Introduction

Adolescents compose a significant proportion of the population of hospitalized patients. They want control over their lives, friendships, and some level of privacy during hospitalization. However, hospitalization entails separation from family and friends, who are often important sources of support and security, requiring the adolescent to significantly change daily life and routines, live in an unfamiliar environment, and face invasive and painful medical procedures and new stressors (Moura de Moura, Costa Junior, de Amorim Silva, da Silva Reichert, & Collet, 2015). The unfamiliar hospital environment and procedures and the changes to daily routines often conflict with the developmental needs of adolescents (Hutton, 2002; Smith, 2004). Needs-based care for adolescents is important because adolescence is a time of transition from childhood to adulthood and is associated with profound biological, mental, and psychosocial changes (Smith, 2004). If security needs are not met, then higher needs cannot be fulfilled (Maslow, 1987). Psychological safety is a subjective concept that is achieved as a result of direct and indirect experiences relative to one's environment (Huisman, Morales, Van Hoof, & Kort, 2012).

Feeling safe is different from being safe (Mollon, 2014). Psychological safety and feeling safe are important to a sense of well-being and important aspects of quality of care (Aro, Pietila, Vehvilainen-Julkunen, 2012; Hupcey, 2000; Krevers & Milberg, 2014; Lasiter, 2011). Exposure to new places such as hospitals may engender feelings of fear, insecurity, anxiety, lack of comfort, fatigue, insomnia, and depression in patients (Avdagic & Carlstrom, 2014). As the largest group of healthcare professionals, nurses must understand the needs of adolescents, including the need for psychological safety. Nurses should be sensitive to patient perceptions regarding level of safety (Stenhouse, 2013). However, the emphasis of previous clinical studies has largely been on the physical safety of patients, with few studies addressing the topic of emotional or psychological safety (Lasiter, 2011; Stenhouse, 2013). The significance of psychological safety in adolescents, especially in qualitative studies, is rarely mentioned. Whereas there has been little research on psychological safety in Iran, studies have been conducted in other countries such as Sweden (Avdagic & Carlstrom, 2014; Fagerstrom, Gustafson, Jakobsson, Johansson, & Vartiainen, 2011; Krevers & Milberg, 2014) and the United States (Hupcey, 2000; Lasiter, 2011). However, the cultural, religious, and clinical contexts of these studies differ significantly from Iran. Furthermore, most research on psychological safety has been done on patients in intensive care units (Wassenaar, Schouten, & Schoonhoven, 2014) and with chronic illness (Krevers & Milberg, 2014) older than 18 years.

As an abstract, context-dependent concept, psychological safety is not particularly amenable to quantitative research, and qualitative techniques are typically preferred. The aim of this study was to describe and explore the sense of psychological safety in adolescents using naturalistic and qualitative techniques that provide insight into subjective perceptions and provide information about the phenomenon.

Methods

Design

This exploratory descriptive study gathered naturalistic and descriptive data (Burns & Grove, 2005) and analyzed qualitative data using conventional content analysis.

Participants

A purposive sample of 16 Persian-speaking adolescents who were 12-18 years old participated in this study between March 2015 and May 2016. The participants were recruited from a hospital in Shiraz (southwestern Iran), which is one of Iran's largest healthcare centers and regularly treats clients referred from all over the country. This hospital has four medical wards and two surgical wards for children. There are no separate wards for adolescents, who are thus hospitalized with other children in rooms with two to six beds. This study recruited adolescents who had been admitted to either a medical or surgical ward in the target hospital, were physically and psychologically fit to be interviewed, and had been hospitalized for at least 2 days. Interviews were arranged by the first author, who went to the hospital on a weekly basis to interview potential participants.

Data Collection

Data were collected using face-to-face, audiotaped, unstructured interviews conducted in a quiet environment. Unstructured interviews start with a general question in the broad area of study. Except for the very beginning of the interview, no predetermined questions were used, which allowed the interview process to be flexible. Researchers followed the interests and thoughts of the participants rather than the researchers' assumptions. Subsequent questions were based on responses to earlier questions. Participants were free to answer at length, providing great depth and detail (Holloway & Wheeler, 2010; Speziale, Streubert, & Carpenter, 2011). Interviews began with the general question, "How do you feel about being in the hospital?" Examples of subsequent questions include "Since your hospitalization, please describe some situations that affected your sense of safety"; "What situations make you feel safer?"; "What situations make you feel unsafe?"; "What or who helps you to relax while in the hospital?"; and "Can you explain that/explain it/give an example?" The first interview was treated as preliminary and used to identify potential areas of interest or concern. We used maximized variation sampling because this approach searches for individuals with widely differing respective experiences and for variations in settings (Holloway & Wheeler, 2010). Participants included men and women with a broad range of ages and diagnoses to maximize variation.

