Objective: To study patients experiences regarding their perioperative safety in a hospital where we unexpectedly found safer care in non-western ethnic minority patients compared to Dutch majority patients.

Methods: By purposive sampling nine Dutch majority patients and eight non-western ethnic minority patients were semi-structured interviewed.

Results: In the first theme ‘Nurse and physicians’ behaviour’, positive determinants related to an attitude of experienced Nurse and physician’ that provide patients with trust. On the other hand, negative determinants provide patients with experiences of unsafety. In the second theme ‘Team performance’, positive determinants involved effective communication and coordinated care of the Nurse and physician’. Negative determinants related to visible disagreement about the treatment. In the third theme ‘Patient behaviour’, positive determinants related to seeking support from Nurse and physician’ and family to recover and to endure an anxious period. Negative determinants related to missing appointments or not consulting the information provided.

Conclusion: Nurses and physicians behaviour, team performance and patient behavior are relevant factors that contribute to patients’ trust and experiences of safe care. More attention should be paid in engaging patients to participate in their own safety. Through stimulating an active attitude of patients in seeking support they contribute to experiences of safe care. Stimulating situational awareness on all levels (society, organisational, team, individual and patient level) may help to improve perioperative safety and safety experience. These results can be used by nurses and physicians to improve patients’ experiences of safe care, for both non-western ethnic minority and Dutch majority patients in an uncertain and vulnerable perioperative period.

Perioperative safety; Perioperative nursing; Ethnic groups; Patient perception; Grounded theory

Gerrit B, Hiske C, Johan D, Gert W, Dekkers W, et al. (2020) Perioperative Safety Determinants in Ethnic Patient Groups an Interview Study in High Risk Surgery Patients. Ann Nurs Pract 7(2): 1114.

Perioperative safety risks, safety experiences and ethnicity

Patients with a non-western ethnic minority background and low language proficiency may be at increased risk for adverse events [1-3]. Patients indicate that nurse or physician-patient interactions, relationships, and trust are the most important determinants in their experience of safety [4,5]. Deficiencies in this respect contribute significantly to racial disparities in outcomes after coronary artery bypass graft surgery [6]. But a significant fraction of this racial disparity remains unexplained. Efforts to decrease racial disparities in health care should focus on centres of care which are both under-performing, and also treating relatively high numbers of non-western patients [6]. In a previous study - performed in one Dutch hospital -we found no difference in perioperative safety guideline adherence between non-western ethnic minority patients [further minority patients] and Dutch majority patients [further Dutch patients] and even better outcomes for minority patients [7].

Exploring both patients, nurses and physicians experience of patient safety

To explain these unexpected better outcomes for minority patients and to get insight in determinants of patients’ perioperative safety experiences. We wanted to investigate what had contributed to these results. It is known that patient satisfaction is strongly associated with good communication and information transfer. Confidence and trust in the clinical team as well as use of mutual understanding, social support, trust and adherence as intermediate outcomes, are important determinants for patient experience and health outcomes [5,8]. We interviewed trauma and oncology nurses, an ICU nurse, an ornurse, a surgeon, and an anaesthesiologist to explore their views on patient safety. It was concluded that nurses and physicians who could bridge the language barrier may have prepared patients better for anaesthesia and surgery which may, in turn, have contributed to better health outcomes [9]. Nurses and physicians payed particular attention to patients with limited language skills because they consider this essential for adequate communication and understanding. Bridging a language barrier is an important condition for safe perioperative care for patients from minority groups with foreign language as well as for native Dutch patients with low language proficiency.

Research aim

In this study we investigated the patients’ perspective using the following research questions: How do high risk surgery patients experience safety in the perioperative period? What influences their safety experiences? What strategies do patients use to ensure and improve their own safety? Perioperative nurses, physicians and other Nurse and physician’ can use the knowledge to engage patients to be a partner in their (perioperative) safety.

Study design

A qualitative grounded theory design was applied. In order to understand the patient’s perspective on the needs and safety in the perioperative period we choose to interview patients in depth and face to face.

