Perception of feeling safe perioperatively: a concept analysis. — TEI-tagged view

Fanny LarssonpersName, Ulrica StrömbäckpersName, Silje Rysst GustafssonpersName, Åsa EngströmpersName (2023date). “Perception of feeling safe perioperatively: a concept analysis..” International Journal of Qualitative Studies on Health and Well-beingtitle·j.

Object of study — feeling safeterm·dom, from the patient's perspective, in a perioperativeterm·key context

Research question — what feeling safeterm·dom means for patients in a perioperativeterm·key setting

Contribution — a definition of feeling safeterm·dom with three attributes, two antecedentsterm·mth and two consequencesterm·mth

Full text — tagged

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Perception of feeling safeterm·dom perioperatively: a concept analysisterm·key.

Abstract The purpose of this study was to explore the concept of feeling safeterm·dom, from the patient perspective, in a perioperativeterm·key context.

The eight-step concept analysisterm·key approach proposed by Walker and Avant was utilized to examine the attributes of feeling safeterm·dom. Uses of the concept, defining attributes as well as antecedentsterm·mth, consequencesterm·mth and empirical referentsterm·mth are presented to describe the concept. Case examples are provided in order to assist the understanding of the defining attributes.

Feeling safeterm·dom is defined as: a person that does not feel worried or threatened. Three attributes were identified: Participationterm·dom, Controlterm·dom and Presenceterm·dom. Knowledgeterm·dom and Relationship are the antecedentsterm·mth of feeling safeterm·dom, while Feeling Acknowledgedterm·dom and Trust are the consequencesterm·mth. Empirical referentsterm·mth are explored in order to find a way to measuring the perceived feeling of safety.

This concept analysisterm·key underscores the importance of including patients’ perceptions in traditional patient safetyterm·dom work. Patients who feel safe perceive that they participate in their care, that they are in controlterm·dom, and that they feel the presenceterm·dom of both healthcare staff and relatives. The perceived feeling of security could, by extension, promote the postoperative recovery of patients undergoing surgery by positively affect the process of recovery.

Introduction For patients, the perceived feeling of safety may be just as important as the fact of actually being safe throughout a procedure (Lasiter, 2011 ; Mollon, 2014 ; Péculo-Carrasco et al., 2020 ). A perceived feeling of safety is influenced by a number of things, including person-centred careterm·dom and information (Péculo-Carrasco et al., 2020 ). Vulnerability, frustration, and anxiety are some feelings that can arise when a person feels unsafe; consequently, due to difficulty in relaxing, the healing process can be more arduous (Mollon, 2014 ; Wassenaar et al., 2014 ). In the postoperative period, patients’ perceptions of feeling safeterm·dom can have an impact on the postoperative recovery. Feeling safeterm·dom is achieved when one is treated as an individual and feels reassured during recovery (Dahlberg et al., 2018 ). However, much of today’s safety-related research focuses on the delivery of safe care, and little research is done on the concept of feeling safeterm·dom and what it entails from the patient’s perspective (Mollon, 2014 ).

The concept of feeling safeterm·dom in nursing has been described by Segesten ( 1984 ), who found that feeling safeterm·dom is consistent with feeling at peace and feeling out of danger. Every person has a desire to feel safe, but the feeling of security varies from person to person. Segesten’s ( 1984 ) definition of the concept consists of two dimensions: internal safetyterm·dom and external safetyterm·dom. The internal dimension is linked to early childhood experiences and continues to grow throughout one’s life; it is described as a feeling of warmth, harmony, calm, and trust, and it includes the ability to believe in oneself and confess one’s flaws. The external dimension of feeling safeterm·dom is comprised of knowledgeterm·dom, controlterm·dom, and trustworthy individuals, and it is influenced by the person’s surroundings (Segesten, 1984 ). Mollon ( 2014 ) has studied the concept of feeling safeterm·dom for hospitalized patients, and she concludes that the concept in that specific context consists of four attributes: (1) feeling trust , (2) feeling cared for , (3) presenceterm·dom of another human being , and (4) knowledgeterm·dom .

