The Journal of Continuing Education in Nursing

Original Article 

New Graduate Nurses' Perceptions of Patient Safety: Describing and Comparing Responses With Experienced Nurses

Thompson H. Forbes III, PhD, RN; Elaine S. Scott, PhD, RN, FNAP; Melvin Swanson, PhD

Abstract

Background:

A significant proportion of the acute health system workforce is composed of new graduate nurses, yet there is a limited understanding of patient safety perceptions among new graduate nurses and how they compare with nurses who have more experience.

Method:

This study used a descriptive approach to complete secondary analysis on two sources of data containing new graduate nurses' (n = 1,613) and experienced nurses' (n = 64,906) responses to the Hospital Survey on Patient Safety Culture.

Results:

New graduate nurses had a more positive perception of safety culture than more experienced nurses. The greatest differences were observed in perceptions of how nurse managers respond to mistakes. Similarities in perceptions were observed on items associated with communication.

Conclusion:

Educational systems and transitional programs must prepare new graduate nurses for patient care. There is an opportunity for academic and practice partners to collaborate on programs that facilitate the transition of new graduate nurses to the workforce. [J Contin Educ Nurs. 2020;51(7):309–315.]

Abstract

Background:

A significant proportion of the acute health system workforce is composed of new graduate nurses, yet there is a limited understanding of patient safety perceptions among new graduate nurses and how they compare with nurses who have more experience.

Method:

This study used a descriptive approach to complete secondary analysis on two sources of data containing new graduate nurses' (n = 1,613) and experienced nurses' (n = 64,906) responses to the Hospital Survey on Patient Safety Culture.

Results:

New graduate nurses had a more positive perception of safety culture than more experienced nurses. The greatest differences were observed in perceptions of how nurse managers respond to mistakes. Similarities in perceptions were observed on items associated with communication.

Conclusion:

Educational systems and transitional programs must prepare new graduate nurses for patient care. There is an opportunity for academic and practice partners to collaborate on programs that facilitate the transition of new graduate nurses to the workforce. [J Contin Educ Nurs. 2020;51(7):309–315.]

There is a link between the safety culture within an organization and its ability to provide effective care to patients. Nurses, as the largest employed profession in hospitals (U.S. Bureau of Labor Statistics, 2018) and those who have the closest contact with patients, are foundational for improving patient safety culture and the quality of care in hospitals (Wei et al., 2018). Patient safety culture is defined as the shared beliefs, values, and norms that influence health care provider action and behaviors that promote safe patient care (Sorra et al., 2016). Poor perceptions of safety culture among nurses is associated with negative patient outcomes, including increased patient mortality (Olds et al., 2017), increased surgical site infections (Fan et al., 2016), and less positive perceptions of the work environment (Kirwan et al., 2013).

Between 2014 and 2030, more than two million new nurses will enter the workforce (U.S. Department of Health and Human Services, 2017). Health systems have implemented transition programs to facilitate acclimation to professional life and promote safe practice when bringing new graduate nurses (NGNs) into the organization (Tyndall et al., 2018). A recent review of the NGN literature indicated that NGNs had a limited understanding of patient safety (Murray et al., 2018). In a separate review, only two research studies linked increased safety behaviors with transition programs (Tyndall et al., 2018). Furthermore, there is an absence of literature that provides any understanding of NGNs' knowledge (Murray et al., 2018) or perception of safety culture during their first 12 months of practice. Without a proper understanding of NGNs' perception of safety culture, it is difficult to develop strategies that assist NGNs with developing behaviors that contribute to a positive patient safety culture and the delivery of safe patient care.

Transitional experiences of NGNs may influence perceptions of safety culture. In one study, the Hospital Survey on Patient Safety Culture (HSOPSC) was adapted for use with nursing students. Initial results found variation in the perceptions of nursing students and those commonly expressed by more experienced nurses working in a health care setting (Ortiz de Elguea et al., 2019). NGNs' perceptions of safety culture also may differ from more experienced nurses whose views may be blinded by existing norms within the hospital environment. Understanding NGNs' perceptions of safety culture may inform health care organizations and educational initiatives. Therefore, the purpose of this study was to understand NGNs' perceptions of patient safety as reported on the HSOPSC. Two main research questions guided this study: 1) How do NGNs rate the safety culture in their organization? and 2) How do NGNs' perceptions of safety culture compare with nurses with more than 1 year of experience?