Purposive sampling continued until data saturation was achieved. Interviews lasted between 25 and 65 minutes and were digitally recorded (Hyundai), converted to audio files on a portable computer, and then transcribed verbatim.

Ethical Considerations

Ethical approval for this study was granted by the ethics committee of Shiraz University of Medical Sciences (no. 94-7495). Written and oral consent was obtained from both the target hospital and participants before data collection. Interviews took place in conditions that ensured the privacy and comfort of the participants. The participants were informed that they could stop the interview or refuse to participate at any point. Data were identified by codes, and participants were identified by pseudonyms in all reports related to this study to ensure participant anonymity and confidentiality.

Data Analysis

The data were subjected to conventional content analysis using the method developed by Graneheim and Lundman (2004). Conventional content analysis was chosen because the existing theories and literature on psychological safety in hospitalized adolescents are limited, and researchers wanted to avoid preconceptions in favor of allowing the categories and names of categories to flow from the data (Elo et al., 2014; Graneheim & Lundman, 2004). The qualitative content analysis method focuses primarily on the subject and context, emphasizing the differences between and similarities within codes and categories. It also deals with both the manifest and latent contents within a text. The manifest content (i.e., what the text says) is often presented in categories, whereas themes are seen as expressions of the latent content (i.e., what the text is talking about; Graneheim & Lundman, 2004).

The interviews were read carefully several times to gain an overall picture of the material. Next, important statements were underlined to identify initial codes or units of meaning related to psychological safety. These units of meaning were organized into themes and subthemes at different levels of abstraction. Data analysis ran concurrently with data collection and continued until saturation was achieved (i.e., until more data did not reveal new information and were considered redundant). The final step in the analysis was to extract the main themes (Graneheim & Lundman, 2004). Data classification and analysis were carried out using MAXQDA10 software (VERBI Software GmbH, Berlin, Germany).

Rigor

The validity and reliability of the study were assessed using the criteria suggested by Lincoln and Guba (1985). Long-term interaction with participants (15 months) established credibility; the investment of sufficient time in collecting data is necessary for an in-depth understanding of the group or phenomenon under study as well as to test for misinformation and distortions and ensure data saturation in key categories. In planning a qualitative study, researchers must ensure that they have adequate time and resources to stay engaged in fieldwork for a sufficiently long period (Burns & Grove, 2005). In this study, researchers transcribed interviews and sorted field notes; organized, ordered, and stored the data; repeatedly listened to and read or viewed the collected materials; and coded and categorized the data. An iterative process of data analysis meant that researchers moved between data collection and data analysis over an extended period (Holloway & Wheeler, 2010).

In addition, the participants confirmed the validity of the findings, interviews were reviewed by external supervisors, and all of the interviews were audiotaped and transcribed verbatim. The reliability of the data was assessed by reviewing the material in consultation with a supervisor and associate professors as well as through data triangulation (time, space, and person triangulation). Triangulation involves the use of multiple data sources for the purpose of validating conclusions (Holloway & Wheeler, 2010). In a qualitative study, triangulation may involve an attempt to reveal the complexity of a phenomenon by using multiple means of data collection to converge on the truth (Polit & Beck, 2010). In this study, we selected different spaces (wards), different times (shifts), and different individuals (of different ages, genders, and diagnoses). Confirmability was ensured by allocating sufficient time to collect a comprehensive set of data (15 months), transcribing all interviews immediately, sampling to maximize variation (age, gender, and time), and logging all procedures to provide an audit trail. Confirmability requires an audit or decision trail that permits readers to trace the data to their sources (Holloway & Wheeler, 2010). In this study, several classes of records constituted an adequate audit trail: (a) raw data (e.g., patient quotes), (b) data reduction and analysis products (e.g., table of main themes, subthemes, and categories), (c) process notes (e.g., methodological process), (d) materials related to researchers' intentions and dispositions (e.g., method and context), and (e) data reconstruction products (e.g., results; Polit & Beck, 2010).

