Abstract

Patient safety in health care is the cornerstone of quality in nursing care. It is a duty of nurses and an objective of the health organizations. This article aims to analyze the scientific evidence on the nurses’ perception and opinion on patient safety in the emergency department. Systematic literature review with 3 steps. 1) Primary search at CINHAL and MEDLINE. 2) A broader search, using the same keywords and search terms in the remaining database of the EBSCOHost platform. 3) Search the bibliographic references of the selected articles. The selected studies were published between 2014 and 2019. Five articles were selected. The nurses’ perception reveal that the work environment, teamwork and matters related to the leadership of hierarchical superiors are fundamental factors to improve the quality of care provided and patient safety. Promoting teamwork improves patient care, reduces adverse events and improves quality. Recognizing the nurses’ perception on patient safety culture in emergency services, contributes to improving the quality of care provided.

Key words:
Emergency service; Hospital; Nurses; Patient safety; Review

Introduction

The nursing practice environment (NPE) is critical to the success of health systems¹1 Almeida S, Nascimento A, Lucas PB, Jesus E, Araújo B. RN4CAST study in Portugal: validation of the Portuguese version of the Practice Environment Scale of the Nursing Work Index. Aquichan 2020; 20(3):e2038. and is related to the nursing care quality (NCQ), patient safety and the effectiveness of care for patients and the efficiency of organizations²2 Carvalho MC, Lucas PR. The effectiveness of the clinical nurse leader practice - systematic review. Millenium 2020; 2(11):57-64.

3 Lucas PRMB, Nunes EMGT. Nursing practice environment in primary health care: a scoping review. Rev Bras Enferm 2020; 73(6):e20190479.^-44 De Sul SIR, Lucas PRMB. Translation and validation of the anticipated turnover scale for the Portuguese cultural context. Nurs Open 2020; 7(5):1475-1481..

Promoting the quality of care that nurses provide and, therefore, contribute to the improvement of the clinical practice contexts is a vital factor for professional and patient satisfaction. NCQ is an essential element in the profession and is related, among other aspects, to the direct relationship between patient and nurse. NCQ depends on many factors, mainly the NPE³3 Lucas PRMB, Nunes EMGT. Nursing practice environment in primary health care: a scoping review. Rev Bras Enferm 2020; 73(6):e20190479..

Lake defines the practice environment as the organizational characteristics of a working context that facilitate or restrict the professional nursing practice¹1 Almeida S, Nascimento A, Lucas PB, Jesus E, Araújo B. RN4CAST study in Portugal: validation of the Portuguese version of the Practice Environment Scale of the Nursing Work Index. Aquichan 2020; 20(3):e2038.^,33 Lucas PRMB, Nunes EMGT. Nursing practice environment in primary health care: a scoping review. Rev Bras Enferm 2020; 73(6):e20190479.^,55 Lake ET. Development of the practice environment scale of the nursing work index. Res Nurs Health 2002; 25(3):176-188.. A favorable NPE leads to improved patient outcomes and it is an essential factor for increasing the nurses’ satisfaction, being essential to maintain teams with safe staffing and retain the nurses in them³3 Lucas PRMB, Nunes EMGT. Nursing practice environment in primary health care: a scoping review. Rev Bras Enferm 2020; 73(6):e20190479.^,44 De Sul SIR, Lucas PRMB. Translation and validation of the anticipated turnover scale for the Portuguese cultural context. Nurs Open 2020; 7(5):1475-1481.. A favorable NPE is characterized by the adequacy of human and material resources, active participation of the nurses in the governance of organizations, quality of care and the provision of nursing care, and good relationships between different professional groups in health services¹1 Almeida S, Nascimento A, Lucas PB, Jesus E, Araújo B. RN4CAST study in Portugal: validation of the Portuguese version of the Practice Environment Scale of the Nursing Work Index. Aquichan 2020; 20(3):e2038.^,55 Lake ET. Development of the practice environment scale of the nursing work index. Res Nurs Health 2002; 25(3):176-188.. According to scientific evidence from recent decades, these favorable NPE have significant impacts on the levels of quality and safety of patient care, health professionals’ well-being, quality and productivity, and effectiveness of services, organizations and health systems¹1 Almeida S, Nascimento A, Lucas PB, Jesus E, Araújo B. RN4CAST study in Portugal: validation of the Portuguese version of the Practice Environment Scale of the Nursing Work Index. Aquichan 2020; 20(3):e2038..

