We extracted 443 codes from the data analysis. After reviewing, removing and merging duplicate or similar codes, we determined one theme, four categories and, nine sub categories. The theme was schemas of the disclosure of patient safety incidents with four categories: 1- misconception of harm to the organization or a person 2- opinions about the disclosure process and outcome, 3- opinions about behaviors 4- inner conflict between feelings. Each of the categories consisted of a number of Subcategories.
Theme: schemas of the disclosure of patient safety incidents
We concluded that attitudes were schemas that acted as a hidden mechanism in a person when disclosing incidents. Schemas are based on reality or experience and shape individuals’ responses and behaviors. According to the participants, the schema of disclosure of patient safety incidents consisted of Four categories: misconception of harm to the organization or a person, opinions about the disclosure process and outcome, opinions about behaviors and the inner conflict between feelings.
1- Misconception of harm to the organization or a person
Participants believed that disclosure of incidents affected the hospital prestige and threatened their personal positions in the hospital and the hospital's position in society, so they had no positive attitude towards the disclosure of the incidents. According to Table 3, This category consisted of two Subcategories included misconception of harm to the individual's position and misconception of harm to the organization's position.
A- Misconception of harm to the individual's position
The participants argued that disclosure of patient safety incidents compromised the offender’s position in the organization and the job position of the discloser. The offender’s reduced acceptability, reduced job promotion, occupational incompetency, and ruined prestige in front of the patient prevented the disclosure of patient safety incidents.
“If we disclosed the incident, the head nurse and nurse would be fired.” (Participant No. 3, a 34-year-old female nurse with 12 years of work experience in the ICU)
“I avoided disclosing the incident because I would lose the trust of others.” (Participant No. 17, a 29-year-old female nurse with 7 years of work experience in the internal medicine department)
B- Misconception of harm to the organization's position
The participants thought that the disclosure of patient safety incidents damaged the hospital reputation and dignity, and healthcare workers working in the hospital would lose their social acceptability. Participants also mentioned reduced social acceptability of the hospital, damaged professional dignity of the nurses, and damaged hospital accreditation.
“If the patient becomes aware of the incident immediately, he or she will lose his/her trust in the healthcare team.” (Participant No. 7, a 36-year-old male nurse with 17 years of work experience in the emergency ward)
“Too much disclosure of patient safety incidents will drop the department's performance indicators, so, we avoid reporting many incidents.” (Participant No. 3, a 34-year-old female nurse, with 12 years of work experience in the ICU)
A competitive atmosphere in Iranian private hospitals for attracting patients was one of the most important factors influencing the disclosure of patient safety incidents.
“We avoid disclosing the incidents in private hospitals because patients lose their trust in the hospital.” (Participant No. 9, a 28-year-old male nurse with six years of work experience in the burn emergency department)
2- Opinions about the disclosure process and outcome
The participants mentioned the process and outcome of the disclosure of patient safety incidents. This category consisted of two Subcategories: beliefs in the disclosure process and beliefs in the disclosure outcome.
A- Beliefs in the disclosure process
Non-disclosure of non-harmful incidents, disclosure of harmful incidents, non-disclosure of compensated incidents, offender’s disclosure, non-disclosure of frequent incidents were factors that determined participants’ attitudes and behaviors towards the disclosure of patient safety incidents.
“We reported the incident because it was serious and we could not ignore it.”(Participant No.1, a 33-year-old female nurse with a 10-year work experience in the emergency ward)
“We did not report the incident because the patient was fine and had no problem.” (Participant No. 10, a 35-year-old female nurse with 10 years of work experience in the surgery ward)
“I quickly reported the incident and the anesthetist intubated the patient again. I reported it because I had no idea how to compensate for it, but I did not report previous incidents because I could solve them.” (Participant No. 11, a 38-year-old female nurse with 13 years of work experience in the CCU & Cath lab)
B-Beliefs in the disclosure outcome
Disclosure to prevent further harm, learning from the incident, respect for the patient's right to know about the incident, and ineffective disclosure outcome were some of the factors considered by the participants.
Nurses participated in the study believed that they should disclose incidents that have positive outcomes for the patient, so they had a positive attitude towards the positive outcome of the disclosure of patient safety incidents but a negative attitude towards the negative outcome of the disclosure.