Method

A secondary analysis of two deidentified data sources was used to explore NGNs' perceptions of patient safety and compare their perceptions with those of more experienced nurses. Expedited ethics board approval was obtained from the researchers' Institutional Review Board.

Data Sources

New Graduate Nurses. Data to understand NGNs' perceptions of patient safety were obtained from the Versant Center for the Advancement of Nursing (VCAN). Use of assessment and evaluation data was approved by VCAN as part of a grant awarded to one of the authors (E.S.S.). The Versant New Graduate Nurse Residency™ program provides hospitals with an education and training program designed to facilitate NGNs' transition into the work-place (Versant, 2019). As part of the program, various assessments and evaluations are used, one of which is the HSOPSC. Data used for this study were from the 2016 cohort of NGNs. This study used only those variables reported on the HSOPSC at 12 and 24 months.

Experienced Nurses. HSOPSC data for experienced nurses were obtained from the U.S. Agency for Healthcare Research and Quality's (AHRQ) established comparative database. Approval for use of the data was granted by AHRQ according to Westat's data release agreement. This study included responses from 680 hospitals submitted in 2016. Data were deidentified from participant and hospital identifiers prior to transfer of the data files to the research team. Data did not include individual demographics.

Survey on Patient Safety

The HSOPSC was developed for the AHRQ to allow providers and other staff to assess patient safety culture in their hospitals (AHRQ, 2019). The survey contains 42 items grouped into 12 composites. Items and composites are based on a 2004 review of the literature on safety management and current published and unpublished climate and culture surveys (Nieva & Sorra, 2003). There are an additional two items to assess the overall grade of patient safety in staff's work area and indicate the number of events an individual reported during the past 12 months (Sorra et al., 2016). With the exception of the Staffing dimension, the HSOPSC has been reported to have acceptable psychometric properties (Sorra & Dyer, 2010). The Staffing dimension's reliability (alpha = .62) falls below the acceptability for reliability (coefficient alpha ≥ .70) but has remained part of the HSOPSC due to its conceptual importance on patient safety (Sorra & Dyer, 2010).

Analysis

HSOPSC response data from the Versant and national sample were analyzed using SPSS® version 24 statistical software. Response frequencies were run on the data to look for outlier values, missing data, or other anomalies. Experienced nurses were identified by filtering the AHRQ data set by those nurses who reported they had worked in their current hospital (item H1), current work area or unit (item H2), and current specialty or profession (item H6) for longer than 1 year. Those who indicated they did not provide direct patient care (item H5) were excluded from the study sample. Only nurses who identified as working in the emergency department, surgery, medicine, or intensive care units were used as they represent nurses who care for adult patients in hospitals. Negative worded items were reverse coded so that higher scores indicated a positive response. Individual items and composites were recoded to a binary response that indicated a positive (i.e., “strongly agree” and “agree”) or negative response.

Descriptive statistics were used to summarize responses to the HSOPSC composite scores. Means, standard deviations, and percent positive responses were computed for all items and composites. Independent samples t tests were conducted to compare NGNs' perceptions of patient safety. When sample sizes are particularly large, as in this study, p values may demonstrate a significant difference, but the difference may be small and meaningless in relation to the research question (Sullivan & Feinn, 2012). Therefore, effect size (Cohen's d) was used to estimate the strength of the difference in average positive response to each dimension for NGNs and experienced nurses.

Results

Table 1 shows the characteristics of the NGNs (N = 1,613) included in this study. The majority of the participants were female (83.2%) and ranged in age from 19 to 25 years (44.3%) with a baccalaureate degree in nursing (61.8%). The proportion of NGNs identifying medicine and intensive care units as their primary work areas was similar, 33.2% and 30.1%, respectively. Fewer characteristics of the nationwide sample were available due to the limited variables included in the data (Table 2). The majority of experienced nurses (N = 64,906) reported working in their current hospital and work area/unit from 1 to 5 years, 35.9% and 45.9%, respectively. Similar proportions of experienced nurses reported working in their current profession for 1 to 5 (28.6%), 6 to 10 (22.2%), and greater than 20 years (24.4%). The primary work area reported was similar among medicine (29.9%), intensive care (26.1%), and surgery units (28.9%).

