Journal of Nursing Education

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Major Articles 

Frameworks for Patient Safety in the Nursing Curriculum

Teri M. Chenot, EdD, RN; Larry G. Daniel, PhD

Abstract

Patient safety has recently received a great deal of media coverage. Professional and regulatory agencies have indicated that patient safety education should be provided to health care workers to improve health outcomes. This study’s primary purpose was to gain a better understanding of the current status of patient safety awareness among prelicensure nursing students. Data were collected from two samples (N = 150 and 318), and nursing curricula were examined from seven institutions. Measurement integrity studies indicated that patient safety awareness can be measured validly and reliably. Demographic variables were correlated with patient safety awareness. A content analysis found that all of the participating nursing schools included at least three of the six core competencies of the Quality and Safety Education for Nurses (QSEN) (Cronenwett et al., 2007) in their curriculum; one school exhibited all six. Our findings led to conclusions and recommendations for nurse educators and for future research on patient safety education in the nursing curriculum.

Abstract

Patient safety has recently received a great deal of media coverage. Professional and regulatory agencies have indicated that patient safety education should be provided to health care workers to improve health outcomes. This study’s primary purpose was to gain a better understanding of the current status of patient safety awareness among prelicensure nursing students. Data were collected from two samples (N = 150 and 318), and nursing curricula were examined from seven institutions. Measurement integrity studies indicated that patient safety awareness can be measured validly and reliably. Demographic variables were correlated with patient safety awareness. A content analysis found that all of the participating nursing schools included at least three of the six core competencies of the Quality and Safety Education for Nurses (QSEN) (Cronenwett et al., 2007) in their curriculum; one school exhibited all six. Our findings led to conclusions and recommendations for nurse educators and for future research on patient safety education in the nursing curriculum.

Dr. Chenot is Associate Professor, School of Nursing, Jacksonville University, and Dr. Daniel is Dean and Professor, College of Education and Human Services, University of North Florida, Jacksonville, Florida.

The authors have no financial or proprietary interest in the materials presented herein.

Presented in part as a poster presentation at the Quality and Safety Education for Nurses National Forum, Denver, Colorado, June 2010.

Address correspondence to Teri M. Chenot, EdD, RN, Associate Professor, School of Nursing, Jacksonville University, 2800 University Blvd. N., Jacksonville, FL 32211; e-mail: tchenot@ju.edu.

Received: December 23, 2009
Accepted: March 17, 2010
Posted Online: July 30, 2010

The increased media coverage of patient safety is partly due to two reports published by the Institute of Medicine [IOM] in 1999 (Kohn, Corrigan, & Donaldson, 1999) and 2001 (IOM, 2001). These reports discussed the number and types of medical errors that have occurred in medical institutions across the United States. The IOM (Kohn et al., 1999) report included a study that found that the number of Americans who die each year due to medical errors may be as high as 98,000, making medical errors the eighth leading cause of death. In fact, more people die in a given year as a result of medical errors than from motor vehicle accidents, breast cancer, or acquired immune deficiency syndrome (Barach & Berwick, 2003; Jacott & Jacott, 2003; Lovern, 2002; Pape, 2001; Woods, 2003). In addition, medication errors cause another 7,000 deaths.

The cost of medical errors to the health care system is astronomical. The IOM estimated that medical errors cost the United States approximately $38 billion per year, with approximately $17 billion of those costs associated with preventable errors (Kohn et al., 1999). Based on data collected over several years from multiple partner institutions, the Institute for Healthcare Improvement (2007) estimated that approximately 15 million incidents of medical harm occur in the United States each year—a rate of more than 40,000 incidents per day. Just from this information, it is evident that medical errors are a national public health problem that has resulted in substantial morbidity and mortality. The U.S. health care system must address this epidemic in the same manner that it targets diseases such as cancer, diabetes mellitus, and heart disease.

As health care organizations seek to enhance safety and quality in a changing environment, organizational learning can help improve existing awareness and skills and provide opportunities to discover better ways of working together. Health care has never been simple, but the complexity of health care has increased, along with increasing demands for greater value and expectations for predictable safety. The economic and ethical burden of preventable injury resulting from medical management failures is immense. Preventable injuries to patients are beginning to be understood in terms similar to adverse events in other complex, risky industries that have learned to rely on the language of systems and causal analysis to create a foundation for continuous quality improvement and high reliability.

