Worldwide studies (e.g., de Vries, Ramrattan, Smorenburg, Gouma, & Boermeester, 2008; Soop, Frysmark, Köster, & Haglund, 2008; Vlayen et al., 2012) established that adverse events causing harm for patients happen to approximately one of 10 patients while receiving health care. Medication errors and nosocomial infections are among the leading threats to patient safety, although many of these events could be prevented with using systematically the best practices. The Institute of Medicine (IOM) revealed the alarming situation, breaking the illusion of infallible health care professionals and launched an onward patient safety movement (Kohn, Corrigan, & Donaldson, 2000). In the recent years, legislation and guidelines for enhancing patient safety have been widely prepared at national and international levels (e.g., European Network for Patient Safety [EUNetPaS], 2010; Ministry of Social Affairs and Health [MSAH], 2009; World Health Organization [WHO], 2011). Investing in improving patient safety is one of the most remarkable opportunities for having a safe and effective health care system. Thus, nursing education has a substantial role in securing patient safety in a complex health care environment (James, 2010).
Patient safety is defined as minimizing a patient’s exposure to hazards and near-misses and, likewise, reducing the risk of unnecessary harm associated with health care to an acceptable minimum (Kohn et al., 2000; WHO, 2009). Hazard is defined as an agent, an action, or a circumstance that has the potential to cause harm for a patient, whereas a near-miss is an event that did not reach the patient (WHO, 2009). To reduce these events in health care, increased emphasis on patient safety in the health care education is imperative, including reforming of nursing curriculum. Several nursing studies (Gregory, Guse, Dick, Davis, & Russell, 2009; Henneman et al., 2010; Mossey, Montgomery, Raymond, & Killiam, 2012) have established the need for change in expressing the truth of nursing students’ unsafe practices. The international patient safety guidelines for health care education (EUNetPaS, 2010; WHO, 2011) highlight the importance of health care professionals having a foundation of knowledge, skills, behavior, and attitudes relevant to patient safety and to similarly underline the importance of practicing patient safety in all their actions. Furthermore, the focus should be increasingly on multiprofessional learning of patient safety to improve effective teamwork and communication (EUNetPaS, 2010; WHO, 2011), as communication failures are major causes for hazards and near-misses (Leonard, Graham, & Bonacum, 2004; Rabøl et al., 2011).
In the United States, the Quality and Safety Education for Nurses (QSEN) initiative, launched by the IOM report (Kohn et al., 2000), has been created to establish the patient safety content in nursing curricula and, thus, to prepare future nurses with the knowledge, skills, and attitudes necessary for continuous improvement of the quality and safety of the health care system. The six QSEN competency areas are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. QSEN defined safety as minimizing the risk to both patients and providers through systematic effectiveness and individual performance (Cronenwett et al., 2007; Sherwood, 2011.) Brady (2011) described five safety behaviors: hand washing, introduction of oneself to the patient and the patient’s family, patient-centered communication, double identifiers, and the use of the SBAR (situation, background, assessment, and recommendation) communication strategy.
In Europe, the EUNetPaS (2010) project enhanced collaboration in the field of patient safety. The outcomes of the project include guidelines for education and training of patient safety with the aim to promote the transferability of the methods from a member state to another. In the United Kingdom, the National Patient Safety Agency (NPSA) works under the auspices of the Department of Health to determine, report, and address key patient safety issues. This incorporates a national reporting and learning service. However, there have been concerns that although the NPSA has raised awareness of adverse events in health care, it should do more to identify exemplars of good practice in the prevention and management of patient safety issues. Furthermore, the addition of the critical educational topic, improving both organizational and individual learning of patient safety, has been suggested by the Department of Health (2006) to enhance the work of the NPSA. Nursing education has a significant role in ensuring safe health care, and specific national guidelines exist related to nursing roles and responsibilities for safe and effective care management and delivery. In the United Kingdom, the Nursing and Midwifery Council (NMC) code of conduct (2008) specifies risk management, prevention, and reporting strategies as core components of professional practice for nurses and midwives, whereas in Finland, the Finnish Patient Safety Strategy for 2009 to 2013 (MSAH, 2009) emphasizes that promoting patient safety should be taken into account in health care education, including undergraduate nursing education.