Transferability means that the findings in one context are transferable to similar situations or participants (Polit & Beck, 2010). In this study, to promote transferability, information such as demographics and study setting were described clearly in terms of culture and context, selection and characteristics of participants, method of data collection, and process of analysis. A thorough presentation of findings and appropriate quotations ensure transferability (Graneheim & Lundman, 2004).

Results

Sixteen adolescents (10 boys and six girls) between 12 and 18 years old and hospitalized in the general medical or surgical pediatric wards with diagnoses including irritable bowel syndrome, appendicitis, nephrotic syndrome, pyelonephritis, and pancreatitis participated in this study.

Four main themes emerged from the content analysis: (a) receiving comprehensive support, (b) protection of human dignity, (c) relaxing environment, and (d) attempts to adapt. In addition, 12 subthemes were defined. Table 1 presents the main themes, subthemes, and primary categories.

TABLE 1. Main Themes, Subthemes, and Primary Categories

Receiving Comprehensive Support

Receiving comprehensive support was identified as a vital and multidimensional need of patients. This main theme encompasses spiritual, psychosocial, physical, and informational support provided by family, friends, staff, God, and school personnel.

Spiritual support

The participants sought support to face new environments, procedures, and people. They viewed God as a particularly good source of support. One patient stated that his family's religious practices made him feel that he was under God's protection:

When my mother read the Qur'an, I felt that God was helping me and that if surgery is necessary, God will take care of me. (P3)

Presence of supporters is another primary category. The participants said that they felt safer, more relaxed, and better able to tolerate pain in the presence of family members, especially their mothers:

The presence of my mother gave me a certain sense of relief. When my mum was with me, I forgot about the pain. (P9)

Having access to nurses and physicians in an emergency was important for patients:

If something happens, nurses and doctors come soon and treat me quickly. (P10)

Psychosocial support

The primary categories of psychological support were emotional support from the healthcare team, family, school personnel, friends, and relatives. One participant related a conversation with a physician:

My doctor emphasized my positive characteristics. For example, they told me that I was a courageous adolescent and that I could tolerate disease more than younger children, so I could cope with my disease. If I was scared from procedures such as angiography, they would help me to be calm with their hopeful speeches. (P6)

Social relationships with school staff and friends were a source of support for adolescent patients, as one explained:

My teachers and friends called on me and said I shouldn't feel stressed about my lessons. They said that they will be there for me. They said that I should try to be healthy as soon as possible. My principal told me when I was discharged and came back to my school, she would tell my teachers to teach me and give the exams. I realized that they supported me in any situation. (P9)

Physical support

The participants emphasized the role of guardians (i.e., family, nurses, and physicians) in supporting their physical needs. According to participants, guardians help protect them and their personal belongings such as cell phones from strangers. Furthermore, family members facilitate their physical needs such as going to the toilet and walking. Nurses and physicians provide proper and professional care and treatment of patients in the hospital. The participants noted that they felt safe when physical support needs were met and when nursing care was provided appropriately and on time:

Nurses come every half an hour. They monitor my blood pressure and body temperature and give me my medications on time. I feel safe and I think I will get better. (P10)

The participants said that the guardians in the wards gave them a sense of psychological safety, which alleviated feelings of being in danger. One participant said:

I don't feel under threat. Because the guardians are here. They stop strangers from coming into the wards. I feel safe, especially when I'm sleeping. (P7)

Informational support

Participants and families appreciated having information about the illness, treatment, medication, and recovery provided by nurses and physicians. One participant said:

When doctors tell me to undergo sonography, I'm afraid. They should explain it and its reasons to me. They should answer my questions. (P15)

Protection of Human Dignity

This main theme covers protection of personal privacy, respect for identity, protection of autonomy, and intimate communication.

Protection of personal privacy

Privacy is an important aspect of human dignity. Because the participants were all Muslim, they reported that having visitors, especially of the opposite gender, was an invasion of their hijab and of their privacy:

I was upset because when I was sleeping, my roommate's visitors came into the room without my permission. I needed to put on my scarf and cover myself with blankets. My feet were blistered, but I couldn't expose them and be calm. (P4)

The participants voiced the desire to protect their privacy:

"I can tolerate the pain, but I can't tolerate that nurses or doctors want to examine me or expose my body without my permission. If this happens, I would be angry" (P10).