Patient safetyterm·dom can be defined as the absence of unintentional injury (Donaldson et al., 2000 ). The World Health Organization (WHO) has recognized patient safetyterm·dom as a priority in health care through their acceptance of the resolution “Global action on patient safetyterm·dom” (World Health Organization, n.d. ). The care that is given should meet the patient’s needs for security, continuity, and desire to feel safe (The National Board of Health and Welfare, 2022 ). Nurses play a crucial part in patients’ feelings of safety (Lovink et al., 2015 ). According to the Nursing Code of Ethics by American Nurses Association (ANA) the promotion, advocation and protection of patients’ rights, health and safety is a part of a nurse’s ethical duty (American Nurses Association, 2015 ). Two of the core competencies for Swedish registered nurse anesthetists, are person-centred careterm·dom and safe care; these include (among other things) the requirement to offer safe care that supports patients’ sense of security and trust (Riksföreningen för anestesi och intensivvård & Svensk sjuksköterskeförening, 2020 ). With more complex health care, the risk of an adverse incident increases (Oregas et al., 2008 ). The perioperativeterm·key context is complex and highly technical, and the environment differs from other health care settings; nevertheless, nurses working in a perioperativeterm·key setting need to provide care that supports patients’ individual needs, even if the environment is fast-paced and filled with challenging situations (Spruce, 2013 ). Moreover, nurses working in a perioperativeterm·key setting need to establish a relationship with their patients based on a meeting in a brief period of time (Lekens et al., 2023 ). Given the complexity that is associated with a perioperativeterm·key context, a focus on patient safetyterm·dom and patient perception of feeling safeterm·dom is crucial.

In summary, the practice of providing a patient with safe care that meets their need to feel safe—in addition to the parts that more directly focus on delivering care that prevents and minimizes risk, mistakes, and injury to patients—is an important part of perioperativeterm·key nursing. Even so, there is a lack of clarity as to what the concept of “feeling safeterm·dom” means in a perioperativeterm·key setting. Therefore, the purpose of this study was to explore the concept of feeling safeterm·dom, from the patient perspective, in a perioperativeterm·key context.

Material and methods The concept analysisterm·key approach proposed by Walker and Avant ( 2011 ) was utilized to examine the attributes of feeling safeterm·dom in a perioperativeterm·key context. Walker and Avant ( 2011 ) shortened Wilson’s ( 1963 ) classic eleven-step concept analysisterm·key approach to eight steps; the latter is summarized in Table 1 . Table 1. Walker and Avant ( 2011 ) eight-step procedure. 1 Selecting a concept 2 Determining the aim of the analysis 3 Identifying all uses of the concept 4 Determining the defining attributes 5 Identifying a model case of the concept 6 Identifying additional cases 7 Identifying antecedentsterm·mth and consequencesterm·mth 8 Defining empirical referentsterm·mth A concept analysisterm·key looks at the structure and function of a concept, which must be investigated in order to have a better understanding of the phenomena being examined (Walker & Avant, 2011 ).

Data sources An initial scoping search was conducted in 2022, using the keyword “feeling safeterm·dom” to scan relevant articles for surrogate terms relevant to the concept. Through this process, the following additional keywords were identified: feel safe, feeling of safety, feeling secure, feeling of security, sense of safety, and sense of security. The scoping search was followed by a systematic literature search of the PsycInfo, CINAHL, and Medline databases. The purpose of the literature search was to identify as many available peer-reviewed scholarly papers as possible that use the concept of feeling safeterm·dom in a perioperativeterm·key setting. Articles were not excluded by a time limit, because one of the aims of this analysis was to identify all uses of the concept. The search comprised the different terms for feeling safeterm·dom that were mentioned above, in combination with various terms for a perioperativeterm·key context, such as perioperativeterm·key, surgery, operation, etc. The Boolean operators AND and OR were used to combine keywords. The search strategy is displayed in Table 2 . Table 2. Search strategy. Query Limiters/expanders Results Cinahl 080322 Limitations: Peer Review, English language S1 “feeling safeterm·dom” 244 S2 “feeling secure” 62 S3 “feeling of safety” 72 S4 “feeling of security” 52 S5 “feel* safe*” 622 S6 “feel* secur*” 139 S7 “sense* of safe*” 263 S8 “sense* of secur*” 571 S9 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 1,664 S10 Preoperative* 80,350 S11 Perioperativeterm·key* 49,192 S12 Peroperative* 283 S13 Intraoperative* 45,721 S14 Postoperative* 196,680 S15 Anesthesia 68,874 S16 Anaesthesia 71,666 S17 Anaesthes* 189,56 S18 Anesthes* 72,533 S19 Surgery 543,644 S20 (MH “Surgery, Operative+”) 620,889 S21 (MH “Anesthesia” 10,891 S22 S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 898,982 S23 S9 AND S22 95 PsycInfo 080322, Limitations: Peer reviewed, English Query Limiters/expanders Results S1 “feeling safeterm·dom” 347 S2 “feeling secure” 64 S3 “feeling of safety” 119 S4 “feeling of security” 182 S5 “feel* safe*” 1,153 S6 “feel* secur*” 271 S7 “sense* of safe*” 593 S8 “sense* of secur*” 828 S9 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 3,047 S10 Preoperative* 5,539 S11 Perioperativeterm·key* 2,565 S12 Peroperative* 10 S13 Intraoperative* 1,463 S14 Postoperative* 12,064 S15 Anesthesia 11,374 S16 Anaesthesia 11,464 S17 Anaesthes* 3,751 S18 Anesthes* 19,889 S19 Surgery 56,018 S20 S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 80,570 S21 S9 AND S20 40 Medline 080322, Limitations: Scholarly journals, English language Query Limiters/expanders Results S1 “feeling safeterm·dom” 326 S2 “feeling secure” 77 S3 “feeling of safety” 154 S4 “feeling of security” 139 S5 “feel* safe*” 929 S6 “feel* secur*” 223 S7 “sense* of safe*” 350 S8 “sense* of secur*” 921 S9 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 2,644 S10 Preoperative* 361,871 S11 Perioperativeterm·key* 144,450 S12 Peroperative* 4,523 S13 Intraoperative* 201,714 S14 Postoperative* 924,763 S15 Anesthesia 345,160 S16 Anaesthesia 190,760 S17 Anaesthes* 194,481 S18 Anesthes* 517,462 S19 (MH “Anesthesia+”) 200,057 S20 Surgery 399,6171 S21 S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S21 4,576,311 S22 S10 AND S21 255 The retrieved articles ( n = 390) were reviewed in terms of their use of the concept of feeling safeterm·dom in a perioperativeterm·key setting. After duplicates were removed, a total of 307 articles were screened, and articles that clearly did not fit the inclusion criteria were removed, leaving 181 articles. The full texts of these articles were retrieved and read to determine whether they met the inclusion criteria. The quality of the papers was not assessed using a formal approach, but each of the articles was critically examined in accordance with the inclusion criteria. The articles were included in the final list for the concept analysisterm·key if they: (1) included a (explicit or implicit) definition, given by the author or others; and/or (2) discussed the uses of the concept; and/or (3) described the antecedentsterm·mth, consequencesterm·mth, or attributes of feeling safeterm·dom in a perioperativeterm·key context. This process led to the exclusion of 161 articles. The reference lists of the retrieved articles were reviewed to find more literature, leading to the inclusion of an additional 11 articles. In total, the analysis comprised 31 articles that met the inclusion criteria. A flow chart in accordance with PRISMA (Page et al., 2021 ) that illustrates the systematic literature search can be seen in Figure 1 . Dictionaries, thesauruses, and literature were searched in order to identify uses of the concept. Figure 1. Flowchart of systematic literature search.