Health care leadership is the focal point in the rapidly growing movement to improve patient safety, and the critical role of educational leadership in this movement is rapidly becoming recognized. Trustees and governing boards of health care organizations have important roles in ensuring the safety of the organizations by holding their leadership accountable for defining and meeting the goals of a safety plan. In so doing, patient outcomes will improve, which will result in an overall safer health system for the organization (Mohr, Abelson, & Barach, 2002). Concomitantly, educational leaders in health care should strive to develop curriculum frameworks that place appropriate emphasis on patient safety. It is important that health care educators communicate a safety vision to their students and a sense of personal responsibility for assuring that systematic planning for addressing errors is a priority in their future professional practice.

With all of the attention being paid in the health care industry and at all levels of government to the quality of health care, the delivery of health care to patients is still far from perfect. The need to address what are already highly visible quality and patient safety problems is becoming increasingly urgent. Many factors contribute to these problems. Among these are minimally applied safety engineering principles, such as systems thinking across health care settings, and cost-driven payer incentives that equally reward low-quality and high-quality care. However, just as health care professionals can be instrumental in the creation of medical successes, so too can they hinder them. There are serious concerns about current health care education approaches to quality and patient safety and the environments in which education and training are conducted. These concerns extend to the ongoing education (life-long learning) of practitioners and emerging health care leaders. Thus far, more studies regarding patient safety education for physicians have been conducted. The current study examined the preservice preparation of registered nurses in patient safety awareness, skills, and attitudes.

Literature Review

Research has indicated that registered nurses and chief nursing officers believe that the shortage of nurses has negatively affected the quality and safety of patient care (Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2006). However, hospitals and other health care delivery organizations are experiencing increasing pressure to provide high-quality and safer patient care, regardless of whether there are shortages of nurses. An emerging body of research shows that nurses are more likely than any other health care professional to recognize, interrupt, and correct errors that are often life threatening (Rothschild, Hurley, Landrigan, & Cronin, 2006).

Little evidence shows that undergraduate or postgraduate programs provide students with the skills necessary to examine patient safety issues as an integral part of their practice. These issues need to be addressed across the spectrum of educational curricula designed to prepare health care students for their future practice. Although more research is required in this respect, the clear evidence of medical errors facing patients suggests that professionals are insufficiently prepared to control risks (Wakefield et al., 2005).

VanGeest and Cummins (2003) conducted an educational needs assessment among physicians and nurses and found that teaching health care professionals new skills can be done with a systematic approach and a comprehensive curriculum but that other actions are clearly required, including changes in organizational culture, the need for health care leaders to publicly demonstrate their commitment to reducing medical errors, and promotion of learning and application opportunities on patient safety for physicians and nurses by organizations. Currently, more literature is available on patient safety curriculum in medical students’ programs than for nursing students’ programs.

For example, one medical student program has successfully implemented a comprehensive and multidisciplinary safety curriculum to address the U.S. Accreditation Council for Graduate Medical Education’s (ACGME) core competencies and to establish a culture of safety for sustainable improvement in health care through integration of safety into the students’ daily activities (Singh et al., 2005). A needs assessment consisting of a 15-minute quiz assessing students’ knowledge and prior exposure to patient safety issues indicated that few had received any formal safety training and all had a poor knowledge base. The patient safety objectives that the program addressed through the ACGME competencies are patient care, medical knowledge, practice-based learning, communication skills, professionalism and ethics, and system-based practice (Singh et al., 2005).

Patient safety contains many new concepts and introduces learners to new ways of thinking about themselves, their colleagues, and their practices. Active learning plays an important role by forcing learners to research topics in more detail and apply them to real-life situations (authentic tasks). The medical student program emphasizes active learning and experiential activities to reinforce safety principles taught, including journals, case presentations, use of palm-base drug formulary software, chart audits, a staff survey, response to video clips, simulated charts, and standardized patient interviews, with the goal of assisting the students to internalize patient safety practice (Singh et al., 2005).Madigosky, Headrick, Nelson, Cox, and Anderson (2006) studied the effects of a patient safety and medical fallibility curriculum on second-year medical students. The students completed a knowledge, skills, and attitudes questionnaire before the curriculum, after the final learning experience, and 1 year later. The curriculum led to changes in the medical students’ knowledge, skills, and attitudes, but not all of the changes were sustained at 1 year, were in the desired direction, or were supported by their self-directed behaviors.

