwill towards the patient (Iedema, Allen, Britton, & Gallagher, 2012 ). Organizational factors such as a busy setting, lack of continuity of care and patients being unaware of incident reporting systems have also been identified as barriers to active patient participation (Doherty & Stavropoulou, 2012 ).

Nurses comprise the largest professional group in health care in Sweden. The main categories of nurses in Swedish health care are registered nurses and nurse assistants, who differ with regard to their level of education, work duties and responsibilities. Registered nurses are critically important to achieve patient safety since they often have a role as coordinator of multidisciplinary care and are involved with many aspects of patient care, from providing comfort and hygiene to administering injections, updating medical records, as well as handling some therapeutic and diagnostic procedures. Several studies have stressed the importance of nurses’ role for identifying, interrupting and correcting medical adverse events (Gaffney, Hatcher, & Milligan, 2016 ) and for reducing patients’ feelings of being unsafe and vulnerable in the health care setting (Kenward, Whiffin, & Spalek, 2017 ).

Thus far, very few studies have investigated nurses and other healthcare professionals’ attitudes, beliefs and behaviours concerning patient involvement for improved patient safety. Research conducted hitherto suggests that providers may be willing to support patient involvement in safety‐relevant behaviours, although the factors behind these preliminary findings remain largely unexplored (Davis, Briggs, Arora, Moss, & Schwappach, 2014 ; Hochreutener & Wernli, 2010 ; Schwappach, Frank, & Davis, 2012 ). A previous Swedish study assessing nurses’ perceptions of factors influencing patient safety found that patient‐nurse interaction was an important factor that could hinder or facilitate enhanced patient safety depending on the quality of the communication (Ridelberg, Roback, & Nilsen, 2014 ). This study provides an in‐depth investigation into nurses’ perspectives on patient involvement for safer care in meetings with healthcare professionals, being the first Nordic study on this topic. The aim was to explore nurses’ experiences and perceptions with regard to patient involvement of relevance for patient safety.


2.1. study setting.

The study was set in Sweden. Health care in Sweden is mainly tax‐funded although private health care also exists. All residents are insured by the state, with equal access for the entire population. Out‐of‐pocket fees are low and regulated by law. The responsibility for health and medical care in Sweden is shared by the central government, county councils and municipalities throughout Sweden. The health care system is financed primarily through taxes levied by county councils and municipalities.

2.2. Study design

A qualitative study approach using standardized (also referred to as structured) open‐ended interviews was deemed appropriate regarding the explorative aim of the study. This qualitative descriptive study is grounded in the assumption that human beings construct the meaning of their experiences in social interaction with their environment. Qualitative descriptive studies comprise a valuable methodologic approach, by using open‐ended interviews where the phenomenon under study is explored in an interaction between the interviewer and the interviewee (Sandelowski, 2000 ).

2.3. Participants

We used a purposeful sampling strategy to achieve a heterogeneous sample of nurses working in different healthcare facilities, with patients who varied in terms of health status (from patients seen in primary health care to ill patients receiving hospital care and, for example, surgery patients), length of stay in health care (from patients visiting outpatient facilities to in‐hospital patients) and age. The aim was to achieve a sample of nurses that represented a broad spectrum of perceptions and experiences concerning patient involvement in relation to patient safety.

The nurses were recruited using an email that briefly described the study. The email request was sent to the manager of each work unit, explaining that we wanted a sample of three or four nurses. The manager in turn forwarded the request to all or a sample of registered nurses and nurse assistants at the unit. An information letter describing the study was sent to interested nurses and the interviews were scheduled. No respondents declined involvement after receiving the information letter.

2.4. Data collection

The interview guide used in the study was developed by the authors and concerned the nurses’ experiences and perceptions regarding patient involvement of relevance for patient safety. There were general questions on patient involvement of relevance for patient safety. There were also specific questions on the respondent's own experiences and examples of patients who have observed and highlighted something of importance for patient safety. The interview guide ended with questions on existing routines to account for patients’ views and experiences and on the nurses’ suggestions on how patient involvement for safer care can be achieved.

Patient safety was defined in accordance with the definition used in Swedish law (SFS, 2010 ), that is: “protection against adverse events” where adverse events is defined as “suffering, bodily or mental harm or illness and deaths that could have been avoided if adequate measures had been taken at the patient contact with the healthcare system”. The definition was read to the nurses at the beginning of the interview and a printed definition was placed on the table during the interview so that the respondents could read it.

The questions were pilot tested in one test interview, not analysed. The test interview indicated that the questions were generic enough to be used in different healthcare contexts and that the wording was clear. The interviews were conducted by KS, CE and JS and were digitally recorded using a Dictaphone. Interviews were held during regular working hours to facilitate involvement. Each interview lasted between 18–53 min. The interviews were transcribed verbally by a firm specialized in transcription. The researchers checked the transcripts and removed statements that could reveal the identity of the informant.

Before starting the interviews, the participants were asked to re‐read the information letter and give their written informed consent to participate. Each interview started with an open question asking the participants to describe their thoughts on how patients can influence patient safety. The questions were open ended to stimulate narratives of the participants’ own experiences. During the interviews, probing questions were asked, for example: “what do you mean?” and “can you explain this a little further?” to deepen or clarify the descriptions or drawing the attention back to the topic (Kvale & Brinkman, 2009 ).

2.5. Data analysis

Data were analysed using content analysis. We followed the analytical procedure for conventional content analysis as detailed by Hsieh and Shannon ( 2005 ). The analysis was data driven and based on the participants’ unique perspectives rather than guided by a pre‐defined theory or hypothesis. Investigator triangulation was used to validate the findings. All researchers read and re‐read the transcripts to gain a sense of the content and an overview of the whole material. With the aim of the study in mind, the researchers highlighted text and made notes and headings in the margins to include all aspects of the content. Initial thoughts and impressions regarding the material were written down. No pre‐defined structures were used as the codes were derived from the data to capture key concepts. Codes that were related to each other were grouped and organized into subcategories and categories. This process was iterative, going back and forth checking the codes against the whole material. The subcategories and categories were subsequently compared for differences and similarities, with the aim of being as internally homogeneous and as externally heterogeneous as possible.

2.6. Rigour

Credibility in the data analysis was strengthened by the fact that the initial coding of the data was performed by several researchers independently (JS, CE and KS). The classification of categories and subcategories was then discussed by two researchers (JS and CE). After they reached consensus, the classification was discussed by all the authors and adjustments were made until all were satisfied. The multidisciplinary research team allowed different perspectives on the issue of patient involvement in relation to patient safety. The team consisted of a nurse with experience in clinical patient work as well as work with miscellaneous patient safety issues (KS), a public health researcher (JS), a behavioural science practitioner working with organizational development and experience in developing and implementing patient involvement policies (CE), a nurse experienced in qualitative methods, patient involvement and system safety issues (ME) and an experienced implementation and patient safety researcher (PN).

2.7. Ethical considerations

The study was performed according to the World Medical Association Declaration of Helsinki ethical principles for medical research involving human subjects. All the participants gave their consent to participate in the interviews. The study did not require ethical approval because it did not involve sensitive personal information, as specified in Swedish law regulating ethical approval for research concerning humans (SFS, 2003 ).


Interviews were conducted with 19 nurses, of which 11 were registered nurses and 8 were nurse assistants. They were employed in five different work units: (i) pulmonary medical unit in a university hospital (550 beds); (ii) surgery unit in a mid‐sized hospital (350 beds), (iii) ear, nose and throat unit in a mid‐sized hospital (500 beds); (iv) one maternity care unit (outpatient care); and (v) one nursing home (18 residents). Table  1 provides information on the participants. The interviews were carried out from May 2015 – February 2016 at the participants’ work units.

Participant characteristics

Analysis of the data yielded four categories related to patient involvement for enhanced patient safety: healthcare professionals’ ways of influencing patient involvement for safer care; patients’ ways of influencing patient involvement for safer care; barriers to patient involvement for safer care; and relevance of patient involvement for safer care (Table  2 ).

Categories and subcategories

3.1. Healthcare professionals’ initiatives to achieve patient involvement for safer care

The nurses expressed that there were a few ways they and other healthcare professionals can influence patient involvement of potential relevance for patient safety. They believed that they could facilitate patient involvement by ensuring favourable conditions for dialogue with the patients, making sure that information is received and understood by the patients and creating a trustful relationship with the patients.

3.1.1. Dialogue

The nurses described that they can facilitate patient involvement by providing conditions that are conducive to this involvement, including taking sufficient time to listen to patients and inviting them to ask questions and be active in the dialogue. Specific ways of achieving this included telling the patients that they are happy to answer any questions they might have, informing the patients that there will be time for their questions or concerns at the end of the consultation (after finishing medical examinations) and encouraging the patients to share their opinions regarding the health care:

Instead you have to be inviting and show a friendly response, encourage conversation and dialogue. You have to make sure it doesn't become a monologue, where you just sit and talk without… We, the staff, must encourage them to ask questions and to become involved. Participant 24

Some nurses mentioned that it is important to adapt to each individual patient they meet. It is especially important to be observant and take in facial expressions with patients who are unable to express themselves verbally.

3.1.2. Information

The nurses expressed that they can influence the patients’ potential to be involved in their care by making sure that the patients receive and understand information provided to them. The information should be given in a language that can be understood by the patients and without medical terms that may be unfamiliar to the patients. The nurses mentioned that the patients’ abilities to assimilate information vary considerably and it may be necessary to repeat information at several time points. Patients with new diagnoses or treatments, patients with fatigue and patients discharged after a longer stay in hospital were all mentioned as groups that could benefit from repeated information:

Sometimes I think you could ask…”Do you think you got the information you needed, did you understand it?” or something like that, so it's not too much [information]. Participant 23

3.1.3. Trustful relationship

The importance of a trustful relationship between the healthcare professional and patient to make the patients feel comfortable raising any concerns was made clear in the interviews. Although the nurses believed that the provider and patient have a shared concern for creating this relationship, the nurses argued that the ultimate responsibility to facilitate a trustful provider‐patient relationship rested with the providers of health care.

The importance of building a trustful relationship was primarily mentioned by nurses working in specialties which patients visit several times. Continuity of healthcare staff to ensure that the patient can meet the same professionals over time was mentioned as a factor that influenced the opportunity to establish a trusting relationship. The presence of a specific contact person to whom the patient could turn with their thoughts or questions was believed to enhance the patients’ confidence to engage in issues of potential relevance for patient safety.

Specific personal behaviours such as being empathic and humble as well as the ability to facilitate an open climate and allow sufficient time were seen as important to build a trustful relationship:

Yes, you have to be open, responsive in order for them [the patients] to open up. You can't just walk in and be really tough…that's not going to make it easy to open up if you have problems. Participant 16

3.2. Patients’ initiatives to achieve patient involvement for safer care

The nurses’ perceptions about what the patients can do differed somewhat depending on the healthcare context and what types of patients they typically meet. However, in general, nurses conveyed that the patients can assume responsibility for their health and treatment and be active in communication with healthcare professionals.

3.2.1. Assuming responsibility for one's treatment and care

The nurses expressed that the patients can participate in their care and enhance patient safety by taking an active interest in their health and treatment. The interest could be manifested as searching for information or actively reading information. Further, using and asking for medical aids such as rollators, reading user manuals for medical devices used in home care or watching out for complications or abnormalities when in treatment were provided as examples of responsible patient actions to increase patient safety:

They [the patients] could get more involved in… to make sure things aren't forgotten, because we have a lot of different hoses and drainage, venous catheters and things like that, where they could help and be observant to prevent infections. Participant 4

3.2.2. Being active in communication with healthcare professionals

Nurses stated that patients who are active in dialogue with healthcare professionals can improve patient safety. Writing down questions and thoughts or bringing a relative to appointments were tips for patients to prepare for communication with the professionals. Also, the nurses stated that the patients could be active by attending regular check‐ups, reminding staff about return visits or treatments and reporting any side effects:

They [the patients] have to tell us about, for example, side effects and things like that, that's nothing we can see ourselves. So, if I don't get that feedback, they might get medications that don't make them feel so good. Participant 3

Sharing detailed information about their medical conditions, heredity and side effects was viewed as important because this could help the healthcare professionals to understand the patients’ symptoms and healthcare needs and reduce the risk of important aspects being neglected:

Well, how it feels and… how they understand the situation, both physically and mentally, how they describe an ailment, how detailed they are… can actually make me reconsider and think otherwise. Participant 21

3.3. Interaction between healthcare professionals and patients to achieve patient involvement for safer care

The nurses were generally in favour of patient involvement and believed that it could lead to improved patient safety. However, they identified numerous potential problems and disadvantages associated with patient involvement, including problems relating to the patients’ lack of will and ability to participate, constraints related to the healthcare system and healthcare professionals’ ambivalent feelings concerning patient involvement.