From the articles, included characteristics that were used in relation to the concept of feeling safeterm·dom were extracted; these include such characteristics as participationterm·dom, autonomy, comprehensive information, and controlterm·dom. In subsequent steps, these characteristics were organized and grouped into categories, which shared similar characteristics. Three categories were chosen as essential attributes of feeling safeterm·dom.

Results Uses of the concept The goal of defining the uses of a concept is to find as many uses of the concept as possible, both ordinary and scientific (Walker & Avant, 2011 ). Dictionaries (Nationalencyklopedin, n.d.; Oxford English Dictionary, 2021a ; Oxford English Dictionary, 2021b ; Svenska akademins ordböcker, 2021 ; Merriam-Webster, n.d.a .; Merriam-Webster, n.d.b .) were used to create a foundation by defining the words “feeling” and “safe”, first independently and then as a phrase together. Additional healthcare literature was scanned to find definitions of the phrase feeling safeterm·dom.

Feeling The word “feel” originates from the Germanic (Oxford English Dictionary, 2021a ) and is defined as: “To have a sensation, impression, perception, or emotion” (Oxford English Dictionary, 2021a ). “To believe, judge, have an opinion” (Oxford English Dictionary, 2021a ). “To examine or explore by touch” (Oxford English Dictionary, 2021a ).

The word “feeling” was first used in the 12 th century with the defined meaning of: “one of the basic physical senses of which the skin contains the chief end organs and of which the sensations of touch and temperature are characteristic” (Webster, n.d.a ). The definition of the word “feeling” includes: “An emotional state or reaction” (Webster, n.d.a ). “Generalized bodily consciousness or sensation” (Webster, n.d.a ). “The undifferentiated background of one’s awareness considered apart from any identifiable sensation, perception, or thought” (Webster, n.d.a ).

Safe The word “safe” originates from the French word salf or salve (Oxford English Dictionary, 2021b ) and the Latin word salvus ; it was first used in the 14 th century (Webster, n.d.b ). It is defined as: “Free from hurt or damage; unharmed” (Oxford English Dictionary, 2021b ). “Free from danger; secure” (Oxford English Dictionary, 2021b ). “Free from harm or risk: unhurt” (Webster, n.d.b ).

In Swedish there is a distinction between the word säker , which is defined as being out of danger (Nationalencyklopedin, n.d. ), and the word trygg , which may be defined in the same way as säker but also as a person that does not feel worried or threatened (Svenska akademins ordböcker, 2021 ).