A great deal of effort has been put into individual health care disciplines to improve the quality and effectiveness of academic and training environments. However, a major upgrade of the education and training of health care professionals to address health outcomes requires efforts among key health care stakeholders focused on core competencies across various education and training programs and work environments. In the report Health Professions Education: A Bridge to Quality (Greiner & Knebel, 2003), the IOM found that nurses and other health professionals are not adequately prepared to provide the highest quality and safest care possible. Embedded in the report are two significant reforms: a shift to a competency-based approach to education for all health care professionals and the core competencies identified as essential for health care professionals to respond to patients’ care.

The outcome-based education movement is not new. Broad outcomes have been incorporated into nursing accreditation processes for several years. However, the ideas underlying competency-based education, such as making learning outcomes explicit, developing clinical education to support students’ attainment of competencies, and ensuring students are competent through standard assessments in the specified areas, have gained new appeal. The approach appears to be responsive to concerns about patient safety, the tremendous variation in nursing practice among geographic settings, and the desire for increased accountability in both higher education and health care (Tanner, 2003).

It is important to note that changes will be required in how future nurses are educated. As the largest single group of health care providers, nurses must be prepared for the practice changes called for by the IOM (Greiner & Knebel, 2003). Because nurses assess, plan, implement, and evaluate patient care, their education on and involvement in patient safety and quality care initiatives are vital (Smith, 2006). It is evident that significant pre-licensure curricular innovation will need to occur now so that the next generation of nurses will emerge from their programs prepared with the requisite knowledge, skills, and attitudes. Nursing education has traditionally focused on the development of individual practitioners able to deliver quality care, whereas little emphasis has been placed on competency development related to improving systems that affect the individual’s ability to provide that care. Curricular changes and the accompanying change in pedagogical strategies are necessary. Barriers to implementation, including an already maximized curriculum, a growing faculty shortage, the need for faculty development in the competency content areas, and the generally slow pace of curricular change, must be addressed.

As a response to the IOM (Greiner & Knebel, 2003) quality and safety challenge, Cronenwett et al. (2007) proposed a conceptual framework (Quality and Safety Education for Nurses [QSEN]) that prelicensure nursing students could have six core competencies, of which the content domains include patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics with related knowledge, skills, and attitudes, to be met by nursing students for competency as a respected nurse. The proposed competency definitions were developed with the goal of being expansive enough to be used as frameworks for educational programs, licensure, and certification for all registered nurses (Smith, Cronenwett, & Sherwood, 2007). Innovative pedagogical strategies to successfully meet these competencies could include narrative pedagogy, simulation experiences (Bremner, Aduddell, Bennett, & VanGeest, 2006; Haskvitz & Koop, 2004; Henneman & Cunningham, 2005; Paparella, Mariani, Layton, & Carpenter, 2004; Seropian, Brown, Gavilanes, & Driggers, 2004), interprofessional learning opportunities (Barnsteiner, Disch, Hall, Mayer, & Moore, 2007), and new approaches to clinical learning (Bakken et al., 2004; Burns & Foley, 2005; Cronenwett et al., 2007; Day & Smith, 2007; Diefenbeck, Plowfield, & Herrman, 2006; Greenfield, 2007; Jacobson, Grindel, & Lewis, 2006; Papastrat & Wallace, 2003; Sherwood & Drenkard, 2007; Smith, 2006; Taylor, 2001; Thomas, Sherwood, & Helmreich, 2003; Thompson, 2003; Wolf & Serembus, 2006) that will help impart these content domains to students. In addition to the curriculum, attention must be also paid to the instructional design.

The critical thinking and problem solving skills necessary to recognize and remediate errors and problems are best taught through andragogical practices rather than traditional pedagogical practices that are typically used in college environments. Ebright, Urden, Patterson, and Chalko (2004) studied human performance factors that characterized novice (newly graduated) nurse near-miss or adverse-event situations in acute-care settings, with findings that suggest the nurses need support in following areas:

  • Clinically focused critical thinking.
  • Seeking assistance from experienced nurses.
  • Knowledge of unit and workflow patterns.
  • First-time experiences.
  • Time constraints.
  • Hand-offs.
  • Influence of peer pressure and social norms.
  • Losing the big picture.
  • Novice assisting novice.

