Exerting Capacity: Mindsets of Bedside RNs in Keeping Patients Safe

J. Michael Leger, University of Texas Medical Branch, School of Nursing
Carolyn A. Phillips, University of Texas Medical Branch, School of Nursing and Graduate School of Biomedical Sciences

Abstract

This classic grounded theory (CGT) study explored the perspectives of bedside nurses about patient safety in the adult acute care environment. The theory that emerged, Exerting Capacity, explains how bedside nurses balance their own capacity against the demands of a given situation to fulfill their duty to keep their patients safe. Exerting Capacity revealed a typology of two mindsets nurses use to approach the demands of keeping patients safe: me-centric and patient-centric. Analysis of the study’s data revealed no connection between the mindset and the skill level of the nurse, unlike Benner’s (1982) “From Novice to Expert” concept. Further, no relationship could be identified between the mindset and the length of time the nurse has been in practice as a bedside nurse. Understanding the mindset nurses use to approach provision of safe care is necessary for understanding how nurses ensure patient safety in the hospital setting.

Keywords: mindset, patient safety, exerting capacity, classic grounded theory

Introduction

The World Health Organization [WHO] (2019) estimates that adverse events occurring in the hospital are the 14th leading cause of morbidity and mortality around the globe.  The United States Institute of Medicine’s (IOM) 1999 seminal report “To Err is Human: Building a Safer Health System,” estimated, to the dismay of healthcare professionals, that between 44,000 and 98,000 people in the United States (U.S.) suffer preventable deaths annually due to medical errors. The Australian Institute of Health and Welfare [AIHW] (2018) published data indicating an age-standardized rate of 105 potentially avoidable deaths per 100,000 population and 5.4 adverse events in hospitals per 100 discharges. In 2016, Johns Hopkins Medicine in Baltimore, MD, (U.S.) reported that medical errors occurring during patient treatment in U.S. hospitals led to more than 251,000 deaths, or 9.5 percent of all U.S. deaths each year (Hopkins Medicine, 2016). This rate is significantly higher than the United Nations projected overall rate of 7.645 deaths per 1000 people (Macrotrends, n.d.) Yet despite the amount of research into patient safety ignited by the IOM report and other findings of patient error data, the numbers of adverse patient outcomes continue to be one of the most significant issues facing healthcare today. As recently as 2019, scientists estimate that more than 161,000 avoidable deaths occur annually in U.S. hospitals (Castellucci, 2019). Why then, if patient safety is deemed a “healthcare priority,” is the global healthcare system unable to make better progress in reducing these potentially preventable adverse events and deaths?

A review of the literature through 2015–the time period ending this research project–related to patient safety revealed a significant gap in the current science. Despite a plethora of research focusing on the data-driven, quantitative outcomes of adverse patient events and surveys that gather information about patient safety, there is a scarcity of qualitative data about the concept of patient safety from the perspective of the bedside nurse, the healthcare worker who is closest to the patient (Author A & Author B, 2017).

In an effort to close this gap in the patient safety literature, the initial study used Classic Grounded Theory (CGT) to focus on the perspectives of bedside registered nurses (RNs) in the U.S., who work primarily in adult acute care environments, as they relate to patient safety. The participants’ main concern–indemnifying duty–in keeping their patients safe and guarding them against loss or harm while in the nurses’ care emerged from the study data. Resolution of this concern occurred through the core category that emerged from the data: exerting capacity. In addition, analysis of the data led to the identification of a typology of two mindsets–me-centric and patient-centric–which describe how nurses approach keeping their patients free from harm. Also emerging from the data were two main categories nurses believe positively or negatively impact their capacity to do what they must do to keep their patients safe from harm: authority and work milieu.

Method, Data Collection and Analysis

Little is known about the perspectives of bedside nurses regarding patient safety; therefore, Classic Grounded Theory (CGT) was selected to discover “what is really going on” (Glaser, 1998, p. 12) with nurses caring for patients in the adult acute units of hospitals and how they define their reality (Glaser, 1992).