3.3.1. Patients’ hesitancy to interact

The nurses described that there are many obstacles to patients being active and participating in their care. They argued that some patients are unwilling to question healthcare professionals because they view them as authorities and reason that they, the doctor in particular, know what is best for them. Nurses believed that some patients might refrain from offering criticisms for fear of receiving suboptimal treatment or care. Patients who perceive that the healthcare professionals are stressed are unwilling to ask questions or start a dialogue because they feel that they might disturb or interrupt more important tasks:

When we seem stressed, they [the patients] feel they should not ask that simple question. You often hear that “I won't bother you [the staff] about this”. Participant 1

For some patients, participating in their treatment or care is hindered by health problems, difficulties with understanding, language problems or feeling uncomfortable with disclosing sensitive issues.

3.3.2. Constraints related to the healthcare system

Several factors in the healthcare system were brought up by the nurses as hindering patient involvement to achieve safer care. Lack of privacy was a problem mentioned by nurses working in clinical wards where patients often share rooms. Shortage of the healthcare professionals’ time was another limitation for patient involvement. Appointments are sometimes just long enough for physical examinations but leave little time for dialogue or questions from the patients. The nurses thought that problems with availability and staff discontinuity can lead to disenchantment for the patients. Further, the possibility of building trustful relationships is decreased:

Temporary doctors mean that they [the patients] won't meet the same [doctor] next time and then they [the patients] say, “It's no use asking.” You often hear that. Participant 12

3.3.3. Healthcare professionals’ ambivalent feelings

The nurses described a range of feelings towards active patients who are informed and may ask more critical questions. By and large, the nurses were pleased to learn from the patients. If they made a mistake, they were grateful that someone pointed it out to them, although the mistake itself could make them ashamed. Some informed and active patients could make the nurses feel incompetent or question their profession. Some nurses expressed concern that patients who question a great deal or want detailed information can take too much time:

They [the patients] have too little knowledge. At the same time, they want to be involved, which requires a lot… a sort of pedagogical responsibility rests with me that demands a lot [of time and energy]. Participant 21

3.4. Relevance of patient involvement for safer care

This category concerns the nurses’ perceptions of the “results” of patient involvement. Some of the nurses could not think of any example where a patient had recognized or reported something relevant for patient safety. They described situations where the patients’ involvement had not directly affected patient safety but had led to positive effects for the patients. Others shared examples of varying relevance for patient safety, for example, how patients’ involvement had directly prevented a mistake or eliminated potential patient safety hazards.

3.4.1. Patients receiving personal benefits

The nurses believed that patients who were active and questioned aspects of their treatment or care, such as long waiting times or outdated medical aids, could gain advantages compared with patients who did not raise any complaints or concerns. Advantages such as getting help quicker, shorter waiting times for medical examinations or receiving a more modern type of medical aid were brought up in the interviews:

If you're active as a patient and ask when you can get an appointment that could definitely shorten the waiting time compared with if you remain quiet and wait. Participant 8

3.4.2. Safer care

Several nurses shared examples of situations when involvement by patients led to improvements in patient safety. The examples included patients reminding about allergies, asking for aids to avoid fall injuries, observing defects in medical devices and asking about referrals that their healthcare provider had forgotten about:

There was one [patient] with coeliac disease who almost ate food that she should certainly not have. And, of course it was [detected] because she asked, “Is this really gluten‐free?” Participant 9

Another example of indirect patient involvement was when the nurses themselves thought of some hazard, such as giving a patient a double dose of medication and asked the patient to verify whether the mistake had been made or not. Although the patients did not notice the error themselves, they could participate by confirming the nurses’ suspicions.


The aim of this study was to explore nurses’ perceptions and experiences with regard to patient involvement of potential relevance for patient safety. The study contributes to the research field by addressing the nurses’ perspective in contrast to much previous work that has concerned patient views. Further, the study provides insights into how patient involvement for safer care can be achieved in the provider‐patient interaction. In general, the nurses expressed positive attitudes to patient involvement and believed it could have a positive impact on patient safety. However, patient involvement does not occur by itself. Rather, both patients and healthcare professionals must take responsibility if patient involvement for safer care is going to be realized.

The nurses in our study emphasized the importance of their own initiatives to achieve patient involvement. They stated that healthcare professionals can facilitate this involvement by initiating dialogue and inviting the patients to ask questions. Our findings are consistent with previous research from the patient perspective, which has shown the importance of healthcare professionals encouraging patients to speak their opinion (Davis, Koutantji, & Vincent, 2008 ; Entwistle et al., 2010 ; Rainey, Ehrich, Mackintosh, & Sandall, 2015 ). It has been suggested that patients, due to imbalance of power and health literacy, are unwilling to speak their mind if they fear negative or judgemental reactions from the providers, or being ignored or not taken seriously (Davis, Sevdalis, Jacklin, & Vincent, 2012 ). This is supported by our findings from the nurses’ viewpoint, because the nurses highlighted the relevance of building a trustful relationship with the patient by actively listen to them and encourage them to express opinions and ask questions.

Further, the nurses pointed to the importance of providing individualized information to the patients. In a previous Swedish study examining facilitators and barriers to patient safety, nurses expressed that providing well‐structured information to patients is a facilitator for patient safety (Ridelberg et al., 2014 ). Further, research from the patient perspective has highlighted the value of patients understanding of information for them to participate in their care and to make informed decisions (Davis et al., 2012 ; Eldh, Ehnfors, & Ekman, 2006 ; Longtin et al., 2010 ). Patients who have been comprehensively informed are also more likely to feel confident and trust their own decisions (Forsyth, Maddock, Iedema, & Lessere, 2010 ; Longtin et al., 2010 ). Provision of appropriate and sufficient information in a supportive environment are key points in patient involvement (Larsson, Sahlsten, Sjostrom, Lindencrona, & Plos, 2007 ). Patients who have access to information on their health and care are more willing and able to be involved in safety issues (Forsyth et al., 2010 ; Iedema et al., 2012 ). It is likely that patients who receive adequate information become more knowledgeable about what to expect from nursing activities, treatment and care, which enables them to detect potential deviations of relevance for patient safety.

The hindering factors associated with patient involvement for safer care that we found in this study are largely consistent with the barriers identified in research on patient involvement from the patient perspective (Howe, 2006 ; Iedema et al., 2012 ; Larsson, Sahlsten, Segesten, & Plos, 2011 ). With regard to shared decision making in health care, Joseph‐Williams, Elwyn, and Edwards ( 2014 ) concluded in a systematic review that patients’ participation depends on their knowledge (about the condition, options for care, outcomes and personal preferences) and power, that is, perceived influence on decision making. The two factors, knowledge and power, are in turn influenced by interpersonal patient‐provider factors, patient characteristics, trust and time allocated for discussions. Assessing nurses’ opinions of factors influencing patient safety in general, Ridelberg et al. ( 2014 ) found factors relating to both patient interactions and healthcare providers skills and feelings to be potential barriers for patient safety.

It has been suggested that nurses believe patients lack sufficient medical knowledge, making it necessary for nurses to retain power and control (Henderson, 2003 ). Grimen ( 2009 ) has highlighted the interconnection between power and trust, arguing that many healthcare professionals fail to recognize the power associated with professional autonomy, which makes equal dialogue between patients and healthcare professionals unrealistic; patients are in an inferior position vis à vis healthcare professionals. Hence, being a patient is to trust that professionals know what they are doing and to temporary delegate power to them. On the other hand, knowledge and power is a two‐edged sword, which if used wisely in a patient‐provider encounter, can foster mutual respect for the knowledge possessed by both patients and healthcare professionals (Eldh, Ekman, & Ehnfors, 2010 ).

Ignorance of this provider‐patient power imbalance could make nurses resistant to patient involvement because they do not believe in and inform themselves about the patients’ opportunities to make informed contributions. This in turn contributes to creating a culture of professional defensiveness towards patient involvement (Henderson, 2003 ; Howe, 2006 ). Some nurses in this study mentioned that active patients can be time consuming and that too much time is wasted on explaining irrelevant matters to the patients. Communication with patients cannot always be prioritized, because nurses also need to focus on taking care of risk situations and complete tasks (Tobiano, Marshall, Bucknall, & Chaboyer, 2016 ). As pointed out by Ekdahl, Hellström, Andersson, and Friedrichsen ( 2012 ), the remuneration system used in Swedish health care favours treating a large number of patients, which leads to time restrictions and insufficient time for many patients. Time barriers exist not only in Sweden. In a study on patient involvement conducted in 15 European countries, time spent with patients and communications were perceived as the most important areas for improvement of patient involvement (European Commission, 2012 ). Organizational factors such as time constraints (Bolster & Manias, 2010 ; Entwistle et al., 2010 ) and lack of continuity in care (Unruh & Pratt, 2007 ) have previously been suggested to have a negative impact on patients’ active involvement in safety work. For individual healthcare professionals to be able to invite patients to be involved in their care, as suggested by the nurses in our study, requires a shift in the healthcare system to allow more time for conversations with each patient. Our study also pointed to the relevance of the nurses’ ambivalent feelings towards patient involvement. Perceiving that one's professionalism is questioned could hinder providers from actively involving patients in some situations.

4.1. Limitations

This study has several shortcomings that must be considered when interpreting the results. The recruitment strategy could have led to a bias towards participation by nurses who were more interested in patient involvement and/or patient safety issues. The importance of patient involvement has recently been highlighted in Sweden. This might have led to the participants providing more positive answers in the interviews because they want to provide responses that are somehow politically correct. On the other hand, the interview guide was constructed to give the responders the opportunity to answer in general terms rather than revealing their personal opinions.

Nineteen individual interviews with registered nurses and nurse assistants working in different types of healthcare settings were conducted. Various ages, work experience and types of patients contribute to a large variation in the sample. This heterogeneity increases the possibility of viewing patient involvement for improved patient safety from different angles, which can be considered a strength in the study. Inclusion of male nurses in the sample would have increased the heterogeneity further. However, the lack of male participants was deemed acceptable since 88% of registered nurses and 84% of nurse assistants working in Swedish health care are female (SALAR, 2015 ). Transparency was sought by describing the sampling procedure and data analyses in detail.

During the interviews and data analysis, it became evident that the nurses did not always share our definition of patient safety. Although the official definition of patient safety was read to the participants at the beginning of the interview, they tended to interpret the concept more broadly to encompass various aspects of health care in general. This was especially common among the nurse assistants; they provided examples that had more to do with regular health care provision than with patient safety as defined. We found this interesting and did not want to interrupt to impede the nurses’ willingness to tell stories they found important. However, our findings primarily relate to various aspects of patient safety, as defined in this study.


We found that nurses are in general positive to patient involvement and believe it can contribute to increased patient safety. The nurses believe that they can influence patient involvement and that they have a responsibility to do so, but that the patients are responsible for being active in meetings with healthcare professionals. Patient involvement also depends on a well‐functioning provider‐patient interaction. The finding also suggest that healthcare professionals need support from the healthcare system to achieve patient involvement of relevance for patient safety.


The authors declare that they have no conflicts of interests.


The authors thank all registered nurses and nurse assistants who participated in the interviews.

Skagerström J, Ericsson C, Nilsen P, Ekstedt M, Schildmeijer K. Patient involvement for improved patient safety: A qualitative study of nurses’ perceptions and experiences . Nursing Open . 2017; 4 :230–239. https://doi.org/10.1002/nop2.89 [ PMC free article ] [ PubMed ] [ Google Scholar ]

This study was funded by The Swedish Research Council for Health, Working Life and Welfare, FORTE, 2014‐4567

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qualitative case study of nurses

Introduction to qualitative nursing research

This type of research can reveal important information that quantitative research can’t.

  • Qualitative research is valuable because it approaches a phenomenon, such as a clinical problem, about which little is known by trying to understand its many facets.
  • Most qualitative research is emergent, holistic, detailed, and uses many strategies to collect data.
  • Qualitative research generates evidence and helps nurses determine patient preferences.

Research 101: Descriptive statistics

Differentiating research, evidence-based practice, and quality improvement

How to appraise quantitative research articles

All nurses are expected to understand and apply evidence to their professional practice. Some of the evidence should be in the form of research, which fills gaps in knowledge, developing and expanding on current understanding. Both quantitative and qualitative research methods inform nursing practice, but quantitative research tends to be more emphasized. In addition, many nurses don’t feel comfortable conducting or evaluating qualitative research. But once you understand qualitative research, you can more easily apply it to your nursing practice.

What is qualitative research?

Defining qualitative research can be challenging. In fact, some authors suggest that providing a simple definition is contrary to the method’s philosophy. Qualitative research approaches a phenomenon, such as a clinical problem, from a place of unknowing and attempts to understand its many facets. This makes qualitative research particularly useful when little is known about a phenomenon because the research helps identify key concepts and constructs. Qualitative research sets the foundation for future quantitative or qualitative research. Qualitative research also can stand alone without quantitative research.

