PReSaFe: A model of barriers and facilitators to patients providing feedback on experiences of safety

Abstract Objective The importance of involving patients in reporting on safety is increasingly recognized. Whilst studies have identified barriers to clinician incident reporting, few have explored barriers and facilitators to patient reporting of safety experiences. This paper explores patient perspectives on providing feedback on safety experiences. Design/Participants Patients (n=28) were invited to take part in semi‐structured interviews when given a survey about their experiences of safety following hospital discharge. Transcripts were thematically analysed using NVivo10. Setting Patients were recruited from four hospitals in the UK. Results Three themes were identified as barriers and facilitators to patient involvement in providing feedback on their safety experiences. The first, cognitive‐cultural, found that whilst safety was a priority for most, some felt the term was not relevant to them because safety was the “default” position, and/or because safety could not be disentangled from the overall experience of care. The structural‐procedural theme indicated that reporting was facilitated when patients saw the process as straightforward, but that disinclination or perceived inability to provide feedback was a barrier. Finally, learning and change illustrated that perception of the impact of feedback could facilitate or inhibit reporting. Conclusions When collecting patient feedback on experiences of safety, it is important to consider what may help or hinder this process, beyond the process alone. We present a staged model of prerequisite barriers and facilitators and hypothesize that each stage needs to be achieved for patients to provide feedback on safety experiences. Implications for collecting meaningful data on patients' safety experiences are considered.

learning processes. When willing and able, there is "considerable scope" for patients to play an active role in ensuring that their care is safe 8 by providing feedback 9 through reporting incidents and/or evaluating safety experiences. Patient experience measures have been shown to provide meaningful information to health-care professionals regarding experiences of safety. 8 Patients can be involved in safety by speaking up at the point of care, making formal complaints or providing feedback via surveys. 10 Research has also demonstrated positive associations between patient experience measures and other outcome measures, such as patient adherence, clinical processes and safety culture. 11,12 Significantly, patients can provide a different perspective on safety to health-care staff, which can inform approaches to managing safety and risk; patients can recognize issues not seen or reported by staff 13 and identify risks to which staff may have become desensitized. A recent review of patient reporting on safety concluded that patients can play a role as part of a larger "error detection jigsaw" to improve quality and care. 10 However, there are many barriers to patients engaging with current reporting structures and systems. 10 Individuals may fear being branded as "difficult" patients if they are seen as questioning staff or their quality of care 14,15 and thus may be reluctant to report safety concerns. Patients may also adopt a "self-protection strategy" by avoiding reporting safety issues to staff who appear unresponsive, uninterested or unapproachable. 16 Such findings underline the importance of providing explicit opportunities for patients to report safety concerns and also serve to highlight safety as a process which is contingent on, and coproduced by, the interactions and relationships between patients and health-care practitioners. [17][18][19] Through reporting safety incidents, patients could operate as an extra source of learning or intelligence, 20 or "safety buffers," within the health-care system. [21][22][23] Previous findings emphasize the necessity of understanding and addressing the barriers and facilitators to engaging patients in safety reporting. Identified barriers include patients' own illness severity and cognitive characteristics, the relationship between the patient and the health-care practitioner, contextual factors and the perception of being subordinate to medical professionals. 15 Given the particularly high-risk process of care transfers, [23][24][25][26][27] this study recruited patients who had been discharged from hospital to understand their perceptions and experiences of safety in the context of their discharge and care transfer. Indeed, Coulter et al. 28 have recently identified a clear need for further research on capturing patient experiences when transitioning between organizations. The aim of this study was to examine the barriers and facilitators to patients reporting on these safety experiences.

| Data collection
In total, 28 patients participated in the study; 10 participants were female (36%) and 18 were male (64%). The mean age of participants was 68 (range 53-86). Patients were given an invitation letter to participate in a semi-structured interview after completing a safety survey, 29 which was handed out to them by health-care staff upon discharge and completed once they had arrived at their next destination. 23 The safety survey was codesigned with patient representatives, 29 based on how patients perceive safety. 21 Patient representatives were also consulted in designing the patient interview guide and contributed to the wider design and conduct of the study via an advisory group.
Patients were recruited from four clinical areas (cardiac, care of older people, orthopaedics and stroke) using convenience sampling after expressing an interest in participating in an interview when returning the survey. Inclusion criteria for patients were that they were able to give informed consent, aged 18 or over and able to take part in an English language interview (one participant was interviewed with the help of an interpreter). Table 1

| Data analysis
Interviews were transcribed verbatim, then coded and analysed using

| RESULTS
Interviews with participants identified three key themes related to patient involvement in providing feedback on their safety experiences: cognitive-cultural, structural-procedural, and learning and change.

| Cognitive-cultural
This theme represents how patients' conceptualizations of safety could influence their safety-reporting behaviour. Within this theme, some participants discussed the importance of safety, whereas others felt it was not a concept relevant to them, and therefore not one they prioritized. The latter group had an assumption of safety as the "default position" of care delivery, and many felt that safety could not be isolated as a concept and instead had to be understood within the context of the complete health-care experience.