Feeling safeterm·dom The phrase “feeling safeterm·dom” has not been found in any dictionaries. The phrase “feeling safeterm·dom” in the context of care has been defined in various ways, including: (1) a feeling of peace and out of danger (Segesten, 1984 ); (2) “an emotional state where perceptions of care contribute to a sense of security and freedom from harm” (Mollon, 2014 , 1729); and (3) freedom from both physical and emotional threats (Lovink et al., 2015 ). Psychological safetyterm·dom is a related concept that has been described in different areas. In management, psychological safetyterm·dom has been defined as “feeling able to show and employ one’s self without fear of negative consequencesterm·mth to self-image, status, or career” (Kahn, 1990 , p. 708). In a healthcare setting, psychological safetyterm·dom has been defined as “a multilevel phenomenon related to a unit culture that facilitates interpersonal risk behaviour” (Ito et al., 2021 , p. 471). Another related concept is that of confidence; Haavardsholmen and Nåden ( 2009 ) relate the concept of confidence to Segesten’s work mentioned above and conclude that the concept of confidence is linked to feelings of trust, assurance, and self-reliance.

For the purpose of this paper, “feeling safeterm·dom” is defined in accordance with the definition of the Swedish word trygghet : a person that does not feel worried or threatened (Svenska akademins ordböcker, 2021 ). This is in line with the definitions of feeling safeterm·dom provided by Lovink et al. ( 2015 ), Mollon ( 2014 ), and Segesten ( 1984 ).

Defining attributes In defining attributes of a certain concept, the goal is to define the characteristics associated with that concept as well as those that distinguish the specific concept from other, related concepts (Walker & Avant, 2011 ). In this analysis, the final attributes that define the concept of feeling safeterm·dom from the patients perspective are Participationterm·dom, Controlterm·dom, and Presenceterm·dom ( Table 3 ). Table 3. Attributes of feeling safeterm·dom in perioperativeterm·key setting. Source Number of attributes Participationterm·dom Controlterm·dom Presenceterm·dom 1. Aasa et al. ( 2013 ) 3 of 3 + + + 2. Adelani and Barrack ( 2019 ) 1 of 3 - + - 21 Barthelsson et al. ( 2003 ) 1 of 3 - + - 3. Bergman et al. ( 2012 ) 3 of 3 + + + 22 Causey-Upton and Howell ( 2017 ) 2 of 3 - + + 23 Costa ( 2001 ) 2 of 3 + - + 4 Cudré et al. ( 2015 ) 2 of 3 + + - 5 Davis et al. ( 2013 ) 1 of 3 - + - 6 Dixon et al. ( 2015 ) 2 of 3 + + - 7 EngströmpersName et al. ( 2017 ) 3 of 3 + + + 8 Forsberg et al. ( 2014 ) 2 of 3 - + + 24 Forsberg et al. ( 2015 ) 1 of 3 - + - 9 Gejervall et al. ( 2007 ) 1 of 3 - + - 25 GustafssonpersName et al. ( 2010 ) 2 of 3 + + - 10 Haapala et al. ( 2013 ) 2 of 3 + + - 11 Heine et al. ( 2004 ) 2 of 3 - + + 12 Hestdal and Skorpen ( 2020 ) 3 of 3 + + + 13 Hommel et al. ( 2012 ) 2 of 3 - + + 14 Høvik et al. ( 2018 ) 1 of 3 - + - 15 Kaptain et al. ( 2019 ) 2 of 3 + - + 26 Karlsson et al. ( 2012 ) 3 of 3 + + + 27 LarssonpersName et al. ( 2022 ) 2 of 3 + + - 28 Lindwall et al. ( 2003 ) 3 of 3 + + + 16 Lingehall et al. ( 2015 ) 3 of 3 + + + 17 Lupieri et al. ( 2016 ) 1 of 3 - + - 29 Mako et al. ( 2016 ) 3 of 3 + + + 30 Mauleon et al. ( 2007 ) 1 of 3 - + - 31 Renholm et al. ( 2014 ) 2 of 3 - + + 18 Rosén et al. ( 2008 ) 1 of 3 - + - 19 Tosuner Akpinar et al. ( 2019 ) 1 of 3 - + - 20 Turesson et al. ( 2019 ) 1 of 3 - + - Participationterm·dom Participationterm·dom and inclusion in care and decision-making (Aasa et al., 2013 ; Cudré et al., 2015 ; GustafssonpersName et al., 2010 ; Haapala et al., 2013 ) was the most frequently used characteristic when describing feeling safeterm·dom in a perioperativeterm·key context. It is important for patients to be able to affect their own care, and staff should take patients’ needs and considerations into account and invite them to engage in a dialogue (Cudré et al., 2015 ; GustafssonpersName et al., 2010 ; Haapala et al., 2013 ; Heine et al., 2004 ; Karlsson et al., 2012 ; Lindwall et al., 2003 ; Mako et al., 2016 ). Furthermore, it is important to be spoken to directly (EngströmpersName et al., 2017 ) and to be seen as a person who is capable and equal, with individual needs, and not just as a patient (GustafssonpersName et al., 2010 ; Hestdal & Skorpen, 2020 ; Kaptain et al., 2019 ; Karlsson et al., 2012 ; Lingehall et al., 2015 ; Renholm et al., 2014 ).

