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CONCEPT ANALYSIS

Feeling safe during an inpatient hospitalization: a concept analysis

Deene Mollon

Accepted for publication 7 December 2013

Correspondence to D. Mollon:

e-mail: [email protected]

Deene Mollon MSN RN NE-BC

Nurse Manager, PhD Student

SharpHealth Care, La Mesa, California,

USA

and University of San Diego, California,

USA

M O L L O N D . ( 2 0 1 4 ) Feeling safe during an inpatient hospitalization: a concept

analysis. Journal of Advanced Nursing 70(8), 1727–1737. doi: 10.1111/

jan.12348

Abstract Aim. This paper aims to explore the critical attributes of the concept feeling safe.

Background. The safe delivery of care is a high priority; however; it is not really

known what it means to the patient to ‘feel safe’ during an inpatient

hospitalization. This analysis explores the topic of safety from the patient’s

perspective.

Design. Concept analysis.

Data sources. The data bases of CINAHL, Medline, PsychInfo and Google Scholar

for the years 1995–2012 were searched using the terms safe and feeling safe.

Methods. The eight-step concept analysis method of Walker and Avant was used

to analyse the concept of feeling safe. Uses and defining attributes, as well as

identified antecedents, consequences and empirical referents, are presented. Case

examples are provided to assist in the understanding of defining attributes.

Results. Feeling safe is defined as an emotional state where perceptions of care

contribute to a sense of security and freedom from harm. Four attributes were

identified: trust, cared for, presence and knowledge. Relationship, environment

and suffering are the antecedents of feeling safe, while control, hope and relaxed

or calm are the consequences. Empirical referents and early development of a

theory of feeling safe are explored.

Conclusion. This analysis begins the work of synthesizing qualitative research

already completed around the concept of feeling safe by defining the key

attributes of the concept. Support for the importance of developing patient-

centred models of care and creating positive environments where patients receive

high-quality care and feel safe is provided.

Keywords: concept analysis, feeling safe, nurse–patient relationship, nursing

theory, patient perspective, patient safety, therapeutic relationship

Introduction

In 2000, when To Err is Human: Building a Safer Health

System was first published by the Institute of Medicine, the

term ‘patient safety’ was a relatively new concept to people

working in health care (Kohn et al. 2000). Public awareness

of the term ‘patient safety’ did not come into the health

care forefront until later in the decade. Not to say health

care professionals were not concerned about the safety of

patients prior to the publishing of this report; but despite

the power of modern medicine to treat illness and disease,

health care was not safe and patients were at risk of harm

(Emanuel et al. 2008).

Concern for safety can be traced back to Florence

Nightingale. In 1860, Nightingale wrote in, Notes on

nursing, that the safety of patients and the care they received

were a primary focus (Nightingale 1860). The safe delivery

of care continues to be a high-priority initiative for

healthcare workers, administrators and policy makers. How-

ever, as people in health care work to improve the safety and

quality of care, is it really known what it means to the

patient to ‘feel safe’ during an inpatient hospitalization? To

feel safe may be much different from being safe. Patients are

not educated in the technical aspects of health care; they only

know what they feel. Researchers have reported feeling safe

as an overarching need for patients during inpatient hospital

stays and an important and contributing factor to wellness

and recovery (Hupcey 2000, Lasiter 2011, Aro et al. 2012).

The concept of safe can be defined in many ways,

depending on the frame of reference. Safety has been linked

to all fields of work, such as industrial, automotive and

construction to name a few. In health care, safety can be

defined from the perspective of risk, environment, climate,

practice or care (Clark et al. 2005, Ackerson 2010, Black

et al. 2011, Lindberg & Lindberg 2012). While all of these

perspectives affect the patient and their care, they do not

take into account the patient’s feelings related to safety.

Multiple enhancements have been implemented to address

the physical safety of the patient; however, the emotional

components of safety, as perceived by the patient, have

received far less attention (Lasiter 2011). The concept of

feeling safe during an inpatient hospitalization from the

patient perspective has limited exploration in the literature.

This concept analysis will explore the critical attributes of

the concept of feeling safe during an inpatient hospitaliza-

tion, in addition to defining the terms feeling and safe.

