Development and Delphi Validation of a Comprehensive High Reliability Program to Improve Nursing Work Environment and Patient Safety

BACKGROUND: Patient safety remains a critical global healthcare priority, with the nursing work environment recognized as a key determinant of safety outcomes. While existing studies have established associations between work environment factors and patient safety, there is a lack of structured, evidence-based interventions that translate these findings into practical frameworks. This study aimed to develop and validate a comprehensive High Reliability Program (HRP) designed to improve the nursing work environment and enhance patient safety. METHODS: A methodological study design employing a modified Delphi technique was used. The HRP was developed based on empirical literature and theoretical frameworks, including the Job Demands-Resources model and Systems Theory. The program comprised five core domains: orientation, guidance and mentorship, continuous support, feedback and evaluation, and integration into the work environment. A purposive sample of 10 experts in nursing, patient safety, and healthcare management participated in three Delphi rounds. Content validity was assessed using the Content Validity Index (CVI) and Content Validity Ratio (CVR), with a predefined threshold of ≥0.80. RESULTS: The Delphi process achieved a 100% response rate across all rounds. Initial feedback led to the refinement of program components to enhance clarity, feasibility, and clinical applicability. Progressive agreement was observed across rounds, culminating in full consensus by the third round. All items achieved maximum validity scores (CVI = 1.00; CVR = 1.00), indicating unanimous agreement on their relevance and essentiality. The final HRP was structured as a comprehensive, modular intervention addressing key determinants of the nursing work environment, including communication, leadership, training, and organizational support. CONCLUSIONS: The study successfully developed and validated a comprehensive HRP with excellent content validity. The HRP provides a structured, evidence-based framework for improving the nursing work environment and strengthening patient safety culture. Its modular and adaptable design supports implementation across diverse healthcare settings, particularly in resource-constrained environments. Future research should evaluate the effectiveness of the HRP through implementation studies and outcome-based assessments.