It is essential that the content of patient safety and the used teaching and learning methods are properly considered in nursing education; the goal is to help nursing students implement evidence-based knowledge of patient safety in practice. Benner, Sutphen, Leonard, and Day (2010, p. 166) disclosed the importance of guided reflection on nursing students’ clinical experiences to improve their everyday practices. Practice-driven learning is highlighted in several studies regarding patient safety education (Girdley, Johnsen, & Kwekkeboom, 2009; Lenburg, Klein, Abdur-Rahman, Spencer, & Boyer, 2009). However, some studies indicate there is a gap between university education and clinical practice, according to nursing students (Attree, Cooke, & Wakefield, 2008; Vaismoradi, Salsali, & Marck, 2011). To reduce the gap, simulation education is one efficient method for nursing students to safely practice complex care situations. Simulation education can include a variety of safety issues that closely mimic the complexity of patient care—for example, the identification of embedded medication errors (Gantt & Webb-Corbett, 2010; Henneman et al., 2010; Ironside, Jeffries, & Martin, 2009). Overall, clinical practice with supportive, blame-free supervision has a significant role in achieving the desired learning outcomes when teaching patient safety (Attree et al., 2008; Reid-Searl, Moxham, & Happell, 2010).
In summary, it is important to review and integrate the current knowledge about the nature of teaching patient safety in nursing education. In addition, understanding the effects of the teaching and learning methods used for patient safety education and how nursing students learn about patient safety are both important areas to consider when developing nursing education.
The aim of this integrative literature review was to critically analyze peer-reviewed studies focusing on patient safety in nursing education and to synthesize the findings. The review considered the following questions:
- How does the nursing research literature describe the content of patient safety in nursing education?
- How does the nursing research literature describe the teaching and learning methods used in nursing education regarding patient safety?
- How does the nursing research literature describe the way nursing students learn about patient safety?
An integrative literature review was conducted to synthesize the research literature related to the content of patient safety, the teaching and learning methods used, and nursing students’ learning of patient safety. This integrative review uses Whittemore’s and Knafl’s (2005) five stages as a framework for data collection, analysis, and synthesis: (a) problem identification, (b) literature search, (c) data evaluation, (d) data analysis, and (e) presentation. A variety of independent studies were synthesized to determine the current knowledge of patient safety in nursing education (Burns & Grove, 2009).
The Figure presents the keywords, as well as the inclusion and exclusion criteria, used in the literature search of electronic databases, electronic journals, and QSEN Web pages. The search aimed to recognize the relevant studies made of the content of patient safety in nursing education and the teaching and learning methods used and nursing students’ learning of patient safety. The year 2006 was selected to be the start point for the search because the WHO (2004) launched the first World Alliance for Patient safety in October 2004, and the nursing research literature was estimated to include these issues from 2006 forward. A librarian was consulted to help with the choice of search strategy. Altogether, 20 research studies about patient safety and prelicensure nursing education were included in this integrative literature review. Another academician confirmed the validity of the selection process.
Systematic literature search process relating to patient safety in nursing education.
The use of an integrative literature review method assists with the complexity of evaluating the quality of diverse primary studies (Whittemore & Knafl, 2005). In this review, further evaluation of selected primary studies was conducted by modifying the data evaluation form created by Hawker, Payne, Kerr, Hardey, and Powell (2002) to evaluate the studies (Jokelainen, Turunen, Tossavainen, Jamookeeah, & Coco, 2011). In the current study, the evaluation examined the following areas: background, aim and research questions, sample, data collection, data analysis, results, ethical issues, reliability, and usefulness of the results. Each section was evaluated using the following criteria, from 0 to 2 points: 0 = does not meet the aim or lacks data; 1 = inaccurate or superficial; 2 = relevant and presented systematically. The theoretical scale of points that a single primary study can score in the evaluation process varies from 0 to 18. The scale of scores of the included studies (N = 20) ranged from 8 to 18 points, with a mean of 14.1 and a mode of 14. To increase the reliability of the data evaluation process, a second academician assessed the quality of the selected studies. The interrater agreement, as evaluated by the kappa test, was very good, at 0.895 (Burns & Grove, 2009).