The study proposal was submitted to and approved by the university institutional review board. Study participants were English-speaking registered nurses with at least two years of recent experience as a bedside nurse in an adult, acute care hospital setting in the U.S. At the time of the data collection, the nurses were employed either full- or part-time. No nurses were excluded from participation based upon age, ethnicity, gender, geographic location, or level of formal nursing education.

The study began by recruiting nurses using purposive sampling strategies to gather data about the nurses’ first-hand experiences with the phenomenon of interest (Streubert & Carpenter, 2011). Initially, eight nurses participated in the study. At the end of each interview session, the participants were asked to share information about the study with other nurses who they believed would be willing to share their experiences about the topic, otherwise known as snowball sampling. Theoretical sampling was utilized when ongoing data analysis revealed emergence of theoretical ideas and concepts, and a theory began to emerge. Theoretical sampling allowed expansion of the concepts and emergence of new concepts and interrelationships among the concepts (Dudovskiy, n.d.).

After obtaining the nurse’s consent to participate in the study, the nurse was asked, “What does patient safety mean to you?” This question was followed by comments or open-ended questions to encourage sharing of thoughts and perceptions, or to “instill a spill” (Glaser, 1998, p. 111).

Data analysis followed the prescribed, yet fluid, steps of CGT: the constant comparative method (CCM), coding, memoing, sorting, developing a theoretical outline, then writing up the findings. Data analysis was an ongoing and iterative process: each transcribed interview was read and coded line-by-line, asking the question, “What is going on?” (Glaser & Strauss, 1967, p. 23) to identify patterns of behavior of the participants. Open coding allowed concepts to emerge from the data; each concept was compared to every other concept and to any new concepts that emerged from the data. Throughout the data analysis and writing up processes, the researcher used memoing extensively to document thoughts and questions related to the developing and evolving patterns within the data. The memos were sorted and became part of the data leading to emergence of the theory.

The Theory: Exerting Capacity

Exerting Capacity, the theory that emerged from the initial study, explains how bedside nurses balance their own capacity against the demands of a given situation to keep their patients safe from harm (Author, 2015). Nurses’ ability to exert capacity comes from one of two mindsets: me-centric or patient-centric. These mindsets drive how the nurses meet the demands of keeping their patients safe.

The data also revealed that the nurses identified two main categories – authority and work milieu – that have either a positive or negative impact on nurses’ capacity to do what must be done to keep their patients safe from harm. Authority includes elements of formal and informal leadership within the departmental unit and hospital organization and nurses’ awareness of their own capacity to impact patient safety. Work milieu includes patient safety equipment and technologic resources, as well as practice and communication patterns within the work environment.

Mindsets Used by Bedside Nurses in Keeping Patients Safe

Exerting Capacity describes how bedside nurses balance their own capacity against the demands of a given situation to fulfill their duty to keep their patients safe from harm. Nurses’ ability to exert their capacity arises from one of two mindsets: me-centric and patient-centric (Author A & Author B, 2017). The mindset typology that emerged from the data should not be confused with the levels of professional nurse skill performance, as described in the Dreyfus Model of Skill Acquisition (Pena, 2010), or as a predictor of patient outcomes. Further, the type of mindset exhibited by the nurse does not reflect the number of years the nurse has been a bedside nurse (Benner, 1982).

Me-centric Mindset

Nurses with a me-centric mindset place themselves at the center of decision making and actions in fulfillment of their duty to keep their patients safe from harm.  Nurses with me-centric mindsets tend to be more reactionary and less proactive regarding issues of patient safety; they are task-oriented in their approach to patient safety and describe their capacity to keep patients safe as doing so to the “best of my ability” (Author A, 2015, p. 46). Nurses who demonstrate a me-centric mindset can identify a patient in distress and solve the problem before the patient suffers harm but are less likely to be proactive in their approach when attempting to prioritize the many factors that impact a patient’s safety. Nurses with a me-centric mindset have a relatively limited view of the healthcare organization’s operations and rely heavily on their working knowledge of departmental policies and procedures or knowledge obtained from other trusted members of the nursing staff to address issues of patient safety. Nurses with a me-centric mindset will circumvent a policy and procedure that guides patient care if they believe the steps impede, or are unnecessary, to their workflow in providing patient care.