On the other hand, poor NPEs, with lack of management support, weak leadership and poor multidisciplinary relationships are associated with: decreased NCQ; adverse events in patients⁶6 Poghosyan L, Shang J, Liu J, Poghosyan H, Liu N, Berkowitz B. Nurse practitioners as primary care providers: creating favorable practice environments in New York State and Massachusetts. Health Care Manage Rev 2014; 40(1):46-55., such as errors; increased mortality and complications; hospital readmissions due to complications; increase in health care costs; ineffective care delivery, conflicts and stress among health professionals⁷7 Tomaszewska K, Klos A, Majchrowicz B. Influence of work environment on the quality of benefits provided by primary health care nurses. J Educ Health Sport 2017; 7(8):1191-1205.; professional dissatisfaction and increased nurse turnover³3 Lucas PRMB, Nunes EMGT. Nursing practice environment in primary health care: a scoping review. Rev Bras Enferm 2020; 73(6):e20190479.. All these aspects strongly contribute to patients’ dissatisfaction with the care they receive.

A safe NPE is characterized by good professional relationships between its members, management support for professionals and well-balanced working hours³3 Lucas PRMB, Nunes EMGT. Nursing practice environment in primary health care: a scoping review. Rev Bras Enferm 2020; 73(6):e20190479.^,88 Alves DFS, Guirardello EB. Nursing work environment, patient safety and quality of care in pediatric hospital. Rev Gaucha Enferm 2016; 37(2):e58817.^,99 Copanitsanou P, Fotos N, Brokalaki H. Effects of work environment on patient and nurse outcomes. Br J Nurs 2017; 26(3):172-176.. It is also characterized by the adequacy between the workload and the nurses’ competences, time to meet the patients’ needs, professional autonomy, adequate resources and opportunities for professional advancement³3 Lucas PRMB, Nunes EMGT. Nursing practice environment in primary health care: a scoping review. Rev Bras Enferm 2020; 73(6):e20190479.^,88 Alves DFS, Guirardello EB. Nursing work environment, patient safety and quality of care in pediatric hospital. Rev Gaucha Enferm 2016; 37(2):e58817.^,99 Copanitsanou P, Fotos N, Brokalaki H. Effects of work environment on patient and nurse outcomes. Br J Nurs 2017; 26(3):172-176..