| Perception that safety is important
Many participants reported that patient safety was a high priority for patients and staff, often drawing on their personal experiences of feeling safe. This can be seen in the extract below: Yeah, well safety is a priority isn't it? Erm, well I always feel totally safe when I'm in there. I feel safe when I'm in hospital. [P980] The priority assigned to safety was further linked to patients' psy- [P4300]

| Safety is not the patient's priority
Other participants suggested that safety was not a priority for patients to think about. Many assumed that their safety was guaran- When such attitudes are held, it is unlikely that patients would be inclined to respond to requests for their involvement in patient safety, for example by flagging up risks or completing feedback forms.

| Structural-procedural
This theme consists of two subthemes related to participants' attitudes towards the structures and processes of providing feedback.
These were the opportunity, means and ease of providing feedback, and the fear of reprisals when doing so.

| Opportunity, means and ease
To provide feedback on their experiences of safety, participants noted that it was necessary for the process of doing so to be relatively easy and structured in a way to make it simple and straightforward to engage

| Fear of reprisals
For some patients, a fear of reprisals from staff was also a barrier to providing feedback. Even if the process was easy, some participants were dissuaded from providing feedback because they thought they

[P1189]
Even if patients did not themselves fear such reprisals, some told stories of others who did. However, it should be noted that there were participants who explicitly stated that they did not believe such reprisals should be a cause of concern.
Participant: I don't think so, I can't see that if they had a problem with certain staff, they would treat them any differently. [P1867]

| Learning and change
Regardless of what patients thought about the process of providing feedback, their views about the effectiveness of their feedback in promoting improvement were a crucial factor influencing whether they did so. Most of the participants felt that providing feedback to staff on the ward or to higher levels of governance would or could make a difference to safety in the future, as highlighted by Participants 980 and 3408:

| DISCUSSION
This paper explored the barriers and facilitators to patients reporting their safety experiences, in terms of three key themes: cognitive-cultural, structural-procedural, and learning and change.
Taken together, we argue that these themes form a staged model of barriers and facilitators (Figure 1), where each stage has different implications. Within this model, we hypothesize that each stage is a prerequisite for the next and that all are required for patients to report on their experiences. For example, a patient may understand the concept of safety (cognitive-cultural), and there may be no structural-procedural barriers in place, but if the patient does not think that feedback will lead to learning and change, they will be less likely to report their experiences.
The first component, cognitive-cultural, relates to how patients conceptualized safety. Whilst most participants understood that safety was a priority, some felt that patient safety was not of relevance to patients. Where safety was deemed not relevant, patients reported that being safe was an assumed default position, or that safety was something that had to be understood within the context of the wider health-care experience; thus, providing feedback on safety relating to discharge and care transfers is perceived as being of little utility. This finding is consistent with classic work by Hughes,31 who posited that the risk and responsibility for complex and risky activities can be transferred to a specialist rather than taken on by the individual themselves, if the specialist (ie the health-care professional) was perceived as trustworthy and competent. This may account for the patients considering safety the "default" position. These "taken-for-granted" safety structures, as described by Rhodes et al.,19 make it difficult for patients to isolate safety from other aspects of their care experience. This difficulty in isolating particular elements of their experience was also reflected in participants' tendency to discuss their care experience as a whole, so that when asked specifically about their experience of care transfers, they discussed aspects of their hospital stay, apparently not viewing the transfer as a discrete part of their health-care experience. Therefore, it may not be appropriate to ask patients to reflect on certain aspects of their experience, when they often consider the holistic experience, rather than a series of discrete stages.
Patients' conceptualizations of safety as identified in the cognitive-cultural theme were different to standard academic understandings of safety, such as those proposed within Reason's model of safety, 3 or the International Classification of Patient Safety. [32][33][34] Whilst this is consistent with previous research, 13,19,[35][36][37][38] it is important to highlight that this difference formed a major barrier to patients providing feedback on their safety experiences and raises the question of whether we should be using the term "safety" at all in materials aimed at patients.
One approach to addressing this is to reconceptualize "safety" to in- A key strength of this paper is that it offers a model for understanding the barriers and facilitators to patients providing feedback on their safety, offering a testable framework for future research as well as considerations for those planning and designing patient feedback mechanisms. However, the research is not without its limitations.
Some patients being discharged may not have been capable of taking part in an interview if there was not a family member or carer to assist them. Furthermore, due to the difficulty among participants in unpicking and reporting on discrete aspects of their care, it was challenging to ensure that participants focused on their experiences of safety within their care transfer during interviews. Given these findings, key learning points from this research are the need to reconsider the use of the word "safety" when asking patients to provide feedback on experiences, and to develop health literacy among patients such that they conceptualize it as an issue relevant to them, in which they can play an active and meaningful role.

| CONCLUSION
Patient interviews offered important information about patients' receptiveness to reporting their safety experiences. To provide feedback on safety experiences, it was necessary for patients to conceptualize safety as something important and relevant to them. Both the ease of the process of providing feedback and the perceived effectiveness of that feedback could result in patients being more or less likely to provide feedback. The PReSaFe model proposed in this paper operationalizes barriers and facilitators to patients' reporting on their safety that we contend have relevance beyond the current work, by offering a testable framework for future work and potentially facilitating patient reporting on other experiences of care that are collected for quality improvement.