Patient safety has been on the forefront of health care since the Institute of Medicine's (1999) report on the number of patient deaths that occurred because of preventable mistakes. A major national initiative within nursing education, Quality and Safety Education for Nurses (QSEN), funded by the Robert Wood Johnson Foundation, was implemented to address this problem (QSEN, n.d.). Educational competencies for prelicensure nursing students are the focus of this effort and include safety, informatics, teamwork and collaboration, quality improvement, evidenced-based practice, and patient-centered care. Faculty are asked to incorporate these competencies into the prelicensure curriculum and prepare nursing students to provide safe beside care (Cronenwett et al., 2007).
Health care providers have been working to reduce medical errors since the Institute of Medicine report, but a significant problem still remains (Wachter, 2010). Better reporting of errors and a greater transparency of results have been identified as keys to improving patient safety (Hession-Laband & Mantell, 2011). Health care providers are reluctant to report errors for a variety of reasons. Some reasons identified are fear of repercussions, embarrassment, and cumbersome reporting systems (Barnsteiner, 2012). Having a culture of safety in an organization is necessary for providers to feel comfortable reporting and discussing errors so solutions can be devised to decrease the occurrence of errors.
Several studies in the literature looked specifically at student perception of safety, incident reporting, and safety competence (Cooper, 2013; Duhn et al., 2012; Ginsburg, Tregunno, & Norton, 2013; Pearson et al., 2010). These studies revealed the lack of student engagement in the safety culture in an organization. Nursing students reported a lack of understanding of incident report completion (Pearson et al., 2010) and difficulty getting errors and near-miss events reported (Cooper, 2013). Nursing students are exposed to a variety of clinicians and facilities during their education. It is important that nursing schools embed a culture of safety regarding errors and near-miss reporting into the curriculum. This will facilitate student learning and experiencing transparency from the beginning of their professional career, potentially making them more effective nurses (Cronenwett, 2012).
An exploratory descriptive study was conducted in a rural public university in the northeastern United States after obtaining institutional review board approval. All junior- and senior-level baccalaureate nursing students were eligible to participate in the study. The current study assessed student perception of safety and communication in the clinical setting. Participants answered the 33-item Patient Safety Survey (Cooper, 2013), which was modeled after the Patient Safety Survey developed by the Agency for Healthcare Research and Quality (2012). Content validity was established through a review by content experts in the field. Internal consistency of students' perception of safety in the clinical setting using Cronbach's alpha in this research study was (α = .709) and internal consistency of students' perception of communication and safety reporting was ((α = .768). This survey assessed patient safety across four domains. The four domains assessed include students' perception of safety in the clinical setting (12 items), students' perception of communication and safety reporting (13 items), near-miss events (four items), and specific event assessments (four items). The tool utilized a Likert scale ranging from 1 to 5, with 1 = strongly disagree and 5 = strongly agree, for the students' perception of safety in the clinical setting. The communication and safety reporting domain used a 5-point Likert scale, with 5 = always and 1 = never.
Data were collected in junior and senior theory courses over a 2-week period in four different courses. Participants were surveyed one time during the study. Participation was voluntary, with approximately 99% participation (N = 196; juniors = 101, seniors = 92, with three students not identifying a year in program). Survey completion took approximately 10 minutes. All responses were anonymous; students placed surveys in a box in the front of the classroom. Students could place a blank survey in the box if they chose not to participate.
Data were analyzed using SPSS® version 22. Descriptive statistics using means, frequency distribution, and independent t tests were used to analyze the data. Results revealed junior-level students' perception of safety in the clinical setting and perception of communication safety reporting was significantly higher than the senior-level students' on several of the survey questions (Table). There were no significant differences in the remaining nine questions on safety in the clinical setting and the 13 questions on communication and safety reporting.
Student Perception of Safety and Communication of Safety Reporting in the Clinical Setting
An analysis of the responses to the questions regarding students' perception of safety in the clinical setting revealed that more than one third reported thinking mistakes are held against them (39% agree or strongly agree) and held against the nurses (46% agree or strongly agree). In addition, 21% (strongly disagree, disagree, or neither) of the students responded that they do not believe nurses and students discuss safety issues. Overwhelmingly, students responded they have a safety focus for their patients (97% agree or strongly agree), policies and procedures are good at preventing errors (93% agree or strongly agree), and students believe they are providing safe care (98% agree or strongly agree).
