During the thematic analysis of the data, more than 200 initial codes were extracted. In later stages, these themes gradually diminished with the removal of similar themes and overlaps, and gradually manifested themselves as clusters of themes. In this study, 5 themes and 11 sub-themes were obtained from the participants' experiences. These included: continuous and dynamic training and upgrading of safety skills, attention to spirituality and conscientiousness and work commitment, effective communication and teamwork, equipping human and logistical resources based on the principle of care, accurate recognition of instructions and error control (Table 1).
1. Continuous and dynamic training and upgrading of safety skills:
In the present study, one of the most important themes tends to be continuous and dynamic training and upgrading safety skills. The interpretation of their experiences showed that training, increased knowledge and awareness and skills lead to an increase in the patient's immune culture.
1.1 The role of education in upgrading patient safety culture to staff:
One of the most important and fundamental themes in the participants' experience of continuous and dynamic training is the upgrading of safety skills, training and promotion of patient safety culture. Interpretation of participants' experiences suggests that training can be reminiscent of points whose absence could greatly jeopardize patient safety. On the other hand, such training should be provided in the right direction by experts so that it can have a proper impact. In this regard, a participant said:
"... The most important factor in increasing patient safety is training personnel about patient safety, training on the need to implement it and how to do it properly. Classes are better to be held, which of course is in the best interest of the staff; however, whatever happens, it would be a problem for everyone, both the surgeon and the staff and the rest of the surgical team. Meanwhile, a 35-year-old operating room expert postulated that: Training classes, staff incentives, regular follow-up, patient complaints can all increase safety. Therefore, it can be concluded that from the viewpoint of the participants, patient safety could be improved along with appropriate training" (a male surgeon / 55 years old).
1.2 Increasing the knowledge, awareness and patient safety skills of the staff:
Another important aspect of increasing patient safety culture is to augment the knowledge, awareness and patient safety skills of the staff. In this regard, the participants considered factors such as safety training for personnel and monitoring them as ways to increase patient safety culture. Skills training can dramatically increase the safety of that skill and reduce the patient's mental and physical complications. In this respect, a participant stated:
"... Patient safety culture is a set of rules and regulations that everyone should probably be trained to do to keep up with patient safety and security. This is an important phenomenon since the patient who comes here so as to be treated and their problem be solved, not another problem be added to its existing problems. If we do not have the skills to do the job, it will definitely bring about a new problem ..." (an operating room technician / 37 years old).
Another thing that expressed by the participants was to increase the safety culture by working in the field. Participants believed that working in only one field could increase repetition and reduce error. A participant said:
"... When I do something several times, that skill is repeated for me and I make fewer mistakes afterwards. In fact and in general, it can be said that wrong training or skill by non-experts can decline patient safety...” (A female instructor / 24 years old).
2. Effective communication and teamwork
In this study, another important and fundamental theme is effective communication and teamwork. It has 3 sub-themes: having a sense of responsibility in patient safety; having an effective relationship in establishing patient safety culture; and improving teamwork and collaborative efforts.
2.1 Having a sense of responsibility in patient safety
The irresponsibility of the staff, the lack of reminders of the person in charge of the operating room and the lack of sufficient information about patient safety are some of the factors that reduce patient safety culture. Being responsible means having responsibilities to the patient, and if a person performs his or her duties to the patient in a good way, it means that he or she is responsible. In this regard, a participant stated that:
"... The irresponsibility of the staff towards the patient and their duties is really excruciating. Lack of reminding the person in charge of the operating room (in fact, the negligence of the person in charge regarding observing patient safety), lack of sufficient information about patient safety and other cases ..." (a male surgeon / 41 years old).
2.2 Having an effective relationship in establishing patient safety culture
Effective communication can greatly improve patient safety, whereas the lack of effective communication can lead to increased error and reduced patient safety. In this regard, a participant stated:
".... I think the main pillar of patient safety is good communication, which means that the more teamwork, the more patient safety there will be. When they want to identify the patient's identity, or the location of the surgery, or the organ being operated on, or even when the patient is injected with blood, if there is collaboration and teamwork, all the work will be performed safely…” (A female operating room technician / 36 years old)
2.3 Improving teamwork and collaborative efforts
Creating a spirit of cooperation among staff and sharing efforts among them to cover services, especially when the patient is discharged, is one of the ways to increase patient safety culture. In this regard, a participant stated:
"... It is the spirit of cooperation among the staff and the continuous training and the right guidance that has a positive effect on teamwork. If a surgical team has a lot of cooperation with each other, in fact, if they have a positive team work, it can be said that there is less error for the patient” (a female operating room technician / 34 years old).