Characteristics of New Graduate Nurses (N = 1,613)

Table 1:

Characteristics of New Graduate Nurses (N = 1,613)

Characteristics of Experienced Nurses (N = 64,906)

Table 2:

Characteristics of Experienced Nurses (N = 64,906)

NGN Positive Responses by Work Area

Table 3 compares NGNs' positive responses to the dimensions and patient safety grade on the HSOPSC survey by work area. NGNs in the intensive care unit consistently reported higher perceptions of patient safety and patient safety grade with only nonpunitive response to errors (62%) being lower than other work areas. Alternatively, NGNs in surgery units had more negative perceptions of patient safety than the other work areas, with seven of 12 dimensions being lower. Although differences existed, they were minimal. The largest single dimension difference was between emergency department (51%) and intensive care unit (63%) nurses' perceptions of teamwork across units.

Average Positive Responses among New Graduate Nurses at 12 Months by Work Area

Table 3:

Average Positive Responses among New Graduate Nurses at 12 Months by Work Area

NGN Versus Experienced Nurse Positive Responses

We also examined whether NGN perceptions of patient safety were different from or similar to nurses with more experience. Table 4 compares average positive response to HSOPSC dimensions between NGNs and nurses with more than 12 months of experience. Cohen's d was calculated for each dimension to determine the effect size of the difference between each group's positive responses. Effects were small to moderate for most of the dimensions. Very small effects, and essentially no differences, were observed in feedback and communication about error, communication openness, and frequency of events reported. Of these, NGNs had less positive perceptions of feedback and communication about error and frequency of events reported compared with experienced nurses, but the differences had small effect sizes (.05 and .06, respectively). The dimensions with the greatest effect sizes existed between organizational learning (18% difference, Cohen's d = 0.61), overall perceptions of patient safety (20% difference, Cohen's d = 0.63), staffing (16% difference, Cohen's d = 0.52), and nonpunitive response to errors (21% difference, Cohen's d = 0.53).

Comparison of Average Positive Responses for New Graduate Nurses at 12 Months with Experienced Nurses

Table 4:

Comparison of Average Positive Responses for New Graduate Nurses at 12 Months with Experienced Nurses

Changes in Perceptions Over Time

We also evaluated whether perceptions of patient safety in NGNs changed over the first year (Table 5) since it was apparent many differences existed at 12 months. Although almost all of the responses decreased from 12 months to 24 months, the effect size of the difference was small for each dimension. The greatest change took place in management support for patient safety, changing from 70% positive at 12 months to 65% positive at 24 months (Cohen's d = 0.14).

Comparison of Average Positive Responses among New Graduate Nurses at 12 Months and New Graduate Nurses at 24 Months

Table 5:

Comparison of Average Positive Responses among New Graduate Nurses at 12 Months and New Graduate Nurses at 24 Months

Discussion

Overall, NGNs have a more positive perception of safety culture than more experienced nurses. This study found NGNs' perceptions of patient safety varied little by work area, with the most variation occurring in those working in medicine and surgery units. This finding is different from other studies that have found emergency departments tend to have a more negative perception of patient safety than other units (Singer et al., 2009). In this study, NGNs in the emergency department had one of the more positive views of patient safety, except for their perception of teamwork across units.

Substantial differences were found in how NGNs perceive the safety culture in their organization compared with more experienced nurses. Organizational learning and nonpunitive response to errors exhibited the greatest difference. It is important to note that the definitions of both dimensions include aspects of how organizations and nurse leaders respond to mistakes (Sorra et al., 2016). The significant differences in overall perceptions of patient safety and staffing highlight the unique perspective NGNs may have of their organization early in their career. This may be due to limited exposure to organizational culture and increased time spent with a preceptor who protects the NGN from experiencing the reality of patient safety. Furthermore, significant differences in NGNs' perspective of patient safety culture may be attributed to the varied personal and educational experiences prior to employment that shape their image of what work will be like after graduation form their nursing program (Scott et al., 2008).