Background

To examine the phenomenon of feeling safe, the concept

analysis framework by Walker and Avant (2011) was used.

Using Wilson’s 1963 classic eleven-step concept analysis

procedure, Walker and Avant (2011) simplified the proce-

dure to eight steps. The eight-step analysis includes the

selection of a concept, determining the aim and purpose of

the analysis, identifying the uses of the concept, defining

the attributes of the concept, constructing a model case

example, creating borderline, related and other case exam-

ples, identifying the antecedents and consequences and

defining the empirical referents (Walker & Avant 2011).

The purpose of a concept analysis is to examine the

structure and function of a concept (Walker & Avant

2011). It is important to examine the structure and function

of a concept to promote an understanding of the phenom-

ena being discussed (Walker & Avant 2011).

Data sources

Literature was reviewed via CINAHL, Medline, PsychInfo

and Goggle Scholar databases for the years 1995 through

2012 using the terms safe and feeling safe. Literature

from many disciplines (e.g. psychology, sociology,

medicine) and industries (e.g. biochemical, industrial,

environmental) was found when searching using the term

safe. When searching the concept feeling safe, a smaller

volume of more health care-related literature was found.

Initially, 70 articles were retrieved and reviewed. Each

article was reviewed for the primary use of the word safe

and its relevance to the concept feeling safe. Reference

Why is this research or review needed?

● Delivery of safe care is a high priority in health care; how- ever little is known about what it means to patient’s to

‘feel safe’ during an inpatient hospitalization.

● Feeling safe is an overarching need for patients during inpatient hospital stays and an important and contributing

factor to wellness and recovery.

What are the key findings?

● Feeling safe is an emotional state where patient’s percep- tions of care contribute to a sense of security and freedom

from harm during an inpatient hospitalization.

● Feeling safe is an abstract concept defined by four main attributes, trust, cared for, presence and knowledge, attri-

butes which are individually perceived by each patient.

● Relationship, environment and suffering are the anteced- ents of feeling safe, while control, hope and relaxed or

calm are the consequences.

How should the findings be used to influence policy/ practice/research/education?

● Advancing the definition of feeling safe provides opportu- nity for improving patient-centred models of care and con-

tributes to increasing healthcare provider awareness

around patient’s perceptions of feeling safe.

● By examining the function and structure of the concept feeling safe, further development of models and theories of

feeling safe can be developed.

D. Mollon

lists of articles using the term feeling safe were reviewed

for other related literature. This resulted in seven

additional articles for a total of 77 articles reviewed.

Articles focusing on safe from the perspective of risk,

environment, care, practice and climate were excluded

because of no specific relevance to feeling safe. All articles

reviewed were published in English. In the end, 31 articles

referenced the concept feeling safe, with the majority

being qualitative research studies.

Results

Uses of the concept

Much of safety-related research centres around the con-

cept of safe care. Safe care can be tied to environment,

patient care practices and the overall climate of the unit

where the care is delivered (Amato et al. 2012, Bae 2012,

Black et al. 2011, Kalisch & Lee 2011, Patrick et al.

2011). Safe care can be defined as care with positive

patient outcomes, free from harm and a low risk of error

(Rush et al. 2008). Research has linked safe care to a

multitude of factors such as an empowered work environ-

ment (Patrick et al. 2011), reduced overtime usage (Bae

2012), staffing and handovers (Kalisch & Lee 2011) and

medication safety (Liu et al. 2012). Another use of the

concept safe is related to the environment where patients

receive care. A safe environment is related to lack of

injury, prevention of patient removal of medical devices,

competent nearby staff and use of protective, safety

equipment (Clark et al. 2005, Rush et al. 2008, Amato

et al. 2012, Olsson et al. 2012). The concept safe is also

related to the idea of practice. Safe practice is associated

with knowledge, skill and competency of the healthcare

provider (Baker et al. 2010, Lindberg & Lindberg 2012).