Nurse managers play a key role in creating a favorable/positive NPE⁸8 Alves DFS, Guirardello EB. Nursing work environment, patient safety and quality of care in pediatric hospital. Rev Gaucha Enferm 2016; 37(2):e58817. and in promoting the provision of quality care²2 Carvalho MC, Lucas PR. The effectiveness of the clinical nurse leader practice - systematic review. Millenium 2020; 2(11):57-64.^,33 Lucas PRMB, Nunes EMGT. Nursing practice environment in primary health care: a scoping review. Rev Bras Enferm 2020; 73(6):e20190479.. They can also provide the necessary tools for the professional development of nurses and future managers¹⁰10 Gea-Caballero V, Castro-Sánchez E, Júarez-Vela R, Díaz-Herrera MA, de Miguel-Montoya I, Martínez-Riera JR. Elementos esenciales de los entornos profesionales enfermeros en atención primaria y su influencia en la calidad del cuidado. Enferm Clin 2018; 28(1):27-35.. The nursing leadership plays a central role in quality patient care, which involves four key activities: facilitating effective and ongoing communication; strengthening of intra- and interprofessional relationships; building and maintaining the teams; and peer involvement²2 Carvalho MC, Lucas PR. The effectiveness of the clinical nurse leader practice - systematic review. Millenium 2020; 2(11):57-64.. Leadership influences the NPE³3 Lucas PRMB, Nunes EMGT. Nursing practice environment in primary health care: a scoping review. Rev Bras Enferm 2020; 73(6):e20190479.^,1111 Weber E, Ward J, Walsh T. Nurse leader competencies: a toolkit for success. Nurs Manage 2015; 46(12):47-50. and the quality of nursing care²2 Carvalho MC, Lucas PR. The effectiveness of the clinical nurse leader practice - systematic review. Millenium 2020; 2(11):57-64.. Nurses, as leaders, are essential to improve communication with and between the team to achieve goals, aiming at the quality of care, patient safety and innovation in health²2 Carvalho MC, Lucas PR. The effectiveness of the clinical nurse leader practice - systematic review. Millenium 2020; 2(11):57-64.^,1212 Nunes EMGT, Gaspar MFM. A liderança em enfermagem e a satisfação dos pacientes em contexto hospitalar. Rev Gaucha Enferm 2016; 37(2):e55726..

Without adequate competences and knowledge, it becomes difficult for nursing leaders to maintain a favorable NPE³3 Lucas PRMB, Nunes EMGT. Nursing practice environment in primary health care: a scoping review. Rev Bras Enferm 2020; 73(6):e20190479.^,88 Alves DFS, Guirardello EB. Nursing work environment, patient safety and quality of care in pediatric hospital. Rev Gaucha Enferm 2016; 37(2):e58817.. The nurse manager is an engine of change on the path to excellence, organizing the existing resources and creating a safe environment in nursing care³3 Lucas PRMB, Nunes EMGT. Nursing practice environment in primary health care: a scoping review. Rev Bras Enferm 2020; 73(6):e20190479..

Studying the NPEs allows us to obtain evidence on how to increase the quality of nursing care⁸8 Alves DFS, Guirardello EB. Nursing work environment, patient safety and quality of care in pediatric hospital. Rev Gaucha Enferm 2016; 37(2):e58817.^,1313 Parro-Moreno A, Serrano-Gallardo P, Ferrer-Arnedo C, Serrano-Molina L, de la Puerta Calatayud ML, Barberá-Martín A, Morales-Asencio JM, de Pedro Gómez J. Influence of socio-demographic, labour and professional factors on nursing perception concerning practice environment in primary health care. Aten Primaria 2013; 45(9):476-485.^,1414 Rabie T, Coetzee SK, Klopper HC. The nature of community health care centre practice environments in a province in South Africa. Afr J Nurs Midwifery 2016; 18(2):27-41. and patient safety, how to improve the achievement of results¹³13 Parro-Moreno A, Serrano-Gallardo P, Ferrer-Arnedo C, Serrano-Molina L, de la Puerta Calatayud ML, Barberá-Martín A, Morales-Asencio JM, de Pedro Gómez J. Influence of socio-demographic, labour and professional factors on nursing perception concerning practice environment in primary health care. Aten Primaria 2013; 45(9):476-485.^,1515 Ayamolowo SJ, Irinoye O, Oladoyin MA. Job satisfaction and work environment of primary health care nurses in Ekiti State, Nigeria: an exploratory study. Int J Caring Sci 2013; 6(3):531-543. and reduce complications for clients¹⁶16 Rabie T, Klopper HC, Coetzee SK. Creating positive practice environments in a primary health care setting. Int J Nurs Pract 2017; 23(4):e12555 .^,1717 Poghosyan L, Boyd DR, Clarke SP. Optimizing full scope of practice for nurse practitioners in primary care: a proposed conceptual model. Nurs Outlook 2016; 64(2):146-155., namely by improving disease control and preventing associated risks¹⁸18 Parro-Moreno A, Serrano-Gallardo P, Díaz-Holgado A, Aréjula-Torres JL, Abraira V, Santiago-Pérez IM, Morales-Asencio JM. Impact of primary care nursing workforce characteristics on the control of high-blood pressure: a multilevel analysis. BMJ Open 2015; 5(12):e009126..

