Introduction

Safety culture is understood through items such as open communication, teamwork, recognition of mutual dependence, organizational learning based on event notifications, as well as the primacy of safety as a priority at all levels of the organization (^{World Health Organization [WHO], 2009}). In Portugal, this theme became more evident and was considered one of the principles of risk management aimed at patient quality and safety. Thus, it is understood that safety culture is transversal to all subjects and that it can directly interfere both in the performance of the organization and in the provision of care to the patient’s health (General Board of Health [DGS, as per its Portuguese acronym] & Portuguese Association for Hospital Development [APDH, as per its Portuguese acronym]).

It is recommended that a health institution, before implementing any action directed to patient safety, conduct a situational diagnosis of the organizational culture and services. In this context, there is currently a concern with the evaluation of safety culture in various scenarios and with various objects of study, but there are still few qualitative studies that approach health organization leaders (^{Ashurst, 2017}).

Nowadays, it is essential to develop health managers with introspection of the key concepts of quality and safety, in order to ensure, in nursing science, a clinical practice, systematized and guided by these concepts. Thus, evaluating safety culture is one of the priority areas, allowing an expanded view of organizational indicators, especially if performed before the implementation of strategies, and can assist organizational and nursing managers in identifying consolidated areas and weaknesses (^{Reis, Laguardia, Vasconcelos & Martins, 2016}).

Organizations with a positive safety culture are characterized by good communication among employees, mutual trust, and common perceptions about the importance of safety and the effectiveness of preventive actions (^{Nieva & Sorra, 2003}). Patients, managers and professionals are increasingly concerned about the quality of health services. Patients are more informed and participatory, while managers are concerned with the optimal use of resources, and they know that efficiency, among other benefits, reduces costs. Health professionals, besides seeking survival in the market, are concerned about quality due to the ethical commitment intrinsic to this area, which involves taking care of people’s most valuable asset, that is, health (^{Gama & Saturno, 2017}).

For this reason, the interest of this study is to contribute to patient safety, particularly by involving nurse managers from a university hospital in Portugal. It is known that, in general, nurses have a huge influence on the organizational safety culture, since they are quantitatively the largest health professional group and the group that remains closest to the patient for the longest time. Besides having specific competencies and skills in the identification, planning, implementation and evaluation of health care. (^{Fernandes & Queirós, 2011}, pp. 37-48).

The Hospital Survey on Patient Safety Culture (HSOPSC) instrument was used in two Portuguese studies, one conducted to compare the safety culture practices among Brazilian and Portuguese nurses in university hospitals (^{Fassarella, Camerini, Henrique, Almeida & Figueiredo, 2018}), and the other talked about evaluating the differences in safety culture dimensions among four services (^{Fassarella, Silva, Carmerini & Figueiredo, 2019}).

In this sense, with the purpose of expanding the dimension of this object of study, the objective is to understand safety culture, from the dimensions of the Hospital Survey on Patient Safety Culture (HSOPSC), by the nurse managers of a Portuguese university hospital.

1. Methods

This is a descriptive study, with a qualitative approach, carried out in a university hospital in Porto, Portugal.

2. Results

Of the total of 16 nurse managers of the University Hospital of Porto, 14 participated in the study. The socio-demographic variables underlined the female gender, a mean age of 42 years, and more than 8 years of experience in the profession, the institution and the service. There was participation from most services, such as medicine, surgery, maternity, pediatrics, operating room (outpatient and central), rehabilitation, psychiatry, occupational nursing and adult and pediatric intensive care medicine.

From the analysis of the interviews, six thematic categories emerged: I) Management, II) Teamwork, III) Shift change and transfers, IV) Supervisor’s expectation and actions to promote patient safety, V) Organizational learning, information feedback and open communication, VI) Management support for patient safety. From each of the thematic categories, a subcategory was chosen that stood out the most by the nurses. These subcategories were organized and analyzed by simple descriptive statistics, with the purpose of later directing the discussion of the data.

Given the results achieved through the analysis of the six categories on the understanding of safety culture, a total of 21 subcategories emerged, which were related to the corresponding thematic categories, based on the HSOPSC instrument, Table 1.