Although qualitative research is diverse, certain characteristics—holism, subjectivity, intersubjectivity, and situated contexts—guide its methodology. This type of research stresses the importance of studying each individual as a holistic system (holism) influenced by surroundings (situated contexts); each person develops his or her own subjective world (subjectivity) that’s influenced by interactions with others (intersubjectivity) and surroundings (situated contexts). Think of it this way: Each person experiences and interprets the world differently based on many factors, including his or her history and interactions. The truth is a composite of realities.

Qualitative research designs

Because qualitative research explores diverse topics and examines phenomena where little is known, designs and methodologies vary. Despite this variation, most qualitative research designs are emergent and holistic. In addition, they require merging data collection strategies and an intensely involved researcher. (See Research design characteristics .)

Although qualitative research designs are emergent, advanced planning and careful consideration should include identifying a phenomenon of interest, selecting a research design, indicating broad data collection strategies and opportunities to enhance study quality, and considering and/or setting aside (bracketing) personal biases, views, and assumptions.

Many qualitative research designs are used in nursing. Most originated in other disciplines, while some claim no link to a particular disciplinary tradition. Designs that aren’t linked to a discipline, such as descriptive designs, may borrow techniques from other methodologies; some authors don’t consider them to be rigorous (high-quality and trustworthy). (See Common qualitative research designs .)

Sampling approaches

Sampling approaches depend on the qualitative research design selected. However, in general, qualitative samples are small, nonrandom, emergently selected, and intensely studied. Qualitative research sampling is concerned with accurately representing and discovering meaning in experience, rather than generalizability. For this reason, researchers tend to look for participants or informants who are considered “information rich” because they maximize understanding by representing varying demographics and/or ranges of experiences. As a study progresses, researchers look for participants who confirm, challenge, modify, or enrich understanding of the phenomenon of interest. Many authors argue that the concepts and constructs discovered in qualitative research transcend a particular study, however, and find applicability to others. For example, consider a qualitative study about the lived experience of minority nursing faculty and the incivility they endure. The concepts learned in this study may transcend nursing or minority faculty members and also apply to other populations, such as foreign-born students, nurses, or faculty.

Qualitative nursing research can take many forms. The design you choose will depend on the question you’re trying to answer.

A sample size is estimated before a qualitative study begins, but the final sample size depends on the study scope, data quality, sensitivity of the research topic or phenomenon of interest, and researchers’ skills. For example, a study with a narrow scope, skilled researchers, and a nonsensitive topic likely will require a smaller sample. Data saturation frequently is a key consideration in final sample size. When no new insights or information are obtained, data saturation is attained and sampling stops, although researchers may analyze one or two more cases to be certain. (See Sampling types .)

Some controversy exists around the concept of saturation in qualitative nursing research. Thorne argues that saturation is a concept appropriate for grounded theory studies and not other study types. She suggests that “information power” is perhaps more appropriate terminology for qualitative nursing research sampling and sample size.

Data collection and analysis

Researchers are guided by their study design when choosing data collection and analysis methods. Common types of data collection include interviews (unstructured, semistructured, focus groups); observations of people, environments, or contexts; documents; records; artifacts; photographs; or journals. When collecting data, researchers must be mindful of gaining participant trust while also guarding against too much emotional involvement, ensuring comprehensive data collection and analysis, conducting appropriate data management, and engaging in reflexivity.

qualitative case study of nurses

Data usually are recorded in detailed notes, memos, and audio or visual recordings, which frequently are transcribed verbatim and analyzed manually or using software programs, such as ATLAS.ti, HyperRESEARCH, MAXQDA, or NVivo. Analyzing qualitative data is complex work. Researchers act as reductionists, distilling enormous amounts of data into concise yet rich and valuable knowledge. They code or identify themes, translating abstract ideas into meaningful information. The good news is that qualitative research typically is easy to understand because it’s reported in stories told in everyday language.

Evaluating a qualitative study

Evaluating qualitative research studies can be challenging. Many terms—rigor, validity, integrity, and trustworthiness—can describe study quality, but in the end you want to know whether the study’s findings accurately and comprehensively represent the phenomenon of interest. Many researchers identify a quality framework when discussing quality-enhancement strategies. Example frameworks include:

  • Trustworthiness criteria framework, which enhances credibility, dependability, confirmability, transferability, and authenticity
  • Validity in qualitative research framework, which enhances credibility, authenticity, criticality, integrity, explicitness, vividness, creativity, thoroughness, congruence, and sensitivity.

With all frameworks, many strategies can be used to help meet identified criteria and enhance quality. (See Research quality enhancement ). And considering the study as a whole is important to evaluating its quality and rigor. For example, when looking for evidence of rigor, look for a clear and concise report title that describes the research topic and design and an abstract that summarizes key points (background, purpose, methods, results, conclusions).

Application to nursing practice

Qualitative research not only generates evidence but also can help nurses determine patient preferences. Without qualitative research, we can’t truly understand others, including their interpretations, meanings, needs, and wants. Qualitative research isn’t generalizable in the traditional sense, but it helps nurses open their minds to others’ experiences. For example, nurses can protect patient autonomy by understanding them and not reducing them to universal protocols or plans. As Munhall states, “Each person we encounter help[s] us discover what is best for [him or her]. The other person, not us, is truly the expert knower of [him- or herself].” Qualitative nursing research helps us understand the complexity and many facets of a problem and gives us insights as we encourage others’ voices and searches for meaning.

qualitative case study of nurses

When paired with clinical judgment and other evidence, qualitative research helps us implement evidence-based practice successfully. For example, a phenomenological inquiry into the lived experience of disaster workers might help expose strengths and weaknesses of individuals, populations, and systems, providing areas of focused intervention. Or a phenomenological study of the lived experience of critical-care patients might expose factors (such dark rooms or no visible clocks) that contribute to delirium.

Successful implementation

Qualitative nursing research guides understanding in practice and sets the foundation for future quantitative and qualitative research. Knowing how to conduct and evaluate qualitative research can help nurses implement evidence-based practice successfully.

When evaluating a qualitative study, you should consider it as a whole. The following questions to consider when examining study quality and evidence of rigor are adapted from the Standards for Reporting Qualitative Research.

Jennifer Chicca is a PhD candidate at the Indiana University of Pennsylvania in Indiana, Pennsylvania, and a part-time faculty member at the University of North Carolina Wilmington.

Amankwaa L. Creating protocols for trustworthiness in qualitative research. J Cult Divers. 2016;23(3):121-7.

Cuthbert CA, Moules N. The application of qualitative research findings to oncology nursing practice. Oncol Nurs Forum . 2014;41(6):683-5.

Guba E, Lincoln Y. Competing paradigms in qualitative research . In: Denzin NK, Lincoln YS, eds. Handbook of Qualitative Research. Thousand Oaks, CA: SAGE Publications, Inc.;1994: 105-17.

Lincoln YS, Guba EG. Naturalistic Inquiry . Thousand Oaks, CA: SAGE Publications, Inc.; 1985.

Munhall PL. Nursing Research: A Qualitative Perspective . 5th ed. Sudbury, MA: Jones & Bartlett Learning; 2012.

Nicholls D. Qualitative research. Part 1: Philosophies. Int J Ther Rehabil . 2017;24(1):26-33.

Nicholls D. Qualitative research. Part 2: Methodology. Int J Ther Rehabil . 2017;24(2):71-7.

Nicholls D. Qualitative research. Part 3: Methods. Int J Ther Rehabil . 2017;24(3):114-21.

O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: A synthesis of recommendations. Acad Med . 2014;89(9):1245-51.

Polit DF, Beck CT. Nursing Research: Generating and Assessing Evidence for Nursing Practice . 10th ed. Philadelphia, PA: Wolters Kluwer; 2017.

Thorne S. Saturation in qualitative nursing studies: Untangling the misleading message around saturation in qualitative nursing studies. Nurse Auth Ed. 2020;30(1):5. naepub.com/reporting-research/2020-30-1-5

Whittemore R, Chase SK, Mandle CL. Validity in qualitative research. Qual Health Res . 2001;11(4):522-37.

Williams B. Understanding qualitative research. Am Nurse Today . 2015;10(7):40-2.

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A Qualitative Case Study Exploring Nurse Engagement With Electronic Health Records and E-Prescribing


  • 1 Creighton University Center for Health Services Research and Patient Safety, Omaha, NE, USA Creighton University College of Nursing, Omaha, NE, USA [email protected].
  • 2 Creighton University Center for Health Services Research and Patient Safety, Omaha, NE, USA Creighton University School of Pharmacy and Health Professions, Omaha, NE, USA.
  • PMID: 25576327
  • DOI: 10.1177/0193945914567359

There is a national focus on the adoption and use of electronic health records (EHRs) with electronic prescribing (e-Rx) for the goal of providing safe and quality care. Although there is a large body of literature on the benefits of adoption, there is also increasing evidence of the unintentional consequences resulting from use. As little is known about how use of EHR with e-Rx systems affects the roles and responsibilities of nurses, the purpose of this qualitative case study was to describe how nurses adapt to using an EHR with e-Rx system in a rural ambulatory care practice. Six themes emerged from the data. Findings revealed that nurses adjust their routine in response to providers' preferential behavior about EHR with e-Rx systems yet retained focus on the patient and care coordination. Although perceived as more efficient, EHR with e-Rx adoption increased workload and introduced safety risks.

Keywords: community; location of care; methods; nurses; nurses as subjects; patient safety; qualitative; workload.

© The Author(s) 2015.

Publication types

  • Research Support, U.S. Gov't, P.H.S.
  • Attitude of Health Personnel*
  • Electronic Health Records / trends*
  • Electronic Prescribing*
  • Nurses / psychology*
  • Qualitative Research

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  • R24HS018625/HS/AHRQ HHS/United States

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  • Roberta Heale 1 ,
  • Alison Twycross 2
  • 1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
  • 2 School of Health and Social Care , London South Bank University , London , UK
  • Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca


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What is it?

Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… ‘a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units’. 1 A case study has also been described as an intensive, systematic investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

Often there are several similar cases to consider such as educational or social service programmes that are delivered from a number of locations. Although similar, they are complex and have unique features. In these circumstances, the evaluation of several, similar cases will provide a better answer to a research question than if only one case is examined, hence the multiple-case study. Stake asserts that the cases are grouped and viewed as one entity, called the quintain . 6  ‘We study what is similar and different about the cases to understand the quintain better’. 6

The steps when using case study methodology are the same as for other types of research. 6 The first step is defining the single case or identifying a group of similar cases that can then be incorporated into a multiple-case study. A search to determine what is known about the case(s) is typically conducted. This may include a review of the literature, grey literature, media, reports and more, which serves to establish a basic understanding of the cases and informs the development of research questions. Data in case studies are often, but not exclusively, qualitative in nature. In multiple-case studies, analysis within cases and across cases is conducted. Themes arise from the analyses and assertions about the cases as a whole, or the quintain, emerge. 6

Benefits and limitations of case studies

If a researcher wants to study a specific phenomenon arising from a particular entity, then a single-case study is warranted and will allow for a in-depth understanding of the single phenomenon and, as discussed above, would involve collecting several different types of data. This is illustrated in example 1 below.

Using a multiple-case research study allows for a more in-depth understanding of the cases as a unit, through comparison of similarities and differences of the individual cases embedded within the quintain. Evidence arising from multiple-case studies is often stronger and more reliable than from single-case research. Multiple-case studies allow for more comprehensive exploration of research questions and theory development. 6

Despite the advantages of case studies, there are limitations. The sheer volume of data is difficult to organise and data analysis and integration strategies need to be carefully thought through. There is also sometimes a temptation to veer away from the research focus. 2 Reporting of findings from multiple-case research studies is also challenging at times, 1 particularly in relation to the word limits for some journal papers.

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

One of the authors of this paper (AT) has used a case study approach to explore nurses’ paediatric pain management practices. This involved collecting several datasets:

Observational data to gain a picture about actual pain management practices.

Questionnaire data about nurses’ knowledge about paediatric pain management practices and how well they felt they managed pain in children.

Questionnaire data about how critical nurses perceived pain management tasks to be.

These datasets were analysed separately and then compared 7–9 and demonstrated that nurses’ level of theoretical did not impact on the quality of their pain management practices. 7 Nor did individual nurse’s perceptions of how critical a task was effect the likelihood of them carrying out this task in practice. 8 There was also a difference in self-reported and observed practices 9 ; actual (observed) practices did not confirm to best practice guidelines, whereas self-reported practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led Clinics (NPLCs)

The other author of this paper (RH) has conducted a multiple-case study to determine the quality of care for patients with complex clinical presentations in NPLCs in Ontario, Canada. 10 Five NPLCs served as individual cases that, together, represented the quatrain. Three types of data were collected including:

Review of documentation related to the NPLC model (media, annual reports, research articles, grey literature and regulatory legislation).

Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their perceptions of the impact of the NPLC model on the quality of care provided to patients with multimorbidity.

Chart audits conducted at the five NPLCs to determine the extent to which evidence-based guidelines were followed for patients with diabetes and at least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and themes arose related to the quality of care for complex patients at NPLCs. The multiple-case study confirmed that nurse practitioners are the primary care providers at the NPLCs, and this positively impacts the quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs. This, along with insufficient resources in the communities where NPLCs are located and high patient vulnerability at NPLCs, have a negative impact on the quality of care. 10

These examples illustrate how collecting data about a single case or multiple cases helps us to better understand the phenomenon in question. Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.

  • Gustafsson J
  • Calanzaro M
  • Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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Data analysis Previous     Next

Qualitative case study data analysis: an example from practice, catherine houghton lecturer, school of nursing and midwifery, national university of ireland, galway, republic of ireland, kathy murphy professor of nursing, national university of ireland, galway, ireland, david shaw lecturer, open university, milton keynes, uk, dympna casey senior lecturer, national university of ireland, galway, ireland.

Aim To illustrate an approach to data analysis in qualitative case study methodology.

Background There is often little detail in case study research about how data were analysed. However, it is important that comprehensive analysis procedures are used because there are often large sets of data from multiple sources of evidence. Furthermore, the ability to describe in detail how the analysis was conducted ensures rigour in reporting qualitative research.

Data sources The research example used is a multiple case study that explored the role of the clinical skills laboratory in preparing students for the real world of practice. Data analysis was conducted using a framework guided by the four stages of analysis outlined by Morse ( 1994 ): comprehending, synthesising, theorising and recontextualising. The specific strategies for analysis in these stages centred on the work of Miles and Huberman ( 1994 ), which has been successfully used in case study research. The data were managed using NVivo software.

Review methods Literature examining qualitative data analysis was reviewed and strategies illustrated by the case study example provided.

Discussion Each stage of the analysis framework is described with illustration from the research example for the purpose of highlighting the benefits of a systematic approach to handling large data sets from multiple sources.

Conclusion By providing an example of how each stage of the analysis was conducted, it is hoped that researchers will be able to consider the benefits of such an approach to their own case study analysis.

Implications for research/practice This paper illustrates specific strategies that can be employed when conducting data analysis in case study research and other qualitative research designs.

Nurse Researcher . 22, 5, 8-12. doi: 10.7748/nr.22.5.8.e1307

This article has been subject to double blind peer review

None declared

Received: 02 February 2014

Accepted: 16 April 2014

Case study data analysis - case study research methodology - clinical skills research - qualitative case study methodology - qualitative data analysis - qualitative research

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qualitative case study of nurses

15 May 2015 / Vol 22 issue 5




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  • Open access
  • Published: 25 March 2024

Outcomes of professional misconduct by nurses: a qualitative study

  • Shokoh Varaei   ORCID: orcid.org/0000-0001-7126-2014 1 ,
  • Nahid Dehghan Nayeri   ORCID: orcid.org/0000-0003-1594-6790 2 ,
  • Leila Sayadi   ORCID: orcid.org/0000-0001-7613-3051 3 ,
  • Mehraban Shahmari   ORCID: orcid.org/0000-0002-2501-8667 4 &
  • Akram Ghobadi   ORCID: orcid.org/0000-0002-7673-7362 5  

BMC Nursing volume  23 , Article number:  200 ( 2024 ) Cite this article

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Professional misconduct by nurses is a critical challenge in providing safe quality care, which can lead to devastating and extensive outcomes. Explaining the experiences of clinical nurses and nursing managers in this regard using an in-depth qualitative method can be beneficial. This study was conducted with the aim of explaining the experiences of nurses regarding the outcomes of professional misconduct.

The present study used a qualitative descriptive with a conventional content analysis approach. A total of 22 clinical nurses and nursing managers were selected through purposive sampling until data saturation was reached. Data were collected using semi-structured in-depth interviews and analyzed using Graneheim and Lundman’s approach.

Analyzed data were categorized into four main themes and 11 subthemes: (1) Physical outcomes: critical threat and weakening patients’ safety; (2) Psychological outcomes: psycho-emotional responses of patients and their families, moral distress, and cautionary tale of nurses; (3) Financial outcomes: imposing costs on the patient and financial loss of the nurse; (4) Organizational outcomes: the normalization of misconduct, chaos in the organization, waste of the organization’s resources, and reputational damage to the organization.

Professional misconduct by nurses can have adverse outcomes for patients in physical, mental, and financial dimensions, their families, nurses, and healthcare organizations. Therefore, it is indispensable to adopt management strategies to reduce the rate of professional misconduct.

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Nurses play a vital role in ensuring patients’ well-being and recovery. They are patients’ trustworthy caregivers, advocates, and instructors [ 1 ]. According to the code of ethics for nurses, they have the responsibility for protecting the patient, society, and the profession against possible harm [ 2 ]. Maintaining nurses’ ethical standards and professional conduct is imperative in ensuring patient safety, trust, and integrity of the nursing profession [ 1 , 3 , 4 ]. In the nursing profession as a caring and humane profession, there is the possibility of another reality termed professional misconduct [ 5 , 6 , 7 ]. Professional misconduct refers to any practice or action by nurses that deviates from the established ethical and professional standards and guidelines [ 8 , 9 ].

Professional misconduct in nursing is a multifaceted issue with wide-ranging outcomes in patient safety (physical and mental harm or even death), trust in the healthcare system, and healthcare workers’ well-being. Professional misconduct can damage the profession’s reputation and weaken nurses’ vital role in society [ 10 , 11 ].

Considering that professional misconduct weakens the integrity of nursing practice, perceiving consequences is of particular importance for nurses, healthcare managers, and policymakers since it emphasizes the prominence of maintaining the highest professional standards [ 12 ]. As part of a broader research initiative, this study extensively examines the multifaceted repercussions of such misconduct, extending beyond immediate effects, to deepen understanding across various dimensions. Given healthcare organizations’ mandate to deliver high-standard care with minimal harm, comprehending these implications becomes paramount. The research enhances related knowledge by categorizing the consequences of misconduct, highlighting potential dangers and irreparable harm. Also, it emphasizes the imperative of responsibility and ethical conduct to enhance patient quality and safety. Through this endeavor, the study addresses gaps in understanding within the field.

Study design, setting, and participants

This qualitative descriptive study was conducted through the generic qualitative design and content analysis approach to data analysis. The study setting was different wards of general and referral hospitals in the capital of one of the western provinces of Iran. The participants included in the study were selected using purposive sampling. The inclusion criteria included at least a bachelor’s degree in nursing, an experience of observing professional misconduct by colleagues, and the willingness to discuss experiences. Before conducting the interview, the researcher coordinated the interview time and location while establishing communication with the eligible participants and explaining the study objectives. In order to achieve maximum diversity and richness of data, participants with diverse personal and professional characteristics were selected. Sampling continued until saturation, resulting in the inclusion of 22 nurses and nursing managers aged between 25 and 48 years (Table  1 ).

Data collection

After preparing the interview guide using the expert opinions of the research team, the data were collected through a semi-structured individual interview. Each interview lasted between 45 and 90 min. Data collection was performed by the first author under the supervision and cooperation of the research team. Participants were asked: “Describe your experience on the outcomes of professional misconduct.” “Who is affected by the outcomes of professional misconduct? Explain it.” At the end of the interview, open questions were asked. The interviews were recorded using a mobile phone with the participants’ permission. Data collection and analysis were performed simultaneously from February 2021 to August 2021.

Data analysis

The conventional content analysis method was employed by following five steps proposed by Graneheim and Lundman [ 13 ]: (1) Implementing the entire interview immediately after each interview, (2) Reading the entire text several times to get an overall understanding of its content, (3) Determining semantic units and basic codes, (4) Classifying primary codes in more comprehensive categories, and (5) Determining the main theme of categories.

Interviews were recorded and transcribed using Word software, followed by iterative readings for content understanding. Semantic units were identified based on study objectives, and primary codes were derived. The initial codes were categorized, and the main and sub-themes were determined. Data management was facilitated by MAXQDA10 software.

It is noteworthy that the researcher, aimed to maintain objectivity during the coding process by closely aligning the codes with the data, and setting aside personal biases and preconceptions.


The following strategies were used to establish the trustworthiness of Study [ 14 ] Credibility was achieved through trust-based communication and prolonged engagement with the participants and the data and by providing a lot of time for data collection. Dependability was ensured by checking the consistency between quotes and codes/subthemes by the research team and two external observers familiar with qualitative research. In addition, confirmability was established by presenting the quotes extracted from each interview and returning the text of several interviews to a number of participants and applying their opinions, Transferability was enhanced by selection of participants with maximum diversity in terms of age, gender, work experience, educational level and position and detailed description of the research process, participant characteristics, and study context. In addition, quotes were expressed directly by providing each participant’s quote (P).

Ethical considerations

The Joint Ethics Committee of the Faculty of Nursing, Midwifery, and Rehabilitation of Tehran University of Medical Sciences approved this study with the ethics code IR.TUMS.FNM.REC.1400.187. The study objectives were explained to the participants at the beginning of the interviews. Due to the disapproving nature of professional misconduct and the sensitivity of the issue, the possibility of voluntary participation, confidentiality, and anonymity of individuals and their organizations were guaranteed. Written informed consent was obtained from all participants. Transcripts were securely stored in an encrypted file on a personal computer and destroyed following data analysis to further protect the confidentiality of participants.

The outcomes of professional misconduct by nurses were categorized into four main themes and 11 sub-themes (Table  2 ).

Physical outcomes

Data analysis indicated that patients were the primary individuals affected by professional misconduct by nurses and experienced more harm than other parties. One of the most critical outcomes of misconduct is the physical impact on patients. This theme is subdivided into two aspects: critical threat and undermining of patient safety.

Critical threat to patients

The participants’ experience showed that professional misconduct by nurses exposes patients to critical and adverse events such as death, disability such as leg amputation, and critical injuries such as pneumothorax, finger gangrene, tissue necrosis, burns, bleeding, and falls.

“ The patient was critically ill and we announced the CPR code ten minutes after the shift was handed over. We checked and noticed that they hadn’t inserted an IV line for him. It was impossible to do it with a blood pressure of 65. We finally inserted the intravenous) IV (, but it was in vain…” (Participant 9).

Weakening patients’ safety

According to the participants’ experiences, in addition to critical injuries, less life-threatening injuries such as mouth sores and infections could occur following professional misconduct by nurses. There was also the possibility of unwanted side effects. Yet most of these complications may not appear right away and be noticed after discharge from the hospital.

“ One of the colleagues, as she said, made a potion, combined several antibiotics into the Microset, and injected it into the patient .” (Participant 14).

This theme shows that considering the physical aspect, professional misconduct by nurses ultimately leads to a decrease in the quality of care and safety and delays the treatment process.

Psychological outcomes

Based on data analysis, professional misconduct by nurses affects psychological aspects in addition to physical dimensions. This outcome may involve not only patients but also their families and nurses. This theme includes the psycho-emotional responses of patients and their families, moral distress, and edification of nurses.

Psycho-emotional responses of patients and their families

Nurses’ experiences showed that professional misconduct sometimes caused psycho-emotional reactions in the patient or their companions. These side effects were reported as crying, feeling abandoned, distrust, dissatisfaction, cursing, aggression, objection, reporting to the authorities, and complaints.

“ At the beginning of the outbreak, a patient suspected of being infected with coronavirus was hospitalized in the ward and was left in the room; the door was closed. She was ordered not to get out of the room because she could spread the coronavirus to other patients; she was crying all the time.” (Participant 11).

Moral distress of nurses

Sometimes, the repercussions of professional misconduct by a nurse affect both the perpetrator and the cooperating and witnessing nurse. The participants stated that, at times, they experienced various emotional reactions, including discomfort, remorse, guilt, and even psychological complications and quitting work after committing misconduct. In addition, the colleagues of a nurse who is the perpetrator of the misconduct may express regret, discomfort, and anger upon witnessing this situation.

“ I know that catheterization is a sterile procedure, and I’m fully aware of it, but at that moment, there may not be a betadine or a sterile set or gloves. I may not do it correctly and scientifically as I should, which is really sad. Most of the time, we feel guilty.” (Participant 10).