Patient safety must always be the objective of the care provided in emergency services. It is not always easy to attain, due to the presence of patients with complex and highly acute conditions, a difficult-to-control work environment and multidisciplinary teamwork that involves frequent transfers with the potential for communication failures¹⁹19 Alshyyab MA, FitzGerald G, Dingle K, Ting J, Bowman P, Kinnear FB, Borkoles E. Developing a conceptual framework for patient safety culture in emergency department: a review of the literature. Int J Health Plann Manage 2019; 34(1):42-55..

Emergency department health professionals work under high-pressure conditions, with multiple interruptions and time constraints. Thus, there is an increased possibility of errors and unfavorable patient outcomes. Although there are many approaches aimed to improve patient safety, establishing a safety culture is considered a core strategy¹⁹19 Alshyyab MA, FitzGerald G, Dingle K, Ting J, Bowman P, Kinnear FB, Borkoles E. Developing a conceptual framework for patient safety culture in emergency department: a review of the literature. Int J Health Plann Manage 2019; 34(1):42-55.. The emergency department is a challenging work environment due to the high influx and turnover of patients, lack of control and the nurses’ work overload and communication difficulties. Thus, it becomes an environment that is vulnerable to risks for patients, putting their safety at risk²⁰20 Källberg AS, Ehrenberg A, Florin J, Östergren J, Göransson KE. Physicians' and nurses' perceptions of patient safety risks in the emergency department. Int Emerg Nurs 2017; 33: 14-19.. Glickman et al.²¹21 Glickman SW, Mehrotra A, Shea CM, Mayer C, Strickler J, Pabers S, Larson J, Goldstein B, Mandelkehr L, Cairns CB, Pines JM, Schulman KA. A patient reported approach to identify medical errors and improve patient safety in the emergency department. J Patient Safe 2020; 16(3):211-215. found that 8.5% of the problems identified by the patients were related to their safety. They found in their study that the emergency department has adverse incidents and was the third most common location for adverse incidents in hospitals. The working environment is an essential factor in this topic.

Therefore, we consider it essential to analyze the scientific evidence about patient safety in a hospital emergency department, according to the nurses’ opinion. The guiding question of this review is: “What is the nurses’ opinion about patient safety in the context of a hospital emergency department?”

Methods

This review was based on the methodology proposed by the Joanna Briggs Institute for reviews²²22 Peters MDJ, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Health Care 2015; 13(3):141-146., aiming at “Analyzing the scientific evidence about the nurses’ perception of the safety culture in an emergency department.” This systematic review answers the question and is based on the PCC (population, concept and context) elements, taking into account the inclusion criteria. The review question is: “What is the nurses’ perception about the safety culture in an emergency department?” The following databases were searched to identify review studies related to nurses’ perception of the safety culture in the emergency department, published between 2014 and 2019: CINAHL Complete; MEDLINE Complete; Nursing & Allied Health Collection: Comprehensive; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Cochrane Methodology Register; Library, Information Science & Technology Abstracts; MedicLatina, via EBSCOhost - Research Databases; BVS - Biblioteca Virtual da Saúde, PubMed, RCAAP - Open Access Scientific Repositories of Portugal. The initial search strategy used search terms mapped to Medical Subject Headings (MeSH). The following descriptors were used: #1 MeSH Emergency department; #2 MeSH Nurse’s perception; #3 MeSH Patient Safety; #4 MeSH Safety culture e #4 [#1 AND # 2 AND #3 OR #4] (explode all trees).

