In the emergency department, patient care depends on teamwork and coordination among clinical groups, because emergency nurses provide front-line care, patient safety competency is crucial to ensure quality safe care. In our opinion, this study is the first study that evaluates the level of teamwork and psychological safety and their relationship with patient safety competency among Iranian emergency nurses using valid tools and, therefore, adds new knowledge in this field.
The teamwork score among emergency nurses obtained in this study was slightly lower than that of Han & Roh study (4) using similar tools. In another study in Iran, the score of teamwork among emergency nurses was slightly lower than our study (5). Nurses' perception of teamwork is related to patient safety (22). Teamwork leads to more employee job satisfaction, increased patient safety, improved quality of care, and greater patient satisfaction (9). Effective teamwork in healthy environments also helps care for high-quality patients (6). Besides, safe and quality patient care can also result from effective teamwork (9). Teamwork is the cornerstone of quality care and patient safety (7). The results of the study indicate the need to increase nursing teamwork at the study site. Emergency nurses can promote teamwork by facilitating communication, resolving disputes among team members, clarifying roles and responsibilities, and encouraging other team members.
The psychological safety of emergency nurses was lower than the results of a similar study in South Korea (4). Psychological safety plays a special role in high-risk work areas such as health care (13). When health care teams are psychologically safe, they are likely to improve the quality and teamwork initiatives (14). Psychological safety supports patient safety by contributing to quality improvement and encouraging employees to talk about mistakes (23). Promoting psychological safety among health care workers increases patient safety and improves the quality of health care. Therefore, promoting psychological safety among emergency nurses increases patient safety. Therefore, promoting the psychological safety of team members is important. Emphasis is placed on the role of leaders to create a safe psychological environment the psychological safety of team members is important. Emphasis is placed on the role of leaders in creating a safe psychological environment.
The level of patient safety competency in emergency nurses in this study was slightly higher than the findings of Han & Roh (4) and lower than the findings of Langari et al. (17). These contradictory findings can be explained by cultural and field differences in patient safety education worldwide. The results of Han's study showed that emergency nurses focus mainly on patient-related emergency activities and have a relatively small understanding of patient safety. Therefore, they need patient safety management activities, training, standardization, and measures to cope with problems (4). Langari et al. (17) in their study showed that European countries (England and Finland) had started patient safety activities and training. They have also integrated patient safety into their nursing education programs. These measures have led to improved nurses' safety competency. Therefore, in Iran, patient safety qualifications are integrated into emergency nurses, and nursing trainers should provide a structured educational program to strengthen the patient's safety qualifications for vulnerable emergency nurses with low safety competency. Therefore, evaluating and improving the competency level of emergency nurses is essential to improve patient safety.
Among the organizational factors of team structure, leadership and psychological safety were among the main factors influencing the patient's safety competency. The emergency department is a potentially unique environment for teamwork and communication (10). The team structure is an integral part of the teamwork process. A properly structured patient care team is an enabler for and the result of effective communication, leadership, situation monitoring, and mutual support. Proper team structure can promote teamwork by including a clear leader, involving the patient, and ensuring that all team members commit to their roles in effective teamwork (6).
organized and effective teamwork in the emergency department has extensive implications on patient safety, quality of care, employee and patient satisfaction. A team with a proper teamwork structure can predict the requirements of other team members. It is dynamically compatible with a changing environment including changing team members' behavior and a common understanding of what should happen (9, 24). The nurses who consider their managers as strong leaders can empower their working environment, which, in turn, leads to their use of professional practice behaviors. These practical professional behaviors, such as effective communication, cooperation, and mutual understanding with clinical leadership's main characteristics, are compatible (25). The findings obtained by Boamah (24) showed that nurses often use clinical leader behaviors in their practice, which leads to the improvement of the patient's adverse events. To ensure the patient's safety, strong nursing leadership for implementation and continuity of effective management methods for training and continuous support for the environment is required to provide high-quality patient care. In our study, leadership has the largest teamwork score and is one of the predictors of patient safety competency. There are many factors, including leadership, communication, monitoring, and supporting behavior which helps create ideal teamwork in the emergency department (10). The findings of the study of Parr et al. show that leaders improve patients' satisfaction with patient services and safety (26). Based on the findings obtained by Kakemam et al. (22), nurses with stronger team leadership tend to report adverse events. Moreover, the result obtained by Kakemam showed that reducing medical errors can be achieved by effective leadership. Effective leadership can develop and strengthen the patient's safety and innovation culture in the health care environment. Accordingly, leaders are recommended to use educational strategies for reducing adverse events (22). The results obtained by Labrague et al. indicate the importance of the advancement of nurses' management in strengthening nurses' safety measures and reducing the results of the patient, and promoting the quality of nursing care (27). The results show that nursing leadership has a significant indirect effect on patient safety results. From a person-centered perspective, the care environment requires the empowerment of the workplace and effective relationships between leaders and nurses (28). Effective teamwork and leadership are recognized as important factors in many adverse events. Thus, a greater understanding of team dynamism and effectiveness and helping improve group training can lead to patient safety development and strengthen individual and team competencies in non-technical aspects of care, such as prioritization, leadership, and decision making.
Having safe teams psychologically can improve learning, creativity, and performance in organizations. In the framework of health care, psychological safety supports patient safety by creating the ability to promote quality and encourage employees to talk about errors (23). Psychological safety has recently been identified as a necessity for effective teamwork (23, 29). Effective teamwork depends on the psychological safety of the team members, which are defined as their ability to trust each other and feel insufficient safety in the team to accept the fault, ask questions, present new data, or test new skills without fear of embarrassment or punishment. Higher psychological safety leads to better reports of adverse events (4). Strategies for increasing the psychological safety of emergency nurses in health care teams are required. When the employees are assured that the organization considers their welfare as the priority, he/she feels psychological safety and can talk about safety concerns, and this makes the patient's safety in everyday clinical performance (30). Providing psychological safety to emergency nurses increases patient safety and increases the quality of care. Therefore, nursing managers should always seek to develop effective methods to improve the psychological safety of their employees.
Old Age was the predictor of the patient safety competency of emergency nurses, such that the safety competency increases with increasing age. This finding was consistent with the results obtained by Alquwez and Chen (31, 32). This finding is probably due to the more professional and responsible behavior of the nurses with increasing age.
Experience in patient safety activities was another factor that affected the safety competency of emergency nurses. Nurses play a key role in coordinating patient safety activities because they are in close contact with patients and are involved in health care teams' decisions about patient safety (33). Having previous information and activities about patient safety can improve nurses' level of safety knowledge and affect their performance in patient safety (34). Therefore, nurses the more Experience in patient safety activities are in the emergency department, the more committed they will be to patient safety and compliance, and the more competent they will be in terms of patient safety.
Gender was also one of the work-related factors predictors of the safety competency of emergency nurses. Hence, the mean score in women was significantly higher than men. These results were consistent with the results obtained by studies Chen and Jabarkhil (32, 35) and were not in line with the results presented in a study by Alquwez (31). This means that women pay attention to patient safety more than men do.
Emergency nurses with non-permanent employment status perceive patient safety competency more than those with permanent employment, which was not consistent with the study by Chegini et al. (36). It can be concluded that employed nurses are in the ultimate employment status. and contractual employees to upgrade to employed status have more efforts to improve their employment status. Therefore, they pay more attention to patient safety. it is necessary to provide in-service patient safety training for this group of employees.