Patient and family engagement in patient safety in resource-limited intensive care units: A qualitative exploratory study

BACKGROUND: Patient and family engagement (PFE) in the intensive care unit (ICU) enhances patient safety through detection and reporting of safety incidents that may be missed by healthcare professionals, providing an important and additional safeguard against harm. However, empirical evidence to inform policy and practice in resource-limited critical care settings remains scarce. OBJECTIVES: The aim of this study was to explore the perspectives and experiences of patients, families, and healthcare professionals on PFE in patient safety in Ethiopian ICUs. METHODS: A pragmatic, exploratory qualitative descriptive study was conducted using in-depth interviews guided by a semistructured interview protocol. Participants were purposively selected and included patients, families, and healthcare professionals. Participants were recruited from four ICUs, including both adult and paediatric/neonatal ICUs in a major university hospital in Eastern Ethiopia. Reflexive thematic analysis with inductive orientation guided by Braun and Clarke's six-phase approach was employed. Convergence and divergence of perspectives across participant groups were identified and reported. Criteria for rigour and trustworthiness including credibility, dependability, transferability, confirmability, and integrity guided the research process. The consolidated criteria for reporting qualitative research were followed to ensure the transparency and consistency of reporting. RESULTS: Fifty-nine in-depth interviews were conducted, including patients (5; 9%), families (15; 25%), and healthcare professionals (39; 66%). Three overarching themes were identified: First, contested safety roles reflected the competing views on engagement, which were endorsed rhetorically but constrained in practice due to structural and hierarchical power dynamics. Second, sociocultural logics of engagement underscored inequities between rural and urban patients/families shaped by sociocultural attributes and faith-based sense-making. Third, tensions inpatient safetyincident disclosure highlighted the discordance between the expectation of transparency and hesitancy to involve patients and families in incident disclosure due to fear of reprisals. CONCLUSION: PFE in patient safety in Ethiopian ICUs was endorsed in principle yet remained constrained by sociocultural contexts, hierarchical power dynamics, and limited institutional support mechanisms. Clearly defining patient safety roles, implementing family-activated escalation pathways, and strengthening formal patient safety incident reporting and disclosure systems are essential to promote inclusive, equitable, and sustainable PFE in patient safety across Ethiopian ICUs and beyond.