Setting and participant selection for the interviews

The Maasstad Hospital in Rotterdam has an above-average amount of minority patients and therefore much intercultural expertise. Non-western minority and Dutch patients, undergoing high risk surgery (mortality risk >1%) (10) in the period from January 2012-January 2014 were eligible to participate in an interview; the same group as in a former study about the impact of ethnicity on safety guideline adherence and health outcomes (7). The interviews took place after the decision for discharge from the hospital had been made. After patients had given their informed consent, they were interviewed at their bedside in their own room if possible, or a quiet location was sought. All interviews were carried out by GB, recorded with a digital voice recorder and transcribed verbatim with F4- transcription software. Field notes made directly after the interview were used during the interpretation of the results. One patient was interviewed by telephone on request of the patient.

Data collection & analysis

A topic list compiled on literature [11-13] was used to interview the patients (Table 1).

After some questions about patient characteristics (Table 2) the interview started with questions that were primarily focused on the preoperative intake by the anaesthesiologist and the period of postoperative stay at the surgical nursing ward. We also asked patients about the strategies they took to ensure and improve their own safety. We focused on perceived barriers to care, and the role of nurses and physicians, family and religion. We asked for examples of situations, interactions, and communication with nurses and physicians as well as other determinants that may have influenced their safety. Finally, patients were asked to describe their experiences about safety of care during the perioperative phase.

The principles of grounded theory were used to analyse the data [14]. Data analyses started as soon as the interviews were transcribed. The interviews were coded and analysed by hand (GB) and also independently read and coded by TB to check whether the same codes were derived from the data. The codes were compared and the differences discussed. This process was repeated and after recoding the interviews, the definitive codes were structured and grouped into categories and themes. Data saturation was reached in both patient groups.

Definition and determination of ethnicity

Country of birth, used to determine patient’s ethnicity, was recorded from the patients’ passports on the day of admission. Patients were categorised as Dutch patients, minority patients or ‘unknown’, using the definition of the Dutch Center of Statistics [15]. The category ‘minority’ patients includes persons with a non-western background, with a Turkish, African, Asian and Latin-American background, following the definition and classification of the population with a foreign background in the Netherlands [16]. Based on their social and economic position in the Dutch society, patients with a Japanese and Indonesian background were classified as western. Patients not born in the Netherlands and not born in a ‘non-western country’ were subsequently excluded [15,16].

Ethics

The research ethics committee of the Radboudumc and the scientific committee of the Maasstad hospital approved the research proposal and informed consent procedure.

Eight minority patients and nine Dutch patients who underwent high risk surgery in the Maasstad Hospital in Rotterdam were interviewed. From the transcripts three themes emerged: “Nurse or physician behaviour”, Team performance” and “Patient behaviour”. In each theme two categories could be distinguished, namely positive determinants and negative determinants.

Looking at different ethnic backgrounds of participating patients we did not find indications of differences in the experiences of safety.

Theme 1: Nurses and physicians’ behaviour

Positive determinants: Respectful, polite and friendly behaviour of nurses and physicians create an open and positive atmosphere between the patient and themselves. This make you feel like a person and not a number. Patients appreciate the friendly ‘welcome with a smile’ in this hospital. They feel that they are treated in a personal way. Nurses and physicians are present for you, show personal interest and take time for you but are also to the point and dedicated. They provide justified reassurance, explain everything to you in a personalised way, are gentle, helpful and in for small talk. There are no thresholds in communication. Patients remark that the operation room is managed smoothly. They feel comfortable when nurses and physicians show an attitude of experience and self-assurance. Nurses and physicians are well skilled. They know where they are talking about and give the right answers. These determinants give patients trust and let them feel safe. Trust in the nurses and physicians and the perioperative process they are in (Table 3, Table 4 and Figure 1).

Figure 1 Conceptual model of determinants of nurses and physicians’ behaviour and team performance that influence the safety experience of high risk surgery patients and the effects on patients’ behaviour.

Table 3: Themes, categories & codes related to determinants that influence the safety experience of high risk surgery patients.

Table 4: Selection of quotes from the interviews that formed codes, categories and themes.