Patients consider competency and skill in the nurse’s

domain and usually assume that they are present;

however, the presence of knowledge can very quickly be

assessed by patients based on how well the nurse answers

questions and provides information and education

(Calman 2006, Kv�ale & Bondevik 2010). All of these

uses of the concept safe, safe care, safe environment, safe

practice, can be related to the concept of feeling safe. To

better understand the concept of feeling safe, the

definitions of ‘safe’ and ‘feeling’ will be explored both

independently and as a phrase together.

Feeling

The word ‘feeling’ has a late 12th century definition of ‘the

act of touching’ and ‘sense of touch’, while in the mid-14th

century, the word ‘emotion’ is found as a meaning (Onions

1966). In the 1580s, the statement ‘capacity to feel’ is first

recorded (Onions 1966). Feeling is defined as:

• ‘an emotional state or reaction’ (Mish 1993); • ‘generalized bodily consciousness or sedation’ (Mish 1993); and

• ‘an idea or belief, especially a vague or irrational one’ (Pearsall & Hanks 2006).

Safe

According to The Oxford dictionary of English etymology,

the word ‘safe’ is derived from the Latin word ‘salvus’ mean-

ing ‘uninjured, healthy, safe’ and from the Old French word

‘sauf’ meaning ‘uninjured, unharmed’ (Onions 1966). The

statement ‘free from risk’ was first recorded in 1580s (Onions

1966). Dictionary definitions of the word safe include:

• ‘Secure from liability, harm, injury, danger or risk’ (Nichols 2001);

• ‘successful at getting to a base in baseball’ (Mish 1993); and

• ‘a place or receptacle to keep articles’ (Mish 1993).

Feeling safe

Russell (1999) defined feeling safe as ‘an emotional state

where no imminent danger of physical or psychological

injury is perceived’. The term feeling safe is not defined as a

phrase in any dictionary references or other on-line refer-

ences outside scholarly manuscripts. For the purpose of this

paper, feeling safe will be defined as an emotional state

where perceptions of care contribute to a sense of security

and freedom from harm during an inpatient hospitalization.

Defining attributes

Defining attributes of a concept are the characteristics most

frequently associated with the concept and those which help

distinguish the concept from other related concepts (Walker

& Avant 2011). By identifying specific attributes of the

concept feeling safe, differentiation from other types of safe

can be determined. In all the articles reviewed, a combined

total of 40 characteristics were used related to the concept

feeling safe. Some of the characteristics frequently used

included relationship, checking, presence (both nurse and

family), safety and security, competent care, trust, cared

for, knowledge and control. After a careful review of the

literature where the concept feeling safe was expressed by

patients, or healthcare providers, defining attributes fell into

four main categories: trust, cared for, presence and knowl-

edge (Table 1).

JAN: CONCEPT ANALYSIS Feeling safe

Trust

According to Kv�ale and Bondevik (2010), trust is a leading

value in the nurse–patient relationship. To trust, patients

must put themselves in a situation of risk, where the out-

come may not be what is expected and the caregiver is

expected to have a minimum level of knowledge and

defined behavioural expectations (Hupcey 2000). Trusting

relationships enhance feelings of safety (Hupcey 2000, Mer-

il€ainen et al. 2010), allow patients to relax (Hawley 2000)

and build relationships with the nurse or healthcare profes-

sional (Calman 2006, Anttonen et al. 2011). Many studies

demonstrate the importance of trust to the concept of feel-

ing safe during the healthcare experience (Russell 1999,

Hawley 2000, Hupcey 2000, France et al. 2008, Stenwall

et al. 2008, Kv�ale & Bondevik 2010, Meril€ainen et al.

2010, Holm & Severinsson 2011, Nieminen et al. 2011).

Trust cannot be effectively built with patients unless ther-

apeutic relationships are developed with patients and staff

meet patient needs timely. In addition, enacting behaviours

which ensure patients that their status is carefully moni-

tored and their best interest for care is considered at all

times contribute to patient trust and overall feeling of

safety. Many patients have an inherent trust in nurses and

the healthcare system; however, when expected behaviours

and actions do not occur, patients begin to develop distrust

and feel unsafe. Hence, it is imperative for nurses to either

establish or maintain trusting relationships with all patients

for feelings of safety to be present throughout the inpatient

hospitalization.