A constant comparison method was used for the data analyses. The method included data reduction, data display, data comparison, the drawing of conclusions, and verification (Whittemore & Knafl, 2005). In the reduction phase, the data from the selected studies were organized into a manageable framework, comprising three sections: the content of patient safety in nursing education, the teaching and learning of patient safety, and nursing students’ learning. Studies are presented in Table A (available in the online version of this article). In the data comparison phase, the data were ordered into groups and themes were identified. The drawing of conclusions and verification was the last phase and included identification of communalities and differences, as well as verification with the primary source data. The final step was to synthesize the important elements into an integrated summation of the topic.
The studies (N = 20) reviewed were published from 2006 to 2012, with many published in 2009 (n = 6). Many of the studies were from the United States (n = 11); the remainder were from Australia (n = 2), Canada (n = 3), Iran (n = 2), Norway (n = 1), and the United Kingdom (n = 1). The studies were quantitative (n = 7) and qualitative (n = 8), and triangulation (n = 5) was used in some (Table A).
Content of Patient Safety in Nursing Education
The results related to the content of patient safety in nursing education showed that if patient safety was not evident as a subject in the nursing curricula but rather integrated in several modules, it could disappear. There was a risk that patient safety was not taught comprehensively in any module (Chenot & Daniel, 2010; Smith, Cronenwett, & Sherwood, 2007; Vaismoradi et al., 2011). The subjects that concerned patient safety in nursing education included learning from errors, responsible individual and interprofessional teamwork, anticipatory action in complex environments, and patient safety–centered nursing (Table A).
Learning From Errors. Learning from errors had an outstanding role in patient safety education for nursing students. To learn from errors requires that nursing students understand why errors occur, identify errors, report errors, analyze the type of errors that occurred, and learn from the process. In nursing education, error identification was taught (e.g., categorizing errors as being rules based, skills based, and knowledge based) (Currie et al., 2007; Henneman et al., 2010.) A nursing student needed to have the knowledge and skills to identify an error and, subsequently, possess the courage to stop the process from continuing. If errors had occurred, nursing students needed to know about them and have the skills to correct them. Furthermore, nursing students had to have the competence to report hazards and near-misses (Currie et al., 2007). Analyzing errors and learning from them was described less in this integrative review. Overall, patient safety and learning from errors required responsible behavior and attitude from nursing students.
Responsible Individual and Interprofessional Teamwork. To facilitate nursing students’ possibility to have adequate patient safety competence, they were taught about working responsibly as individuals and in teams. Nursing students were helped to reflect their own role as individual caregivers and members of a care team (Chenot & Daniel, 2010; DeBourgh, 2012; Miller & LaFramboise, 2009; Mulready-Shick, Kafel, Banister, & Mylott, 2009; Sullivan, Hirst, & Cronenwett, 2009; Vaismoradi et al., 2011). Strengths and limitations were identified, for example, through realistic simulation scenarios, including using interprofessional groups to understand interprofessional team performance and their own role within the group (DeBorough, 2012; Gantt & Webb-Corbett, 2010; Henneman et al., 2010; Ironside et al., 2009; Kyrkjebø, Brattebø, & Smith-Strøm, 2006; Mossey et al., 2012). In patient safety education, a debriefing session after a simulation scenario was used to facilitate a self-evaluation of the nursing students and to receive feedback from group members and educators, thus gaining information about their own strengths and limitations. Crew resources management (CRM) and best and systematic trauma care (BEST) principles were used to teach clear communication, cooperation, and leadership (Kyrkjebø et al., 2006). Overall, patient safety education included emphasizing the importance to communicate clearly in an interprofessional team to be able to act safely in a complex environment.