Negative determinants: Contradictory (or conflicting) policy between specialisms was difficult for patients. One patient experienced limited communication between the oncology and surgery departments. The surgical intervention was changed short before surgery without informing the patient on time. Every department has his own director and disagreement is detrimental for patients’ interests. Unexpected treatment or late strategy changes create doubts and uncertainty. For instance a sudden cancelling of the operation can cause extreme stress and made one patient introvert. Contradictory information and criticism between nurses and physicians about activities leads to experiences of unsafety and undermines the self-assurance of patients and the trust in nurses and physicians. Nurses and physicians talking negative about colleagues handling also undermine patients’ trust and safety experience.

Theme 2: Team performance

Positive determinants: Effective and corresponding communication and optimal coordinated care of the surgeon, anaesthesiologist and nurse contribute to an experience of safety. Patients expect expertise, reassurance, kindness, a smile, and that the nurses and physicians act effectively, self-assured, correctly and in concordance.

Negative determinants: Patients can be anxious, uncertain and worried for the risk of complications, not waking up or dying and leaving family behind. They have worries for inadequate support and follow-up and delay of surgery. With anxiety before surgery, confidence in the nurses and physicians is necessary but you can never know for sure whether it is safe or not. It is safe until something dangerously is happening. If patients don’t have a lot of family support, simply because it isn’t available, they worry about how to get the help they need. Life becomes more difficult and more limited. If several specialisms are involved in the treatment, visible disagreement about the treatment or poor interprofessional communication let patients experience that they may fall between the cracks. Contradictory information is annoying and confusing and raises distrust. Doubts about a smooth care process and accuracy originate from the speed of the process, a change of policy, and insufficient knowledge of the necessity. On the one hand, patients have to be critical on the preoperative interventions for their own safety, on the other hand they cannot be too critical because they feel to show trust to the nurse or physician. There is extreme relief when an operation is survived and completed successfully. Any distrust triggers anxiety and may influence patients’ experiences of well-being negatively during their stay in hospital. Distrust also creates an experience of permanent unsafety. Distrust is not only stressful for patients themselves but may also threaten the relationship between patient and nurse or physician.

Theme 3: Patient behaviour

Positive determinants: Patients need information about planning, procedures, expectations, late complications, treatment, diet, stitches removal, appointments and medication. Trust depends on whether the information provided is perceived correct, clear and honest.

Patients seek support from nurses and physicians to find guidance to recovery. Unclarity about the best way to recover also leads to feelings of insecurity and uncertainty. Explanations help to give better insight and motivates patients. Regimen, clarity and clear explanations can help to survive. When patients have recovered from surgery, they are prepared for discharge. The discharge information provided ranges from (pain) medication instructions to instructions about treatment, potential short and long term complications and diet. Some patients missed a followup appointment from the hospital, a discharge conversation and a formal checkpoint or information about pain medication. They feel a need for contact with fellow patients. A telephone number to call for help if there are problems, and clear advice about actions to be taken will assist patients. One patient missed information and started experimenting with food that she could endure after gastric bypass surgery because she had problems with the food volume and digestion.

Patients also seek for help from their family. Family has several functions for patients: Family thinks with them and supports them. Family provides practical help by going to the hospital, translating and arranging patients’ business and they can stand in for them. During visits they share emotions with their relatives. Family takes over; they take care of the children and arrange things that patients cannot do. They bring children to school or sports, do the housekeeping. In other words, family is taking worries away. They are questioning details and help in the shared decision making process and take care. They respect the decision for undergoing surgery.

Patients use several strategies to endure the perioperative period. Avoiding being a number in the organization, stay in the spotlight and “don’t fall between the cracks” is described as a strategy for surviving in running up for admission for surgery in the hospital. To take the decision to be operated, patients listen to experiences of others. They listen well and ask for information when anaesthesia is explained. Dependency is difficult to bear. Have trust in the surgeon, avoid anxiety and stay calm, help patients’ to overcome the difficult and insecure period.

Negative determinants: Some patients reported that they missed appointments with their surgeon or anaesthesiologist. Some patients’ surgery needed to be postponed because patients had not fasted.

Differences in experiences of participating patients

We compared quotes and codes of participating patients with different ethnic backgrounds. We did not find indications of differences in experiences mentioned, except for minority patients who reported to be accompanied to the operation room because of a language barrier. This was not the case for Dutch patients (Table 5).