Cared for

The meaning of cared for encompasses multiple characteris-

tics which were expressed by patients in the literature in

conjunction with the concept feeling safe. Some key terms

related to being cared for include responsiveness, checking,

following up, getting help timely, anticipating needs and

Table 1 Attributes of feeling safe.

Sources

Number of

attributes Trust Cared for Presence Knowledge

Andersson et al. (2011) 2 of 4 + +

Anttonen et al. (2011) 1 of 4 +

Aro et al. (2012) 2 of 4 + +

Calman (2006) 2 of 4 + +

Capuzzo et al. (2005) 1 of 4 +

Engstr€om and S€oderberg (2007) 1 of 4 +

France et al. (2008) 2 of 4 + +

Granberg et al. (1998) 3 of 4 + + +

Hawley (2000) 4 of 4 + + + +

Holm and Severinsson (2011) 1 of 4 +

Hornsten et al. (2005) 3 of 4 + + +

Hupcey (2000) 4 of 4 + + + +

Karlsson and Forsberg (2008) 2 of 4 + +

Karlsson et al. (2012) 2 of 4 + +

Kralik et al. (1997) 3 of 4 + + +

Kv�ale and Bondevik (2010) 2 of 4 + +

L€am�as et al. (2011) 2 of 4 + +

Lasiter (2011) 2 of 4 + +

Lindwall et al. (2003) 1 of 4 +

McKinley et al. (2002) 3 of 4 + + +

Meril€ainen et al. (2010) 2 of 4 + +

Nieminen et al. (2011) 2 of 4 + +

O’Brien and Fothergill-Bourbonnais (2004) 3 of 4 + + +

Russell (1999) 2 of 4 + +

S€oderberg et al. (2012) 1 of 4 +

Stenwall et al. (2008) 2 of 4 + +

Sutton et al. (2012) 1 of 4 +

Van Dover and Pfeiffer (2012) 3 of 4 + + +

W�ahlin et al. (2006) 2 of 4 + +

Westin et al. (2009) 1 of 4 +

Wong and Arthur (2000) 2 of 4 + +

D. Mollon

availability (Hawley 2000, Hupcey 2000, McKinley et al.

2002, W�ahlin et al. 2006, Karlsson & Forsberg 2008,

Kv�ale & Bondevik 2010, Andersson et al. 2011, Aro et al.

2012). Patients have minimum care expectations on entry

into the healthcare environment; however, receiving care at

these minimum expectations does not necessarily equate to

feeling cared for. Patients express feeling cared for when

the healthcare provider is willing and available to help and

do not create the perception of being bothered and provides

additional care over and above minimum expectations

(W�ahlin et al. 2006, Kv�ale & Bondevik 2010, L€am�as et al.

2011, Karlsson et al. 2012, Van Dover & Pfeiffer 2012).

When nurses cared for patients in every way, patients

expressed feeling safe and secure, which allowed for

improved rest and relaxation (Granberg et al. 1998, Haw-

ley 2000, Andersson et al. 2011, Karlsson et al. 2012).

Presence

The value of the presence of another human being during

hospitalization cannot be overestimated and is closely

linked to the concept of feeling safe. The meaning of pres-

ence took on different forms, although most referred to

someone’s actual presence at or near the bedside, in addi-

tion to availability and proximity of the nurse (McKinley

et al. 2002, Lasiter 2011). Presence can be categorized into

two types: nurse presence and family presence.

Nurse presence

Patients described nurse presence as creating a sense of car-

ing and safety (Karlsson & Forsberg 2008), decreasing vul-

nerability (O’Brien & Fothergill-Bourbonnais 2004) and

feelings of security and being cared for (McKinley et al.

2002). Nurses who were readily available and attended to

patient needs timely created a feeling of assurance in

patients they were safe when in vulnerable states (McKinley

et al. 2002, Lasiter 2011). Hospitalized patients many times

are in situations where they are sedated, confused or so

acutely ill that they are unable to care for themselves or

make decisions. The caring presence of nurses during times

of reduced ability and increased vulnerability helped

patients to feel safe (Hupcey 2000, O’Brien & Fothergill-

Bourbonnais 2004, Van Dover & Pfeiffer 2012).