Controlterm·dom The second attribute of feeling safeterm·dom is Controlterm·dom, which includes ability to trust the staff, their abilities, and competence, as well as to feel like that the staff are in controlterm·dom and supportive and that they are looking after the patient (Aasa et al., 2013 ; Bergman et al., 2012 ; Cudré et al., 2015 ; Dixon et al., 2015 ; EngströmpersName et al., 2017 ; Forsberg et al., 2014 ; Gejervall et al., 2007 ; GustafssonpersName et al., 2010 ; Hommel et al., 2012 ; Kaptain et al., 2019 ; Karlsson et al., 2012 ; Lindwall et al., 2003 ; Lingehall et al., 2015 ; Mako et al., 2016 ; Mauleon et al., 2007 ; Turesson et al., 2019 ). During surgery, when patients cede controlterm·dom of their body to the staff, there is a risk that the patient feels insecure and has a fear of being abandoned (Dixon et al., 2015 ; Karlsson et al., 2012 ). On the personal level, patients have described that it is important to be in controlterm·dom (Forsberg et al., 2014 ), One way of enabling patients to stay in controlterm·dom may be to have regional anaesthesia, in order for patients to maintain awareness during the procedure (Forsberg et al., 2014 ); some patients have also described a wish to stay in controlterm·dom by following the procedure from the monitor (Haapala et al., 2020). When patients feel worried and thus less in controlterm·dom, feelings of insecurity arise (Haapala et al., 2013 ).

Presenceterm·dom The last attribute of feeling safeterm·dom in a perioperativeterm·key setting is Presenceterm·dom, and it can mean both presenceterm·dom of family and presenceterm·dom of staff. Presenceterm·dom of family members can help patients discuss questions that might arise (Aasa et al., 2013 ) as well as help patients take part in the information provided (Mako et al., 2016 ); it could also make patients feel less lonely (Hestdal & Skorpen, 2020 ). Presenceterm·dom of staff can help patients feel that they are not left alone (Causey-Upton & Howell, 2017 ; Hestdal & Skorpen, 2020 ; Lindwall et al., 2003 ). If patients have eye contact with or physical closeness to the staff, it helps them understand that they are able to make contact when needed, it provides an opportunity to be confirmed, and it shows the staff are a resource for the patient Bergman et al. ( 2012 ); (Forsberg et al., 2014 ; Heine et al., 2004 ; Hestdal & Skorpen, 2020 ; Karlsson et al., 2012 ; Mako et al., 2016 ). If staff are perceived as stressed or having a negative attitude, or if the staff are not physically close to the patient, the patient might feel insecure about who will respond if they call for attention, and their sense of safety might decrease (EngströmpersName et al., 2017 ; Karlsson et al., 2012 ).

Constructed cases Constructed cases are illustrations of the concept and its defining attributes. Multiple types of constructed cases are used to fully depict the concept. First, a model case that describes all defining attributes is constructed. Then, additional cases—including a borderline case, which describes a case with most (but not all) of the attributes, a related case are related to the concept but do not contain all of the defining attributes, and a contrary case, which describes a case where the attributes are absent—are constructed (Walker & Avant, 2011 ). These constructed cases may be helpful in attempts to understand what “feeling safeterm·dom” does and does not entail. To illustrate the concept’s attributes in real-life situations, the following sections discuss a model case, a borderline case, a related case, and a contrary case, which are based on the authors’ previous clinical experiences and examples available in the literature.

Model case Daniel is having knee replacement surgery. Unlike the routine procedure, Daniel’s surgery is scheduled to be performed as a day surgery. Together with his husband, Daniel attended a preoperative appointment where he met the surgeon, a nurse, and a physiotherapist. At the appointment, the couple were provided with information, both orally and written, about the procedure, the postoperative period, and what Daniel might expect in terms of pain and other complications that might occur during the recovery process. He also received information about what it means to undergo this procedure as a day surgery and had the opportunity to ask questions. On the day of the surgery, Daniel meets the surgeon and has the opportunity to ask question that have arisen since the appointment. The staff at the unit speaks directly to him and provides him with information on what is about to happen. During the surgery, a nurse is close to Daniel all the time, so he is able to ask questions and feel included and seen in the conversations among the staff. Before discharge, Daniel and his husband received information about how the surgery went and about the postoperative period.