Table 5: Differences in perioperative care between minority patients and Dutch patients.

The purpose of this explorative case study was to describe patients experiences regarding their perioperative safety in a hospital were we unexpectedly found safer care in minority patients [7]. The research questions we tried to answer were: How do high risk surgery patients experience safety in the perioperative period? How and what influences their safety experiences and which strategies do patients use to overcome their perceived problems?

The results from the interviews show that determinants of nurse or physician behaviour influences patients’ experience of safety in a positive or negative way. Nurse or physician behaviour contributes to patients’ trust or distrust and in that way to a safe or unsafe experience. Therefore patients seek: trust in nurses and physicians, family support, support from nurses and physicians for the optimal guidance to recovery and they use several strategies to endure the uncertainty in the perioperative period. They try to avoid being just a number in the organisation and prefer individual attention by staying in contact with the surgeon. Social support from family and friends is needed to be able to undergo anaesthesia and surgery and to get the help and support that is needed. The patients in the Maasstad hospital felt safe when they were surrounded by nurses and physicians, family and friends who were kind and friendly. Recognition of risks or unsafety, situational awareness and (the courage to) speak up are important determinants for a safe perioperative environment [17,18].

Nurses and physicians behaviour

Patients undergoing high risk surgery face uncertainty and risk for mortality. In three international studies it was concluded that negative nurse or physician behaviour can be disruptive for patients in the perioperative setting and can also have an impact on patient safety [19,21]. Therefore, responsibility and trust are fundamental existential issues concerning both patients and doctors before high-risk procedures [22]. The model based on the results can help nurses and physicians’ to behave in a way that patients experience a safe perioperative period.

Team performance

Nurses have an important role in engaging patients in their own safety [23]. Evidence suggests, however, that health care settings are rife with disrespectful behavior, poor teamwork, and unsafe working conditions [23,24] Interactions between nurses, physicians and patients form patients experience of safety. Patient experience is one of the three pillars of quality in healthcare; improving it must be a key aim to improve the overall quality of healthcare [25,26]. Patient satisfaction was strongly associated with experiences of good communication and transfer of information. Confidence and trust in the clinical team is an important determinant of patients’ experience [5]. Perioperative anxiety is often overlooked but it is associated with poor surgical outcome [27].

Patient behaviour

Patients are partners in their safety during their hospital stay and it is a right for patients to involve in their own safety [28,29]. There are many ways in which patients can contribute to their safety. E.g. incident reporting, hand hygiene, surgical site marking and medications use are subject’s patients can influence their safety and safety experience. But also report self-perceived changes in comfort when talking with nurses and physicians about questions and concerns [30-32]. Patients’ perspective on safety is underreported in research [28,33] and little is known how nurses and physicians can support patient engagement as a safety strategy. Patients seek support from nurses and physicians to find the optimal path to recovery. Instructing and guiding patients after surgery is essential for successful recovery. Patients use conversations with nurses and physicians as a strategy to reduce their anxiety [34]. The contribution of ethnicity to this result seems to be limited in this study. Patients undergoing high risk surgery often feel very dependent and restricted when they are ill. They have to regain their sense of self-worth. Although patients are in a dependent situation, they do want to feel safe. Experiences of unsafety may be unbearable. Nurses and physicians have an important role to play in ensuring that patients feel protected and safe.

The strategies and needs of patients reported in this study can help nurses and physicians to create a safe environment and facilitate the experience of safety in patients.

Strength and limitations

Our study has some limitations. Firstly, only one minority patient didn’t master the Dutch language and needed translation from a family member. All the other patients were - more or less able - to understand and speak the Dutch language. This may have caused selection bias. Secondly, this study took place in only one hospital with much intercultural expertise. So, it is possible that in a multi-centre study more detailed data could be collected and moreover that the results could be extrapolated more widely. Thirdly, it was difficult to include patients with a minority background in this study. Three times patients agreed to participate in the study, but refused to participate in the interview on the day it was planned. In future studies, contact with multi-cultural institutions and minority organisations can possibly help to improve the data collection of a minority study. The interviews of both patient groups yield rich data. We reached a point of data saturation.

