In the recent times, the paradigm of providing medical services has shifted from being provider- and disease-centered to patient-centered.12 To achieve patient-centered care, the Organisation for Economic Co-operation and Development (OECD) has emphasized and confirmed the importance of patient experience in the provision of medical services.3 Measuring patient satisfaction and experience is now an important factor in medical services.4 Patient experience is a concept that goes beyond the patient’s expected clinical outcome or health status, and is essential in providing patient- and family-centric care.56 However, patients’ expectations and experiences reported have been different, and related to overall patient satisfaction.7

Many countries, including the United States, Denmark, Norway, the United Kingdom and Canada, are investigating patient experiences to assess health system performance.89 The UK’s National Health Service (NHS) emphasizes the importance of patient-centered health care, focusing on a cultural shift that accepts patients as the pivotal facet, and the increasing value of patient experience feedback as an indicator for monitoring and improving health quality and safety.10 Similarly, the results of statistical analysis by the US Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) show that hospital profits were related to patient experience scores, and that reduction of physicians’ medical errors and provision of patient experience services were highly correlated.11 Since 2017, the Korean Health Insurance Review and Assessment Service has been evaluating patient experience.12 Twenty-four questions, including experience of physicians’ and nurses’ behavior during hospitalization, medication and treatment process, hospital environment, patient rights guarantee, and personal characteristics, have been employed for the survey.12

Patient safety is a crucial indicator of health care quality; adequate management of safety-related risks is the primary responsibility of medical service providers and healthcare systems. Treatment without patient safety does not guarantee patient-centeredness and can reflect disastrous health outcomes.13 Previous studies were aimed to some situations exploring the experiences of patients in a specific setting or elderly patients, or were focused on confirming the experiences of patients with anxiety or satisfaction.1415161718 Furthermore, although there is a study on physicians’ and nurses’ perception of patient safety culture,19 there have been few studies that specifically explored the experiences of factors that constitute patient safety. Qualitative research can offer the direction on how to identify and correct problems.2021 It is thus necessary to explore the subjective perception of patient safety from the patient's point of view as a consumer of healthcare services.

This qualitative study, thus, is aimed at understanding the patients’ experience of safety with hospitalization, and specifically, identifying the themes that constitute the patients’ feeling of safety during hospitalization.

A qualitative study, with five focus group discussions (FGDs), was conducted, and a conventional content analysis was utilized. This qualitative study was performed according to the Consolidated Criteria for Reporting Qualitative Research (COREQ).22 The research team consisted of a physician, nurses, and national healthcare researchers. Nurses (SGJ, JEC, WL) with doctoral degrees and experience of conducting qualitative research several times and had been a modulator for FGD progression. While maintaining the anonymity of the participants, the interviews were recorded and transcribed. All researchers performed the content analysis together.

There was a total of 35 participants (10 males and 25 females), with an average age of 45.4 years (range, 19–65), and an average hospitalization period of 9.8 days (range, 3–32). The general characteristics of the participants in this study are shown in Table 2. There were four themes and 14 sub-themes of patients’ feeling of safety during hospitalization (Table 3).

A qualitative study was conducted through FGDs to identify the themes that influenced patient safety sentiment during hospitalization. Patients want to take initiative in controlling their reception of information and want healthcare providers to make the patient feel safe. Patients felt safe when hospitals do unstinted and generous support. Also, public sentiment about national healthcare and safety made an effect on patient safety sentiment.

First, participants of this study mentioned that they obtained information from the media, and through direct or indirect ways, such as listening to others’ experiences similar to how patients obtain health information from the internet, publications, friends, acquaintances, and relatives.2425 The participants tried to secure safety by communicating actively with healthcare providers based on information collected through various channels, but they did not utilize reliable information provided by healthcare providers or the nation. When it comes to communication with healthcare providers, if patients have low trust in their physicians, their safety may be jeopardized by intentionally failing to provide medical information that may be important to them.26 On the other hand, patients' active efforts to obtain information can improve the patient-physician relationship and help patients participate in the decision-making process.27 Healthcare providers not only provide accurate medical information to patients, but also establish a trusting relationship with patients through patient-centered decision-making methods such as SDM,28 which ultimately protects patient safety. Also, patients are aware of the existence of information provided by the nation, such as the accreditation system, but are unable to use it. It is necessary to secure patients’ trust in information through active publicity and education at the government level.

Second, interpersonal care quality such as kindness, sympathy, and sincerity, was an important factor in determining patient satisfaction.29 In this study, participants emphasized the efforts of the healthcare provider as a response to their requests, such as detailed explanations of treatment and resolving questions, rather than any unconditional kindness by them. Participants also said that they felt safe upon observing the efforts of the healthcare provider in making patients feel safe. To improve patient satisfaction, medical institutions have begun making service-oriented efforts, such as shortening waiting times,30 and conducting customer service training.31 These efforts should not only improve for patient-centeredness, but also patient safety, which is the ultimate goal. Participants also considered not only physical privacy but also privacy of their own information within the scope of patient safety. Medical institutions conduct anonymizing patient information to protect patients. Furthermore, guidelines for protecting medical photographs are also being developed.32 However, measures to protect patients, such as single-room use, teamwork, surveillance, monitoring and keeping patients safe, may backfire and threaten patient safety.33 It is thus, necessary to strike an appropriate balance between patient privacy and safety.