Anticipatory Action in Complex Environments. The prevention of errors in a complex health care environment must be systematic. The prevention of hazards and near-misses before they occurred was an essential part of patient safety education. One way this was taught was with the use of competency and critical thinking checklists in simulation education (Gantt & Webb-Corbett, 2010). In addition, good practices were used as evidence-based anticipatory actions that help to ensure patient safety in complex environments. For example, patient identification, hand hygiene, medication safety, and patient allergy verification were used as measures to prevent errors (Attree et al., 2008; Gantt & Webb-Corbett, 2010). In simulation education, nursing students practiced working in a clinical environment. The complexity of real patient care situations were closely mimicked in patient scenarios, which included minor and major disruptions (Henneman et al., 2010; Ironside et al., 2009; Kyrkjebø et al., 2006). It was essential for nursing students to practice in complex situations before starting a clinical practice placement. Good practices that develop as work habits help nursing students to ensure patient safety. Thus, nursing students needed to have information-seeking and critical-thinking skills to implement evidence-based, anticipatory practice (Chenot & Daniel, 2010; Gantt & Webb-Corbett, 2010; Miller & LaFramboise, 2009; Mulready-Shick et al., 2009; Sullivan et al., 2009). All anticipatory actions to confirm patient safety were important to nursing students for learning to provide care that was patient centered and safe.
Patient Safety–Centered Nursing. In nursing education, a patient-centered approach was taught as a prominent part of patient safety. Patient-centered care highlights the patient’s viewpoint and the nursing student’s role in enhancing patient safety. Ensuring the patient was in the center of care and a member of the care team was important for patient safety. In addition, a positive nursing role model about ensuring patient-centered care and patient safety was considered as outstanding (Chenot & Daniel, 2010; Miller & LaFramboise, 2009; Mulready-Shick et al., 2009; Sullivan et al., 2009). Thus, it was important to highlight patient safety–centered nursing in undergraduate nursing education.
Teaching and Learning Methods Used for Patient Safety Education
In nursing education, different teaching and learning methods were needed to help nursing students learn to act safely in real patient situations. In this integrative literature review, the teaching and learning methods used for patient safety in nursing education consisted of combining multiple methods for the learning of patient safety competence (Table A).
Embedding patient safety into nursing education and adequately preparing nursing students with the necessary competencies required multiple teaching and learning methods. It was important to include in the curricula the teaching and learning methods that were best suited for patient safety education. Logical order of used methods, continuing construction of patient safety competence, and forming comprehensive entirety of the used methods to support the learning process of patient safety competence were considered the most crucial for patient safety education (Attree et al., 2008; Miller & LaFramboise, 2009; Vaismoradi et al., 2011); these aspects could be implemented as follows: Structured patient safety lectures in academic settings, a Web-based hazard and near-miss reporting system in clinical practice, and conducting a root cause analysis of patient safety incidents were used as teaching and learning methods to reduce the gap between education in academic settings and clinical practice (Currie et al., 2007; Miller & LaFramboise, 2009). Similarly, an academic and service partnership was implemented to promote effective nursing education and nursing students’ clinical practice (DeBourgh, 2012). Other methods for deepening the learning of patient safety included interprofessional simulation scenarios, followed by debriefing sessions. Nursing students preferred interprofessional training especially because it involved realistic videos and simulation exercises (Kyrkjebø et al., 2006). In simulation education, competency and critical thinking checklists and the reporting of errors were conducted to increase nursing students’ critical thinking skills (Gantt & Webb-Corbett, 2010). Traditional teaching and learning methods, reading, clinical practices, and return demonstrations were still part of patient safety education (Luhanga, Yonge, & Myrick, 2008; Smith et al., 2007).
Nursing Students’ Learning of Patient Safety
Nursing students’ learning of patient safety was related to continuity, sensitivity, and a supportive environment, each of which is explored in depth. It was important that nursing students constantly improved their own patient safety competencies, were sensitive to their own role in securing patient safety, and had the potential to learn the identification of specific issues in a supportive learning environment (Table A).
Continuing Improvement of Patient Safety Competence. To learn patient safety, it was important for nursing students to continuously increase patient safety competence. Nursing students did not necessarily demonstrate adequate patient safety knowledge and skills after theoretical lectures (Henneman et al., 2010). Furthermore, nursing students could express dissatisfaction with the way patient safety issues were discussed in the classroom (Vaismoradi et al., 2011). However, opposite findings support classroom teaching; patient safety knowledge improved successfully when taught in a classroom, whereas patient safety skills, such as those regarding hazards and near-misses, improved most when taught in a health care environment (Sullivan et al., 2009). Academic and service partnership effectively promoted nursing students’ learning of patient safety and quality knowledge (DeBourgh, 2012).