Future research

In the last decade perioperative patient safety has improved vastly because it became the focus of research and development projects in many hospitals. In our opinion, a better focus on patients’ experiences of safety in research will help to improve quality of perioperative care. More research on patient’s perceptions and perioperative experiences will contribute to better insight in patients safety strategies. With multi-centre research more detailed data could be collected and moreover, the results could be extrapolated more widely.

Nurses and physicians behavior, team performance and patient behaviour are relevant factors that contribute to patients’ trust and experiences of safe care. More attention should be paid in engaging patients to participate in their own safety. Through stimulating an active attitude of patients in seeking support they contribute to experiences of safe care. Stimulating situational awareness on all levels (society, organisational, team, individual and patient level) may help to improve perioperative safety and safety experience. These results can be used by nurses and physicians to improve patients’ experiences of safe care, for both non-western ethnic minority and Dutch majority patients in the often uncertain and vulnerable perioperative period.

Practice implications

Nurses and physicians must become much more aware of the impact that their behaviour and team behaviour has on patients’ experience of perioperative safety. Anxiety is a common phenomenon that no longer should be ignored. Reassurance, comfort talk and quick and correct proceedings let patients experience safety. At present several validated questionnaires are available to measure perioperative anxiety. Preoperative counselling and proper education regarding surgery will help in reducing preoperative anxiety and improving the quality of care. Reliability, timely and adequate information without sudden policy changes will improve patients’ safety experiences. Many examples and citations in this study show the importance of effective communication between nurse or physician and patient. More public/societal attention should be paid to the role that patients have in monitoring their own perioperative safety. Nurses and physicians can help patients take responsibility in their perioperative safety, through paying specific attention and communicate about safety with patients in the running-up to surgery & anaesthesia.

1. The authors would like to thank Maasstad Hospital for its kind cooperation in this research project, Thimpe Beune for helping with coding interviews, Ans Bloo for transcription of some interviews and Vivien Moffat for advice and textual improvement.

2. Financial support: This work was funded by ZonMw, The Netherlands Organization for Health Research and Development (Dossier number: 80-82315-97-11100 and Project number: 1711030089).

3. Presentations of preliminary data: none declared.

1. Fransen MP, Harris VC, Essink-Bot ML. Beperktegezondheidsvaardighedenbijpatiënten van allochtoneherkomst. NedTijdschrGeneesk. 2013; 157: 1-6.

2. Bloo GJA, Hesselink GJ, Oron A, Emond EJJM, Damen J, Dekkers WJM, et al. Meta-analysis of operative mortality and complications in patients from minority ethnic groups. Br J Surg. 2014; 101: 1341-1349.

3. van Rosse F, de Bruijne M, Suurmond J, Essink-Bot ML, Wagner C. Language barriers and patient safety risks in hospital care. A mixed methods study. Int J Nurs Stud. 2016; 54: 45-53.

4. Dixon JL, Tillman MM, Wehbe-Janek H, Song J, Papaconstantinou HT. Patients’ Perspectives of Surgical Safety: Do They Feel Safe? Ochsner J. 2015; 15: 143-148.

5. Jones CH, O’Neill S, McLean KA, Wigmore SJ, Harrison EM. Patient experience and overall satisfaction after emergency abdominal surgery. Bmc Surg. 2017; 17.

6. Rangrass G, Ghaferi AA, Dimick JB. Explaining Racial Disparities in Outcomes After Cardiac Surgery The Role of Hospital Quality. Jama Surg. 2014; 149: 223-227.

7. Bloo GJA, Calsbeek H, Emond EJJM, Teerenstra S, Peters Y, Damen J, et al. Peri-operative Risk in non-western minority patients A single center cohort study. Nederlandstijdschrift voor anesthesiologie. 2019; 32: 11-19.

8. Street RL, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Educ Couns. 2009; 74: 295-301.

9. Bloo GJA, Calsbeek H, Dekkers W, Westert G, Akkersdijk G, van Krugten R, et al. Enhanced Peri-operative Safety for Ethnic Patients Groups. An explorative case study among professionals in a Dutch hospital. Submitted. 2020.

