This study examined the relationship between emergency nurses’ perception of PSC and LCB with their intention to report errors. The results show that, based on PRR scores, none of the 12 dimensions achieved scores of 75% and cannot, therefore, be considered to represent areas of patient safety strength. This result is in contrast to findings of other research . It was also lower than other studies conducted in countries including Taiwan , Lebanon  and Saudi Arabia , with cultural and organizational differences relating to patient safety thought to explain the differences.
Perhaps one of the most important factors to mention in the same studies is the disparity in accreditation policies and procedures in three countries where the study was conducted. For instance, there is a mandatory accreditation system in the Iranian health system monitored by the Ministry of Health which has not fully taken shape, while Lebanon and Saudi Arabia were among the countries in the Eastern Mediterranean region whose accreditation standards have been approved by the International Society for Quality in Health Care (ISQUA) and are monitored by international organizations .
Another challenge of the Iranian healthcare system is staff shortages, the financial pressures experienced by hospitals, lack of senior management support for patient safety culture and lack of systematic approach for reporting errors [43, 44] which means patient safety is seen as a low priority by managers. For patient safety to be effective, there is a need for continuous educational advancement at every level of the organization. In addition, provision of necessary infrastructure, resources (human, financial, technological and material) and procedures necessary for the development of patient safety culture needs to be implemented .
A previous Iranian study conducted in an academic intensive care unit , like the results in this study, found that all dimensions needed to be improved. These findings contrast with those of Habibi et al. (2016) where a higher PRR score was found in teaching hospitals in Tehran . A recent Iranian systematic review illustrates that, compared to the results of studies conducted in other countries, the mean of the responses in Iran for the different dimensions of PSC is low, a finding which underlines the fact that, for many people working in Iranian hospitals (including the managers), the concepts of PSC are unknown . This is possibly because, rather than the issue being neglected, PSC is a relatively new concept in Iranian hospitals and has not been fully recognized .
The dimension with the highest PRR was “teamwork within units”. Whilst this reflects the findings of other studies [50, 51], in our study it was an area of patient safety weakness. “Non-punitive response to error” had the lowest PRR, a finding which follows an earlier study conducted in a public hospital in Tabriz and which examined the same issues . These findings are consistent with other local findings  and those from international studies [16, 50, 53], and would suggest that a major barrier to error reporting is the risk of a punitive response. When non-punitive measures are taken, errors will be detected and reported early and further occurrences will be prevented .
Punishing staff for their mistakes has been a strong measure taken by administrators and senior colleagues in many Iranian hospitals, without considering the reasons for such errors. This policy has affected continuous education and the work environment at large . For example, nurses in this study, like those in other similar studies, felt that if they reported their errors, a record of their mistakes would be held in their personal file and may be used against them at some point in the future and, for this reason they preferred silence over-reporting errors.
It is of interest that 50% of nurses in this study tended to rate their managers’ coaching behaviour as high. In line with the study conducted by Ko and Yu  the highest and lowest perceived LCB in this study was attached to “performance evaluation” and “direction”. It is important to note that, in respect of “performance evaluation”, only half of the participants described their leaders as being high-performing coaches and that in respect of “direction” the percentage was 35.9%. Given the evidence that a lack of performance appraisal can impact negatively on nurse performance  and that coaching on the part of team leaders supports learning from problems and errors amongst members , it can be concluded that the perceived coaching behaviour in this study may impact negatively on nurse performance in respect of safety-related issues.
This study found that, overall, 43% of nurses had a high intention to report errors, a similar finding to those of earlier studies in other countries [57-59] in which it was demonstrated that the proportion of error reporting amongst nurses was less than 50%. These findings are significant as there is evidence which suggests that whilst nurses intercept 86% of potential errors ,between 34% and 50% don’t report medical incidents .
In looking to explain the low rates found in these studies, it is possible that an intention to report is linked to an attitude towards reporting and an awareness of reporting, as well as the existence of support . There are also a multitude of reasons, including fear, humiliation, a punitive reporting culture and limited follow up, following error reporting, that may lead to under-reporting . Having said this it was found, in an Ethiopian study, that the proportion of error reporting amongst nurses was 57.4% , a difference that may be related to differences in error reporting systems and to differences in the time frame in which the studies were conducted.
Human behaviour is influenced by motivators which are borne out of their intentions, which show peoples’ willingness and commitment to their actions and behaviour . Ajzen (1991) explained this in the Theory of Planned Behavior (TPB) that intention can predict an individual’s needs and it has been confirmed in many studies . According to the TPB, intention mediates between attitude and actual behaviour or performance .
This study found a significant association between nurses’ intention to report errors and the level of their education. Those nurses with an associate degree education were 78% more likely to report errors than nurses at a different educational level. This may be because professional nurses have a fear of legal consequences or of losing their occupational position . In contrast, a study conducted by Poorolajal et al. (2015) found that managers and staff who had attained higher educational levels had a greater willingness to report errors . Another study also revealed that reporting medical errors depends on individual’s marital status. , while this is not confirmed in our study.
Nurses who experienced a high level of PSC were found to be more likely to report errors in this study, a finding which reflects that of Kagan et al. (2013) whose Israeli study confirmed that a readiness to report errors was influenced by an organization’s safety culture . Furthermore, a flexible culture can promote patient safety and error reporting within an organization by developing trust and improving the problem-solving capabilities of nurses .
This study also found that nurses who saw their managers’ coaching as being at a high level of performance reported a stronger intention to report errors, a finding which follows that of Ko and Yu . In nursing, a manager develops capabilities by exposing nurses to appropriate coaching strategies which together with regular feedback encourages them to work independently . As has been pointed out by Reid Ponte et al  nurses who have experienced coaching describe it as helping them to recognize and modify behaviours that have hampered their performance, and in doing so, improve their effectiveness and that of the organization.
Strengths and limitations
This study has several strengths. Notably, it is the first study to have investigated the LCB of Iranian nurses, using validated tools to measure variables with a homogeneous study population. However, the study also has limitations. Participants in the study were emergency nurses working in hospitals in Tabriz, Iran and, as such, the results may not be generalized to other hospitals or different clinical settings. Given such limitations, further studies in settings other than an emergency department may be required if the findings of this study are to be fully justified. Furthermore, as nurses were the focus of this study a more complete picture might be obtained if other studies focusing on other staff were conducted.
Besides, as this study adopted a cross-sectional approach and did not seek to establish cause and effect, it is recommended that further studies adopt a longitudinal evaluation. It is also the case that potential organizational factors and a blame culture that were both identified in this study would benefit from a further in-depth study in which a qualitative approach was adopted. Finally, the near misses are counted as insignificant since there is no harm to the patient and because of poor research evidence, due to ineffective recording and reporting systems in developing countries such as Iran, this study has measured the intention to report errors, instead of the actual number of errors reported. Therefore, it is suggested to measure numbers of errors reported in future studies.