Thematic category I - Management: the most prevalent subcategory was “work plan”, this is portrayed in the following statements:

(...) Yes, a plan is made, a nursing plan, made weekly and in advance I make this plan in which the nurse in charge of the shift, the one in the donor collection room and the one assigned to the nursing office are highlighted. (N6)

(...) with the management area, we have the team, which is 20 nurses at this moment and who are and are assigned to care provision only. Therefore, they have, in fact, a monthly scale and on a rotating schedule and, on a daily basis, they have a work plan, that is, that distributes and assigns each professional to a certain number of patients. (N7)

Thematic category II - Teamwork: the most referenced subcategory was “intra-team help”, which emerged from the statements:

(...) teamwork, within the teams, it was visible and expressed, but there was no cooperation between the teams. Oh! And there was (and still is) no cooperation with teams from other departments either. (N5)

(...) In this service, the teamwork, despite everything, sometimes it's more teamwork than I sometimes wanted, because they have, but they realize that and they know that, the patients (...) among the hospital services, I don't have that good impression so much. (...)”. (N8)

Thematic category III - Shift change and transfers: the subcategory that stood out the most was the “direct exchange of information among professionals”, with the following statements:

(...) Therefore, the shift change. Oh! As a moment of clinical communication between teams or between nurses of the same team. The transfer of patients within the same service or between services or between departments. The moment of clinical communication par excellence of any team is from the point of view of care delivery; therefore, the best and safest care delivery that you can offer to patients is to have shift changes. (N5)

(...) So, it’s like this, we have three shifts, we have the morning shift, so, in the morning we receive the shift, we have a meeting between all the nurses, although we have everything computerized, everything systematized (...). On the afternoon shift, there is a more relaxed meeting, let’s say, and we always pass it on; and, at night, they also do that, the afternoon colleagues pass it on to the night colleagues. Three times, let’s say in the 24 hours, we do a shift change, checking all the patients. (N12)

Thematic category IV - Supervisor’s expectation and actions to promote patient safety: the subcategory that stood out the most was “regular training and information”, this is portrayed in the following statements:

(...) It’s promoted in several instances. It’s promoted with mandatory training actions on quality. They all have to go to biannual, every two years, all nurses have to do this training. (N8)

(...) Oh, it’s that man who also provides us with the information and training necessary for the prevention of accidents with implications for patient safety, isn’t it? So, it’s the regular and mandatory information related to patient safety. (N9)

Thematic category V - Organizational learning, information feedback and open communication: the subcategory that emerged the most was “verbal and non-verbal communication”, being portrayed in the following statements:

(...) We are a very large team here, so we work very much by e-mail; therefore, when I see that there is a need to transmit this information, I immediately send an e-mail with the information to all the elements of the service. (N2)

(...) Or talk directly (...) We always have to do it via print. By means of a printed resource, always. And then we can talk to the risk technique too. (N6)

Thematic category VI - Management support for patient safety: among all the subcategories, the most expressive observed was “good responsiveness and creation of actions for patient safety”, this is exposed in the following statements:

(...) And, therefore, in all services, in all workplaces, there is a minimum condition to apply this safety culture, and when there isn’t one, one tries to create one, unless it is a costly one in which one tries to wait until the best time (...) Nonetheless, the problems are raised by such audits, which I say, the problems, as well as the solutions, are put in the activity plan every year (...). (N4)

(...) the hospital management provides the services with the technical means and adequate training, guaranteeing money for this training; therefore, it facilitates the acquisition, (...) providing information, knowledge in the training field. In training and in the services, thus providing the appropriate equipment so that patients have safety. (N9)

3. Discussion

According to the results described, as relevant information in the first category, 12 (85.71%) of the participants stand out, who manage based on the realization of the work plan. The nurse has performed numerous functions in various fields, both intra and extra-hospital, and one of his/her most important competencies is the management, both of human resources and material resources, arising from the provision of care (^{Szerwieski & Oliveira, 2015}, pp.68-74). It is the nurse who complies with and ensures compliance with the legislation relating to the exercise of the profession, collaborates in all initiatives that are of interest and prestige to the profession, contributes to the dignification of the profession, participates in the pursuit of the attributions of the Portuguese Order of Nurses, fulfils the obligations arising from these statutes, the Deontological Code and other applicable legislation, and communicates the facts that he/she is aware of and that may compromise the dignity of the profession or the health of individuals or that may violate the legal norms for the exercise of the profession (^{Nunes, Amaral & Gonçalves, 2005}, pp.21-42).