10. de Vries EN, Dijkstra L, Smorenburg SM, Meijer RP, Boermeester MA. The Surgical Patient Safety System (SURPASS) checklist optimizes timing of antibiotic prophylaxis. Patient Saf Surg. 2010; 4: 4-6.

11. Suurmond J, Uiters E, de Bruijne MC, Stronks K, Essink-Bot ML. Explaining ethnic disparities in patient safety: a qualitative analysis. Am J Public Health. 2010; 100: S113-117.

12. Suurmond J, Uiters E, de Bruijne MC, Stronks K, Essink-Bot ML. Negative health care experiences of immigrant patients: a qualitative study. BMC Health Services Research. 2011; 11: 10.

13. Partida Y. Language barriers and the patient encounter. Virtual Mentor. 2007; 9: 566-571. 14.Morse JM, Field PA. Nursing Research The application of qualitative approaches: Chapman & Hall. 1996.

15. Kei i. Hoe doet het CBS datnou? Standaard definitieal lochtonen Den Haag: CBS; 2000. 16.Alders M. Classification of the population with a foreign background in the Netherlands; Paris: Statistics Netherlands. 2001; 18.

17. Green B, Parry D, Oeppen RS, Plint S, Dale T, Brennan PA. Situational awareness - what it means for clinicians, its recognition and importance in patient safety. Oral Dis. 2017; 23: 721-725.

18. Reid J, Bromiley M. Clinical human factors: the need to speak up to improve patient safety. Nurs Stand. 2012; 26: 35-40.

19. Blomberg AC, Bisholt B, Lindwall L. Responsibility for patient care in perioperative practice. Nurs Open. 2018; 5: 414-421.

20. Villafranca A, Hamlin C, Enns S, Jacobsohn E. Disruptive behaviour in the perioperative setting: a contemporary review. Can J Anaesth. 2017; 64: 128-140.

21. Sandelin A, Gustafsson BA. Operating theatre nurses’ experiences of teamwork for safe surgery. 2015.

22. Schaufel MA, Nordrehaug JE, Malterud K. “So you think I’ll survive?’’: a qualitative study about doctor-patient dialogues preceding high-risk cardiac surgery or intervention. Heart. 2009; 95: 1245-1249.

23. Morath J, Morath J, Filipp R, Cull M. Strategies for Enhancing Perioperative Safety: Promoting Joy and Meaning in the Workforce. 2014.

24. Leape L, Shore M, Dienstag JL. A Culture of Respect Reply. Acad Med. 2013; 88: 741-743. 25.Wintle S, Fregene T, Raman VV, Edmond H. Making the experience of elective surgery better: a quality improvement project. Anaesthesia. 2017; 72: 106.

26. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013; 3.

27. Sigdel S. Perioperative anxiety: A short review. Glob anaesthperioper med. 2015; 1: 107-108.

28. Wright J, Lawton R, O’Hara J, Armitage G, Sheard L, Marsh C, et al. Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm. Programme Grants for Applied Research. Southampton (UK). 2016

29. Doherty C, Doherty C, Stavropoulou C. Patients’ willingness and ability to participate actively in the reduction of clinical errors: A systematic literature review. 2012; 75: 257-263.

30. Burrows Walters C, Burrows Walters C, Duthie EA. Patients’ Perspectives of Engagement as a Safety Strategy. 2017.

31. Schwappach DLB, Schwappach DLB, Frank O, Buschmann U, Babst R. Effects of an educational patient safety campaign on patients’ safety behaviours and adverse events. J Eval Clin Pract. 2013; 19: 285-91.

32. Schwappach DL. Review: engaging patients as vigilant partners in safety: a systematic review. Medical Care Research and Review. 2009; 67: 119-148.

33. Ward JK, Armitage G. Can patients report patient safety incidents in a hospital setting? A systematic review. Bmj Qual Saf. 2012; 21: 685- 699.

34. Aust H, Rusch D, Schuster M, Sturm T, Brehm F, Nestoriuc Y. Coping strategies in anxious surgical patients. BMC Health Serv Res. 2016; 16: 250