Cautionary tale

According to some participants’ experiences, the effect of a nurse’s encounter with a colleague’s misconduct depended on the morale and personality of the witnessing nurse. By witnessing misconduct and its negative outcomes for the patient and the nurse committing it, the nurse may learn never to commit such misconduct. According to the famous quote, “A man profits more by the sight of an idiot than by the orations of the learned,” it should also be instructive and improve patient care quality.

“ Misconduct by a colleague can influence the nurse seeing it and make them improve, that is, not perform that wrong deed. Due to a written warning to a few colleagues because of the rapid infusion of antibiotics, the others learned and are now very careful .” (Participant 10).

This theme showed that professional misconduct by nurses might harm patients not only physically but also mentally and occasionally cause psychological problems for the nurses. It should be noted that, besides all the negative outcomes, professional misconduct by nurses has a positive consequence, which is a cautionary tale of other nurses and, subsequently, efforts to improve care.

Financial outcomes

Data analysis showed that another outcome of professional misconduct by nurses was the financial outcomes that could affect the patient or nurse. This theme includes two subthemes: ‘imposing costs on the patient’ and ‘financial loss of the nurse.’

Imposing costs on the patient

According to the obtained data, additional costs are imposed on the patient due to adverse events and unwanted complications caused by the reduced care quality resulting from professional misconduct by nurses. These costs may be related to increased length of hospital stay and the need for additional procedures or medication.

“ Unfortunately, some colleagues don’t observe the principles of sterile technique when dressing, which can cause the patient to return with an infection at the surgery site and need to take intravenous antibiotics such as Ciprofloxacin and Clindamycin and be hospitalized for a few days, all of which impose an additional cost to the patient.” (Participant 11).

The financial loss of the nurse

Several participants’ experiences showed that the nurse might experience legal issues such as warnings, reprimands, and referrals to the administrative violations department following committing misconduct, which, especially if repeated, could negatively affect the process of recruiting the training nurses or changing their employment status, in-service promotion process when being appointed to a position until retirement. Based on the participants’ experiences, addressing misconduct might have financial outcomes for the nurse who committed it. These financial damages included a deduction of salary and wages, no further promotion after warning, reprimand and its negative impact on salary, and incurring damages.

“Our nurse colleague hadn’t paid attention to the warmer’s temperature. The mask on the baby’s nose was almost burnt and caused nasal necrosis. The baby’s family pursued it. The nurse was fined to pay the damages. ” (Participant 8).

This theme generally indicated the financial damages resulting from professional misconduct by nurses, which might affect patients and nurses.

Organizational outcomes

Professional misconduct by nurses has negative outcomes not only for individuals but also for the organization. This theme includes the subthemes of normalization of misconduct, chaos in the organization, waste of the organization’s resources, and reputational damage to the organization.

The normalization of misconduct

Participants stated that one of the organizational outcomes of misconduct was its normalization for the perpetrator, modeling, and contagion of misconduct to other colleagues, leading to the normalization of erroneous conduct in the organization.

“M isconduct possibly affects others as well, as it is considered a routine, as they think somebody did it, and there was no problem. Now, in ward X, it has become routine that vital signs aren’t monitored and are only recorded .’ (Participant 10).

Chaos in the organization

The data analysis showed that due to professional misconduct by nurses, colleagues might be forced to compensate for their colleague’s misconduct by carrying out the medical orders for the maltreated patient. As a result, nurses usually avoided working shifts together with that nurse. There might also be turmoil, chaos, arguments, protests, complaints, and even physical encounters between patients and their companions with the medical staff or colleagues.

“ My colleague’s work burden falls on my shoulders, so I should also manage her duty. For example, in my shift, I followed up on a medicine that had to be prepared in the previous shift and made a prescription for the patient; the patient prepared it but growled at me because the medicine was expensive. The doctor talked to me as if I was the one who hadn’t done it while it hadn’t been followed up in the previous shift .” (Participant 19). “ Colleagues who impatiently do the patient’s tasks get angry at the patient. The patient or the companion asks one question or two; upon the third question, they conflict with the patient’s companion. We have a code called code 44 for a security guard, which is often announced during their shifts.” (Participant 19).

Waste of the organization’s resources

After analyzing the data, it was revealed that due to the professional misconduct by nurses, the patient might need a transfer to the intensive care unit or more specialized centers, additional procedures, such as debridement, intubation, dialysis, surgery, re-surgery, or cancellation of surgery, increased hospital stay, and re-hospitalization. By jeopardizing the quality and safety of patient care, these cases lead to complications, and managing them can impose additional costs on the hospital. Some participants believed that failure to provide optimal care caused the patient’s condition to aggravate and the nurse’s workload to increase.

“ The patient, who was just discharged from the operating room, was bleeding badly. The nurse hadn’t followed up or informed the doctor. The patient was transferred to the ICU due to severe bleeding and was treated for approximately 15–16 days. He was operated on twice .” (Participant 14).

In addition, nurses’ professional misconduct directly leads to the waste of resources and equipment.

“ For example, in the COVID-19 situation, when the equipment and supplies were scarce from the beginning, they rationed it for the wards. A male colleague poured Septicidine. Well, it was wasted. It could be used in the COVID-19 ward .” (Participant 7).

Reputational damage to the organization

According to the data analysis, professional misconduct could lead to damage to the reputation and credibility of the nursing profession and loss of public trust in nurses and healthcare organizations in general.

“ Sometimes we refer the patient to a certain hospital, but they say they wouldn’t go there even if they die. They believe whoever is referred to that hospital won’t stay alive .” (Participant 13).

This theme revealed outcomes of misconduct that threatened and affected the healthcare organization.

In the present study, nurses’ experiences regarding the outcomes of professional misconduct were investigated. The results showed that this phenomenon had widespread outcomes in different dimensions and levels, including patients, nurses, and healthcare organizations. In line with the present study, researchers concluded in a systematic review that unprofessional conduct included multidimensional issues and serious outcomes concerning patient safety, nurses, colleagues, managers, and healthcare organizations [ 6 ].

One of the significant outcomes of professional misconduct is physical outcomes, which can critically threaten patients’ health and life or jeopardize their safety. In a review, the threat to patients’ safety has been identified as the main reason for adopting disciplinary measures against nurses [ 15 ]. In addition, in a qualitative study, various unsafe practices leading to physical harm to patients have been identified and classified [ 16 ]. In line with the present study, Rooddehghan et al. (2018) reported that missed nursing care could lead to the elimination or postponement of scheduled therapies, which causes serious life threats, complications, and, as a result, patient dissatisfaction [ 17 ]. Professional misconduct in health care can jeopardize patients’ safety, health, and well-being [ 5 , 18 , 19 ]. Since the main goal of health care is to provide quality and safe care to patients, the physical outcomes of professional misconduct by nurses are considered the most important outcomes, and their prevention is absolutely vital.

Another consequence of professional misconduct by nurses is its psychological effects on patients and nurses. Healthcare workers’ misconduct can cause psychological harm to patients, including anxiety, feeling insulted, and fear [ 18 ]. Moreover, misconduct demonstrates the violation of patients’ human rights and dignity [ 7 ]. Since the quality of services provided to patients is an important component of their satisfaction [ 20 ], professional misconduct can reduce patient satisfaction by negatively affecting the quality of care. Nurses charged with professional misconduct face a variety of outcomes, including psychological, physical, and mental suffering [ 21 ]. Furthermore, observing misconduct can lead to moral and emotional distress, sympathy for patients, and increased negative emotions such as distress, sorrow, guilt, bias, and negative stigma in fellow nurses [ 18 , 22 ]. These nurses may to leave their positions and may experience anxiety, sleep disturbances, and uncertainty in dealing with their colleagues [ 16 ]. In general, professional misconduct can cause psychological problems not only for patients but also for nurses, which supports the need for prevention and corrective action.

Unprofessional conduct is a complex phenomenon that impacts nurses’ practice [ 6 ]. In the present study, it was found that professional misconduct could serve as edification for other nurses. In other words, misconduct by colleagues can serve as a cautionary tale to assist nurses in improving their performance. In this regard, studies have shown that unsafe practices by colleagues and related complaints can provide an opportunity for nurses to strengthen their abilities by focusing more on themselves and being more attentive, and contribute to professional development and increased patient safety [ 16 , 23 ]. Therefore, it seems that, when encountering colleague misconduct, nurses can use negative experiences in the organization and enhance their skills and precision in order to improve professional conduct and patient safety.

Other outcomes of professional misconduct by nurses obtained in the present study were financial outcomes that could affect patients and nurses. In line with this finding, a study shows that unsafe practices can impose additional costs on patients [ 24 ]. The financial losses of nurses caused by professional misconduct can be related to legal outcomes such as restrictions, suspension, revocation of professional license, or finement [ 15 , 25 , 26 ]. It can be concluded that, regarding economic issues, professional misconduct by nurses can harm the patients and even the nurses.

Professional misconduct by nurses has outcomes not only for patients and nurses but also for the healthcare organization. These outcomes include issues such as the normalization of misconduct, chaos in the organization, waste of the organization’s resources, and reputational damage to the organization. These issues can reduce the organization’s efficiency and cause concerns about the safety and quality of services provided by nurses. Professional misconduct is often initiated by one individual; however, it can spread quickly, change the organization’s dominant values, norms, and behaviors, and become established [ 27 ]. These disciplinary processes affect the nursing profession, and these impacts become more significant in retaining nurses, particularly in global staffing shortage conditions [ 25 ]. In addition, professional misconduct in health care can jeopardize the quality of nurses’ teamwork [ 5 ], increase colleagues’ workload [ 22 ], and threaten the organization’s long-term credibility and ultimate sustainability by deviating the organization from achieving its main goals [ 10 ]. Misconduct in health care can cause patients and the general public to mistrust medical affairs and damage the reputation of the nursing profession and the organization [ 24 , 28 , 29 ]. Jeopardizing satisfactory standards of practice is a clear violation of nursing ethics, norms, and laws, particularly public trust in nurses and the nursing profession as a whole [ 30 ]. To prevent these challenges, the organization can create a safety culture, develop protocols to report misconduct, and encourage and support nurses. These measures can prevent misconduct, help increase public trust in the nursing profession, and improve the working conditions of nurses.

The present study had several limitations. At first, some participants had doubts about the confidentiality of their names and institutional information in the study. This concern was resolved by assuring them about the anonymity and confidentiality of the information. This research was conducted qualitatively, and therefore, the generalizability of the findings is limited.

According to the results of this study, it is revealed that the outcomes of professional misconduct in the nursing field affect not only patients and nurses but also the healthcare organization. The outcomes of professional misconduct have diverse and widespread dimensions. Physically, professional misconduct can lead to a critical threat to patients or jeopardize their safety. Psychologically, it can create psychological responses in patients and nurses or become an edification for other nurses. Financially, it might impose costs on patients and financial losses for nurses. Organizational effects include the normalization of misconduct, chaos in the organization, waste of resources, and damage to the dignity and credibility of the organization. To prevent these complications, there is a need for programs and management measures to deal with professional misconduct and ensure the provision of safe, quality, and compassionate care to patients. To reduce serious outcomes, further studies in diverse nursing communities are required.

Data availability

Availability of data and materials: Data are available by contacting the corresponding author.


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The research team appreciates the School of Nursing and Midwifery of Tehran University of Medical Sciences.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Shokoh Varaei

Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran

Nahid Dehghan Nayeri

School of nursing & midwifery, Nursing and Midwifery Care Research Center, Tehran University of Medical Sciences, Tehran, Iran

Leila Sayadi

Department of Medical-Surgical, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran

Mehraban Shahmari

School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran

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Study conception and design: ShV, NDN, and AGh; Drafted the article: AGh, NDN,LS,MSh and ShV; Critical revision of the article: NDN,LS,MSh and ShV; Approved the version to be published: AGh, NDN,LS,MSh and ShV.

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The proposal for this study was approved by the Ethics Committee of the Research Council of Tehran University of Medical Sciences (TUMS), with the IR.TUMS.FNM.REC.1400.187. To participate in the study informed written consent obtained from the participants.

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Varaei, S., Nayeri, N.D., Sayadi, L. et al. Outcomes of professional misconduct by nurses: a qualitative study. BMC Nurs 23 , 200 (2024). https://doi.org/10.1186/s12912-024-01859-3

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Organizational learning starting points and presuppositions: a case study from a hospital’s surgical department.

Jaakkola M, Lemmetty S, Collin K, et al. Organizational learning starting points and presuppositions: a case study from a hospital’s surgical department. Learn Org. 2024;31(3):337-357. doi:10.1108/tlo-12-2022-0160.

Organizational learning is a continuous process of integrating data and knowledge to ensure improvement. This qualitative study focuses on the starting points and presuppositions of organizational learning within a surgical department. Starting points for individual learning were informal and based on day-to-day work (e.g., solving a specific problem) and organizational learning encompassed more formal and intentional practices. Factors presupposing and framing the learning process can be divided into four categories: leadership and roles, practices and resources, collaboration and climate, and motivation and activity.