Borderline case James is having a cholecystectomy. James has suffered with gallstones for years, but his decision to have surgery was only made a few days ago at a visit with his family doctor. During that appointment, James had time to ask questions and the doctor and he had time to talk about the decision to have surgery, both its advantages and disadvantages. On the day of the surgery, the staff appears to be competent and supportive. James trusts the staffs’ competence and feels in controlterm·dom. James is being spoken to directly by the staff prior to the induction of anaesthesia, and up until that point, he is maintaining eye contact with a nurse. However, at the post anaesthesia care unit James feel abandoned. He has nurses around him, but when he wants his wife present to keep him company and to help him remember information provided, that is not allowed due to regulations at the unit.

Related case Hanna was recently diagnosed with breast cancer, and she is scheduled for a mastectomy. It has been just a few days since Hanna got her diagnosis, and since then, everything has been happening quickly. She received information about her diagnosis at an appointment, from which she does not remember anything. She does not feel like she had the opportunity to ask any questions, and she is not sure why she is undergoing this procedure today. At the surgery unit, the staff do not seem to have any answers, and they are not able to tell Hanna what the next step after surgery is. Furthermore, the staff seem unsure about the routines for this procedure, and the nurse repeatedly excuse her uncertainty. Hanna is nervous and has a lot of questions, and the staff are perceived as being close, they show empathy for Hanna’s situation, and they do not feel stressed.

Contrary case Susan is having shoulder surgery. She is afraid of being anesthetized and wants to be awake during the procedure. Upon arrival at the surgery unit, the staff convince her to undergo general anaesthesia, even though Susan has heard that this type of surgery is performed with regional anaesthesia in other surgery units. She is not provided with any explanations on why regional anaesthesia is not possible for her case. Susan is left alone in the waiting hall for a long time, and nobody can provide her with sufficient information about the schedule and about what is about to happen. The staff she meets at the surgery are perceived as being stressed, and Susan does not know whom to turn to when she has questions. Before the induction of the anaesthesia, Susan feels like the staff are talking over her head, and she falls asleep feeling out of controlterm·dom. When the surgery is completed and Susan is about to be discharged, she wants to have her husband present when she talks with the surgeon, but due to regulations, relatives are not allowed to be present. As Susan has had general anaesthesia, she is tired, and she does not remember what the surgeon said, nor does she remember what the staff said about postoperative medications and about the recovery time.

Antecedentsterm·mth According to Walker and Avant ( 2011 ), antecedentsterm·mth are the events or incidents that need to take place before the concept occurs. The primary antecedentsterm·mth that need to be fulfilled before patients feel safe in a perioperativeterm·key context are Knowledgeterm·dom and Relationship. In order to be able to participate, patients should be provided with easy-to-understand information and receive explanations on why certain actions should be carried out (Aasa et al., 2013 ; Haapala et al., 2013 ; Hestdal & Skorpen, 2020 ; Lingehall et al., 2015 ; Mako et al., 2016 ; Rosén et al., 2008 ). Knowledgeterm·dom might be facilitated by information on how the department looks and by the opportunity to familiarize oneself with the environment and to meet the staff beforehand (Aasa et al., 2013 ; Bergman et al., 2012 ; Haapala et al., 2013 ). The staff may help the patient feel supported, cared for, and in controlterm·dom around getting help when needed by providing proper information beforehand about what is about to happen (Bergman et al., 2012 ; Tosuner Akpinar et al., 2019 ), about when things like timetables change (Haapala et al., 2013 ), or about how to handle pain (Adelani & Barrack, 2019 ). Knowledgeterm·dom from previous experience could also increase the sense of controlterm·dom (Rosén et al., 2008 ).

A relationship with the staff promotes patients’ feelings of safety and helps them realize that they do not need to be in complete controlterm·dom of the situation and that they are not alone (Barthelsson et al., 2003 ; GustafssonpersName et al., 2010 ; Lindwall et al., 2003 ; Renholm et al., 2014 ). Patients have described a wish to have personal preoperative conversations with, e.g., the surgeon, in order to obtain accurate information and be able to ask questions (Dixon et al., 2015 ; Haapala et al., 2013 ; Hestdal & Skorpen, 2020 . Such a relationship promotes communication (Dixon et al., 2015 ), as the attitude and empathy of the staff are important for patients (Hommel et al., 2012 ). One way of promoting communication between the patient and the staff is continuity of care, which might improve knowledgeterm·dom and facilitate participationterm·dom (Barthelsson et al., 2003 ; GustafssonpersName et al., 2010 ; Renholm et al., 2014 ). In contrast, if a patient feels like the nurses are not listening to their specific needs, the feeling of security decreases (Costa, 2001 ), and patients may feel neglected (LarssonpersName et al., 2022 ).

