Nursing students’ knowledge of patient safety and development of competences over their academic years: Findings from a longitudinal study

There is an increasingly recognized need to prepare future healthcare professionals for Patient Safety (PS) (1), and different policies have been developed internationally establishing that PS should be included as a major area of nursing education (e.g., 2, 3). As a consequence, in recent years healthcare faculties have reviewed their programs by introducing theoretical and clinical educational interventions aimed at increasing PS awareness, knowledge, and competences among students (1, 4). These interventions aim at ensuring that graduated healthcare professionals are capable of performing at the entry level according to PS principles. Behind these efforts, specific tools capable of assessing PS knowledge and competences acquired both for educational and research purposes have been developed and validated (5, 6). However, no data on PS programs introduced in the nursing curricula in recent years has been assessed from the students’ perspective (7), and to date no data with regard to the progression over time of their PS competences has been documented (8).

According to their professional role and closeness to patients, nurses need to be prepared to recognize, respond to, and disclose possible safety risks, protecting patients from close calls, adverse events and avoidable risks (9). The nurses’ adherence to PS principles has been reported to be influenced by their knowledge, attitudes and perceptions of safety issues (10). Therefore, nurse educators in both academic and practical settings are crucial in helping students acquire and implement evidenced-based safe practices during their clinical experiences (1, 5, 11). However, despite pioneer research in the nursing education field identifying this issue back in 1973 (12), little knowledge is still available on how students learn PS principles and the progression of such knowledge and competences over time (1).

Several cross-sectional studies have been performed reporting sensitivity, accountability, and awareness of PS principles among nursing students (e.g., 13, 9). However, only Lukewich and collegues (14) have measured the progression over time of the perceived PS knowledge and competence among a cohort of undergraduate nurses by adopting a repeated (annual basis) cross-sectional study design. Despite the novelty of this study, a paired analysis involving a cohort study design embracing the entire nursing program and offering a comprehensive perspective on trends regarding self-confidence on PS (14) is still lacking. Therefore, this study aims: (a) to explore PS knowledge and competences as perceived by nursing students, and their progression over time, from the 1st to the 3rd and final nursing program years; and (b) to explore how PS concepts are integrated and enacted in the nursing curriculum, as perceived by students.

A cohort of 90 students agreed to participate. Their average age at study enrolment was 22.2 years (SD=4.7). The majority were female (66; 73.3%). Only four students (1.1%) had previously obtained a degree (in economics and biology).

At the end of the 1st year, students reported an average 4.19 out of 5 of PS knowledge acquired in the classroom (CI 95%, 4.11–4.28), which was stable at the end of the 2nd year (4.16; CI 95%, 4.06–4.26) and 3rd year (4.26; CI 95%, 4.16–4.32). Both at the factor and item levels, no statistical differences emerged over the years (Table 2).

With regard to PS competence acquired during clinical rotations, at the end of the 1st year students reported an average 4.28 out of 5 (CI 95%, 4.20–4.37), which significantly decreased at the end of the 2nd year (4.15; CI 95%, 4.07–4.23; p=0.02) and increased at the end of the 3rd (average 4.37; CI 95%, 4.27–4.47; p<0.01). For what concerns each factor, only the perception of “Culture of safety” significantly decreased from the 1st (average 4.38; 95% CI, 4.28–4.47) to the 2nd years (4.06; 95% CI, 3.88– 4.25) and from the 2nd to the 3rd years, while all other factors showed significant increases, with the exception of “Working in a team”, which remained stable. From the 1st to the 3rd years only the “Managing safety risks’” factor significantly increased (from 4.18; 95% CI, 4.05–4.31 of the 1st year to 4.38; 95% CI, 4.26–4.51 of the 3rd year).

The overall perception of preparedness with regard to the PS knowledge and competences acquired in the classroom and in the clinical settings showed higher correlations at the end of the 1st year (r=0.639; p=0.01), as well as at the end of the 2nd (r=0.592; p=0.000) and 3rd years (r=0.429; p=0.01).

Moreover, at the end of the 1st year, students reported that PS concepts were well integrated in the overall curriculum (4.39 out of 5; 95% CI, 4.26–4.52) and PS clinical factors were largely covered in the program (4.37; 95% CI, 4.23–4.50) (Table 3). An improvement in the opportunities for PS learning was reported in the 2nd year (4.16; 95% CI, 4.02–4.30) compared to the 1st year (3.94; 95% CI, 3.78–4.11). Furthermore, from the 2nd to the 3rd years there was a significant increase reported in the clarity of the scope of the practice (p=0.007), in the consistency with which the PS issue was handled by different clinical supervisors (p=0.005), in the integrity of the PS concepts in the curriculum (p=0.021), and in how system aspects of PS were covered in all programs (p=0.002). All aspects increased significantly from the 1st to the 3rd years, with the exception of the items measuring the consistency across clinical supervisors with regard to PS issues and the understanding that reporting adverse events/close calls may improve quality of care.