Although major differences in perceptions existed between NGNs and those with more experience, two dimensions associated with communication, feedback and communication about error and communication openness, varied minimally. The similarity between experienced nurses' and NGNs' perceptions enhances the importance of communication on patient safety (Makary & Daniel, 2016). This suggests that perceptions of communication regarding patient safety are developed early during a career. NGNs may be more sensitive to communication and its effect on patient safety as they transition from the structure of academic training to the complexity of the health care environment. The sensitivity of communication on patient safety perceptions highlights the importance for health care organizations to continue to focus improvement efforts and academic programs to provide real-life experiences for students.

Variation in perceptions of patient safety among NGNs and experienced nurses has important implications for health care organizations. A more positive response on HSOPSC dimensions could misdirect organizational efforts designed to improve patient safety away from NGNs when programs only focus on subgroups with more negative perceptions. This difference makes one-size-fits-all approaches to improving patient safety not applicable to a substantial and impressionable group within the workforce. Designing transition to practice programs that are specific to NGNs is essential for an inclusive program to improve patient safety. Transition programs should include active discussion about how mistakes in health care can lead to positive change and contribute to the development of a learning health system.

The findings from this study highlight some unique educational needs of NGNs and nursing students. Clinical rotations prior to graduation and transition to practice experiences in a first job often focus on assessment of clinical presentation and the technical aspects of nursing tasks. Although both are a foundational part of training and transitioning new nurses to the practice environment, the need for patient safety and quality competencies also should be included (VanGraafeiland et al., 2019). Moving from a passive understanding of patient safety and quality concepts to the actual incorporation of this knowledge into practice is a critical shift for new nurses. Health systems are fertile areas of practice for NGNs to have educational opportunities to apply patient safety and quality competencies. Education leaders in academia and industry should collaborate to create innovative debriefing models and simulations for new graduate nurses to discuss and learn from the clinical environment about the application of patient safety and quality in their own practice.

It is unclear how rapidly positive perceptions of patient safety begin to deteriorate among nurses. This study showed that perceptions tend to remain the same through the first 24 months of practice. More research is needed to understand how perceptions change over time. With a large gap in perceptions of patient safety among NGNs, more research is needed to understand how this varied perception may contribute to turbulent transitions to practice and therefore burnout and turnover.

Limitations

A limitation of this study is the process by which we isolated experienced nurses in the nationwide data set. Although we removed any participant from the data set who reported less than 1 year of experience on three items, there may still be nurses who are similar in experience to NGNs. This study is also a secondary analysis of two large data sets. Secondary data analysis is limited to the data and variables previously collected. For example, this limited our ability to describe the participants in the AHRQ data set. We also were unable to determine the effect the VCAN transitional program had on perceptions of patient safety. Although all NGNs participated in a structured orientation to their hospital, it is unknown how many experienced nurses participated in similar programs.

Conclusion

This study supports the importance of educational systems and transitional programs in preparing NGNs for the real world of patient care and the safety environment. This dissonance between NGNs and experienced nurses' perceptions of patient safety supports the potential for a traumatic transition between academic life and professional life (Kramer, 1974). Although residency programs have been broadly implemented in health care to facilitate this transition to practice (Tyndall et al., 2018), there remains an opportunity for academic and practice partners to work together to project an accurate picture of patient safety and professional work. Without efforts directed toward preparation and transition, the potential for a discrepancy in what NGNs expect of health care systems and the professional reality will continue to exist.