Consequencesterm·mth Consequencesterm·mth are the outcomes of the concept (Walker & Avant, 2011 ). The literature establishes the consequencesterm·mth of the concept of feeling safeterm·dom in a perioperativeterm·key context as Feeling Acknowledgedterm·dom and Trust. Feeling acknowledgedterm·dom involves patients’ desire to be seen as a person, not just a patient (Kaptain et al., 2019 ). By having a nurse anaesthetist close by and by being able to participate in their own care, patients feel safe and thus feel seen and acknowledged (Bergman et al., 2012 ; Hestdal & Skorpen, 2020 ; LarssonpersName et al., 2022 ). Nurse anesthetists play an important role in making patients feel acknowledged, as they are the person closest to the patient; however, if the patient feel like the nurse anaesthetist is distant, this causes feelings of not being acknowledged in patients (Karlsson et al., 2012 ), and patients might feel forgotten (Kaptain et al., 2019 ).

If the staff are perceived as competent and experienced and if patients are able to participate, the patient feels safe (Davis et al., 2013 ; Heine et al., 2004 ; Lindwall et al., 2003 ) and can trust the staff when they take over the responsibility of the patient’s body (EngströmpersName et al., 2017 ). If patients feel like they are in safe hands, their feelings of trust increase (GustafssonpersName et al., 2010 ). Furthermore, if patients feel that the staff are competent and experienced and in controlterm·dom, and if they are provided with enough information, patients’ confidence levels increase, which helps them deal with any postoperative complications that might occur (Heine et al., 2011). By participating and by feeling supported, and by feeling in controlterm·dom, patients may have help in coping, which may facilitate their recovery and their regaining of independence (Karlsson et al., 2012 ; Lingehall et al., 2015 ; Mako et al., 2016 ; Turesson et al., 2019 ).

Empirical referentsterm·mth The final step in the concept analysisterm·key process of Walker and Avant ( 2011 ) is to determine the empirical referentsterm·mth. Empirical referentsterm·mth are a way of recognizing or measuring the defining attributes of a concept, thereby determining its existence. Thus, the empirical referentsterm·mth for feeling safeterm·dom should comprise indicators that measure the previously-established defining attributes of feeling safeterm·dom. As described by Mollon ( 2014 ), the validation of a patient’s perception of feeling safeterm·dom may be difficult, due to the fact that feelings are subjective and that perceptions may change. One instrument measuring the perceived feeling of safety in patients undergoing surgery with regional anaesthesia is available (LarssonpersName et al., 2021 ). The items in its questionnaire were identified from the results from a systematic review (Wassenaar et al., 2014 ) that found the themes nursing care, patients’ issues, relatives, and technological support were most important for patients’ perception of feeling safeterm·dom in an intensive care unit, with the most important factor being nursing care. Even though these themes differ from the attributes in this analysis, similarities can be seen; for instance, the importance of a personal approach, information, being in controlterm·dom and included, as well as the presenceterm·dom of nurses, corresponds to the attributes of this analysis. Thus, this instrument may be used as one way to evaluate the perception of feeling safeterm·dom perioperatively.

Person-centred perioperativeterm·key care leads to feelings of being respected as a unique person, with one’s needs taken into consideration; thus patients feel involved (Arakelian et al., 2016 ). One way of measuring patients’ perceptions of person-centred careterm·dom has been proposed by Fridberg et al. ( 2020 ), who developed and evaluated an instrument measuring patients’ perceptions of person-centred careterm·dom. Evaluating person-centred careterm·dom may be another way to evaluate patients’ perceptions of feeling safeterm·dom.

Discussion This concept analysisterm·key examines the concept of feeling safeterm·dom from the patient perspective in a perioperativeterm·key setting and contributes to the development of the concept of feeling safeterm·dom ( Figure 2 ). The concept of feeling safeterm·dom is an important part of patient safetyterm·dom work that, as stated by the World Health Organization ( n.d. ), should be a priority in health care. Figure 2. Antecedentsterm·mth, attributes, and consequencesterm·mth of feeling safeterm·dom in a perioperativeterm·key setting.

This is one of the first studies that explores the concept of feeling safeterm·dom in this particular (i.e., perioperativeterm·key) context. Nevertheless, previous studies have been conducted to explore the concept of feeling safeterm·dom in healthcare contexts. For instance, Mollon ( 2014 ) defined the concept for hospitalized patients. Furthermore, other studies have been conducted with the aim of exploring which factors may contribute to patients’ perceptions of feeling safeterm·dom as well as patients’ experiences of feeling safeterm·dom. Lasiter ( 2011 ) and Wassenaar et al. ( 2014 ) studied feeling safeterm·dom in an intensive care context. Lasiter and Duffy ( 2013 ) studied perceived feelings of safety for older patients in both rural and urban acute care. Kenward et al. ( 2017 ) explored the factors that contribute to patients’ feelings of unsafety in healthcare settings.