The participating students’ profiles were in line with those enrolled in Italian nursing programs (22) and with the characteristics documented in previous studies in the PS research field (8, 9, 14, 22). We used the H-PEPSSIta, which is considered suitable to assess students’ perceptions of PS at different levels of their education (19), and has been shown to have excellent internal consistency.

The participants reported high scores in all H-PEPSSIta factors measuring PS knowledge acquired in the classroom. The factors “Communicating effectively” and “Culture of safety” achieved the highest scores at the end of the 1st year. At the end of the 2nd year, the scores remained high, but a slight decrease emerged in all factors with the exception of “Managing safety risks”. At the end of the 3rd year, the scores were higher in all factors as compared with those expressed at the end of the previous academic years, showing a slight increase in the PS knowledge the students possessed. This data suggests the PS course taken at the beginning of the nursing program may have affected the degree of knowledge perceived by students over the years, while the course offered in the 3rd year may have reinforced some theoretical principles with regard to PS (8). Therefore, while the nursing program seems to be unable of increasing students’ PS knowledge over the years, the combination of theoretical courses with clinical rotations may have hindered the inevitable decline in knowledge acquired in the classroom. This confirms that academic and clinical staff are both responsible for teaching PS within the undergraduate nursing curricula (23).

Different trends emerged with regard to the PS competence acquired during the clinical placements: while at the end of the 1st year, students reported perceiving high competences, a slight decrease at the end of the 2nd year emerged, although statistically significant only in the “Culture of safety” factor. In contrast, at the end of the 3rd year, the scores increased in all factors as compared to those reported in the 2nd year.

The complexity of some learning tasks (e.g., administering medications), the increased independence from clinical supervisors, and the variability of the nurses’ behaviour across units attended by students may have jeopardized the confidence in the competences acquired as perceived by the 2nd year students (8). On the one hand, the low complexity of clinical competences expected at the end of the 1st year may have generated overconfidence among students who reported higher scores; in contrast, 2nd year students might have a better understanding of the complexity of PS issues given that they are exposed to an increased complexity of clinical situations, and they are also more engaged with patient care, thus more aware of the difficulties that may be encountered in implementing the theoretical contents of the program in practice. At the end of the 3rd year students have developed more independence and confidence in patient care, including also patient safety skills. In contrast with our findings, Lukewich and collegues (14) and Usher and collegues (9), documented a decline in the “Working in team”, “Managing safety risks”, and “Recognizing and responding to adverse events” factors over the years: however, the cross-sectional study design adopted by these earlier studies suggests being caution is needed in comparing the findings.

Moderate correlations emerged in our study between PS knowledge and competences at the end of each academic year, and the strength of the correlations decreased over time. In accordance with Usher and colleagues (9), students increased their independence in clinical settings, and this allowed them to recognize possible gaps between their theoretical knowledge and the competences required in clinical practice, thus affecting their self-confidence with regard to PS issues.

Students reported positive feedback on how PS concepts were integrated and actualized in the nursing curriculum, and this increased over the years, reaching the highest scores at the end of the 3rd year. Lower scores from the 1st to the 3rd year were found with regard to how PS issues were dealt with by different clinical supervisors in the clinical settings. Previous studies (24, 25, 26) documented inconsistencies across settings that can affect the perception of curriculum integrity among students; this can also develop uncertainty among students that may arise for newly graduated nurses due to a lack of understanding of the complexity of PS in actual healthcare systems. According to these findings, nursing education on PS issues should be based on theoretical and clinical learning opportunities, including debriefing sessions, which are capable of stimulating learning through experience (26, 27, 28), thus helping students to critically appraise the knowledge acquired in classrooms. According to Tella and colleagues (1), different teaching methods are needed to more effectively integrate the concept of PS within nursing curricula, while the learning activities undertaken during the clinical rotations should improve self-learning skills with regard to PS and critical events in real practice (29).

Nursing students increase their PS competence over the years, while the related knowledge remains stable. Second year students seem to be more vulnerable as they perceive the lowest level of PS competence.

The findings suggest that PS issues should be continuously included as learning aims at both the theoretical and clinical levels, as well as in didactical strategies aimed at linking the learning processes promoted in the classroom with the practical settings. Faculties and healthcare institutions should work together in offering consistent messages and supporting clinical supervisors in understanding the relevance of their role in developing and modelling PS competences for their students.

Moreover, tailored policies at the national and international levels, aimed at harmonizing and supporting PS learning aims and teaching strategies undertaken in each nursing program, are recommended. Studies aimed at developing evidence on the most effective educational interventions capable of increasing PS knowledge and competence are also needed.