Patient-centric Mindset

Nurses with a patient-centric mindset place a patient at the center of their decision-making process and address patient safety issues by anticipating the potential for harm or injury to patients and formulating preventive interventions. Nurses with patient-centric mindsets describe their actions as coming from “intuition, [ . . .] that sixth sense, [ . . . and going] with your gut” (Author A, 2015, p. 47). These nurses adopt a big picture viewpoint of their work environment and are more likely to raise questions about the organization’s policies or procedures that do not seem compatible with patient safety. Further, nurses with a patient-centric mindset are likely to circumvent a policy and procedure if the nurse thinks the policy does not fit the patient’s current situation.

Mindset Responses to Factors that Influence Capacity

CGT data analysis revealed two organizational factors that directly or indirectly impact nurses’ capacity to do what must be done to keep their patients safe from harm. These organizational factors are authority and work milieu.

Authority

Authority encompasses the healthcare organization’s formal and informal leadership, including communication by the nurse with the leaders. Authority also includes nurses’ capability to demonstrate characteristics of their own empowerment.

Nurses with a me-centric mindset recognize issues related to authority that are, or can, pose a risk to their patients’ safety. These nurses are less likely to be proactive in response to these issues as they tend to avoid communicating with formal leaders about issues surrounding patient safety. Thus, they are likely to avoid opening lines of communication with organizational leaders as they maintain their focus on their respective patient and nursing unit and are less likely to have an awareness of patient care issues facing the leaders and nurses from other areas within the organization.  Nurses with a me-centric mindset are aware of edicts reflecting the decision-making process at the leadership level that can, and do, impact patient safety, such as designated staffing levels, patient-to-nurse ratios, and the availability and maintenance of bedside patient equipment. Nevertheless, nurses with a me-centric mindset believe leaders’ priorities are often misaligned. Nurses with a me-centric mindset assert that while leaders may appear to be staunch advocates for providing patients with a safe environment, they see these leaders as less supportive and more likely to respond negatively when nurses ask for resources they contend are needed to keep patients safe. In addition, nurses with a me-centric mindset recognize the gap that exists between what patients and organizational leaders expect of them (the nurses) to keep patients safe and what they, as bedside nurses, can do in their role to keep their patients safe. However, nurses with a me-centric mindset do not see bridging this gap of knowledge as a priority for themselves because they see them as “things outside of our control” (Author A, p. 64).

Nurses with a patient-centric mindset are “comfortable [and] persistent” (Author A, p. 64) when communicating with all levels of their organization’s leadership and do not hesitate to make the needs of the patient, as well the nurse, known. Nurses with a patient-centric mindset respect the departmental and organizational chain of command, but they do not hesitate to overstep the chain of command if they believe the patient’s safety is in jeopardy. Unlike nurses with me-centric mindsets, nurses with a patient-centric mindset are well-aware of their own capabilities to keep their patients safe. This awareness leaves a much smaller gap between what they believe they can do to keep their patients safe, and the expectations of safety held by patients and hospital leaders. Nurses with a patient-centric mindset are aware of limitations faced by the organization, such as financial and human resources, that may interfere with their requests for resources such as equipment, technology, or additional staff, but they often find ways to circumvent such barriers and keep patients safe until their requests can be met.

Work Milieu: Equipment/Technology, Practice Patterns, Communication

Work milieu includes factors that nurses identify as having direct or indirect impact on their capacity to do what they believe must be done to keep patients safe. Work milieu also includes factors such as patient safety equipment and technologic resources, practice patterns (policies and procedures), and communication within the culture of the practice environment.