Van Gelder (2005) argued that critical thinking must be studied and practiced in its own right; it must be an explicit part of the curriculum. Unless the students are actively doing the thinking themselves, they will never improve their skills.

Method

Purpose

The purpose of this exploratory study was to examine current patient safety education for nursing students and investigate nursing student awareness, skills, and attitudes about patient safety. The overall goal was to provide recommendations for the needed knowledge base for nursing competence for nurses to function as safe practitioners in the health care workforce.

Design

This exploratory quantitative study used a survey research design to examine current patient safety education for nursing students and provide recommendations for improving patient safety education in the academic nursing curriculum with the goal of enhancing the health outcomes for patients. This study consisted of three phases. In Phase I, the Healthcare Professionals Patient Safety Assessment Curriculum Survey (HPPSACS) was administered to a group of 400 scholarly professional nurses to obtain supportive validity and reliability data on the patient safety assessment survey. Phases II and III were the substantive phases of the study. Phase II entailed survey research conducted with nursing students at seven universities and community colleges. The independent, or predictor, variables were age, gender, race and ethnicity, program of study, and schools. The dependent, or criterion, variables were the perceptions of patient safety awareness, skills, and attitudes as measured by scores on the four subscales of the HPPSACS. Phase III was qualitative in nature and consisted of a content analysis of the patient safety curricula from the participating institutions and completion of a final analysis and data interpretation. The analysis focused on placement, nature, and extent of patient safety content within the curriculum. Each program’s learning activities, expected learning outcomes, and instructional design were examined for the QSEN (Cronenwett et al., 2007) competencies in patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.

Research Sample

For Phase I, the population of interest was 400 members of a scholarly professional nurses’ organization in the southeastern United States. For Phase II, the population of interest was 618 associate degree and baccalaureate nursing students enrolled in the spring 2007 term at seven state universities and colleges in the southeastern United States via a “snowball” sampling process. This study population was composed of nursing students in the last term of their associate or baccalaureate (accelerated, traditional, or RN-to-BSN) program. Accelerated, in this case, refers to students who had already attained a bachelor’s degree prior to entering the baccalaureate program in nursing. For Phase III, the unit of analysis was the nursing program and curricula from the seven academic institutions.

Research Instrument

The HPPSACS, a 34-item instrument used in Phases I and II, is an adapted version of the Patient Safety/Medical Fallibility Assessment Pre and Post Curriculum Survey created by Madigosky et al. (2006) for use with medical students. Approval to use the instrument with adaptation was obtained from the principal investigator of the study from which the instrument originated. The survey design was reflective of curricular goals and objectives. Multiple-choice questions assessed knowledge of patient safety. A Likert-type scale assessed attitudes and comfort with skills contributing to patient safety. The Dean of the College of Health and the Director of the School of Nursing at one of the participating institutions served as reviewers for instrument face validity.

Procedures

The three phases of the current study required differing methods and procedures. Phase I was a pilot test for reliability and construct validity analysis for the HPPSACS using exploratory factor analysis and alpha reliability analysis. Sample size was based on Tabachnik and Fidell’s (2001) recommendation that at least 5 respondents per item are needed for a factor analysis. Therefore, a minimum sample size of 115 participants was planned. After approval from the institutional review board at the University of North Florida, the HPPSACS, cover letter, and postage-paid return envelope were mailed to 400 scholarly professional nurses. These participants were randomly drawn from a complimentary mailing list obtained from an officer of a scholarly professional nursing organization. Of the 400 surveys that were mailed, 150 were returned completed, for a response rate of 38%. Twenty-one were returned as undeliverable via mail to the participant, which accounted for 5% of the total surveys mailed. Per institutional review board approval, return of the survey indicated consent to participate in the study.