In this study, the attributes of feeling safeterm·dom are established as Participationterm·dom, Controlterm·dom, and Presenceterm·dom. Péculo-Carrasco et al. ( 2020 ) conclude that person-centred careterm·dom, together with information and communication, have the most impact on the perceived feeling of safety during prehospital emergency care. In line with this study’s result, the important aspects of person-centred careterm·dom and feeling safeterm·dom include the presenceterm·dom of healthcare staff and being treated “humanely” (Péculo-Carrasco et al., 2020 , p. 4725). For patients treated at a psychiatric inpatient clinic, the perceived feeling of safety is influenced by a predictable, supportive environment with staff who are communicative and who take time to talk to the patients (Pelto-Piri et al., 2019 ). Despite its different context, this study is in line with the attributes identified in our study. As suggested above, one way of measuring patients’ perceptions of feeling safeterm·dom is evaluating person-centred careterm·dom in certain contexts. With person-centred careterm·dom, the importance of knowing the person behind the patient is highlighted (Ekman et al., 2011 ). The relationship between the caregiver and the patient considers their narrative and their thoughts, values, and preferences, which is a crucial component of person-centred practice (Ekman et al., 2011 ). Thus, person-centred careterm·dom could make patients feel a greater sense of participationterm·dom, controlterm·dom and presenceterm·dom, that is, feeling safeterm·dom in a perioperativeterm·key context. By defining antecedentsterm·mth, attributes, and consequencesterm·mth of feeling safeterm·dom, the development of pre-existing theories and models in traditional patient safetyterm·dom work through the incorporation of patients’ perspectives is made possible. This could broaden the traditional view on patient safetyterm·dom and thus promote patient safetyterm·dom work.

Person-centred careterm·dom practice may be linked to the “little ethics”, termed by the French philosopher Paul Ricoeur (Ekman, 2022 ). In short, Ricoeur’s “little ethics” (Ricoeur, 2011 ) is defined as: “aiming for the good life, with and for others in just institutions” (Ricoeur, 2011 , p. 68). Ekman ( 2022 ) created an adapted definition to fit it to a healthcare context; this adaptation states: “Aiming for health and wellbeing with and for patients, relatives and staff in just institutions” (Ekman, 2022 , p. 2). In a perioperativeterm·key context, there sometimes is an opinion that due to the efficient, highly technological environment, person-centred careterm·dom is hard to incorporate (Nilsson, 2019 ). Nevertheless, patients’ perceptions of feeling safeterm·dom may increase with person-centred careterm·dom (Ekman et al., 2020 ). Nurses in the perioperativeterm·key setting have the important task of being present, both emotionally and physically, to promote the perception of person-centred careterm·dom (Arakelian et al., 2016 ). This concept analysisterm·key concludes that patients undergoing surgery feel safe when they feel that they participate in their care, that they are in controlterm·dom, and that both healthcare staff and relatives are present. This may be linked to the definition of person-centred careterm·dom: “health and well-being with and for patients, relatives and staff” (Ekman, 2022 , p. 2, emphasis added). Thus, person-centred careterm·dom could increase patients’ sense of safety.

Strengths and limitations A limitation of this study is that it lacks a systematic assessment of the quality of the included publications. However, because the goal of this paper’s examination of the literature was to investigate how the concept was used—and not to present evidence of feeling safeterm·dom in a perioperativeterm·key context—a critical assessment of the quality of the included studies was deemed unnecessary.

The inclusion criteria in this analysis may have resulted in bias, as the analysis included only peer-reviewed literature that was written in English; therefore, relevant articles might have been missed. Furthermore, there is a risk that alternate terms for “feeling safeterm·dom” other than those included in this search might have led to the exclusion of potentially relevant articles. However, in order to minimize the risk of this bias, potential keywords for “feeling safeterm·dom” were identified before the systematic literature search.

Conclusion Promoting patients’ sense of safety in a perioperativeterm·key setting is an important part of nursing. This concept analysisterm·key has identified the defining attributes of the concept in this specific context. By defining the concept of feeling safeterm·dom in a perioperativeterm·key setting, this study provides an opportunity to develop already-existing theories and models. This concept analysisterm·key underscores the importance of including patients’ perceptions in traditional patient safetyterm·dom work. Person-centred careterm·dom could be one possible way of evaluating patients’ perceptions of feeling safeterm·dom, as well as increasing the perceptions of feeling safeterm·dom of people who undergo surgery. Patients who feel safe perceive that they participate in their care, that they are in controlterm·dom, and that they feel the presenceterm·dom of both healthcare staff and relatives. The perceived feeling of security could, by extension, promote the postoperative recovery of patients undergoing surgery.