An analysis of the responses to the questions regarding students' perception of communication and safety reporting revealed students are afraid to speak up if they see something wrong that could negatively affect the patient (36% never, rarely, or sometimes). Regarding communicating errors, findings found:
- Students and nurses in the unit discuss ways to prevent errors from happening (44% responded never, rarely, or sometimes).
- Students are afraid to ask questions if something does not seem right (20% responded most of the time or always).
- Students are informed about errors that happen during the semester (53% responded never, rarely, or sometimes).
An alarming finding was students responding (57%) they would never, rarely, or sometimes report an incident when an error was made that does not have the potential to harm to the patient. When an error was made that could harm the patient but does not, 33% of the students responded that they would never, rarely, or sometimes report the occurrence. Overwhelmingly, the students responded that they were concerned about errors (95%), that the nurses were concerned about errors (93%), and that the clinical instructor was supportive of the student when an error occurred (82%). Students were asked to identify the type of errors they encountered. Sixty-two percent of the students responded they have never encountered an error. When an error was encountered, the most common error reported was a medication error (19.5%). To a smaller degree, needle sticks, wrong treatment, and omission of treatment made up 10% with the remainder noted as “other.” Of the students who encountered an error, 18% reported they did the reporting, 38% were reported by the instructor, and 44% of the time a safety tool was not completed. Of the students who did complete the tool, 36% said it was easy to access, 4% did not find the tool easy to access, and 60% could not recall. The question regarding ease of use of the tool revealed that 36% of the students who completed the tool reported it was easy to use, 3% said it was not, and 61% reported no recall of use.
Students were also asked to report on the number of near-miss events encountered. Sixty-seven percent of the students stated they never encountered a near miss. The most common near-miss error reported was potential medication administration errors (20%), with the remaining 17% including potential wrong patient, wrong treatment, and treatment omission. Students who stated they witnessed or encountered a near miss were asked if a safety tool was completed. Only 11% of the time a tool was completed by the student, 12% of the time by the instructor, and 77% of the time a tool was not completed.
In an attempt to glean more information on safety concerns from the student, an additional open-ended question was asked: “Do you have any additional feedback regarding safety?” Only 25 of the participants responded to the open-ended question. Although no themes emerged from the responses, several students commented on a desire to learn how to complete an incident report, a request there be more discussion on safety in the clinical setting, as well as the classroom, and verbalization of fear of making mistakes.
Findings from this study are consistent with findings of other studies in the literature. For example, the more favorable perception of the junior-level students than seniors in the areas of the student, patient, and faculty having a safety focus is consistent with findings from Duhn et al. (2012) and Ginsburg et al., (2012). They found that students were more confident in learning about patient safety earlier in the program than in the junior and senior years, suggesting a need for consistently engaging students in safety principles throughout the program. Being afraid to speak up if they see something wrong, afraid to ask questions if something does not seem right, and not being informed about errors that happen during the semester are all findings consistent with Cooper's (2013) findings on safety communication and barriers to reporting. Our findings that there is limited involvement in incident reporting among students is consistent with the past findings (Pearson et al., 2010). Although these findings are consistent with the literature, it should be noted that this study was a single-site study; therefore, generalizability is a limitation.
Overall, the findings showed that students reported concern for patient safety as a focus of clinical practice, along with their perception that their practice is safe. They also reported that the nurse was focused on patient safety and nursing faculty was supportive if an error occurred in the clinical setting. However, other findings in this study were not consistent with promoting a culture of safety, such as the areas of communication regarding patient safety and reporting of errors and near misses. Findings such as mistakes were held against them, the lack of open discussions about safety issues, errors not being reported that do not cause patient harm, the lack of reporting near misses, and not feeling free to speak up if they see safety concerns are areas that need to be addressed. These findings are consistent with the literature that identifies continued barriers to reporting errors and near-miss events (Cooper, 2013; Duhn et al., 2012). In an environment where there is such an emphasis on patient safety, these findings are of great concern. The results indicated further action in the areas of education, practice, and research are warranted. It is imperative that educators work closely with clinicians to address ways to enhance the safety culture in health care.