Respect for identity

The participants expressed the desire for hospital staff to respect their age and gender identity. Because of legal and resource limitations, in Iran, no hospital maintains a dedicated ward for adolescents, who are hospitalized in children's wards. Given sufficient space in the pediatric wards, adolescents are typically hospitalized with their peer group in one room. If sufficient space is not available, adolescents may be hospitalized with younger children in one room.

One participant said that he did not feel it was right for him to be hospitalized in the children's ward:

They shouldn't have put me in a pediatric ward. I'm 16 years old and they admitted me in a pediatric ward. I can't sleep at night at all. When I'm sleeping, I am awakened by crying children. (P1)

Protection of autonomy

Protection of autonomy is particularly important to adolescents. The participants in this study desired control over their activities and reported that some procedures disrupted their sleep and autonomy:

We can't sleep well at nights. In the morning when we fall asleep, nurses want to do procedures such as blood test for us. This means we can't control our sleep in the hospital. (P4)

Patients in Iran are not allowed to leave their wards during hospitalization without permission from the head nurse. The participants said that this restriction on movement threatened their autonomy:

If I could go out of the ward and play around, I would feel more freedom. But, the personnel don't allow me to go there. In our home, we feel more autonomy, but I feel I'm in prison in the hospital. (P10)

Intimate communication

According to the participants, intimate communication involves kind, friendly, and respectful behavior toward patients and their families by nurses, physicians, and guardians. One participant explained the need for respect:

If someone doesn't communicate well, we don't feel safe. But when they communicate well, we do feel safe. It's a law of physics; every action has a reaction. It means I want friendly nurses who call me by my first name and communicate respectfully with me and my family. (P4)

Relaxing Environment

The participants explained that a silent environment with appropriate structural factors and adequate facilities gave them comfort and was a source of psychological safety.

Appropriate structural factors

The participants said that cleanliness in the ward was an important factor in psychological safety: "The ward is a clean environment. They use disinfectants here. The cleaning crews clean the ward regularly" (P6).

In addition, being in a quiet environment was relaxing and made the participants feel safe. One participant said:

Relaxation means that there isn't much noise in the ward. For example, my roommates and visitors should speak in low voices. There shouldn't be too many visitors at any one time. Also, they shouldn't make much noise when they want to move chairs in the room. (P10)

Adequate facilities

Recreational facilities were also important to the comfort of participants. One mentioned the adverse effects of the lack of recreational facilities:

I feel so bad because I don't have Internet in the ward. I cannot play and use chat forums. (P11)

The dimensions and temperature of the room were also identified as important factors. One participant said:

My room is too small. When I and my roommate have visitors, there isn't enough air to breathe. Also, it is so cold when the air conditioner is turned on. (P4)

Attempts to Adapt

Adaptation was another main theme that emerged from the data. This theme reflects the perception that external and environmental factors are not sufficient to ensure the psychological safety of a patient and that the patient must also adapt and adjust to the hospital environment and to his or her disease. The participants in this study reported that psychological safety is the motivation to adapt to stressors and that they used the two approaches of problem- and emotion-focused coping.

Problem-focused coping strategies

Problem-focused coping involves accepting new experiences, trying to participate in care, and asking peers and friends for helpful experiences and coping strategies. The participants said that asking questions might be useful in reducing their fear of surgery:

I had many questions about surgery, so I asked my hospitalized friend, who had undergone surgery, about his experience. He told me that a nurse got him ready and asked him some questions before he was taken to the operating room. Also, I asked my questions about pain, anesthesia, period of unconsciousness, and so on. I felt that I knew about my surgery and would have a good surgery without adverse consequences. (P9)

Emotion-focused coping strategies

In addition to problem-focused coping, the participants also used emotion-focused coping strategies. Recreational activities such as games and entertainment and trust in God helped them stay calm and cope with stress. One participant told us that he felt he would cope better if he were able to play and have fun:

Look, in this ward, there is no games room. My legs are in plaster, so I can't go to the opposite ward to play. If there was a games room, I could entertain myself and the time would pass faster. (P13)

Discussion

Interviews indicated that respecting human dignity and providing comprehensive support in a relaxing environment were important to maximize psychological safety. However, patients must also be able to adapt to new circumstances.