Certain clinical patient safety procedures emerged when nursing students performed clinical practice and simulation scenarios of patient care. Nursing students’ performances of clinical procedures of patient safety varied. Poor infection control practices, mostly due to inadequate hand hygiene, verification of patient’s allergies, and patient identification, were considered as common hazards, whereas medication administration was described as a common near-miss for nursing students (Currie et al., 2007; Gantt & Webb-Corbett, 2010; Henneman et al., 2010). Other clinical procedures included incomplete allergy verification and insufficient interaction with the doctor by nursing students. In contrast, Henneman et al. (2010) found that nursing students focused on coordinating information with patients and families. Clear communication required nursing students to be sensitive to their own role.
Sensitivity to Their Own Role. Nursing students were sensitive to their own roles in clinical practice and considered safety to be a significant issue (Chenot & Daniel, 2010; Mossey et al., 2012; Sullivan et al., 2009; Vaismoradi et al., 2011). Most of the nursing students reported making a hazard or a near-miss in simulation settings or during clinical placements (Gregory et al., 2009; Henneman et al., 2010). Just culture encourages the reporting of patient safety incidents without fear of punishment; this integrative literature review demonstrated that it was important for nursing students to feel safe when reporting errors in clinical practice (Attree et al., 2008; Koohestani & Baghchegi, 2009; Mulready-Shick et al., 2009). Web-based hazard and near-miss reporting systems promoted nursing students’ mindfulness and sensitivity to their own role and responsibility regarding patient safety (Currie et al., 2007). On the other hand, nursing students’ unsafe practice types were identified to increase understanding of the fact that nursing students need to be considered as individuals to encourage their learning of patient safety (Mossey et al., 2012).
By observing potential errors, nursing students learned to identify dangerous situations; they learned to stop errors from progressing and correct the situation. Nursing students’ age, tolerance of ambiguity, and self-reported grade point average did not correlate with learning of patient safety competencies (Henneman et al., 2010; Ironside et al., 2009). In clinical practice placement, errors and near-misses could lead to nursing students’ failing the clinical practice. Failing depended on the stage of nursing students’ studies and the type of errors that occurred (Tanicala, Scheffer, & Roberts, 2011). In addition, nursing students learned about personal reactions and the limits of their own competence in interprofessional simulation education. While in clinical practice placement, nursing students did not necessarily consider themselves as being competent enough for safe practice (Kyrkjebø et al., 2006; Vaismoradi et al., 2011). The support of the learning environment had an influence on nursing students’ learning of patient safety.
Supportive Learning Environment. A supportive learning environment had a crucial role in the teaching of patient safety. In dedicated learning units, nursing students could perform clinical practice in a safe environment and feel comfortable to practice what they had learned about patient safety. Students thought it was easier to learn about hospital systems such as bracelet scans and potential adverse event alerts with a smaller student-to-teacher ratio (DeBorough, 2012; Mulready-Shick et al., 2009). The potential for making errors decreased when nursing students were adequately supervised. The reverse was also true: when nursing students lacked sufficient supervision, the risk of errors increased (Reid-Searl et al., 2010; Reid-Searl, Moxham, Walker, & Happell, 2008). A defensive, blame culture was detrimental to learning and could affect how nursing students reported hazards and near-misses in clinical practice. Fear and administrative barriers, such as having no positive feedback from the preceptor and focusing on an individual’s performance, negatively influenced nursing students’ performance (Attree et al., 2008; Koohestani & Baghcheghi, 2009).