Educational institutions should lay the foundation for expectations of safe practice in the clinical setting. The findings indicate a need for curricular change with more emphasis on the safety culture. The concept of safety needs to be integrated throughout the nursing curriculum, beginning with fundamentals and concluding with program completion. QSEN competencies need to be incorporated in all clinical and theory courses, with an emphasis on application in the clinical setting. An effective teaching strategy to integrate safety concepts into clinical practice is the use of clinical simulation. Students would have an opportunity to practice safety aspects of patient care in a protected environment. Simulations need to be developed that incorporate collaborative practice with a focus on the health care team and the patient being an integral part of that team.
This could also provide an opportunity to aid the students in enhancing communication with other health care providers by using the tools provided by the Agency for Healthcare Research and Quality (2017)—situation, background, assessment, recommendation handoffs; medication reconciliation; and rounding. Special emphasis should focus on areas of concern including (a) incident report completion, (b) the importance of near-miss event reporting, and (c) how this can help to prevent patient harm. Students need to be made aware and shown that the information obtained through the reporting system will be used to identify system issues within the organization that contributed to the error occurrence, not to penalize individuals for their mistakes. Students should also be made aware that any error is significant enough to report. In order for systems issues to be identified, errors and near misses need to be reported. For this to occur, it is critical that all nursing students are aware of what constitutes an error and realize the importance of reporting all errors regardless of their belief about the error's significance or insignificance.
The culture in a university nursing program and clinical sites should be nonpunitive regarding error occurrence. Faculty and clinical agencies should be supportive of students learning from mistakes. Creating this type of nonpunitive culture takes time. The education and health care industries can learn much from the aviation industry, where there is a focus on dealing with the unexpected and being alert to the possibility of errors. Every day, nurses are expected to handle a variety of issues and situations that are not expected. It is important that nurse faculty and health care leaders create an environment where this is recognized and students and staff are rewarded for discussing these situations. Nurse faculty and health care leaders should openly discuss errors that have occurred and obtain feedback from students and staff on the way these errors could be prevented in the future. This will reinforce to the students and nursing staff that not only is it safe to report errors, but that something is actually being done to prevent them from occurring in the future.
The study findings support continued qualitative and quantitative research in this area. Qualitative studies are needed to investigate student perceptions of safety and communication in more detail. These types of studies could clearly assist more in identifying barriers to the implementation of a safety culture in educational institutions and in health care settings. Also, the findings indicated the need for research on interventions to enhance safety and communication practices in the classroom and clinical settings. In addition, an investigation of best practices in nursing programs and organizations with better safety outcomes should be explored and implemented when appropriate.
This study indicates nursing students may be entering the workforce not prepared to embrace a safety culture. The students revealed a lack of understanding of the importance of communicating and addressing errors and near-miss events in patient care practice. Nursing programs and health care organizations must move away from expecting perfection from students and providers and recognize that individuals make mistakes. A culture where reporting is encouraged, and system improvements are made is needed to enhance the quality and safety provided to patients. Practice settings need to develop this culture and become role models for students during clinical rotations. This transformation requires a different approach to quality improvement—one where emphasis is placed on identification of errors and proactive identification of system problems that lead to errors.
- Agency for Healthcare Research and Quality. (2012). Hospital survey on patient culture: 2012 user comparative database report. Retrieved from https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/2012/hospsurv121.pdf
- Agency for Healthcare Research and Quality. (2017). Implement teamwork and communication. Retrieved from https://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/modules/implement/index.html
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Student Perception of Safety and Communication of Safety Reporting in the Clinical Setting
|Clinical Setting Questions: Your Work Area in the Clinical Setting||Junior Students' Mean Score on 1–5 Likert Scale||Senior Students' Mean Score on 1–5 Likert Scale||t||p|
|As a student, I have a safety focus for my patient.||4.56||4.37||2.340||⩽ .020|
|My patient has a safety focus for my shift.||4.00||3.75||2.214||⩽ .028|
|My clinical instructor focuses on safety issues.||4.25||4.01||2.073||⩽ .039|
|Students are informed about errors that happen during the semester.||3.45||3.10||−1.245||⩽ .021|