Equipment/Technology. Nurses with a me-centric mindset rely heavily on patient safety equipment such as bed or chair alarms, and technology such as bar code scanning devices and software for medication administration and electronic medical records, as their primary strategies to keep patients safe. These nurses are knowledgeable in the use of equipment designed to mitigate injury or harm to patients in the hospital environment. Nurses with a me-centric mindset approach the use of equipment and technology understanding that safety equipment should be tested to verify it is in good working condition; they recognize that failure to confirm proper functioning of equipment can result in patient harm. Nurses with me-centric mindsets know there are procedures in place for checking the functionality of patient safety equipment and expect the equipment not to fail. Further, these nurses believe they know how to respond in the event of scheduled or unscheduled equipment or technology downtime.

Nurses with a me-centric mindset are very comfortable with trends in technology that are designed to improve patient safety and know that implementing new technology is not easy. Nurses with a me-centric mindset depend on the equipment being available, well maintained, and accessible when it is needed to provide safe patient care. Although they rely heavily on equipment and technology for patient safety, they may not use proven behaviors, processes, and actions, such as the “six rights” of medication administration (the right patient, right route, right drug, right dose, right time, and right documentation [Federico, (n.d.)]). They routinely abbreviate or avoid such processes because they see them as time consuming even though such processes have a positive impact on patient safety.

Nurses with a patient-centric mindset respect technological interventions and patient safety equipment but see them as supporting safe care of patients (Author A, 2015); these nurses know that equipment, by itself, cannot be trusted to prevent patients from suffering harm. Nurses with a patient-centric mindset are less likely to rely solely on patient safety equipment and technology to avoid patient safety risks, viewing these resources as adjuncts to promotion of patient safety. Implementation of technology does not lead nurses with a patient-centric mindset to abandon work practices, such as the “six rights” of medication administration, that will protect patients. Moreover, these nurses see over-reliance on equipment and technology as an impediment to nurses’ critical thinking skills and a potential inhibitor of face-to-face communication among the team. In addition, nurses with a patient-centric mindset contend that technology results in nurses’ spending less time with their patients and “dumbs things down” (Author A, p. 65) further impeding nurses’ critical thinking.

Nurses with a patient-centric mindset understand the necessity of ongoing equipment maintenance in addition to routine equipment checks by the nurse; they do not rely on others to be responsible for the ongoing maintenance of safety equipment.  They are aware of the defined process for handling equipment that must be serviced or disinfected after use although they might bypass these processes to meet the immediate needs of their patients. Patient-centric mindset nurses see the workflow process of managing equipment maintenance and cleaning as an added responsibility for nursing and blame others for failing to be accountable for the maintenance of safety equipment after they have used it. The patient-centric mindset nurse can deal with equipment and supplies that are not readily available by implementing workarounds to avoid a delay in their ability to keep patients safe. Although there are processes in place to correct such failures, these nurses are more likely to handle the situation independently followed by reporting the problem to management.

Practice Patterns. Me-centric minded nurses view organizational policies and procedures as dictating how safe patient care should be provided while simultaneously admitting failure to communicate to leadership actual practices that do not follow policies and procedures. While nurses with me-centric mindsets admit to making exceptions to the policies and procedures, they view this action as a conscious decision made to facilitate provision of safe patient care. Nurses using a me-centric mindset approach acknowledge they may not follow strictly policies and procedures intended to keep patients safe from harm including hourly rounding (seeing each patient every hour to assess needs are met), use of double patient identifiers (using two patient identifiers to verify patient identity prior to medication administration or beginning a procedure), and the time-out process prior to a procedure (when the team stops to verify that they are about to perform the correct procedure on the correct patient). Me-centric minded nurses do not view failure to follow such processes as either right or wrong; instead, they see their choice simply as a manner in which to improve the efficiency of care to the patient.

