How does using a digital story influence Registered Nurses' perceptions of safety culture and patient safetyrelated behaviours within an Acute NHS Trust? A mixed methods explanatory sequential study.

Background: From 2000 to the present day, patient safety and safety culture continues to be a significant global concern as patient harm rises. As the most trusted profession and significant workforce, nurses are fundamental to preventing harm and promoting a positive safety culture. Conversely, the unpredictability of the clinical environment makes it the ultimate focus where patient safety systems fail, resulting in patient harm. Patients also have a role in improving patient safety, yet despite the political intention to involve and engage patients, the uptake is relatively low, and there is limited evidence to suggest that patient involvement improves patient safety. Digital stories, a method of patient engagement, have the potential to enhance patient safety, yet no studies have substantiated this claim. Studies using digital stories have reported positive outcomes. However, these studies are scarce with the majority focusing on pre-registration nurse education. Furthermore, no studies have used digital stories to examine perceptions of safety culture and patient safety.
Aim: The study was designed to explore the impact of using a digital story in assessing RNs' perceptions of safety culture and patient safety-related behaviours. It sought to measure and explore safety culture perceptions at four different timepoints to establish how the digital story may have changed RNs' perceptions of safety culture and patient safety-related behaviours.

Methods: A mixed methods explanatory sequential design was chosen and took place from September 2017 to December 2017. The quantitative study used a non-experimental descriptive design using a Safety Attitude Questionnaire (SAQ) (Short Form) to measure safety culture perceptions across four timepoints. A total of 103 RNs from six specialised medical wards participated in the quantitative study using a purposive sampling method. Of the 443 surveys distributed across the four timepoints, 335 were returned, yielding an overall response rate of 81%. The qualitative study adopted an Interpretative Phenomenological Analysis method. A subsample of 15 RNs who were purposively selected from the quantitative sample were randomly allocated (n=5/group) into one of the following intervention groups:
Trust education (G1), digital story (G2), or digital story and 30 minutes reflection time (G3).
Fifty-one (out of 60) one-to-one, semi-structured interviews were conducted across the four timepoints, yielding a total response rate of 86%.

Findings: The qualitative interviews revealed three group experiential themes: Professional
Duty of Care, Professional Duty of Candour, and Professional Duty to Continuing Professional Development. These themes reflected the RNs' perceptions of safety culture and the impact of the digital story. The quantitative findings represent the RNs' perceptions of safety culture against six domains in the SAQ survey. The merged data sets revealed mixed perceptions of the factors that created a negative or positive safety culture and their implications for patient and nurse outcomes. The qualitative findings showed that the digital story had many qualities as a learning resource compared to trust education. The RNs in the digital story groups reported positive changes relating to patient assessment and compliance with risk assessment tools, communication skills, decision-making, reporting behaviours, and personal and professional development.

Conclusion: The RNs' perceptions of safety culture illustrate the complexities of safety culture that incorporate many influential facets in promoting a positive or negative safety culture. These are influenced by external factors such as communication, teamwork, inadequate staffing, and leadership, which all impact their working environments, reporting behaviours, job satisfaction, and stress levels. Using a digital story has the potential to promote positive changes. The qualities of digital stories make them an effective learning tool and alternative source of knowledge that can be used to positively change safety culture perceptions and patient safety-related behaviours, leading to a positive safety culture and safer quality nursing care.