To identify relevant studies that met the defined inclusion criteria, surveys were carried out that included the studies published between 2014 and 2019, in Portuguese, English and Spanish. After their combination with the Boolean operators in search engines to obtain the full texts of the publications that had been identified, the following formulations resulted: ((“Emergency department”) AND “Nurse’s perception”]) AND “Patient Safety “]) OR “Safety culture”].

The following were defined as inclusion criteria: studies published in the aforementioned databases, presented in full text, in English, Portuguese and Spanish, and whose title and/or abstract cited the nurses’ opinion on patient safety in the context of the hospital emergency department.

The selection process was based on the Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist for systematic reviews²³23 Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the Prisma Statement. PloS Med 2009; 6(7):e1000097. and the Joanna Briggs Institute methodology regarding the guidelines of a systematic review²²22 Peters MDJ, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Health Care 2015; 13(3):141-146., which was used as part of the search strategy. The full text of each article was reviewed to determine whether it met the study inclusion criteria by two reviewers after discussions between them to reach a consensus on the exclusion of articles.

The search in the databases resulted in the identification of 57 articles. Thus, in the first phase, the critical and reflective reading of the titles and abstracts of the identified studies was carried out. In a second phase, after removing the repeated articles in the databases (n = 23), a sample of 34 articles was established. After applying the inclusion criteria, a sample consisting of 15 articles was considered for eligibility. Subsequently, a careful analysis of the selected articles was carried out, with the exclusion of five articles as they did not discriminate the nurses’ perceptions among those of health professionals and retaining five articles from which evidence was extracted related to the nurses’ perception about the safety culture in the emergency department. At this phase, aiming to organize the entire analysis by performing an exploratory reading of each article, we identified, translated and transcribed phrases/words that corresponded to the topic of nurses’ perception about the culture of safety in the emergency department. Aiming to systematize the information from the articles, the data extracted from the studies were descriptively compiled into a previously created table, which facilitated the identification and reformulation of thematic categorizations.

Figure 1 depicts the results of the analysis phases, according to the PRISMA Flow Diagram²³23 Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the Prisma Statement. PloS Med 2009; 6(7):e1000097. model.

Data extraction

The data extracted from the articles were aligned with the objectives and research questions and the respective instrument indicated by the analysis methodology developed by the Joanna Briggs Institute²²22 Peters MDJ, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Health Care 2015; 13(3):141-146.. Both reviewers independently analyzed the first five studies using the data form, and subsequently met to determine whether the approach to the extracted data was consistent with the present research²⁴24 Levac D, Colquhoun H, O'Brien KK. Scoping studes: advancing the methodology. Implement Sci 2010; 5:69..

Chart 1 shows the synthesis of the articles included in the review..

Results and discussion

The analyzed articles are unanimous in considering that knowledge of the perceptions of health professionals, especially nurses, about patient safety in the context of emergency services contributes to improving patient care, reduces adverse events and can concentrate the efforts on providing quality care. Promoting safe practice environments and, consequently, promoting patient safety are two main challenges for hospital organizations. When trying to improve these two results in a synergistic and interconnected way, psychosocial working conditions, leadership and perceptions of the patient safety culture should be considered. The studies showed that these key topics are interrelated and create a critical foundation for the promotion of patient safety in the emergency department. Patient safety is promoted, with an effect on the nursing practice environment in order to ensure the quality of nursing care.

Health organizations should promote the development of patient safety²⁸28 Van Noord IV, Wagner C, Van Dyck C, Twisk JWR, De Bruijne MC. Is culture associated with patient safety in the emergency department? A study of staff perspectives. Int J Qual Health Care 2014; 26(1):64-70.^,2929 Tourani S, Hassani M, Ayoubian A, Habibi M, Zaboli R. Analyzing and prioritizing the dimensions of patient safety culture in emergency wards using the TOPSIS technique. Global J Health Sci 2015; 7(4):143-150.. The health organizations’ safety culture is related to the product of values, attitudes, perceptions, competences and behavior patterns of individuals and groups that determine the commitment, the style and proficiency of an organization’s safety and health management³⁰30 Wagner A, Rieger MA, Manser T, Sturm H, Hardt J, Martus P, Lessing C, Hammer A, WorkSafeMed Consortium. Healthcare professionals' perspectives on working conditions, leadership, and safety climate: a cross-sectional study. BMC Health Serv Res 2019; 19:53.. Emergency services with a positive patient safety culture are characterized by communications based on mutual trust, shared perceptions of the importance of safety and trust in the effectiveness of preventive measures²⁸28 Van Noord IV, Wagner C, Van Dyck C, Twisk JWR, De Bruijne MC. Is culture associated with patient safety in the emergency department? A study of staff perspectives. Int J Qual Health Care 2014; 26(1):64-70..