Third, lack of physician-nurse and patient-staff interactions, and lack of effective nurse handover are major factors influencing patient outcomes, and effective communication and teamwork improve patient safety.3435 We found that patients felt that it was safe to be supported not only by the competence of individual medical personnel, but also by systematic support from medical institutions, such as communication systems, personnel, procedures, and facilities. Thus, patients become aware of the absence of a system or procedure, such as the lack of communication between healthcare providers, which subsequently affects their feeling of safety during hospitalization. Accordingly, a systematic approach should be used to ensure that patients feel safe during hospitalization. Organizations recommend and support the use of communication tools such as Situation, Background, Assessment, Recommendation (SBAR), Acknowledge, Introduce, Duration, Explain and Thank (AIDET), and I-PASS Nursing Handoff Bundle.3637 Additionally, the participants experienced anxiety and believed that their own safety was not guaranteed in situations where manpower was scarce. According to the OECD, the number of active nurses per 1,000 patients exceeds 17 in Norway and Switzerland; however, in Korea, it was less than half, at 7.2.38 Shortage of manpower is related to burnout of medical personnel.3940 Previous research shows that clinicians maintain patient safety despite overwork.41 This is a problem that cannot be solved by single medical personnel; it is, thus, necessary to secure and deploy sufficient personnel at the institution and national level.

Lastly, the overall public consciousness about healthcare was at the base of the patient safety sentiment factor experienced by patients. Rather than trusting the safety indicators of hospitals, the worse the health of a patient, the higher their distrust of the national health care system.42 Participants were not fully trusted the factors used internationally as patient safety indicators: adequacy indicators, medical institution certification, hospital infection rate, re-admission rate, and number of reported medical accidents, among others. According to Dean et al.,43 the physician’s recommendation and health insurance program were the main factors in choosing a hospital, demonstrating high confidence in objective indicators in Iran. However, patients in this study had a negative perception that they did not trust even if they had heard particular information. By providing education to the public to improve health literacy, we can expect to restore confidence in the healthcare system.44 In addition, adequate patient literacy should be thus provided so that the patients can judge medical institutions based on national safety indicators.

Insensitivity to safety indicates that people are unaware of safety-related accidents or have become accustomed to those, and do not think much of the dangers of accidents. In general, healthcare providers’ failure to follow safety guidelines leads to accidents. Conversely, patients’ exaggerated concerns regarding safety make the healthcare provider tired. For example, immediately after experiencing the Middle East Respiratory Syndrome in 2015, people were very alert about infectious diseases; however, they soon forgot and returned to their daily lives. As they re-experience the pandemic of coronavirus disease 2019 (COVID-19), recent changes in patients’ perceptions prioritize patient safety without making them uncomfortable.45

This study limited the participants’ regions to Seoul and Gyeonggi-do, and identified only patients with a history of hospitalization. Therefore, it was difficult to provide a broad view of the patients’ feeling safe during hospitalization because inpatients outside of Seoul and Gyeonggi-do regions and outpatient patients were excluded. In addition, the average age of the study participants was 45.4 years, and only three were in their twenties. People in their over 50s are more likely than those in their 20s to be admitted to hospital in general.46 There are inevitable differences between generations in terms of views on the subject. It seems necessary to discuss what patients in their 20s and 30s think about patient safety. For follow-up studies, it is necessary to use methods such as online video calls to collect data beyond regional limitations, and include many types of patients according to classifications such as age, admission days, type of hospital, treatment option, and hospitalized department. Nevertheless, we tried to collect diverse and rich experiences by recruiting patients who have been hospitalized for at least three days, and this study is meaningful in that it qualitatively explored whether the patient experienced safety, an unfamiliar concept to the patient.

This study confirmed the overall experience of hospitalization, including hospital facilities and systems. Patients wished to have an active communication and objective information exchange with healthcare provider consistently and felt safe when they acquired all the relevant information. However, as much sufficient and accurate information as they wanted was not delivered to patients, and information regarding patient safety activities of medical institutions and healthcare providers was not provided adequately. Public consciousness and the social atmosphere about healthcare also may affect the patient safety sentiment. Healthcare providers, medical institutions, and government should make efforts to narrow the gap in factors of safety perception between each position, through patient safety activities with patients. This study can be used as basic data to understand the perception and feeling of safety from the patient's point of view. In addition, it should be utilized to create a safe medical environment along with objective numerical values such as surveys, a patient reported outcome measurement.