Family presence

The presence of the family plays an important role in con-

tributing to the patient feeling safe. A family sitting at the

bedside or providing a loving touch was extremely valuable

and comforting to patients (Wong & Arthur 2000, Eng-

str€om & S€oderberg 2007, Karlsson & Forsberg 2008).

Encouraging family involvement in the patient’s care not

only enhances the patient’s experience, but it adds greatly

to the patient’s feeling of safety, security and comfort (Hup-

cey 2000, Engstr€om & S€oderberg 2007, Karlsson & Fors-

berg 2008). Overall, having the physical presence of

another human being is enormously valuable to patients

and contributes to their feeling safe.

Knowledge

A final attribute of feeling safe is knowledge. Knowledge

can be associated with the healthcare provider or the provi-

sion of knowledge to the patient and/or family. The attri-

butes of knowledge and staff competency were both found

to be related to feeling safe in the literature. As competency

requires knowledge, these two attributes are combined in

the attribute of knowledge. Many patients enter into the

healthcare environment with the assumption of staff compe-

tence and a minimum level of knowledge (Hornsten et al.

2005, Calman 2006, Kv�ale & Bondevik 2010). When

patients develop distrust in the staff’s ability to competently

care for them, their feelings of safety and security are

eroded (Hupcey 2000). Patients relate competency to the

technical skills staff perform as part of their job (Hornsten

et al. 2005, Calman 2006, Kv�ale & Bondevik 2010), in

addition to their knowledge demonstrated in their interac-

tions and relationships with the patient (Hawley 2000,

Hornsten et al. 2005, Calman 2006, Kv�ale & Bondevik

2010). Through interactions with the nurse, patients decide

the knowledge and competency of the nurse and when

patients determine that a deficit is present, they begin to

feel unsafe, vulnerable and potentially distrustful. Once this

breakdown in the relationship occurs, it can become quite

difficult for the nurse to reverse these feelings. Patients may

not carry unsafe feelings from nurse to nurse; however,

consistent occurrence of limited knowledge or competency

over multiple encounters may lead to permanent unsafe

feelings and distrust. Therefore, having nurses who are

competent and knowledgeable in all aspects of care is an

important contribution to patients feeling safe (Hawley

2000, Hupcey 2000, Kv�ale & Bondevik 2010, Meril€ainen

et al. 2010, Lasiter 2011).

Another aspect of knowledge is the process whereby

knowledge is provided to the patient and family. Several

studies found the concept of feeling safe related to the gain-

ing of knowledge by patients and families about their cur-

rent situation and their health-related status (Russell 1999,

Wong & Arthur 2000, W�ahlin et al. 2006, Stenwall et al.

2008). By providing knowledge to patient and families,

fears could be alleviated, which increased feelings of emo-

tional safety (Russell 1999). Not only is knowledge impor-

tant to the safe provision of care, but its contribution to

JAN: CONCEPT ANALYSIS Feeling safe

patients’ overall feelings of safety and security cannot be

overestimated.

Constructed cases

Constructed cases illustrate the concept by using the defin-

ing attributes, antecedents and consequences of the concept

in a case. A model case demonstrates all the defining attri-

butes, while a borderline case contains most of the attri-

butes and a contrary case is the absence of the concept

(Walker & Avant 2011).

Model case

Cindy is a 44-year-old woman admitted postautomobile

accident. The nurse caring for Cindy today has developed a

therapeutic relationship with her by introducing herself and

asking about her family. Cindy has called for the nurse on

two occasions and the nurse has come promptly. Cindy’s

nurse inquires about her pain when she checks on her, pro-

vides pain medication when the pain is increasing and fol-

lows up to assure she is comfortable. The nurse educated

Cindy about the importance of pain control and to let the

nurse know when her pain is increasing. Cindy’s husband

spends three hours a day at her bedside supporting her.

Cindy expressed to her husband she feels cared for and safe

as the nurses are always right outside her door. Cindy also

tells her husband the nurses are so knowledgeable and

always watching over her. She trusts them to take care of

her even when she is unable.