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Clinical handover of patients arriving by ambulance to the emergency department: a literature review. October 13, 2010

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Hamilton Acute Pain Service Safety Study: using root cause analysis to reduce the incidence of adverse events. April 2, 2014

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Team safety and innovation by learning from errors in long-term care settings. August 22, 2012

Quantitative assessment of workload and stressors in clinical radiation oncology. June 13, 2012

Handing over patient care: is it just the old broken telephone game? November 9, 2011

Investigating US medical students' motivation to respond to lapses in professionalism. October 3, 2018

The relationship between patient safety climate and occupational safety climate in healthcare—a multi-level investigation. August 16, 2017

Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic. March 1, 2017

Patient safety culture: the impact on workplace violence and health worker burnout. February 8, 2023

How does workplace violence-reporting culture affect workplace violence, nurse burnout, and patient safety? December 7, 2022

Misreading injectable medications—causes and solutions: an integrative literature review. April 29, 2020

Work hours, work stress, and collaboration among ward staff in relation to risk of hospital-associated infection among patients. March 25, 2009

Hand-off communication: a requisite for perioperative patient safety. November 19, 2008

Bedside handover: quality improvement strategy to "transform care at the bedside." November 12, 2008

Outreach and Early Warning Systems (EWS) for the prevention of Intensive Care admission and death of critically ill adult patients on general hospital wards. August 8, 2007

What do medical records tell us about potentially harmful co-prescribing? July 18, 2007

Potassium and phosphorus repletion in hospitalized patients: implications for clinical practice and the potential use of healthcare information technology to improve prescribing and patient safety. February 14, 2007

Patient Safety Leadership WalkRounds™ at Partners HealthCare: learning from implementation. August 10, 2005

Patient safety culture in nursing: a dimensional concept analysis. July 30, 2008

Errors in the medication process: frequency, type, and potential clinical consequences. March 6, 2005

Potentially inappropriate medication use among elderly home care patients in Europe. April 15, 2005

Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting. October 25, 2006

Critical care nurses' role in rapid response teams: a qualitative systematic review. May 22, 2024

Pediatric Readiness in the Emergency Department. November 1, 2018

Patients' perspectives on quality and patient safety failures: lessons learned from an inquiry into transvaginal mesh in Australia. May 8, 2024

Supporting error management and safety climate in ambulatory care practices: the CIRSforte study. May 1, 2024

Organizational learning in the morbidity and mortality conference. March 27, 2024

Inter-hospital transfer is an independent risk factor for hospital-associated infection. March 20, 2024

How do we learn about error? A cross-sectional study of urology trainees. June 28, 2023

Green Cross method in a postanaesthesia care unit: a qualitative study of the healthcare professionals' experiences after 3 years, including the COVID-19 pandemic period. June 14, 2023

Patient safety trends in 2022: an analysis of 256,679 serious events and incidents from the nation’s largest event reporting database. May 17, 2023

The relationship between patient safety culture and the intentions of the nursing staff to report a near-miss event during the COVID-19 crisis. April 5, 2023

Quality and safety: learning from the past and (re)imagining the future. March 29, 2023

Evaluation of policies limiting opioid exposure on opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large American health system. March 8, 2023

The incidence of opioid misuse among the surgical patients with persistent opioid use. February 8, 2023

Am I safe? An interpretative phenomenological analysis of vulnerability as experienced by patients with complications following surgery. January 18, 2023

Patients' experience of patient safety information and participation in care during a hospital stay. November 16, 2022

A health system that won't learn from its mistakes. September 21, 2022

Variation in the reporting of elective surgeries and its influence on patient safety indicators. July 6, 2022

Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care organizations. June 22, 2022

Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories. April 6, 2022

Morbidity and mortality caused by noncompliance with California hospital licensure: immediate jeopardies in California hospitals, 2007-2017. March 9, 2022

Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient. February 2, 2022

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care. October 27, 2021

Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation. October 20, 2021

Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program. September 29, 2021

Towards safer healthcare: qualitative insights from a process view of organisational learning from failure. August 25, 2021

Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with computer simulation. June 9, 2021

Learning during crisis: the impact of COVID-19 on hospital-acquired pressure injury incidence. June 2, 2021

Assessing patient safety culture in hospital settings. June 2, 2021

Achieving zero inequity: lessons learned from patient safety. May 27, 2021

Support for healthcare professionals after surgical patient safety incidents: a qualitative descriptive study in 5 teaching hospitals. May 26, 2021

To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. May 5, 2021

A human factors intervention in a hospital--evaluating the outcome of a TeamSTEPPS program in a surgical ward. April 14, 2021

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Article Contents

Healthcare professionals’ perspectives on use of pcsk9 inhibitors in cardiovascular disease: an in-depth qualitative study.

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Geraldine A Lee, Angela Durante, Edward E Baker, Ercole Vellone, Gabriele Caggianelli, Federica Dellafiore, Mutiba Khan, Rani Khatib, Healthcare professionals’ perspectives on use of PCSK9 inhibitors in cardiovascular disease: an in-depth qualitative study, European Journal of Cardiovascular Nursing , 2024;, zvae081, https://doi.org/10.1093/eurjcn/zvae081

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Injectable medicines such as PCSK-9 inhibitors are increasingly used to manage risk factors for cardiovascular events with little information around the perceptions of healthcare professionals (HCPs) on the administrative and clinical practicalities. The aim was to identify the facilitators and barriers on the use of injectable therapies with CV benefits through interviews with HCPs.

Qualitative interviews were conducted in the United Kingdom (London and Leeds) and Italy (Rome and Milan) in 2021. Coding was undertaken using NVivo and thematic analysis performed. A total of 38 HCPs were interviewed, 19 in each country composing of physicians (n = 18), pharmacists (n = 10), nurses (n = 9) and pharmacy technician (n = 1). Four themes emerged: (i) Clinicians’ previous experiences with injectable therapies (ii) Challenges with patients’ behaviours and beliefs (iii) Clinicians’ knowledge of injectable therapies and therapeutic inertia and (iv) Organisational and governance issues. The behaviour and beliefs from healthcare professionals focused on facilitating behaviour change as well as the poor interdisciplinary working and collaboration. Therapeutic inertia was raised where physicians either lacked awareness of injectable therapies or were unwilling to prescribe them. The importance of facilitating patient education on injection techniques was highlighted while organisational and governance issues identified the lack of guidance to inform practice. Clear pathways are required to identify those who were eligible for injectable therapies as well as on how injectables should be prescribed.

If medicine optimisation is to be achieved, there needs to be structured processes in place to identify eligible patients and the development of educational material.

Graphical Abstract

  • dyslipidemias
  • cardiovascular diseases
  • organizations
  • patient education
  • pharmacists
  • knowledge acquisition
  • behavioral change
  • cardiovascular event
  • qualitative research
  • pharmacy technicians
  • pcsk9 inhibitors

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This paper is in the following e-collection/theme issue:

Published on 23.5.2024 in Vol 8 (2024)

Barriers to Implementing Registered Nurse–Driven Clinical Decision Support for Antibiotic Stewardship: Retrospective Case Study

Authors of this article:

Author Orcid Image

Original Paper

  • Elizabeth R Stevens 1 , MPH, PhD   ; 
  • Lynn Xu 1 , MPH   ; 
  • JaeEun Kwon 1 , MPP   ; 
  • Sumaiya Tasneem 1 , MPH   ; 
  • Natalie Henning 1 , MPH   ; 
  • Dawn Feldthouse 1 , RN-BC, MSN   ; 
  • Eun Ji Kim 2 , MSc, MS, MD   ; 
  • Rachel Hess 3, 4 , MS, MD   ; 
  • Katherine L Dauber-Decker 2 , PhD   ; 
  • Paul D Smith 5 , MD   ; 
  • Wendy Halm 6, 7 , DNP   ; 
  • Pranisha Gautam-Goyal 2 , MD   ; 
  • David A Feldstein 6 , MD   ; 
  • Devin M Mann 1, 8 , MS, MD  

1 Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States

2 Northwell, New Hyde Park, NY, United States

3 Department of Population Health Sciences, University of Utah, Salt Lake City, UT, United States

4 Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States

5 Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States

6 Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States

7 University of Wisconsin-Madison School of Nursing, Madison, WI, United States

8 Department of Medicine, New York University Langone, New York, NY, United States

Corresponding Author:

Elizabeth R Stevens, MPH, PhD

Department of Population Health

New York University Grossman School of Medicine

180 Madison Ave

New York, NY, 10016

United States

Phone: 1 6465012558

Email: [email protected]

Background: Up to 50% of antibiotic prescriptions for upper respiratory infections (URIs) are inappropriate. Clinical decision support (CDS) systems to mitigate unnecessary antibiotic prescriptions have been implemented into electronic health records, but their use by providers has been limited.

Objective: As a delegation protocol, we adapted a validated electronic health record–integrated clinical prediction rule (iCPR) CDS-based intervention for registered nurses (RNs), consisting of triage to identify patients with low-acuity URI followed by CDS-guided RN visits. It was implemented in February 2022 as a randomized controlled stepped-wedge trial in 43 primary and urgent care practices within 4 academic health systems in New York, Wisconsin, and Utah. While issues were pragmatically addressed as they arose, a systematic assessment of the barriers to implementation is needed to better understand and address these barriers.

Methods: We performed a retrospective case study, collecting quantitative and qualitative data regarding clinical workflows and triage-template use from expert interviews, study surveys, routine check-ins with practice personnel, and chart reviews over the first year of implementation of the iCPR intervention. Guided by the updated CFIR (Consolidated Framework for Implementation Research), we characterized the initial barriers to implementing a URI iCPR intervention for RNs in ambulatory care. CFIR constructs were coded as missing, neutral, weak, or strong implementation factors.

Results: Barriers were identified within all implementation domains. The strongest barriers were found in the outer setting, with those factors trickling down to impact the inner setting. Local conditions driven by COVID-19 served as one of the strongest barriers, impacting attitudes among practice staff and ultimately contributing to a work infrastructure characterized by staff changes, RN shortages and turnover, and competing responsibilities. Policies and laws regarding scope of practice of RNs varied by state and institutional application of those laws, with some allowing more clinical autonomy for RNs. This necessitated different study procedures at each study site to meet practice requirements, increasing innovation complexity. Similarly, institutional policies led to varying levels of compatibility with existing triage, rooming, and documentation workflows. These workflow conflicts were compounded by limited available resources, as well as an implementation climate of optional participation, few participation incentives, and thus low relative priority compared to other clinical duties.

Conclusions: Both between and within health care systems, significant variability existed in workflows for patient intake and triage. Even in a relatively straightforward clinical workflow, workflow and cultural differences appreciably impacted intervention adoption. Takeaways from this study can be applied to other RN delegation protocol implementations of new and innovative CDS tools within existing workflows to support integration and improve uptake. When implementing a system-wide clinical care intervention, considerations must be made for variability in culture and workflows at the state, health system, practice, and individual levels.

Trial Registration: ClinicalTrials.gov NCT04255303; https://clinicaltrials.gov/ct2/show/NCT04255303


Antibiotic resistance is a major public health risk, with more than 35,000 deaths each year in the United States due to antibiotic-resistant bacterial infections [ 1 , 2 ]. Overprescribing and misuse of antibiotics for upper respiratory infections (URIs) remain the most significant combined factors causing antibiotic resistance [ 3 , 4 ]. In the United States, up to 50% of all outpatient antibiotic prescriptions for URIs are inappropriate [ 5 , 6 ].

An estimated 80%-90% of antibiotic prescribing occurs in outpatient settings, such as doctors’ offices, urgent care facilities, and emergency departments [ 7 - 9 ]. From 1996 to 2010, 72% of adult patients in primary care with a diagnosis of acute bronchitis received antibiotics contrary to guideline recommendations against antibiotic treatment, and prescription rates actually increased during this time frame [ 10 ]. Patients with sore throats received antibiotics 61% of the time when the prevalence of group A streptococcus, the only clear indication for antibiotics, was only 10% in adults [ 11 ].

By providing real-time evidence-based data to assist providers (physicians, nurse practitioners, and physician assistants) in estimating the likelihood of a patient having either pneumococcal pneumonia or group A streptococcus, electronic health record (EHR)–integrated clinical prediction rules (iCPRs) can help address prescriber-level barriers to antibiotic stewardship and reduce antibiotic prescribing for URIs in primary care [ 12 - 15 ]. Indeed, CPRs have already been validated to successfully distinguish between viral and bacterial respiratory infections [ 16 - 18 ].