Phase II and III were the substantive components of the study. On further review of the HPPSACS, it was determined that items 24 through 28 were limited in scope and were deleted from the survey for Phase II. Demographic items were also added to the survey for Phase II. Sample size was based on Tabachnik and Fidell’s (2001) recommendation that at least 5 respondents per item are needed for a factor analysis. Therefore, a minimum sample size of 115 participants was planned. After receiving approval from the institutional review board at the University of North Florida, a snowball sampling process was used to secure participation commitments from seven university and college schools of nursing. Also, the participating schools provided access to their current patient safety curriculum. Detailed institutional liaison guidelines, the HPPSACS, student cover letters, informed consents, and a pre-paid mailer for the completed surveys were sent to the designated liaison of each of the seven participating schools of nursing. The liaison administered the HPPSACS to the nursing students at each school. Confidentiality and protection of participants were maintained. No student names were requested. Return of the survey indicated consent to participate in the study. There was no penalty to the students for choosing not to participate. The students who agreed to participate in the study were requested to complete the HPPSACS, which took approximately 15 minutes, while in class. The liaison returned the students’ completed surveys, as well as the current patient safety curriculum, from that institution in the pre-paid mailer. Of the 618 surveys mailed to the seven university and college schools of nursing, 318 were returned completed, for a response rate of 51%.

Phase III consisted of a qualitative content analysis that was completed so that the seven participating schools’ patient safety curriculum and instructional methodologies (e.g., experiential learning, discourse, and critical reflection and thinking) that would promote meaningful learning were compared with the QSEN (Cronenwett et al., 2007) six core competencies for nursing. The six core competencies are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. A scoring rubric was constructed for a patient safety curriculum quantitative comparison among the seven participating schools of nursing.

Data Analysis

Phase I used exploratory factor analysis and alpha reliability to test the HPPSACS scores for validity and reliability. The items on the patient safety instrument were grouped together to form subscale scores by determining the underlying factor constructs. This allowed more flexibility in data analysis. Descriptive statistics were also used.

Phase II used exploratory factor analysis and alpha reliability analysis to explore validity and reliability of scores on the HPPSACS and to test research questions 1 and 2. The items on the patient safety instrument were then grouped together to form subscales by determining the underlying constructs. This allowed more flexibility in data analysis. Descriptive statistics, canonical correlation analysis, and discriminant function analysis were also used to test substantive research questions 3, 4, and 5.

Phase III consisted of a qualitative content analysis of the patient safety curriculum and instructional methodologies among the participating schools of nursing. A scoring rubric was constructed for a patient safety curriculum quantitative comparison and analysis among the seven participating schools of nursing. These data were used to test research question 6.

Delimitations and Limitations

This study was delimited to senior nursing students from a purposive sampling of collegiate professional nurse preparation programs located in the southeastern United States. The research sample consisted of students completing their last semester of study prior to graduation. Conclusions drawn from this sample may not be generalized to other schools of nursing or other nursing student populations. The survey instrument, institutional curriculum content analysis, and survey findings of this study add to the body of knowledge on patient safety education and may be useful to nursing leaders, faculty, and educators who are committed to improving patient safety and health outcomes.

This design has the possibility of posing several limitations. First, the HPPSACS was adapted from an instrument developed for use with medical residents. To address this limitation, the adapted instrument was pilot tested with a group of registered nurses who volunteered to participate for the purposes of establishing reliability and validity of the data. Second, the survey is a self-report instrument subject to weaknesses of all such instruments in that participants’ answers were subjective and could have been influenced by social desirability (i.e., the desire to appear personally competent or to assure that their programs were viewed in a positive light). A low rate of return was observed from some of the participating institutions. Third, the HPPSACS was administered at only a few universities and colleges. The awareness, skills, and attitudes about patient safety among the schools’ nursing faculty are unknown. In consideration of these delimitations and limitations, care must be exercised in applying these findings.

Findings

Overall, the findings from the current study provide a clear understanding of the current status of patient safety awareness among prelicensure nursing students. The frequencies for the demographic variables are presented in Table 1. Findings for the research questions follow.

Sample Demographic Data (Phase II) (N = 318)

Table 1: Sample Demographic Data (Phase II) (N = 318)

The first research question was “Will interpretable constructs be identified when responses to the HPPSACS are intercorrelated and factor analyzed using R-technique exploratory factor analysis?” The results from the exploratory factor analysis for Phases I and II provided evidence in support of this research question and are presented in Tables 2 and 3. Four identifiable factor constructs were based on the data from Phase II of the study, with themes of comfort, error reporting, denial, and culture. Scores for the entire instrument and for the four subscales were considered adequately construct valid for an instrument in developmental stages.