The above case is an effective representation of a model

case because it demonstrates all four attributes of feeling

safe. Trust is established with the patient through the devel-

opment of a therapeutic relationship. Feeling cared for is

reinforced when the nurse answers the call light promptly,

addresses pain control regularly and follows up on care

provided. Both nurse and family presence are occurring.

The nurse demonstrates knowledge by her competency in

her role, in addition to educating the patient about pain

control.

Borderline case

John is a patient with diabetes with unstable blood sugars.

John’s nurses have monitored his blood sugars closely and

his sugars are now in normal range. From John’s perspec-

tive, the nurses are competent because they make adjust-

ments to his insulin doses and his blood sugars normalized

quickly. Frequently when John rings for the nurse, there is

a long delay in response and an even longer delay in meet-

ing his needs. The nurses rarely check on him unless they

have a task to complete. Conversations between John and

his nurses are only about his care. Although John has trust

in their technical skills and feels safe in their care, he feels

lonely and wants to go home so he can spend time with his

dog. John has no family in town and his dog is his best

friend.

In this borderline case, the nurses have monitored the

patient and followed up on his needs adequately enough for

the patient to have trust in their clinical competency and

feel safe and cared for. What is missing in this case is pres-

ence. As the nurses had long delays in responding to patient

needs and related minimally to the patient outside basic

needs, there is little opportunity to develop a relationship.

In this case, the patient did not perceive the nurses as pres-

ent and as he had no family, there was no one to meet his

emotional needs.

Contrary case

Harold is in the hospital recovering from abdominal surgery

related to his new diagnosis of colon cancer. Harold has

been able to do little for himself due to pain, overall weak-

ness and anxiety. Harold does not normally suffer from anx-

iety, but since coming to the hospital he has been fearful

with increased anxiety. Harold is distrustful of the nursing

staff because, on several occasions, they have given him

inconsistent information. Harold has found the nurses to be

dishonest with him, telling him he is allowed to eat when no

diet was ordered. His nurse today comes into the room per-

forms what she needs to and leaves. She talks with Harold

only when needed for his care. As Harold cannot do much

for himself, he has been relying on the nurses for help with

bathing, but they are so rough he is afraid to ask again. Har-

old has taken to watching the nursing staff closely because

he does not feel safe and lacks confidence in their care. He

wishes his family was closer so they could assist him.

In this contrary case, none of the attributes of feeling safe

is present. Harold is distrustful of the nursing staff, does

not feel cared for and worries that the staff are not knowl-

edgeable or competent. Presence is lacking from the nursing

staff and there is no opportunity for family presence at the

current time.

Antecedents

Events leading up to or occurring before a concept are the

antecedents of the concept (Walker & Avant 2011). The lit-

erature identifies several conditions, which must be met for

patient’s to feel safe. The primary antecedents to feeling

safe are the relationship between the patient and nurse, the

environment where care takes place and the presence of

some form of suffering.

D. Mollon

A nurse has a professional and ethical responsibility to

develop a therapeutic, caring relationship with each patient

(Lindwall et al. 2003, Capuzzo et al. 2005, Karlsson &

Forsberg 2008, Lasiter 2011). This relationship is essential

to positive patient outcomes and satisfaction with care and

is an antecedent to feeling safe. Therapeutic relationships

are established through interaction with patients, whereby

nurses demonstrate caring by spending time with patients

and individualizing each aspect of care (Kralik et al. 1997,

Karlsson & Forsberg 2008). Once a therapeutic relationship

has been established, patients begin to develop trust in the

nurse, which leads to the experience of feeling safe (O’Brien

& Fothergill-Bourbonnais 2004, Lasiter 2011, Nieminen

et al. 2011).

The environment where patients receive care plays a role

in patients feeling safe. Environment takes into account

equipment and instruments needed to provide care, lighting,

noise and temperature, in addition to staff, patients and vis-

itors interacting in the environment. An environment which

is comforting and positive, where patients receive good

care, creates a feeling of safety for the patient (W�ahlin et al.

2006, Meril€ainen et al. 2010, Andersson et al. 2011, Sutton

et al. 2012). In addition, an environment where help is

close by and patients are encouraged to participate in their

own care and decision-making is correlated with feelings of

safety and security (Andersson et al. 2011).