"Receiving comprehensive support" was one of the main themes and involves ensuring that help and support are always available to patients (Bruwer, Emsley, Kidd, Lochner, & Seedat, 2008). The participants stated that receiving "physical and psychosocial support" from family, friends, teachers, and relatives; "informational support" from nurses and physicians; and "spiritual support" from God provided a sense of psychological safety. Once a patient has been admitted to a hospital, the physical presence and mental support of trusted personnel, particularly nurses, play an important role in promoting a sense of peace and psychological safety (Burstrom, Brannstrom, Boman, & Strandberg, 2012; Hupcey, 2000). This study, like other studies, found that physical protection in the form of accessible and timely nursing care was important to psychological safety (Lasiter, 2011; Mollon, 2014). Participants in this study stressed the importance of reassurance provided by the presence and supervision of guardians. This issue has received less attention in other studies. One of the most important duties of guardians is to supervise the movement of visitors and to prevent strangers from gaining access to the wards.

The subtheme "informational support" refers to giving sufficient advice and information. It is important for patients to learn about the illness, treatment, and recovery process (Mattila, Kaunonen, Aalto, Ollikainen, & Astedt-Kurki, 2010). Participants in this study wished to be informed about their illnesses, procedures, and medications.

Spirituality is the expressed essence of human beings made visible in relationships both vertically (with a higher power) and horizontally (humans), the consequences of which are love, faith, hope, and a purpose for being. A caring presence helps patients heal, strengthens the feeling of spiritual support, and involves an interaction wherein a reciprocal experience relates to the whole person, goes beyond the technical, and attends to the complexity of a person's needs (Rankin & DeLashmutt, 2006). A caring presence has a calming effect on the patient. Adolescents desire to have family members with them when they are in the hospital (Beresford & Sloper, 2003). Family support and family participation in patient care improve mood and reduce feelings of isolation and depression (Mattila et al., 2010; Yektatalab, Sharif, Kaveh, Khoshknab, & Petramfar, 2013). Adolescents seek independence but remain physically and psychologically dependent on their family. The problems that visiting a patient in the hospital causes for the family-travel difficulties, delays, and/or expenses-may cause patients to feel guilty and blame themselves, although they need and welcome the support. Moreover, visits from friends, a source of support that has been mentioned in other studies (Mattila et al., 2010), are helpful because these allow adolescent patients to talk about their disease, everyday problems, loneliness, and entertainment. Furthermore, the need for spiritual support was mentioned by the participants. Spirituality is an inherent quality, a connective force, and a source of cohesive strength in all humans. A patient who feels under the protection of a powerful God will improve, feel safe, and be less anxious and fearful (Jaberi, Momennasab, Yektatalab, Ebadi, & Cheraghi, 2017). The importance of spiritual support in this study relates to the religious and cultural background of the participants, who were all Muslim.

Our findings indicate that respect by the staff and others for the human dignity of patients promotes psychological safety. Human dignity is at the core of human relationships and is a fundamental human right (Narayan, Hooker, Jarrett, & Bennett, 2013). Respect for human dignity of patients is more important because they are in a particularly vulnerable position. This finding is consistent with an earlier study showing that respecting patient dignity helps give them a sense of security (Borhani, Abbaszadeh, & Rabori, 2015). Autonomy is essential to the dignity of adolescents because of its central role in this developmental stage. In fact, hospitalization robs them of control over many issues, and most adolescent patients disagree with some hospital rules (Findlay et al., 2008). Previous studies show that many adolescent patients believe that their healthcare team does not involve them in decisions about their care and that any decision made without their consent is unacceptable (Barkay & Tabak, 2002). This is consistent with the results of this study. The participants in this study expressed the belief that strict rules and procedures that disrupted their sleep undermined their autonomy and dignity. It is essential to involve patients and their families in decisions about care and treatment and to make the rules governing the care of adolescent patients more flexible.