While potentially effective, there is low uptake of the iCPR tools among physicians in primary care practices, thus indicating implementation barriers to antibiotic stewardship iCPRs among physicians [ 19 ]. This outcome is consistent with other literature, indicating that physicians perceive antibiotic stewardship as onerous and would require substantial assistance to change their antibiotic prescribing behaviors [ 20 ]. Due to these limitations associated with the physician-driven iCPR implementation model, such as “alert fatigue” and time constraints [ 21 , 22 ], the iCPR intervention was adapted so antibiotic stewardship tasks could be delegated to other qualified members of the medical team.

A registered nurse (RN)–driven implementation model of iCPR for low-acuity URIs has the potential to be an effective alternative to the physician-driven implementation model. RNs have demonstrated equivalent symptom resolution compared to physicians when using protocols to improve ambulatory care across a number of chronic diseases [ 23 ] as well as the treatment of acute minor illnesses [ 24 , 25 ]. Therefore, the iCPR intervention was adapted for RNs to include the identification of patients with low-acuity URI followed by clinical decision support (CDS)–guided RN visits. The intervention was implemented in February 2022 as a stepped-wedge trial in primary and urgent care practices within 4 academic health systems in New York, Wisconsin, and Utah [ 26 ].

Despite a seemingly straightforward URI clinical workflow, the RN-driven iCPR intervention encountered significant barriers early on during implementation. While these issues were pragmatically addressed as they arose during study implementation, a systematic assessment of the barriers to implementation is needed to better understand and address these barriers. The CFIR (Consolidated Framework for Implementation Research) [ 27 ] has been widely used to guide the systematic assessment of multilevel implementation contexts to identify contextual determinants of implementation success [ 28 ]. Using the updated CFIR as a guide [ 29 ], we sought to identify and categorize the barriers experienced during the implementation of the RN-driven antibiotic stewardship “iCPR3” intervention.

We performed a retrospective case study, collecting quantitative and qualitative data from expert interviews, study surveys, routine check-ins with practice personnel, and chart reviews over the first year of implementation of the iCPR3 intervention. We used the updated CFIR [ 29 ] to characterize the initial barriers to adapting a URI iCPR intervention for RNs in ambulatory care.

Ethical Considerations

The study protocol and procedures were approved by the NYU Langone Health institutional review board, which served as the study’s single institutional review board (NYULH Study: i19-01222). Informed consent was received from all participants. Documentation of consent was waived for this study. All study data reported in this manuscript are deidentified. Compensation was not provided for participation.

Study Intervention

The study intervention consists of triage followed by an in-person iCPR–guided RN visit for patients with low-acuity URIs ( Figure 1 ). RNs perform telephone triage (or in urgent care, an RN or medical assistant performs a similar assessment through a rooming protocol) for patients reporting cough or sore throat symptoms to assess acuity, need for primary care, urgent care, or ED visit, and appropriateness for an in-person iCPR–guided RN visit. In the urgent care setting, the assessment is dichotomous as either a need for a provider visit or appropriateness for an iCPR-guided RN visit. The triage tool consists of a prepopulated note template integrated into the EHR system designed to document patient symptoms and their severity and determine the most appropriate level of care. Triage algorithms were based on institutional triage resources for decisions about ED or urgent care visits, primary care visits, and home care [ 30 ].

Patients triaged as low acuity and appropriate for an RN visit are invited for an in-person RN visit that replaces the standard of care provider visit. During the RN visit, guided by iCPR tools, the RN evaluates a patient to determine their risk of bacterial infections of strep pharyngitis (sore throat) or pneumonia (cough). Prepopulated note template EHR tools lead RNs through a focused history and physical examination. Once an RN completes the patient history and physical examination, they use an iCPR tool specific to cough or sore throat to calculate the risk of bacterial infection based on the patient’s vitals, symptoms, and pertinent history [ 26 ]. The iCPR tools are informed by the CPRs [ 17 , 18 , 31 ] used in the iCPR1 and iCPR2 studies [ 12 , 19 ], which were validated in prior studies among patients with acute respiratory illnesses [ 17 , 18 , 31 ]. The CPRs are integrated into the EHR, and upon completion of the calculator, the level of risk with an approximate probability of having either strep pharyngitis or pneumonia is displayed. After completion of the risk calculator, the RN is linked by the EHR to an order set specific to the level of risk, along with relevant patient education.

qualitative case study of nurses

Setting and Participants

The iCPR3 intervention study was implemented in February 2022, as a randomized controlled stepped-wedge trial, in 43 primary and urgent care practices associated with 4 academic medical centers including 2 in New York, 1 in Wisconsin, and 1 in Utah. To be eligible for participation, a practice must include general internal medicine, family medicine, or urgent care practices. Furthermore, practices must have at least 1 RN full-time equivalent capable of performing triage within the EHR and in-person RN visits.

For this case study, purposive sampling was used to select experts with key knowledge and insight on study implementation from members of the research team and study practices. This sample included research study team members engaged in the implementation of the iCPR3 study (ie, research coordinators, research assistants, and investigators) and study practice personnel (ie, RNs, RN or practice managers, and providers) from each study site (academic medical center). At least 2 research study team members per site participated in semistructured interviews, with those experts determining which practice personnel to include in their data collection. All RNs participating in the iCPR3 intervention were included in study acceptability surveys and routine implementation check-ins with study staff.

Of note, approximately 8 months into iCPR3 implementation, 1 New York–based study site withdrew from the intervention study due to limited practice recruitment and insurmountable barriers to implementing the intervention. Interviews were still performed with site personnel and their comments are included in these analyses.

Data Collection

A semistructured interview guide containing questions based on the 5 domains of CFIR [ 27 , 29 ] was developed. The CFIR constructs supported the research team in defining topics for the interviews and ensured that all major domains in the framework that influence implementation were addressed. Interview questions did not explicitly name or ask participants to name the CFIR domains or constructs. The interviews were performed via in-depth email interviews [ 32 ], in which research study team interviewees were asked questions to identify which of the 48 CFIR constructs were perceived as current barriers to iCPR3 implementation and provided detailed descriptions of the identified barriers and strategies that have already been used by the iCPR3 research study team.

Surveys and Routine Check-Ins

The perspectives of practice personnel were incorporated into the case study based on notes from surveys; individual interviews; or written feedback from RNs, providers, and RN and practice managers collected over the implementation period as routine intervention study procedures. As this was a pragmatic study, study staff routinely elicited informal feedback from practice personnel throughout intervention implementation to identify barriers and improve intervention implementation.

At 6 and 12 months post-RN visit implementation, participating RNs completed a short survey that asked about burnout, job satisfaction, and comfort levels with performing tasks related to treating patients reporting cough and sore throat. The survey also collected information on ease of use of the EHR tools as well as feedback on elements of the intervention, such as training, and recommendations.

Chart Review

Clinical workflows and EHR note templates (triage and RN visits) use in the first 12 months of implementation were collected via chart review. A subset of EHR template uses initiated was evaluated for appropriateness and completeness. To determine the total number of potential patients in a practice eligible for triage template use, patients with visits resulting in a diagnosis code for cough or sore throat were documented ( International Classification of Diseases-10 [ ICD-10 ] codes: R05, R07.0, J20.9, J06.9, and J18.9). The EHR records related to the visit were reviewed to determine patient eligibility for triage and document the workflow leading to the patient visit (ie, how the appointment was scheduled, by whom, and whether appointment notes were present).

CFIR Domains and Constructs

The CFIR was used to retrospectively describe the implementation process of the iCPR3 intervention to identify determinants in this process. Only the determinants relevant to the iCPR3 intervention implementation process were described. The CFIR is composed of 48 constructs sorted into 5 major domains including innovation, outer setting, inner setting, individuals, and implementation process [ 27 , 29 ]. Operationalization of CFIR domains for this study are shown in Table 1 .

a iCPR3: integrated clinical prediction rule 3.

b RN: registered nurse.

Data Coding and Analysis

Insights gathered from the surveys, chart reviews, and formal and informal check-ins with study practice personnel helped inform research study team members’ responses to the semistructured interview guide. The written responses and notes collected from the email interviews were analyzed using techniques of qualitative content analysis, inspired by a deductive-directed approach, deemed applicable because the data were analyzed in light of an existing framework [ 33 ]. The analysis was performed by 3 authors (ERS, LX, and JK) in a stepwise interactive process. The first step in the analysis, after reading all transcripts, notes, and written responses to obtain an understanding of the whole, was to develop initial coding nodes and subnodes based on the domains and constructs of the CFIR [ 29 ].

In the second step, units of analysis, such as sentences or sections of thought, were deductively coded into the nodes and subnodes. Third, the coded text was rated based on the recommended method described by the authors of CFIR, Damschroder and Lowery [ 34 ]. In the rating process, a consensus process was used to assign a rating to each construct obtained from each study site. The ratings reflected the positive or negative influence and the strength of each construct that emerged based on the coded text. When all constructs obtained from all study sites were rated, we compared and compiled ratings for each construct across study sites. Constructs were coded as missing, not distinguishing between positive or negative implementation factors (0), or weakly (+1/–1), or strongly (+2/–2) distinguishing low from high implementation factors ( Table 2 ).

a CFIR: Consolidated Framework for Implementation Research.

b iCPR3: integrated clinical prediction rule intervention.

Barriers and facilitators to implementation were identified within the CFIR domains and constructs and are presented within the frame of CFIR domains including innovation, outer and inner settings, individuals, and implementation process ( Table 3 ).

c Construct lettering and numbers correspond with Damschroder et al [ 27 ].

d Only constructs applicable to the iCPR implementation are cited.

e –2: strong negative influence; –1: weak negative influence; 0: neutral influence; 0 (mix): mixed positive and negative influences, which balanced each other; +1: weak positive influence; +2: strong positive influence; missing: not asked or miscoded.

Outer Setting

Local conditions , primarily driven by the COVID-19 pandemic, served as one of the strongest barriers to implementation as COVID-19 impacted nearly every aspect of implementation from changes in workflows and staffing availability to patient volume and URI care protocols. There were observed changes to URI care protocols including shifts from in-office care to telehealth and redirection to urgent care, driven by COVID-19–testing requirements and hesitancy from both patients and practices to have on-site care. Furthermore, COVID-19 affected local attitudes among practice staff as health issues and burnout led to staff shortages, turnover, and shifting of responsibilities. These barriers were further compounded by regional nursing shortages and financial incentives that drew RNs out of primary care practices.

Policies and laws, such as state regulatory laws and institutional policies, also had a strong impact on the study procedures and implementation. RN scope-of-practice varied by state and between institutions. Wisconsin has existing RN delegation protocols, allowing for more clinical autonomy among RNs than at institutions in New York and Utah. This required additional training and modification to the RN visit portion of the intervention at institutions, where RNs had a more limited scope of practice and could not function autonomously. For example, the New York sites were required to adopt a “co-visit” structure to ensure that providers could oversee RN visits. This created additional scheduling constraints and complexity, as well as an unanticipated burden for providers. Multimedia Appendix 1 shows the analysis of performance measurement pressure and the innovation construct.

Inner Setting

Within the construct of structural characteristics , work infrastructure served as a strong barrier to the intervention implementation as practices across institutions experienced staff changes, RN shortages and turnover, and competing responsibilities that all hindered their ability to effectively participate in the study. Notably, at practices with only 1 RN, implementation was negatively impacted as clinic participation was dependent on 1 individual, whereas at other practices, study responsibilities were distributed across multiple RNs. Within the culture construct, a norm of limited deliverer centeredness , related to the prioritization of the needs and desires of RNs, served as a barrier to the implementation of this RN-focused intervention. As patient ( recipient centeredness ) and provider preferences were prioritized over RN activities, the innovation activities that would have been performed by the RNs were overridden. For example, to ensure patient autonomy, if a patient preferred to see a provider, they were not scheduled for an RN visit even if they were eligible. Similarly, at most institutions (except those with more RN autonomy), RNs tended to defer to providers in terms of preference and final decisions. Therefore, if the provider preferred seeing a patient themselves, the patient, even if eligible for an RN visit, would not be seen by an RN.

Overall, relational connections , specifically the RN-provider dynamic, negatively affected implementation. RNs in the study did not always have open bidirectional communication with providers, thus limiting the self-efficacy of RNs to explain or justify intervention-related activities. As observed within the culture construct, many practices had limited deliverer centeredness , typically deferring to providers to make final decisions, and therefore RNs were hesitant to push these boundaries or make decisions that were contrary to a provider’s preferences. In particular, some sites mentioned some practices having poor relationships among practice staff, even requiring team-building training in some instances. On the other hand, this was less of a barrier at practices, where RNs had more clinical autonomy or had developed stronger relationships within the practice.

Communications culture within practices served as a barrier to effectively implementing aspects of the study; for example, some practices did not have a culture of communicating with patients prior to visits in the form of triage or lacked formalized documentation as information was often conveyed informally (eg, verbal, secure chat message, and free-text note). In some practices, a strong communication system between RNs (ie, a chat channel used by most RNs) served as a facilitator to innovation implementation by allowing RNs to support and answer each other’s questions.