Nurses approaching practice patterns using a me-centric perspective fear retaliation by leaders and “being blamed for” (Author A, 2015, p. 67) failures in patient safety. While me-centric minded nurses may report an actual patient safety issue, particularly when reporting such incidents can be done anonymously, they are more likely to report such issues to a more experienced nurse. The me-centric mindset nurses believe the more experienced nurse will be less likely to make them feel at fault for lapses in patient safety. Using the me-centric mindset, nurses are apt to blame patient safety issues on a faulty process rather than a personnel error or omission believing that process issues require reeducation of the nurse involved instead of disciplinary action.

Nurses using a patient-centric mindset recognize the importance of having policies and procedures for patient safety; they also recognize and readily point out the flaws in policies and procedures to managers. Moreover, these patient-centric minded nurses know some policies and procedures lack the necessary resources and support for successful implementation. Nurses who use the patient-centric approach identify when policies and procedures lack consistency or when they are reactionary rather than proactive for keeping patients safe. These nurses see policies as being more a reflection of the organization’s culture and leadership than a reflection of actual nursing practice. In addition, they contend the policies often lack the perspectives of bedside nurses because policies presume that patient safety can be achieved with a top-down, one-size-fits-all approach.  Nurses with a patient-centric mindset believe a nurse who does not adhere to a known policy or procedure has made a conscious decision between right and wrong and has done so with the welfare of the patient in mind.

Nurses with a patient-centric mindset know that potential compliance and/or patient safety issues are more likely to go unreported when nurses work in a punitive or retaliatory work environment. They believe that fear of retaliation contributes to non-collaboration, poor communication, and a higher incidence of patient safety incidents because inadequate or broken processes are not reported and, therefore, they are not corrected. Nurses with a patient-centric mindset believe that workplace environments managed by retaliatory leaders will tend to have the nurse “take the fall” (Author A, 2015, p. 68) for a patient safety issue despite having full knowledge that the issue was the fault of a broken process. Further, these nurses believe that adverse patient safety events may not be investigated fully, demonstrating a lack of support from organizational leadership for failing to find the root causes of patient safety events.

Communication. Nurses with a me-centric mindset are aware of the unit’s and organization’s overarching goals pertaining to patient safety but are more focused on the results for their own patients. Although these nurses understand the importance of patient safety initiatives, they consider them as additional steps in their patient care routine, disrupting their workflow, and potentially increasing the risk of errors. They are less inclined to proceed up the organization’s chain of command when answers to questions cannot be found at lower levels (Author A, 2015).

Nurses with a me-centric mindset also are less likely to verbalize their concerns about staffing levels, particularly their own patient assignment, fearing that doing so could be interpreted by leaders as their own lack of skill and knowledge. These nurses are less likely to seek feedback from leaders following an investigation of an unsafe patient event, choosing instead to wait for feedback.  They are more likely to participate in anonymous employee surveys that seek feedback about the status of the organization’s patient safety culture. Finally, nurses with a me-centric mindset may consider attendance at staff meetings as unimportant because the meetings disrupt workflow patterns.

Nurses with a patient-centric mindset recognize when staffing levels and assignments might place patients at greater risk, and they are more likely to share their concerns with a manager. They have fewer reservations about utilizing the organization’s chain of command when they believe a patient safety issue is not being responded to at lower levels on the leadership hierarchy. Nurses with a patient-centric mindset respect the chain of command, but do not hesitate to sidestep the hierarchy to report patient safety issues although they know this could create tension with lower-level leaders.

Nurses with a patient-centric mindset do not hesitate to publicly identify co-workers who do not participate actively as team members; they quickly recognize the lack of teamwork on their patient unit and attempt to “lead by example” (Author A, 2015, p. 70) to improve patient safety. These nurses often believe there is inadequate feedback provided to staff following an investigation of a patient safety incident; they want debriefing to occur following the incident so nursing staff can learn from the outcome and prevent future occurrences of similar incidents. Finally, nurses with a patient-centric mindset identify it as a failure of management to lack effort in giving credit to nurses for good patient safety results; at the same time, they believe excessive sharing of patient safety data may be overwhelming or seem redundant to bedside nurses.