Suffering is another antecedent to feeling safe. Whether

suffering is related to physical (pain), anxiety (fear of

unknown) or any other element which led to the hospital-

ization, the alleviation of suffering is a core value of the

healthcare profession. Alleviation of suffering is the motive

for caring, when nurses are able to address and alleviate

suffering through providing information, being present and

available, patients feel safe and experience relief from suf-

fering (Lindwall et al. 2003, Karlsson & Forsberg 2008,

Kv�ale & Bondevik 2010, S€oderberg et al. 2012).

Consequences

Events which are a result of the concept occurring are the

consequences of the concept (Walker & Avant 2011). The

literature refers to several consequences resulting from the

patient feeling safe during an inpatient hospitalization.

These consequences include control, hope and relaxed or

calm. Maintaining control of one’s life and actions is a goal

most patients desire. To maintain or sometimes regain con-

trol, patients must feel safe and have confidence that the

nurses are competent (Hupcey 2000, Andersson et al.

2011). In an environment where patients feel safe, patients

are more likely to report feeling in control and confident to

participate in their care and health care decision-making

(Meril€ainen et al. 2010, Lasiter 2011). It is when patients

do not feel safe feelings of helplessness and frustration are

exhibited and patients go to extremes in an attempt to

regain control (Hupcey 2000, Meril€ainen et al. 2010).

The ability to remain hopeful is greatly influenced by the

presence of family and by the encouragement of staff (Hup-

cey 2000, Karlsson et al. 2012). When patients feel safe,

this feeling becomes a source of hope for the patient, an

important factor in the recovery process (Holm & Severins-

son 2011, Karlsson et al. 2012).

Both the consequences hope and control are closely

aligned to the third consequence of being relaxed or calm.

Knowing that the nurse will be there when help is needed

and having a comfort level with the nurse’s skill and

competence reinforce the patient’s perception of being

cared for, which enables the patient to relax (Hawley

2000, Westin et al. 2009). On the other hand, if patients

feel unsafe or insecure in their situation, they will not be

able to relax and the recovery process is inhibited. Over-

all, when patients feel safe, they tend to be hopeful about

their recovery, in better control of themselves and their

circumstances and more relaxed than patients who are

not feeling safe.

Empirical referents

Empirical referents are a way to measure or recognize the

presence of defining characteristics or attributes (Walker &

Avant 2011). Validating a patient is feeling safe can be a

difficult task, given that feelings are subjective in nature

and are what the patient perceives. Due to the abstractness

of the concept feeling safe, defining the empirical referents

is more difficult. There is no exact method for determining

whether or not the patient feels safe and patients’ feeling of

safety can change from shift to shift, day to day or even

hour to hour. Probably, the truest way to determine if a

patient feels safe is to ask them. However, sometimes the

patient does not have the ability to answer or is unwilling

to give a true reflection of their feelings. These difficulties

require the nurse to rely on the presence of other behav-

iours and characteristics to help determine whether the

patient feels safe.

The presence of family contributes greatly to patients

feeling of safety and security. Patients who have regular vis-

itation from family are more likely to feel safe (McKinley

et al. 2002, Karlsson & Forsberg 2008). Monitoring for the

occurrence and frequency of supportive family presence and

family involvement in care is a way for nurses to gain

insights into the safety and security patients feel during

their hospitalization.

JAN: CONCEPT ANALYSIS Feeling safe

Establishing trust in the nurse–patient relationship and in

the healthcare system is difficult. One method for assessing

patient’s level of trust is to ask questions, which address

elements of a trustful relationship. The Trust in Nurses

Scale measures nurse availability, advocacy, competency,

follow-up, reliability and overall trust, many of the charac-

teristics of the concept of feeling safe (Radwin & Cabral

2010). The items in this instrument could be used as a ref-

erence for healthcare providers to inquire into the presence

of the attributes of feeling safe, thus providing insights into

how the patient perceives the care they are receiving and

whether or not they may be feeling safe in their current sit-

uation.