References

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Characteristics of New Graduate Nurses (N = 1,613)

Variablena%b
Gender (n = 1,603)
  Female1,33383
  Male27017
Age, y (n = 1,586)
  19 to 2570244
  26 to 3042227
  31 to 3521313
  36 to 401268
  ≥ 411238
Basic nursing education (n = 1,612)
  Diploma5<1
  Associate59437
  Baccalaureate99762
  Master's161
Race (n = 1,569)
  White1,23078
  Asian1328
  Multiracial1188
  Black/African American755
  American Indian/Alaska Native14<1
Primary work area (n = 1,613)
  Medicine53533
  Intensive care48530
  Emergency department31520
  Surgery27817

Characteristics of Experienced Nurses (N = 64,906)

Variablen%a
Worked in current hospital, y
  1 to 523,31836
  6 to 1016,70126
  11 to 159,76415
  16 to 205,3558
  ≥ 219,76815
Worked in current unit, y
  1 to 529,80646
  6 to 1016,91926
  11 to 158,75114
  16 to 204,1706
  ≥ 215,2608
Worked in current specialty/profession, y
  1 to 518,54829
  6 to 1014,38922
  11 to 158,82514
  16 to 207,29811
  ≥ 2115,84624
Primary work area
  Medicine19,40230
  Intensive care16,96526
  Emergency department9,81215
  Surgery18,72729

Average Positive Responses among New Graduate Nurses at 12 Months by Work Area

Dimension/Patient Safety GradeMedicineSurgeryEDICU




n% Positiven% Positiven% Positiven% Positive
Teamwork within units53593278903159348595
Supervisor/manager expectations53187275823128447985
Organizational learning53589278883158948589
Management support for patient safety53471278693156948470
Overall perceptions of patient safety53575278753147548579
Feedback and communication about error53161277593126048363
Communication openness53159277613126348365
Frequency of events reported53062276553125847962
Teamwork across units53460278613155148463
Staffing53561278663156448570
Handoffs and transitions53447278493155448454
Nonpunitive response to errors53562278663156348562
Patient safety grade52873276753057647982

Comparison of Average Positive Responses for New Graduate Nurses at 12 Months with Experienced Nurses

Dimension/Patient Safety GradeNew Graduate NursesExperienced NursesAbsolute DifferenceCohen's d


n% Positiven% Positive
Teamwork within units1,6139364,6628113*0.48
Supervisor/manager expectations1,5978561,6837312*0.41
Organizational learning1,6138964,6347118*0.61
Management support for patient safety1,6117063,8456010*0.26
Overall perceptions of patient safety1,6127664,6125620*0.63
Feedback and communication about error1,6036161,47263−2**0.05
Communication openness1,6036261,467593*0.07
Frequency of events reported1,5976062,52563−3**0.06
Teamwork across units1,6115963,891536*0.16
Staffing1,6136564,6564916*0.52
Handoffs and transitions1,6115163,776456*0.14
Nonpunitive response to errors1,6136364,5754221*0.53
Patient safety grade1,5887660,3836412*0.26

Comparison of Average Positive Responses among New Graduate Nurses at 12 Months and New Graduate Nurses at 24 Months

Dimension/Patient Safety GradeNew Graduate Nurses 12 MonthsNew Graduate Nurses 24 MonthsCohen's d


n% Positiven% Positive
Teamwork within units1,61393456910.09
Supervisor/manager expectations1,59785452820.12
Organizational learning1,61389456870.10
Management support for patient safety1,61170456650.14
Overall perceptions of patient safety1,61276456720.13
Feedback and communication about error1,60361452570.10
Communication openness1,6036245262<0.01
Frequency of events reported1,59760452600.01
Teamwork across units1,61159456600.01
Staffing1,61365456630.05
Handoffs and transitions1,61151456470.10
Nonpunitive response to errors1,6136345663<0.01
Patient safety grade1,58876451720.09
Authors

Dr. Forbes is Assistant Professor and Dr. Scott is Professor and Chair, Department of Nursing Science, and Dr. Swanson is Professor and Statistician, College of Nursing, East Carolina University, Greenville, North Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The SOPS® data used in this analysis were provided by the SOPS Database. The SOPS Database is funded by the U.S. Agency for Healthcare Research and Quality (AHRQ) and administered by Westat under Contract Number HHSP233201500026I/HHSP23337004T.

Address correspondence to Thompson H. Forbes III, PhD, RN, 2313 Wheaton Village Drive, Greenville, NC 27858; email: Forbest17@ecu.edu.

Received: August 23, 2019
Accepted: January 28, 2020

10.3928/00220124-20200611-06

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