In addition to the ethical aspect, it is also possible to perceive the nurse manager’s concern with the error culture, which is a theme transversal to the patient safety culture, and which should be worked on. It is demonstrated in the subcategory “implementation of corrective measure” (57.14%), belonging to the thematic category V. Our results are consistent with the study that evaluated the nursing team's perception of safety culture in an operating room, in which four weak areas were identified, one of which was precisely “non-punitive response to error” (^{Bohomol & Melo, 2019}, pp. 132-138).

Based on the statements of the nurse managers, each one, in their particular sector, performs management by distributing their teams according to the degree of complexity of each patient and the need for care, according to the hours of the weekly occupation and their competencies, the daily activity plan, and the need for quality of care. When the nurse acts in the management dimension, he/she develops actions directed to planning, work organization and human resources, whose purpose is to make possible the adequate conditions both for the offer of care to the patient and for the performance of the nursing team (^{Mororó, Enders, Lira, Silva & Menezes, 2017}).

Another relevant result is the perception of teamwork or work within teams, where nine nurses (64.28%) perceive teamwork predominantly intra-team, that is, in a team than between teams. In the statements, it is noted that, in order to operationalize the work, the collaboration of the professionals in a broad field of interactions is necessary, although the managers expressed the importance of teamwork for the performance of daily activities, they mention that it is not easy to conquer it among teams external to the service (^{Silva et al., 2018}, pp. 122-130). This gives us evidence that nurses understand that working in a team means joining efforts in a mutual manner for the purpose of achieving goals and/or solving problems in an organization (^{Fassarella, Silva, Camerini & Figueiredo, 2019}).

A study conducted in southern Portugal showed a positive correlation, with statistical significance, between affective organizational commitment in nursing and the three dimensions of “engagement” (vigor, dedication and absorption), where the training and education of managers allowed the increase of this engagement, and should be encouraged through formal and informal team learning and socialization activities (^{Orgambidez & Almeida, 2018}).

The use of practical group activities that aim at sociability, such as parties, games of a playful and interactive nature, and celebrations, sometimes provide a more relaxed work environment, thus strengthening the bonds and the interpersonal relationship that consequently favors a more effective teamwork. It is worth emphasizing that, from the moment each component becomes aware of the work of the other and understands the importance of each member’s insertion in the team, their roles and functions become clearer to all professionals and the work process reveals better results (^{Peruzzo et al., 2018}).

In this sense, it is observed that 13 nurse managers (92.85%) characterize the shift change and transfer as a direct exchange of information among professionals, highlighting the fact that the shift change is one of the richest moments for learning and for the continuity of patient care. For researchers, the shift change is a strategic opportunity for the nursing team to analyze the general condition, report the occurrences of the shift, check the requirements regarding the care of each patient and understand the care activities performed by the professionals. When carried out effectively, it can bring huge benefits to the health institution, the patient and all the professionals involved, thus ensuring continuity of care and better nursing service (^{Silva et al., 2017}).

It is known that the change of shift and transfer of care is an immeasurable moment in ensuring continuity of care. A study reveals that this moment should be the target of quality improvement efforts in health institutions, because they generate a high risk of patient safety incidents, which can lead to loss of relevant information and fragmentation of patient care (^{Lee, Phan, Dorman, Weaver & Pronovost, 2016}).

With regard to the manager’s expectations and actions to promote patient safety presented by the nurse leaders, 6 (42.85%) of the 14 interviewees characterized it as “regular training and information”, where the nurses themselves ensure the necessary information and training for the prevention of incidents, as well as annually apply a questionnaire to raise the specific training needs of the team. Organizational education is pointed out as the strategy at the management level that promotes the improvement of the quality of care, by promoting these spaces for discussion among team members to raise the problems at work and create strategies to produce changes in practices and in the organization of the work process. From the perspective of integrality and expansion of the autonomy of the subjects involved, this means valuing the articulation between health care, management and social control (^{Fagundes, Rangel, Carneiro, Castro & Gomes, 2016}).

This concern is evidenced in thematic category V “Organizational learning, information feedback and open communication”, because six subcategories emerge, three of them with percentages above 50%, related to communication, feedback and quality of care, as elements that facilitate or hinder the implementation of safety culture. This leads us to perceive that the art of leading/managing is linked to continuous learning, with the purpose of directing actions, facilitating changes and achieving results.