Varimax and Sorted Rotated Factor Structure Matrix for the HPPSACS (Phase I) (n = 150)a

Table 2: Varimax and Sorted Rotated Factor Structure Matrix for the HPPSACS (Phase I) (n = 150)

Varimax and Sorted Rotated Factor Structure Matrix for the HPPSACS (Phase II) (N = 318)a

Table 3: Varimax and Sorted Rotated Factor Structure Matrix for the HPPSACS (Phase II) (N = 318)

The second research question was “Will responses to items on the HPPSACS yield scores that are internally consistent as indicated by alpha reliability coefficients?” The alpha reliability coefficients obtained yielded evidence in support of this research question. Alpha estimates for scores on the expected subscales were above or near the range of the recommended level of 0.70 (Nunnally, 1978). Specifically, coefficients alpha for scores on the comfort, error reporting, denial, and culture subscales (Phase II) were 0.82, 0.70, 0.65, and 0.64, respectively, all of which are appropriate for an instrument in its developmental stages (Pedhazur & Schmelkin, 1991).

The third research question was “What are the perceptions of nursing students about their awareness, skills, and attitudes regarding patient safety?” The descriptive statistics of the nursing students’ responses on the HPPSACS provided the evidence for this research question. The statistics provided evidence of variation in responses on the full-scale 23-item survey and for responses on the four subscales. Generally, the participants’ perceptions reflected a sensitivity to their own role (i.e., their responsibility for patient safety), as well as a general range of opinions about other matters relative to patient safety.

Part A of the fourth research question was “To what extent is there a relationship between the demographic variables of age and gender and nursing students perceptions of their patient safety awareness, skills, and attitudes?” The effects of age and gender on the HPPSACS were examined as the two independent predictor variables. The four dependent or criterion variables consisted of scores on the four subscales of the HPPSACS. The ethnicity variable was collapsed from the original six categories into five, with the Native American (n = 1) category being collapsed into the Other category.

Canonical function 1 (Rc2 = 0.17) indicated that for the best set of weights for variables across the two sets, the independent variables shared approximately 17% of their variances with the dependent variables, which is a small effect but well above the 10% standard suggested by Pedhazur (1982) to be considered noteworthy. Function 1 was statistically significant (p < 0.001). Function 2 was trivial (Rc2 = 0.00) and was not statistically significant. The results from the canonical correlation analysis provided evidence for this research question in that older male participants had higher comfort sub-scale scores and lower culture subscale scores than did younger female participants. Younger women were not as comfortable with patient safety issues but were more likely to agree with items relative to the culture of patient safety.

Part B of the fourth research question was “To what extent is there a relationship between the demographic variable of race and ethnicity and nursing students’ perceptions of their patient safety awareness, skills, and attitudes?” The effect of race and ethnicity as a dependent variable was examined using discriminant analysis. Because ethnicity was collapsed into five categories and there were four predictive subscales, the analysis yielded four discriminant functions.

Function 1 accounted for 20% of the variance between groups (Wilks’ lambda = .80; p < .001). Function 2, also of noteworthy size, accounted for 10% of the variance between groups (Wilks’ lambda = .90; p < .01). The remaining two functions (Wilks’ lambda values of .98 and 1.00, respectively) were negligible in statistical effect and not statistically significant (p > .05). For function 1, groups were most distinguished by the denial and culture subscales (structure coefficients = .72 and .52, respectively), whereas for function 2, comfort and error reporting were the more weighted predictors (structure coefficients = .59 and .77, respectively).

The results from the discriminant analysis provided evidence in support of this research question. Asian American participants were clearly distinguished from the combined set of African American and Hispanic participants on the denial and culture scores. The other ethnic identity was clearly distinguished from the combined set of Caucasian and Hispanic participants on the comfort and error reporting scores.

The fifth research question was “To what extent is there a relationship between the type of collegiate nursing program and nursing students’ perceptions of their patient safety awareness, skills, and attitudes?” A discriminant function analysis was conducted. For this analysis, the program type served as the grouping variable and the four HPPSACS subscales were the predictors. The analysis yielded two discriminant functions. Function 1 accounted for 24% of the variance between groups (Wilks’ lambda = .76; p < .001). Function 2 was negligible in its effect size, accounting for only 2.6% of the variance between groups (Wilks’ lambda = .97; p < .05). For function 1, groups were most distinguishable by the error reporting and comfort (structure coefficients = .82 and .46, respectively), whereas for function 2 culture and denial (structure coefficients = .57 and .44, respectively) accounted for group differences.