The patient safety culture reflects how safety is seen and treated, in the specific case of the emergency department. However, the nurses’ perceptions are not always positive²⁷27 Alzahrani N, Jones R, Abdel-Latif ME. Attitudes of doctors and nurses toward patient safety within emergency departments of two Saudi Arabian hospitals. BMC Health Serv Res 2018; 18:736., regardless of gender, length of professional experience in the emergency department and position held, suggesting the need for improvements at the level of patient safety in the emergency department, in terms of teamwork , safety culture, the recognition of stress, the management of the emergency department and the hospital and the working conditions. The valorization of teamwork and open communication as a guarantee of a patient safety culture²⁵25 Rigobello MCG, Carvalho REFL, Guerreiro JM, Motta APG, Atila E, Gimenes FRE. The perception of the patient safety climate by professionals of the emergency department. Int Emergency Nurs 2017; 33:1-6.^,2727 Alzahrani N, Jones R, Abdel-Latif ME. Attitudes of doctors and nurses toward patient safety within emergency departments of two Saudi Arabian hospitals. BMC Health Serv Res 2018; 18:736.

28 Van Noord IV, Wagner C, Van Dyck C, Twisk JWR, De Bruijne MC. Is culture associated with patient safety in the emergency department? A study of staff perspectives. Int J Qual Health Care 2014; 26(1):64-70.^-2929 Tourani S, Hassani M, Ayoubian A, Habibi M, Zaboli R. Analyzing and prioritizing the dimensions of patient safety culture in emergency wards using the TOPSIS technique. Global J Health Sci 2015; 7(4):143-150., is common to all analyzed studies.

The safety attitudes of physicians and nurses in the emergency services in Saudi hospitals are less positive and are correlated with the number of reported errors²⁷27 Alzahrani N, Jones R, Abdel-Latif ME. Attitudes of doctors and nurses toward patient safety within emergency departments of two Saudi Arabian hospitals. BMC Health Serv Res 2018; 18:736.. Safety training interventions and management support seem to be the most likely ways to improve the health professionals’ attitudes and performance in relation to patient safety.

Teamwork, job satisfaction and the nursing practice environment are correlated with a lower number of reported errors²⁷27 Alzahrani N, Jones R, Abdel-Latif ME. Attitudes of doctors and nurses toward patient safety within emergency departments of two Saudi Arabian hospitals. BMC Health Serv Res 2018; 18:736.. These factors are reported by and valued by nurses as promoters of patient safety in an emergency department²⁷27 Alzahrani N, Jones R, Abdel-Latif ME. Attitudes of doctors and nurses toward patient safety within emergency departments of two Saudi Arabian hospitals. BMC Health Serv Res 2018; 18:736..

Management support, professional performance, teamwork, feedback from nurse managers, training to deal with errors are significant factors when promoting patient safety²⁹29 Tourani S, Hassani M, Ayoubian A, Habibi M, Zaboli R. Analyzing and prioritizing the dimensions of patient safety culture in emergency wards using the TOPSIS technique. Global J Health Sci 2015; 7(4):143-150..