Discussion

As healthcare providers go about their task-filled work,

considering how the patient is feeling can sometimes be lost

or forgotten. A lack of caring relationships in the healthcare

environment creates anxiety, unnecessary discomfort, dis-

satisfaction, uncertainty and sometimes, functional decline

(Duffy 2003). As the healthcare industry continues to strive

to reduce the risk of harmful events by redesigning systems

and processes, one cannot lose sight of who is at the centre

of these redesigned systems. Sometimes, focus on task com-

pletion and attending to the technological aspects of care

interfere with the development of a caring, therapeutic rela-

tionship. To find a balance between conflicting priorities

and patient-centred care, perspectives of the patient must

be obtained.

Advancing the definition of feeling safe from the patients’

perspective provides opportunity for examination on how

the concept can contribute to existing theories and models.

Many theoretical frameworks of caring and patient-centred

care (Watson 1985, McCormack & McCance 2010) have

as a primary focus the relationship between the patient and

the nurse or healthcare provider. In the literature reviewed

for this concept analysis, there was a distinct lack of any

theoretical foundation to the research conducted. However,

recent research by Lasiter and Duffy (2013) is focused on

the development of a theory around safety from the

patient’s perspective as opposed to emphasis on providers.

Using a grounded theory approach, Lasiter and Duffy

(2013) considered older adults’ perceptions of feeling safe

in two hospital acute care units. This work began the devel-

opment of a feeling safe theory, identifying the factors of

oversight, predictable, personalized and advocate, as con-

tributors to the patient’s perception of feeling safe in acute

care (Lasiter & Duffy 2013). This concept analysis exam-

ines the function and structure of the concept feeling safe,

which contributes to the further development of the theory

of feeling safe (Figure 1).

Under the Quality Caring Model©, developed by Duffy

and Hoskins in 2003, safety is a terminal patient outcome

in the model. Many of the antecedents and attributes

defined by this concept analysis are reflected in the struc-

ture, process and outcomes of the model. At the heart of

patient and healthcare team with an immediate outcome of

feeling ‘cared-for’ (Duffy & Hoskins 2003). Through the

establishment of therapeutic relationships and feeling

‘cared-for’ perceptions, the patient develops trust in the

nurse and the terminal outcome of feeling safe is achieved.

Further development of theories and models supporting

patient perceptions of feeling safe is needed. This analysis

has begun the work of synthesizing qualitative work

already completed around the concept of feeling safe by

defining the key attributes of the concept.

Limitations

The work of this analysis primarily considered inpatient

hospital environments and the nurses who care for patients

in this environment. Further research and analysis is needed

to explore feeling safe in other environments such as ambu-

latory settings, homecare settings, physician offices and out-

patient clinics. With limited empirical referents available to

measure the concept of feeling safe, it may be too prema-

ture to quantify the concept. Additional qualitative research

specifically focusing on the patient’s perception of feeling

safe could further develop the understanding of the concept

allowing for measurement through quantitative means.

Findings from this analysis can be used for future develop-

ment of measurement tools to assist healthcare providers to

accurately measure patients’ perceptions of their care and

feelings of safety.

Feeling Safe

Relationship Environment Suffering

Consequences Control Hope Relaxed

Trust Cared For Presence Knowledge

Antecedents

Defining Attributes

Figure 1 Antecedents, defining attributes and consequences of feeling safe.

D. Mollon

Conclusion

This concept analysis considers the topic of safety from the

perspective of the patient by analysing the concept of

feeling safe. A great deal of research has been completed

around system redesign and safety improvement initiatives;

however, research focusing on the patients perspective is

limited. By defining the attributes, antecedents and

consequences of feeling safe, awareness is brought to

healthcare professionals for evaluation of their own

practice. This analysis gives support to the importance of

developing patient-centred models of care and creating posi-

tive environments where patients receive high-quality care

and feel safe (W�ahlin et al. 2006). What is known at this

time is feeling safe is an abstract concept defined by four

main attributes, trust, cared for, presence and knowledge,

which is uniquely perceived by every individual patient.

Funding

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the author.

Author contributions

All authors have agreed on the final version and meet at

least one of the following criteria [recommended by the IC-

MJE (http://www.icmje.org/ethical_1author.html)]:

• substantial contributions to conception and design, acquisition of data, or analysis and interpretation of

data;

• drafting the article or revising it critically for important intellectual content.

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