Privacy is fundamental to human dignity. Holistic care must involve respect for the privacy of patients, especially in the case of hospitalized adolescents. Adolescence is a time when individuals try to establish their identity and autonomy, and any interference with this is perceived as a threat to their dignity (Reed, Smith, Fletcher, & Bradding, 2003). The participants in this study, especially the women, felt that having people of the opposite gender come into the ward without their permission was an invasion of their privacy, especially if these intrusions involved exposing parts of their body. Unwelcome ward visits clearly increased the anxiety of the participants and undermined their sense of safety. Perceptions of human dignity are rooted in culture. As noted above, all of the participants in this study were Muslim. In Islam, there are clear boundaries for encounters with the opposite gender. Adolescents regarded themselves as adults who were bound by Islamic rules, which made gender identity a particularly important issue in this study. However, even in non-Muslim countries, there is evidence that teenagers prefer not to have individuals of the opposite gender in their room and would prefer to be in single-gender wards (Narayan et al., 2013).

The psychological safety of adolescents is undermined when arrangements for hospital care do not take age and gender identity into account. In the target hospital, adolescents were exposed to the tantrums of younger children in their rooms. Hutton concluded that adolescents want to be hospitalized in a private room (Hutton, 2002). Others have also noted that adolescents do not feel that they belong in pediatric wards (Narayan et al., 2013), and it has been recommended that, whenever possible, adolescents should be cared for in adolescent wards or otherwise placed with their age peers (Hockenberry & Wilson, 2014).

We also found that a relaxing environment contributes to psychological safety. In fact, psychological safety is a subjective feeling that originates from environmental factors. The environmental factors that were mentioned by the participants in this study as contributors to psychological safety were silence, adequate facilities, and appropriate structural factors. Several studies have revealed that light, sound, temperature, and peripheral equipment affect the psychological safety of patients (Vogus, 2016). Attempting to adapt, although a main theme in this study, has received less attention in other studies. It is inevitable that hospitalization brings stress, concerns, and fears and that patients use both problem- and emotion-focused coping strategies (Fortinash & Worret, 2011). The participants in this study said that accepting new experiences, trying to participate in care, and communicating with peers and friends helped them to adapt. They also mentioned using emotion-focused strategies such as playing, having fun, and trusting in God. Trust in God boosted their confidence and power for enduring hardships, and performing religious practices such as prayers provided psychological safety and peace (Jaberi et al., 2017; Tartaro, Luecken, & Gunn, 2005). Our results show that the psychological safety of hospitalized adolescents depends not only on external factors such as the provision of comprehensive support, protection of human dignity, and a relaxing environment but also on an internal factor-the ability to cope with a new situation.

This study was performed in one hospital. Focus groups could not be conducted because the adolescent patients were distributed among several wards. Further qualitative and quantitative research at other locations and in other cultures is necessary to explore the concept of psychological safety. Future research should include investigations into the perceptions of healthcare providers regarding the psychological safety of their patients.

Implications

Optimal patient care cannot be achieved if hospital staffs do their best to maintain the physical safety but neglect the psychological safety of their patients. Ensuring both will help minimize the length of hospital stays as well as maximize patient comfort and well-being. Adolescence is a time of transition during which adolescents experience many physical, psychological, and social changes. Not working to ensure the psychological safety of patients during hospitalization may have irreversible consequences for their future lives. Furthermore, officials and hospital staffs should provide dedicated wards for adolescents to address the concerns that this age group typically has for self-identity.

Conclusions

This study shows that a relaxing environment that offers comprehensive support and that respects dignity promotes feelings of psychological safety in adolescents. However, the ability of adolescents to adapt is also an important factor.

Having a ward dedicated to this age group is necessary to prevent violations of dignity because adolescents have needs that differ from both children and adults. In addition, Muslim adolescents, especially female adolescents, regard themselves as adults who should wear hijabs. This issue made gender identity a particularly important issue in this study. The participants expressed a preference to be placed in single-gender hospital accommodations. In this study, female adolescents, especially the older ones, were particularly anxious about their privacy in the hospital.

Acknowledgments

This article is a part of the doctoral dissertation of Neda Jamalimoghadam, which was financially supported by the Shiraz University of Medical Sciences, no. 7495-94. The authors would like to thank the participants for their close cooperation; the Shiraz University of Medical Sciences, Shiraz, Iran; the Center for Development of Clinical Research of Nemazee Hospital; and Dr. Nasrin Shokrpour for editorial assistance.

References