Regarding the communication of nurses and multidisciplinary teams, all the interviewed nurses characterized that there is verbal and non-verbal communication for the information feedback between and/or among the sectors of the hospital and for organizational learning, where it includes communication through online systems, notes, transmission of verbal information from one to another, and among others.

Communication has great importance in the work of nursing teams; because, without it, the probability of failure is very significant, due to the fact that communication is the pillar in the elaboration of diagnosis, treatment and provision of quality care. It is worth noting that if the nurse manager and his/her team have effective communication with the patient and his/her family, this can increase understanding in the exchanges of information from the nurse to the family and the patient about his/her pathology and his/her treatment, which results in the creation of a relationship of trust and helps in motivating the patient to better understand his/her disease and take responsibility for his/her treatment, that is, for his self-care (^{Ferreira, Consciência, Duarte & Silva, 2018}, pp. 33-39 ).

It was evident that 11 (78.57%) of the nurse managers consider that the management support for patient safety has good receptivity and creation of actions for patient safety, where the managers themselves in their services have minimum conditions to whether to apply the safety culture in question; and, when there is not, they try to promote a strategy for the cultural maturation of the team. In addition, all actions that the team proposes to meet the needs of the service, in relation to patient safety, receive full support from their respective leaders. The objective of implementing patient safety strategies is to reduce, to a minimum level, unnecessary risks arising from health care, and the moment of active listening to those led is an important item in the process of improving the quality of care, as the implementation of patient safety strategies mainly involves professionals who are committed to direct patient care (^{Reis et al., 2017}).

The implementation of safety strategies requires the nurse manager to have an entrepreneurial capacity, as daily it is necessary to deal with and overcome difficulties from various areas to move forward proactively, elements present here in the speeches. In a Brazilian study on the challenges of nurses in a strategic leadership position, one of the thematic categories that emerged was precisely "learning to establish an enterprise", as a challenge of a leadership responsibility, with mobilization of knowledge, innovation, creativity and constant qualification, which are fundamental elements for the desired change (^{Richer, Santos, Kaiser, Capellari & Ferreira, 2019}).

Thus, the current study becomes of great importance to understand the perception of each nurse leader as the manager of a group of nurses about the implementations of actions that promote patient safety in the institution where they work and in the sectors they are responsible. Accordingly, it shows that, even if it has recommendations to be followed, not all of them follow them; however, most of them still comply with these guidelines, but there are still failures.

As limitations of this research, it is considered that, because it is the practice of a Portuguese educational institution, where there was no expansion to other institutions and the interviews were conducted only with nurse managers, restricting the collection of information and perception about patient safety, only with the information that was provided by the managers, the information that could be given by other members that make up their health team ended up reduced.

It is considered achieved, as part of the purpose of this study, the deepening about patient safety in favor of the perspective of each nurse manager. Moreover, it is intended to increase the knowledge of the team and the patient safety itself, together with that of the managers and other institutions, applying it effectively in all sectors of the hospital structure.

Regarding the main limitation of this study, it can be mentioned that, although it was carried out in only one university hospital, the results obtained do not allow generalizations because it was obtained in only one institution.

Conclusion

The objective set out in this study was achieved and made it possible to analyze that nurse leaders have different perspectives and values. It was evidenced that safety culture is understood by management as a work plan, by teamwork within the service, at shift change and direct transfer of information among professionals, the supervisor’s expectation and actions to promote patient safety as regular training and information, organizational learning, information feedback and increase in the communicational spectrum, verbal and non-verbal communication, and, finally, management support for patient safety as good responsiveness and creation of actions focused on producing improvements in the institution.

It is perceived that there is a diversity of understanding about safety culture among nurse leaders, who, despite sharing the same institutional goals, have different views and perspectives.

From this study, it is believed that there will be greater sensitivity to the theme of safety culture within the university hospital institution, especially in the possibility and existence of other qualitative studies for the deepening of the most intrinsic issues, in order to enable advances and continuous improvement.

It is suggested the application of qualitative study in other institutions to better deepen the issues related to safety culture, enabling the implementation of institutional safety policies, because there are a number of reasons to investigate patient safety issues, being the culture one of the indicators to help managers in the identification, notification, prevention and investment in areas that deserve to be invested, especially in services with direct action to the patient.