“I reported the incident because I did not want to cause more harm to the patient.” (Participant No. 17, a 29-year-old female nurse with seven years of work experience in the internal ward)
“We reported the incident to learn and prevent it from happening again.” (Participant No. 2, a 32-year-old male nurse with 14 years of work experience in the military hospital)
3- Opinions about behaviors
The study participants mentioned three factors: negative beliefs in punitive behaviors, beliefs in supportive behaviors of the organization, and negative beliefs in patients’ behaviors.
A- Negative beliefs in punitive behaviors
The study participants had a negative attitude towards the disclosure of patient safety incidents because they were afraid of being punished by the organizational authorities. This Subcategory consisted of: belief in the inability to predict the reaction of authorities, belief in the existence of authoritarian and harsh management, and belief in the organizational punishment.
“I think disclosure is the right thing to do, but I regretted reporting the incident when I saw that the management mechanism was tyrannical.” (Participant No. 8, a 27-year-old male nurse, with four years of work experience in the CCU ward)
“My colleague administered the wrong medication for which she was reprimanded and severely punished. Based on this experience, I have chosen not to report the incident.” (Participant No. 12, a 30-year-old female nurse with 6 years of work experience in the postpartum & pediatric ward)
B- Beliefs in the supportive behaviors of the organization
Belief in the organizational incentive, belief in organizational non-punishment, and belief in the impact of organizational support on the disclosure were among factors mentioned by the participants.
“I reported an incident because the hospital gave incentives and increased the monthly salary of those who reported incidents.” (Participant No. 10, a 35-year-old female nurse with 10 years of work experience in the nursing management office)
“We always report errors because we are sure that the authorities will support us and there will be no problems for us.” (Participant No. 4, a 37-year-old female nurse with 15 years of work experience in the surgery ward)
C- Negative beliefs in the patients’ behaviors
Study participants reported the following negative beliefs: disclosure led the patient to file a legal complaint, disclosure led the patient's companion to physically assault, disclosure led the patient to misinterpret the incident, and disclosure made the patient anxious.
“I was replaced by someone who had been fired for a patient safety incident and heavily fined by the court, so I was afraid to report my mistakes and tried not to report them.” (Participant No. 7, a 36-year-old male nurse with 17 years of work experience in the emergency ward)
"Unfortunately, in all experiences I have had or witnessed, when an incident occurs, patient companions do not behave appropriately, and this inappropriate behavior by physicians and patients led us not to report the incidents.” (Participant No. 6, a 27-year-old male nurse with three years of work experience in the ICU & internal ward)
4- Inner conflict between feelings
A person experiences inner conflict that is the result of the confrontation of desires, the battle of moral beliefs, mental conflicts, feelings of insecurity and confusion, experience, doubts. The study results showed that the inner conflict between emotions was effective in nurses’ attitudes towards the disclosure of patient safety incidents. This category contained two Subcategories: shame and embarrassment that prevented disclosure, and internal conditions that caused disclosure.
A- Shame and embarrassment that prevented disclosure
The study participants admitted that shame and embarrassment affected their attitudes towards the disclosure of patient safety incidents. This subcategory consisted of: feeling ashamed of being blamed by patients, feeling ashamed of being blamed by colleagues, feeling ashamed of being mocked by colleagues, feeling ashamed of being blamed by doctors.
“We avoid reporting incidents because patients blame us, which makes us feel guilty.” (Participant No. 1, a 33-year-old female nurse, with 10 years of work experience)
“I was a new nurse, so I was afraid that my colleagues would make fun of me; I did not want my colleagues to point their fingers at me.” (Participant No. 5, a 49-year-old female nurse with 22 years of work experience in the general surgical & psychiatric)
B- Internal conditions that caused disclosure
Some internal factors rooted in religion, beliefs and personality characteristics of people and affected nurses’ attitudes towards the disclosure of patient safety incidents. This subcategory included: feeling guilty, feeling responsible, seeing God as an observer, having an obligatory sense to disclose oneself.
“I will report incidents in order not to feel guilty; if I had caused a patient death, I would not have had a comfortable life.” (Participant No. 15, a 32-year-old female nurse with nine years of work experience in the postpartum)
“I reported an incident because my religion and the moral principles are more preferable to me. Nothing is hidden from Almighty God.” (Participant No. 3, a 34-year-old female nurse with 12 years of work experience in the ICU)