The results of this integrative literature review reveal that the content of patient safety education varies within the nursing education field. Many different teaching and learning methods are used to educate nursing students about patient safety. Furthermore, nursing students’ knowledge of patient safety does not necessarily improve after their formal education. Nursing curricula play a prominent role in ensuring that nursing students can demonstrate suitable patient safety competencies. The content of patient safety education must be clear and explicit in nursing curricula, and effective teaching and learning methods need to be properly described and used in both academic settings and clinical practice placements. Nursing students must learn the fundamentals of patient safety, learn from errors, and report hazards and near-misses from the very beginning of their nursing studies (EUNetPaS, 2010; Vaismoradi et al., 2011; WHO, 2011). In addition, nurse educators should respond to the errors that nursing students make in their clinical practice placements and thus develop better educational methods and curricula to improve patient safety competencies. Understanding the importance of the interactive connection between academic and clinical education is essential (Benner et al., 2010).
This integrative review identified the content of patient safety in nursing education to be learning from errors, responsible individual and interprofessional team working, anticipatory action in complex environments, and patient safety–centered nursing. It is important for nursing students to develop good attitudes to work with the patient’s best interests at heart. Christiansen, Robson, and Griffith-Evans (2010) wrote that nursing students perceive service improvement learning as important to patient safety and their future career development. The patient is at the center of safe care, and nursing students can make a positive difference through their behavior by having a questioning approach and the confidence to work differently. In this literature review, the national and international patient safety standards or legislation was not identified as being obviously relevant to patient safety education. Thus, it is important to highlight the existing official patient safety standards, strategies, and legislation when devising the patient safety content of nursing education.
In this integrative review, the teaching and learning methods used for patient safety education show the importance of combining multiple teaching and learning methods to promote the continuity, logical order, and entirety of the patient safety competence. The use of patient safety tools is an important element for graduating nursing students. Patient safety tools, such as checklists, SBAR, CRM, and BEST, were used, for example, in simulation education, but it was not clear in this integrative literature review whether these tools were used systematically throughout the entire education, applying different teaching and learning methods. In addition, Vaismoradi et al. (2011) described how nursing students feel insecure in clinical practice. Nursing students indicated that they needed help with internalizing patient safety principles and values; in this regard, they viewed themselves as not being competent enough. Interprofessional patient safety education can provide a deeper view for nursing students to learn patient safety and realize their own role in multiprofessional teams. The systematic practicing of patient safety principles using comprehensive tools with a variety of well-established teaching and learning methods is essential in nursing education.
Nursing students’ learning of patient safety was composed of continuing improvement in patient safety competence, sensitivity to their own role in securing patient safety, and a supportive learning environment. Together, studies at the university and clinical practice placements should lead to the desired level of education about patient safety. Understanding systematic failures, acting transparently, and learning from errors are essential for safe patient care (Sherwood & Drenkard, 2007; Wakefield et al., 2005). Thus, a just culture is needed in nursing education, as it holds every individual accountable for their own actions. It focuses on behavioral choices and distinguishes between human error, unintentional risk-taking behavior, and intentional risk-taking behavior. A just culture supports nursing students’ reporting of errors and near-misses without fear of retribution by providing appropriate, fair, and consistent resolution of adverse student practice events (Barnsteiner & Disch, 2012; North Carolina Board of Nursing, 2012).
Most of the studies in this integrative review originated from the United States, where the QSEN initiative has led to many improvements of patient safety in nursing education (Sherwood, 2011). Only two of the studies were from Europe. For example, the EUNetPaS (2010) provides guidelines for nursing education to promote similar patient safety competencies among nursing students in Europe. Thus, further studies are needed to compare the patient safety competencies of nursing students across Europe.
This integrative literature review has several limitations. First, the studies selected in this review included participants from different levels and phases of nursing education. Second, the implementation of primary studies varies and can influence the reliability of this integrative review. Some studies shared the same data, which could have biased the results of this integrative review. Third, the integrative review method itself has some limitations, such as the combination of diverse methodologies, which can lead to inaccuracy and bias (Whittemore & Knafl, 2005). However, the authors tried to mitigate these issues by using a second academician to validate the literature selection process and the evaluation of the quality of selected research articles.
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Note. HPPSACS = Healthcare Professionals Patient Safety Assessment Curriculum Survey; QSEN = Quality and Safety Education for Nurses; MSTAT-I = Multiple Stimulus Types Ambiguity Tolerance Scale-1; BEST =Better & Systematic Trauma Care.