The nurses indicated that the human factors are the most effective and important in improving the patient safety culture in the emergency department²⁹29 Tourani S, Hassani M, Ayoubian A, Habibi M, Zaboli R. Analyzing and prioritizing the dimensions of patient safety culture in emergency wards using the TOPSIS technique. Global J Health Sci 2015; 7(4):143-150.. The results showed that the expectations and performance of the hierarchical superior and the hospital management support were at a medium level; 30% of participants reported that their hierarchical superior did not pay attention to their recommendations to improve patient safety and 52% of nurses stated that their hierarchical superior supported them when they performed a task based on the principles of the patient safety culture; 17% mentioned the improvement in patient safety is considered a critical factor that has to do with all levels of management of the emergency service²⁹29 Tourani S, Hassani M, Ayoubian A, Habibi M, Zaboli R. Analyzing and prioritizing the dimensions of patient safety culture in emergency wards using the TOPSIS technique. Global J Health Sci 2015; 7(4):143-150.. In other words, each hierarchical superior must create a support environment in their section, such as the implementation of safety programs and training courses²⁹29 Tourani S, Hassani M, Ayoubian A, Habibi M, Zaboli R. Analyzing and prioritizing the dimensions of patient safety culture in emergency wards using the TOPSIS technique. Global J Health Sci 2015; 7(4):143-150.. Human factors were the most effective and important in improving patient safety in the emergency department, suggesting the need to pay more attention to these factors in the implementation of improved patient safety culture²⁹29 Tourani S, Hassani M, Ayoubian A, Habibi M, Zaboli R. Analyzing and prioritizing the dimensions of patient safety culture in emergency wards using the TOPSIS technique. Global J Health Sci 2015; 7(4):143-150.. Training, good organizational environment conditions and motivating environmental factors were the main measures that should be taken into account by nurses. Nurses consider that the psychosocial work conditions and safety culture vary, although they work in the same environment³¹31 Kristensen S, Hammer A, Bartels P, Suñol R, Groene O, Thompson CA, Arah OA, Kutaj-Wasikowska H, Michel P, Wagner C. Quality management and perceptions of teamwork and safety climate in European hospitals. Int J Qual Health Care 2015; 27(6):499-506.. There are close relationships between NPE and patient safety³3 Lucas PRMB, Nunes EMGT. Nursing practice environment in primary health care: a scoping review. Rev Bras Enferm 2020; 73(6):e20190479.^,3232 Aiken LH, Sloane DM, Bruyneel L, Van den Heede K, Griffiths P, Busse R, Diomidous M, Kinnunen J, Kózka M, Lesaffre E, McHugh MD, Moreno-Casbas MT, Rafferty AM, Schwendimann R, Scott PA, Tishelman C, van Achterberg T, Sermeus W; RN4CAST consortium. Nurse staffing and education and hospital mortality in nine European countries. A retrospective observational study. Lancet 2014; 383(9931):1824-1830.^,3333 McHugh MD, Rochman MF, Sloane DM, Berg RA, Mancini ME, Nadkarni VM, Merchant RM, Aiken LH. American Heart Association's get with the Guidelines-Resuscitation Investigators. Better nurse staffing and nurse work environments associated with increased survival of in-hospital cardiac arrest patients. Med Care 2016; 54(1):74-80.. Therefore, it can be assumed that the NPE improvement leads to nursing care quality and patient safety. To optimize the patient safety culture, it is also essential to ensure a favorable NPE, psychosocial work conditions, with effective leadership from nurse managers.

Conclusions

The knowledge of nurses’ opinions about patient safety in emergency services contributes to improving the quality of nursing care, reducing adverse events and can concentrate efforts to improve the quality of care provided to patients. One of the most evident human rights is the right to be safe from possible risks while receiving healthcare. Patient safety is gaining prominence around the world and, every day, nurses in emergency departments face several challenges regarding how to provide safe care to patients.

Evidence shows that the negative perceptions of nurses working in emergency services still persist, considering that NPE, teamwork and issues related to the leadership of nurse managers are fundamental factors to have a culture of safety that can ensure nursing care quality.

References

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History