3. Attention to spirituality, conscientiousness and work commitment
Another major theme of the study was attention to spirituality, conscientiousness and work commitment, which had two sub-themes: respecting religious principles and beliefs of the patient and the impact of commitment and conscientiousness on spiritual health.
3.1 Respecting religious principles and beliefs of the patient
Spiritual health means respecting religious principles and beliefs of the patient, in other words, spiritual health means choosing religion based on one's own studies, not the ones imposed on one. In this regard, a participant stated:
"... Respecting one's religious principles and beliefs, such as a catheterization for a patient performed by staff of the same sex, or, for example, maintaining the patient's privacy during and after the operation. Or, for example, paying attention to the patient's religious beliefs and culture. For instance, some things are forbidden in some cultures, but in some not. In short, care should be taken in this regard ..." (a female anesthesiologist / 31 years old).
3.2 The impact of commitment and conscientiousness on spiritual health
Spiritual health is about one's conscientiousness and beliefs. Spiritual health is work conscience that will directly affect other human actions. In this regard, a participant said:
".... Spiritual health means having a work conscience and a sense of effective cooperation among the staff and building a better relationship with the patient and respecting the patient's right. This in turn means to do his works in the best way i.e. the observance of all the principles while doing his works. For example if we imagine the patients are our loved ones and be bound to respect all the rights of the patient to promote and protect patient safety during treatment and always have a clear conscience and consider God to be in charge of our actions and to observe the privacy and safety of the patient, then we have helped the patient a lot…" (a male anesthesiologist / 37-year-old).
4. Equipping human and logistical resources based on the principle of care:
One of the main themes of this study is equipping human and logistical resources based on the principle of care, which has two sub-themes of material and human resources and sufficient equipment, and patient care as the pillar of patient safety.
4.1 Material and human resources and sufficient equipment
One of the important sub-themes in this study is material and human resources and sufficient equipment. In this study, participants believed that inefficient and unaware staff, high workload, high and tedious shifts could adversely affect patient safety culture. In this regard, a participant stated:
"... The lack of follow-up by officials, inefficient and ignorant staff, high workload, and high and tedious shifts all cause fillers. The fact that an unsuccessful surgery is reported is because the whole team has done badly. Not just the surgeon or anesthesiologist…" (A male surgeon / 47 years old).
4.2 Patient care as the pillar of patient safety
Caring is the essence, the core, and the main element of the health system that facilitates the promotion of health and well-being and safety of patients. Quality in the health system is defined in the form of safe, timely, effective and patient-centered care. In this regard, a participant said:
"... Safety culture means the patient without side effects, that is, not adding problems to the patient. Patient safety means respecting the patient's rights. In any case, to prevent doing things that pose a risk to the patient; therefore, to do things correctly, or at least to the standard level, as well as to train them for the future so that the patient does not suffer from possible complications..." (A female instructor / 37 years old).
5. Accurate knowledge of instructions and error control:
Another main theme in this study is accurate knowledge of instructions and error control, which includes two sub-themes of careful instructions and treatment protocols, and recognizing and controlling errors and risks.
5.1 Careful instructions and treatment protocols
According to the participants in this study, inadequate accuracy in following the instructions is one of the factors that reduce patient safety culture. In this regard, one of the participants said:
"....Lack of adequate supervision, inadequate care in the proper implementation of instructions, limited human and financial resources can impair the patient's safety ...." (A female, head of the operating room / 44 years old).
Patient safety culture means improving the quality of services provided to patients in medical centers, so if this quality is low, it can jeopardize patient safety. The experience of one of the participants in this regard was as follows:
".... The quality of the pillar is very important. We should not just think about doing the work, we should also pay attention to its quality. Quality working is always better..." (A male surgeon / 49 years old).
5.2 Recognizing and controlling errors and risks:
Safety culture is defined as the prevention of injuries and the dangers that threaten the life of the patient, which can be real or partial injuries, in other words, recognizing errors and eliminating them is a factor contributing to increased safety culture. One participant stated:
"....We have a duty to provide safety for the patient so that he is not harmed like falling from a bed, burns caused by a cutter, etc. For example, as a surgeon, I must check my patient's tourniquet to make sure that the perp solution does not penetrate under the cuff. "Sometimes people think that if the solution goes down, nothing will happen, but it's not, and it makes very bad burns ..." (a male surgeon / 43 years old).