The intervention’s compatibility , or lack thereof, with existing workflows was a strong barrier to implementation, as the necessary intervention-specific workflow adaptions required great effort on the part of the practice if not already in place (eg, front desk forwarding eligible patients for triage, RNs performing triage after appointments had been scheduled, and filling out EHR note templates as opposed to free text). As the new study workflow required changes to the status quo, tension for change also served as a barrier since practices perceived little anticipated benefit from the study as compared to the difficulty of change. Relatedly, relative priority of the intervention was a strong barrier as competing clinical responsibilities and the voluntary nature of the study meant staff would not prioritize study-related tasks.

Overall, there was a lack of incentive systems in place related to study activities, which hindered RN participation. While gift card incentives for RNs performing triage were used, these tended to incentivize the same RNs already using the tools as opposed to encouraging new RNs to participate. Additionally, at institutions where RNs were unable to bill for visits and did not receive any other recognition for their efforts, this lack of incentives was a strong barrier to participation. One institution was able to reduce the influence of this barrier by providing incentives to RNs through continuing education credits, an employee recognition fund, and paid time for training.

Multimedia Appendix 1 presents the analyses of physical infrastructure, IT infrastructure, access to knowledge and information, available resources, learning-centeredness, and mission alignment.

Individuals: Characteristics Subdomain

Both capability and motivation were barriers to implementation. As these tools were new to many of the participating RNs, they were less confident in their skills and required continuous feedback, training, and support. In addition, RNs were not motivated to participate in the study largely due to competing priorities, lack of a strong incentive, and COVID-19–related stress and burnout. Opportunity was also a strong barrier, as RNs did not have many opportunities to use the innovation tools. Conflicting responsibilities, staff shortages, workflow barriers, patient volume, and patient eligibility were observed as contributors to this barrier.

Multimedia Appendix 1 shows the analyses of roles subdomain constructs high-level leaders, mid-level leaders, opinion leaders, innovation deliverers, innovation recipients, implementation facilitators, implementation leaders, and implementation team members. Multimedia Appendix 1 shows the analyses of the implementation process domain constructs assessing context and assessing needs, innovation deliverers, doing, planning and tailoring strategies, teaming, engaging the innovation deliverers, reflecting and evaluating, and adapting.

Principal Findings

This case study identified numerous barriers to the successful implementation of iCPR3, an RN-driven antibiotic stewardship intervention. Many of the identified barriers are consistent with those observed in other interventions that sought to alter nursing responsibilities and workflows within primary care [ 35 , 36 ]. The most impactful barriers were noted within the outer setting, and these conditions were observed to influence the inner setting constructs. The effects of COVID-19 served as an overarching barrier that impacted nearly all implementation constructs, shifting the culture and conditions at many participating practices as well as decreasing the capacity of practices to engage in activities perceived as nonessential. These barriers, however, were less prevalent within clinics that had previously established workflows with patient care within the RN role description. Takeaways from this study can be applied to support integration and improve uptake during the implementation of other RN delegation protocols involving CDS tools into existing workflows.

Policies impacting innovation deliverers’ (RNs) clinical autonomy at both the state and institutional levels need to be considered when developing RN delegation protocols as they can impact implementation depending on compatibility with existing workflows. As a multisite study with implementation spanning 3 states, the differing state regulatory laws and institutional policies dictating RN scope-of-practice had a substantial impact on the compatibility of the iCPR3 implementation at each site. This was evident in the higher rate of RN visits occurring in practices in Wisconsin compared to New York. At the Wisconsin study site, there were established delegation protocols for RNs to see patients with minimal provider supervision. In contrast, for the 2 New York study sites, a more complex “covisit” design was developed, which involved joint scheduling of the iCPR3 RN visit followed immediately by a visit for the provider to see the patient and confirm the RN plan of care. The addition of a provider visit component increased the intervention’s dependency on already limited provider availability, thus inhibiting the ability to schedule the iCPR3 RN visits even when a patient was appropriate and willing and an RN was available to conduct the visit. As observed in other RN delegation protocols, considerations for local regulations must be made when assessing the viability of implementing these types of interventions [ 36 ].

Consideration of practice-level culture and work infrastructure is also essential for the successful implementation of an intervention that includes RN delegation protocols. This implementation study revealed impactful differences in existing workflow expectations that affected RN capability and intervention complexity. One unexpected barrier was the influence of practice personnel who were part of the local workflow but were not directly involved in the implementation of the iCPR tools. For example, at one institution, successful implementation of the intervention was reliant on administrative staff to forward patients reporting cough and sore throat to participating RNs for triage. Implementation planning with greater efforts to clarify practice-level workflows, identifying potential stakeholders early on, and engaging these personnel who ultimately support the innovation deliverers can support a successful implementation.

Similarly, when delegating provider tasks to RNs, it is important to secure provider buy-in early on in the implementation process, even with a seemingly RN-focused intervention. Consistent with previous research demonstrating the importance of RN-provider relationships in job satisfaction [ 37 ], this study showed that power dynamics between providers and RNs can serve as a barrier to RN intervention engagement. With a culture of deference to providers, many RNs did not want to overstep these boundaries and would not engage with the intervention if there was any perceived resistance from practice providers. Barriers experienced due to this power structure were further compounded when poor relations existed between RNs and providers. Furthermore, as seen in other clinical academic partnerships, future implementation efforts would benefit from more active engagement of leadership at all levels [ 38 ].

Future clinical delegation interventions may also need to consider alternate care mechanisms to account for unexpected shifts in clinic workflows. Due to the timing of the implementation, one of the largest observed barriers to implementation was the COVID-19 pandemic, which amplified nearly all other barriers and created additional unique challenges. As an intervention specifically designed for in-person care, the shift toward telemedicine driven by the pandemic [ 39 ] had a particularly negative impact on implementation. One study institution piloted a program to divert all patients with URI to telemedicine visits with a centrally employed nurse practitioner, which bypassed all potential points of intervention for the iCPR study. Further diverting potentially eligible patients away from primary care practices was the increased popularity of urgent care centers [ 40 ], which served as an expedient solution for patients with URI seeking to avoid long wait times at many primary care practices. Incorporating alternate care mechanisms to provide agility in the intervention may support the success of study implementation. Similarly, integrating CDS tools with existing EHR tools and templates can help minimize changes in workflow, thereby allowing interventions to be resilient in the face of unforeseen events.

As observed in this case study, the pandemic also directly impacted practice staff and their ability to participate in activities beyond the essential, including research. Practices across all study institutions experienced nursing staff shortages due to RNs themselves being sick, covering for others who are sick, or leaving the practice altogether, thus resulting in a redistribution of responsibilities. An increased workload, along with outside stressors, led to increased reported stress and burnout among practice staff [ 41 ], making it difficult for them to view the study as a daily priority. The voluntary nature of the study and these conflicting responsibilities greatly reduced the opportunity for RNs to use the innovation and participate fully. This was particularly evident in practices that required greater workflow modifications. Practices with existing expectations of note documentation and template use facilitated implementation; however, in other practices, the lack of RN familiarity with these EHR functions required the creation of additional training and workflow modification efforts, as well as a greater perceived effort burden on the part of RNs.

Future implementation should consider the value of face-to-face communication in encouraging engagement and team building during the implementation process [ 42 ]. In addition to its impact at the institutional and practice level, the effects of COVID-19 hindered the implementation process itself, especially early in the planning phase by limiting in-person interactions and creating communication barriers [ 43 ]. With nearly all communication occurring remotely, interactions to collect practice workflow information and engage stakeholders were perceived as less efficient, requiring additional follow-up meetings and hindering the development of relationships of the study team with leadership and innovation deliverers. When in-person practice visits by the research team became feasible, an improvement in practice responsiveness and innovation uptake was observed [ 42 ].

This study had several limitations. First, the use of an emailed in-depth interview hindered the study team’s ability to probe respondents for further information at the moment, potentially limiting the collection of further details that may have impacted the interpretation of interview responses. However, the emailed format increased the feasibility of conducting a long interview and created an opportunity for study sites to compile perspectives from multiple team members, thus improving the richness of information provided. Second, the reported barriers and facilitators were self-reported and not directly observed and are therefore based on the perceptions of the study site research teams. Similarly, as the data collection was primarily retrospective, it may be subject to recall bias. We attempted to mitigate this by conducting semistructured interviews during the implementation process. Finally, this analysis was performed prior to the completion of implementation at all sites and analysis of the primary intervention effectiveness outcomes. Therefore, it was not possible to link perceived implementation constructs to intervention outcome measures, and additional implementation construct influences may have been missed.


Both between and within health care systems, significant variability exists in workflows for patient intake and triage. Even in a relatively straightforward clinical workflow, seemingly nuanced workflow and culture differences appreciably impacted successful intervention adoption. Barriers to intervention adoption existed within multiple constructs and domains. When implementing a system-wide clinical care intervention, stakeholders should consider the variability in workflow policy and culture at the health system, practice, and individual levels, as well as create accommodations for changing care patterns.


This work was funded by NIAID 5R01AI108680 (PI Mann). Generative AI was not used in the writing of this manuscript.

Data Availability

The data sets used and analyzed during this study contain personally identifiable information and are therefore not made publicly available. Data are available from the corresponding author upon reasonable request.

Authors' Contributions

ERS wrote the original draft and contributed to conceptualization, methodology, data collection, and analysis; LX contributed to writing the original draft, methodology, data collection, and analysis; JK contributed to writing the original draft, methodology, data collection, and analysis; ST contributed to data collection and project administration; NH contributed to data collection and writing editing; DF contributed to data collection and writing editing; EJK contributed to data collection and writing editing; RH contributed to data collection and writing editing; KLD-D contributed to data collection and writing editing; PDS contributed to data collection and writing editing; WH contributed to data collection and writing editing; PG-G contributed to data collection and writing editing; DAF contributed to the conceptualization, funding acquisition, and writing editing; DMM contributed to the conceptualization, funding acquisition, and writing editing. All authors reviewed and approved the final manuscript draft.

Conflicts of Interest

None declared.

Consolidated Framework for Implementation Research domain barrier analysis results.

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Edited by A Mavragani; submitted 30.11.23; peer-reviewed by R Hillard; comments to author 21.02.24; revised version received 13.03.24; accepted 15.03.24; published 23.05.24.

©Elizabeth R Stevens, Lynn Xu, JaeEun Kwon, Sumaiya Tasneem, Natalie Henning, Dawn Feldthouse, Eun Ji Kim, Rachel Hess, Katherine L Dauber-Decker, Paul D Smith, Wendy Halm, Pranisha Gautam-Goyal, David A Feldstein, Devin M Mann. Originally published in JMIR Formative Research (https://formative.jmir.org), 23.05.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.


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    This is an exploratory-descriptive qualitative research study with a case study design. The case study design allows for knowledge to be gained about a specific topic, for example, facility and staff characteristics on COVID-19 infection control, in a specific setting, that is, care homes. ... Yet, research has shown that addressing nursing ...

  19. A Qualitative Case Study: Jamaican Nurses Intent to Migrate

    A contextual analysis of the Caribbean region with respect to forces shaping the current and emerging nursing workforce picture in the region is provided and the Managed Migration Program is described as a potential framework for addressing regional and global nurse migration issues.

  20. Experiences regarding Home Care for Older Adults from the Viewpoint of

    This qualitative study was conducted based on the explorative content analysis approach between 2021 and 2022 in Tabriz, Iran. The participants were selected using the purposeful sampling method, and the data were collected through in-depth semistructured personal interviews. ... HC workers (including nurses and unqualified paid caregivers ...

  21. Organizational learning starting points and presuppositions: a case

    Organizational learning is a continuous process of integrating data and knowledge to ensure improvement. This qualitative study focuses on the starting points and presuppositions of organizational learning within a surgical department. Starting points for individual learning were informal and based on day-to-day work (e.g., solving a specific problem) and organizational learning encompassed ...

  22. Healthcare professionals' perspectives on use of PCSK9 inhibitors in

    Qualitative interviews were conducted in the United Kingdom (London and Leeds) and Italy (Rome and Milan) in 2021. Coding was undertaken using NVivo and thematic analysis performed. A total of 38 HCPs were interviewed, 19 in each country composing of physicians (n = 18), pharmacists (n = 10), nurses (n = 9) and pharmacy technician (n = 1).

  23. JMIR Formative Research

    Methods: We performed a retrospective case study, collecting quantitative and qualitative data regarding clinical workflows and triage-template use from expert interviews, study surveys, routine check-ins with practice personnel, and chart reviews over the first year of implementation of the iCPR intervention.