Function 1 most clearly distinguished the associate nursing degree program from the combined set of the accelerated and traditional nursing degree programs. Discriminant structure coefficients indicate that the associate degree students had higher error reporting and comfort scores. Function 2 was not interpreted due to the small effect size, although it was statistically significant. The results from the discriminant analysis provided the evidence for this research question. The associate nursing degree programs were clearly distinguished from those in the combined set of the accelerated and traditional nursing degree programs.

An ancillary analysis was conducted to examine the relationship between the seven participating schools of nursing in this study and nursing students’ perceptions of their patient safety awareness, skills, and attitudes using discriminant function analysis. Function 1 accounted for 33% of the variance between groups (Wilks’ lambda = .67; p < .001). The remaining three functions (Wilks’ lambda values of .94, .96, and .99, respectively) were negligible in statistical effect and not statistically significant (p > .05). For function 1, groups were most distinguished by the error reporting and comfort (structure coefficients = .83 and .39, respectively). Function 1 most clearly distinguished participants in the associate nursing degree programs from the combined set of accelerated and traditional nursing degree programs, with associate nursing degree programs having higher error reporting and comfort scores.

The sixth research question was “To what extent are there discernable program curriculum and instructional methodologies that have been traditionally associated with more positive student perception of awareness, skills, and attitudes regarding patient safety?” The results from the Phase III content analysis provided evidence in support of the research question: all of the schools that participated in the study included at least three of the QSEN (Cronenwett et al., 2007) six core competencies in their curriculum. One school exhibited all of the core competencies. The nursing students’ perceptions of awareness, skills, and attitudes regarding patient safety were reflected by the variability of scores on the HPPSACS.

Recommendations

The current study is the first known study conducted on nursing students’ perceptions about their awareness, skills, and attitudes regarding patient safety. Although this study considered six research questions, there are significant opportunities for future research in patient safety given the limited empirical studies that have been done thus far. This study examined nursing students’ awareness, skills, and attitudes regarding patient safety that were in associate nursing degree, accelerated nursing degree, or traditional nursing degree programs of study.

One recommendation for a future research study would be to build on the findings from the current study and examine patient safety awareness among students in associate, baccalaureate, master’s, and doctoral nursing degree programs of study. This study would include an assessment of adult learning concepts and tools to promote meaningful learning in the patient safety domain. Longitudinal research studies could be conducted to ascertain whether patient safety awareness increases with practitioner maturation and skill development and whether the patient safety awareness is carried into professional practice.

A second recommendation for future study would be an examination of patient safety awareness conducted with the nursing faculty, particularly as it relates to their students’ patient safety awareness. For example, increased patient safety awareness among nursing faculty might correlate to increased patient safety awareness among their students. Such a study might administer the HPPSACS to the nursing faculty and their students for comparison.

Finally, a recommendation for a future research study would be to develop a design method whereby learning outcomes would be measured as they relate to health outcomes to demonstrate that patient safety knowledge and skills obtained by the nursing students have a positive effect for their patients. An analysis of the nursing students’ patient safety curriculum and instructional methodologies would be conducted to determine whether there was a positive correlation to their learning outcomes (i.e., patient safety knowledge and successful competency completion) compared with health outcomes indicators, such as medical errors and near-miss reports.

Conclusion

The current study is the first known research conducted on nursing students’ perceptions about their awareness, skills, and attitudes regarding patient safety, which is perhaps the study’s most significant contribution to the field of nursing education. Furthermore, the sample size was relatively large (N = 318) and encompassed a diverse group of respondents from associate, accelerated, and traditional nursing degree programs. It is the only known study on the current status of patient safety awareness among prelicensure nursing students. The design of this study offers future nurse researchers a basis on which to conduct further empirical research on nursing students’ perceptions of their patient safety awareness, skills, and attitudes at any institution of higher education.

Findings from the current study support the evidence from the nursing research conducted by Smith et al. (2007) that there are opportunities for improvement for patient safety curriculum in schools of nursing. These findings emphasize new ways of thinking, interacting, and learning that can be addressed through adult learning concepts, tools, and instructional methodologies to enhance patient safety awareness, skills, and attitudes. In so doing, the level of clinical excellence can be increased, medical error prevention can be addressed, and health outcomes can be improved.