Discussion

The theory, Exerting Capacity, emerged from data provided by bedside nurses that explored their perceptions of patient safety. The theory explains how bedside nurses balance the demands of keeping their patients safe while strategically managing several factors that can impact their capacity to do so. These factors include authority and work milieu, both of which directly and indirectly impact how the nurses keep their patients safe. Authority includes the healthcare organization’s formal and informal leadership in addition to the nurse’s capacity to demonstrate empowerment. Work milieu includes equipment and technology; practice patterns, including policies and procedures; and communication, including work environment and culture.

Within the theory, Exerting Capacity, a typology of two mindsets–me-centric and patient-centric--was identified; these mindsets affect how nurses approach their role in patient safety and make decisions to satisfy their duty to provide safe care to their patients. It is important to note that neither mindset is unsafe; nurses with either mindset can do what is needed to keep their patients safe. The difference is the nurse’s approach to accomplishing patient safety. Nurses with a me-centric mindset are self-focused in their decision making, more task-orientated in their approach to keeping patients safe and are willing to circumvent policies and procedures if the nurse believes that they hinder the nurse’s workflow and ability to provide safe patient care. Nurses with a patient-centric mindset place the patient at the center of their decision-making process. They can see the impact of their actions on the organization beyond their unit. While such nurses will circumvent a policy or procedure, they see the decision to do so as arising from their assessment of the circumstances of the patient who may be at risk for harm at a given point in time.

Recognizing and understanding the mindsets of nurses in providing safe patient care are important steps for healthcare organizations’ leaders, particularly nursing leaders, and for the bedside nurses themselves. How a nurse perceives the workplace culture and environment provides valuable insight for leaders. Feng et al. (2008) found that a key component of patient safety includes “a non-blame and forgiveness environment” (p. 313). Leaders promoting this type of workplace culture and environment find nurses are more open to communicating errors and more likely to report patient safety concerns. In addition, being aware of the differences and preferences of the nurses with a me-centric or patient-centric mindset can be beneficial in the development and implementation of patient care policies and preferred communication styles. The bedside nurse, too, should not underestimate the importance of understanding their own approach to keeping patients safe and whether their approach is a suitable fit for their designated unit or, for that matter, the entire organization.

The findings from this study, in particular the concepts that emerged from the theory Exerting Capacity, are substantiated by work conducted exploring nurses’ activities to promote safety through coordinating care, prioritizing care, and workplace conditions (O’Brien et al., 2019; O’Donnell & Andrews, 2020). Orchestrating, the concept O’Brien et al. (2019) identified as how perioperative nurses minimize patient risk, aims to improve patient outcomes “through the effective managing, pacing and timing of how work is done” (p. 1459) and examines the important role of leadership in using orchestration to promote patient safety. O’Donnell and Andrews (2020) discussed the concept of care accommodation to describe how nurses respond to the challenging aspects of constraints within the healthcare environment to deliver safe, quality patient-centered care.

Limitations

Some elements of this study may be perceived as potential limitations including the number of study participants (n=13), the limited geographic area from which the study participants were recruited (Southeast Texas U.S.), and study participants’ self-selection. Nevertheless, the qualitative researcher focuses on the data offered by the study participants. Glaser (1978) contended that demographics are less important than the concepts and categories that emerge from a CGT study, stressing that findings and the theory that emerges from a CGT study should have “grab” (p. 4), or make sense and be interesting to people with similar experiences; the findings should “fit” and explain the data or “work” (p. 4). Moreover, a CGT study must be modifiable as new data emerges.