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Sample Demographic Data (Phase II) (N = 318)

Demographic VariableCategoryn%
SchoolA309.4
B6620.8
C257.9
D4614.5
E247.5
F3912.3
G8827.7
ProgramAssociate14244.7
RN-to-BSNa
Accelerated4714.8
Traditional12940.6
GenderFemale22972
Male299.1
Missing6018.9
EthnicityAfrican American299.1
Asian American123.8
Caucasian15147.5
Hispanic4413.8
Native American*10.3
Other166.3
Missing6519.2
AgeRange = 41 (min. of 19 to max. of 60)
Mean = 29, standard deviation = 8.97

Varimax and Sorted Rotated Factor Structure Matrix for the HPPSACS (Phase I) (n = 150)a

HPPSACS Item Numbers123
Comfort
  23. Disclosing an error0.860.04–0.07
  22. Disclosing an error to a faculty0.840.07–0.08
  21. Advising a peer0.750.11–0.16
  19. Completing an incident report0.710.05–0.31
  20. Analyzing a case0.70–0.16–0.11
Error Reporting
  9. Communication on safety–0.010.650.02
  10. Routine report medical errors–0.000.65–0.01
  8. Healthcare professionals share–0.140.54–0.11
  6. Deal constructively with errors–0.150.550.08
  11. Reporting systems do little–0.11–0.490.22
  17. Work harder0.080.470.33
  3. Working to improve patient0.220.33–0.04
  5. Should not tolerate uncertainty0.280.320.07
  18. Gap between “best care”–0.24–0.310.01
  2. Professionals do not make errors that lead to patient harm0.160.29–0.03
  1. Making errors is inevitable–0.15–0.16–0.14
  12. Physicians should report errors0.040.13–0.10
Denial
  15. If I saw a medical error–0.21–0.150.73
  14. There is no need to address–0.21–0.140.71
  4. Only physicians can determine0.110.180.55
  13. Effective responses–0.040.270.49
  7. Learning how to improve0.120.07–0.48
  6. Can’t do anything about it–0.13–0.180.43

Varimax and Sorted Rotated Factor Structure Matrix for the HPPSACS (Phase II) (N = 318)a

HPPSACS Item Numbers:1234
Comfort
  21. Advising a peer0.770.110.01–0.03
  19. Completing an incident report0.760.0990.10–0.08
  20. Analyzing a case0.750.080.050.05
  23. Disclosing an error0.750.11–0.100.08
  22. Disclosing error to faculty0.690.10–0.030.15
Error Reporting
  6. Deal constructively with errors0.170.68–0.010.10
  8. Healthcare professionals share0.250.66–0.080.14
  10. Routine report medical errors0.190.62–0.030.11
  4. Only physicians can determine–0.120.390.37–0.37
  2. Professionals do not make errors that lead to patient harm0.150.390.170.07
  13. Effective responses–0.120.350.07–0.16
  17. Work harder–0.060.35–0.030.26
  5. Should not tolerate uncertainty0.090.33–0.100.23
Denial
  16. Can’t do anything about it0.020.110.71–0.11
  14. There is no need to address–0.020.230.69–0.13
  15. If I saw a medical error0.00–0.140.670.02
  11. Reporting systems do little–0.01–0.160.57–0.07
Culture
  7. Learning how to improve0.120.22–0.150.72
  3. Working to improve patient0.030.13–0.180.67
  9. Communication on safety0.160.16–0.090.51
  1. Making errors is inevitable–0.04–0.120.320.40
  18. Gap between “best care”–0.17–0.340.240.34
Authors

Dr. Chenot is Associate Professor, School of Nursing, Jacksonville University, and Dr. Daniel is Dean and Professor, College of Education and Human Services, University of North Florida, Jacksonville, Florida.

The authors have no financial or proprietary interest in the materials presented herein.

Presented in part as a poster presentation at the Quality and Safety Education for Nurses National Forum, Denver, Colorado, June 2010.

Address correspondence to Teri M. Chenot, EdD, RN, Associate Professor, School of Nursing, Jacksonville University, 2800 University Blvd. N., Jacksonville, FL 32211; e-mail: .tchenot@ju.edu

10.3928/01484834-20100730-02

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