Implications

Exerting Capacity, the substantive theory that emerged from the study describes what bedside nurses believe are necessary to indemnify their duty to their patients and how bedside nurses balance their capacity against the demands of a situation to keep their patients safe from harm. Bedside nurses approach patient safety using one of two identified mindsets: me-centric or patient-centric.

The mindset typology, me-centric and patient-centric, has several implications for healthcare organizations, leaders of healthcare organizations, bedside nurses, and ultimately, patients themselves. Although keeping patients safe is important to each of these stakeholders, the implications for patient safety can be impacted by the mindset of nurses who provide care and fulfill their duty to keep their patients safe.

Bedside nurses should reflect on their own behaviors and approach to their role so they can recognize their primary mindset and how this can contribute, or detract from, how they keep their patients safe. When bedside nurses recognize which mindset seems to be most predominantly reflected in their actions, they also can evaluate the apparent mindsets of other nurses in their unit in an attempt to determine how their approach, along with the mindsets of their colleagues, can work together to keep patients safe within the existing culture of the unit and the healthcare organization.

The nursing leader’s knowledge of the me-centric and patient-centric mindsets can help them to identify the behaviors of nurses and consider the optimal mix of nurses for the particular needs of the patients served by that nursing unit. The nursing leader who is aware of the differences and preferences between the two mindsets will have a better understanding of what these nurses will do to keep their patients safe and how the combination of nurses from these varying mindsets can complement each other in keeping different types of hospitalized patients safe based on their respective needs. The recognition of nurse mindsets also can provide unit leaders with insight into how nurses practice and why they make some of the decisions they do when working to keep their patients safe from harm. Despite the differences between the two mindset types, nursing leaders should note that bedside nurses of both mindset types see themselves as the most crucial factor in keeping patients safe (Author A & Author B, 2017).

Healthcare leaders should be cognizant that nurses’ perceptions of patient safety may not be congruent with the perceptions of the leaders within the organization. Further, healthcare leaders’ perceptions of what is needed to foster patient safety can be different from what bedside nurses believe is necessary for keeping patients safe. For healthcare leaders, patient safety is primarily an objective value achieved by technology, policies, and procedures, and is measured by clinical outcomes.

Although the focus of this study was on the juxtaposing mindsets utilized by bedside nurses in their approach to keeping their patients safe, there is an opportunity for further conceptual development, and possibly development of a formal theory, using data generated within other disciplines or jobs.

Conclusion

The use of Classic Grounded Theory methodology to explore the perspectives of bedside nurses about patient safety resulted in the substantive theory, Exerting Capacity, that explains how bedside nurses fulfill their duty to keep their patients safe. Bedside nurses exert capacity to protect their patients from harm through their actions and decisions. How nurses approach these actions and decisions arises from two mindsets: me-centric and patient-centric.

Nurses with a me-centric mindset place themselves at the center of their decision making, and their resulting actions, to keep their patients safe from harm. Nurses with a me-centric mindset function from a more limited view of patient safety, that of the unit or department level rather than the organization in its entirety. Nurses with a patient-centric mindset place their patients at the center of their decision making while maintaining a broader viewpoint of the work environment recognizing the impact that patient safety at the unit level has on the organization as a whole.

Nurses exert their capacity to keep their patients safe within two contexts, authority and work milieu, each of which directly or indirectly impact bedside nurses’ capacity to keep their patients safe. Recognizing the implications of these findings by leaders of healthcare organizations, nursing leaders, and bedside nurses can enhance understanding of how nurses approach patient safety in the hospital setting. Understanding how each mindset type responds to boundaries of capacity within the nurses’ environment provides insight into how each mindset successfully exerts their capacity in an effort to protect their patients from harm.

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Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors received financial support for the research, authorship, and/or publication of this article from the following sources:

The Board of the John P. McGovern Foundation

Alpha Delta Chapter of the Sigma Theta Tau International Honor Society of Nursing

Texas Nurses Association, District 9, Houston, Texas

© John Michael Leger and Carolyn A. Phillips, 2021

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