Original Article

Learning Patient Safety in Academic Settings: A Comparative Study of Finnish and British Nursing Students’ Perceptions Susanna Tella, RN, MNSc • Nancy-Jane Smith, PhD, MA, BA(Hons) • Pirjo Partanen, RN, PhD • Hannele Turunen, RN, PhD

ABSTRACT Keywords Patient safety, learning, nursing students, nursing education, academic settings

Background: Globalization of health care demands nursing education programs that equip students with evidence-based patient safety competences in the global context. Nursing students’ entrance into clinical placements requires professional readiness. Thus, evidence-based learning activities about patient safety must be provided in academic settings prior to students’ clinical placements. Aims: To explore and compare Finnish and British nursing students’ perceptions of learning about patient safety in academic settings to inform nursing educators about designing future education curriculum. Methods: A purpose-designed instrument, Patient Safety in Nursing Education Questionnaire (PaSNEQ) was used to examine the perceptions of Finnish (n = 195) and British (n = 158) nursing students prior to their final year of registration. Data were collected in two Finnish and two English nursing schools in 2012. Logistic regressions were used to analyze the differences. Results: British students reported more inclusion (p < .001) of “gaining knowledge,” “training skills,” and “highlighting affirmative attitudes and motivation” related to patient safety in their programs. Both student groups considered patient safety education to be more valuable for their own learning than what their programs had provided. Training patient safety skills in the academic settings were the strongest predictors for differences (odds ratio [OR] = 34.69, 95% confidence interval [CI] 7.39–162.83), along with work experience in the healthcare sector (OR = 3.02, 95% CI 1.39–6.58). Linking Evidence to Action: To prepare nursing students for practical work, training related to clear communication, reporting errors, systems-based approaches, interprofessional teamwork, and use of simulation in academic settings requires comprehensive attention, especially in Finland. Overall, designing patient safety-affirming nursing curricula in collaboration with students may enhance their positive experiences on teaching and learning about patient safety. An international collaboration between educators could help to develop and harmonize patient safety education and to better prepare nurses for practice in the global context.

INTRODUCTION Building safer health care is a global concern that depends on the quality of nursing education. Rapidly changing, complex healthcare systems with multiple challenges set demands for education to better prepare new nurses for working life (Francis, 2013; Institute of Medicine, 2011). International guidelines stress a need for healthcare students to learn evidence-based patient safety competences such as key terms and concepts, national and international policy, methods and tools, and, moreover, for nursing faculty to develop and harmonize patient safety education in healthcare curricula (European Network for Patient Safety [EUNetPaS], 2010;

154

World Health Organization [WHO], 2011). The comparability of nursing curricula in different countries has a potential to enhance patient safety and quality of care (Sherwood & Shaffer, 2014). As a relatively new discipline, patient safety applies methods of safety science and aims to achieve creating a trustworthy system of health care delivery to avoid, prevent, and ameliorate “adverse outcomes or injuries stemming from the process of health care” (Vincent, 2010).

BACKGROUND On national levels, system-wide efforts to improve patient safety have been undertaken in the United Kingdom since Worldviews on Evidence-Based Nursing, 2015; 12:3, 154–164.  C 2015 Sigma Theta Tau International

Original Article 2000, launched by the report An Organisation With a Memory (Secretary of State for Health, 2009). The following year, the National Patient Safety Agency (NPSA) was established to lead and contribute in the development of safe patient care with guidance such as Seven Steps to Patient Safety (NPSA, 2004, 2014). In Finland, the development of a safer health care started in 2007 with the planning of the Finnish Patient Safety Strategy 2009–2013 (Ministry of Social Affairs and Health [MSAH], 2009), continuing with the Health Care Act (2010) and a national program in 2011 that supports healthcare institutions in systematic promoting of patient safety based on the Finnish strategy (National Institute for Health and Welfare [NIWH], 2014). In both countries, healthcare educators have been instructed to embed patient safety strategies comprehensively in the undergraduate and other levels of education (NIWH, 2014; Secretary of State for Health, 2009).

Patient Safety in Nursing Curricula The Quality and Safety Education for Nurses (QSEN) initiative in the United States is a good example of a national effort to comprehensively develop patient safety education in a nursing program. According to the QSEN (2014), safety is defined as the minimization of risks to patients and providers through system effectiveness and individual actions. The main competences include patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Safety knowledge, skills, and attitudes include patient safety issues such as human factors, preventing errors (such as with checklists and barcodes), analyzing errors, and designing system improvements (root cause analysis), safety culture (open communication and error reporting systems), and concepts related to a just culture (Cronenwett et al., 2007; Bryer & Peterson-Graziose, 2014; Sullivan, Hirst, & Cronenwett, 2009; QSEN, 2014). In the United Kingdom, the Nursing and Midwifery Council [NMC] (2010) provides comprehensive and detailed guidance to help nursing educators embed patient safety in nursing curricula. The principles of preregistration nursing education are connected to the standards of competence for registered nurses. Thus, nursing education includes such patient safety competences as person-centered care, infection control, clear and effective communication, teamwork, and reporting errors, which is described in more detail by two progression points. Nevertheless, national patient safety guidelines for nursing education to build evidence-based curricula can be fairly general in nature, such as in Finland (NIWH, 2014). In Finland, new national instructions for designing nursing curricula with patient safety as an eligible competence are in process and have the purpose of reworking former guidelines (Ministry of Education [ME], 2006). However, the intention of the WHO’s (2011) multiprofessional patient safety curriculum guide was to be utilized on national levels. The guide gives recommendations for patient-centered curricula with systems-based, team-dependent approaches highlighting the preventability of adverse events, learning from errors, Worldviews on Evidence-Based Nursing, 2015; 12:3, 154–164.  C 2015 Sigma Theta Tau International

and integrating patient safety in all professional learning in health care. Unfortunately, the role of patient safety varies in nursing education. Despite having been recognized as an important topic, patient safety is not necessarily evident in written nursing curricula, but is nevertheless taught in both academic and clinical settings (Cresswell et al., 2013; Steven, Magnusson, Smith, & Pearson, 2014). In academic settings, it is important for nursing students to learn about complex patient safety issues, internalize sufficient knowledge about basic principles and policies, practice multiple skills such as structured communication and reporting on errors, and have affirmative attitudes, such as holding themselves accountable before entering clinical placements (WHO, 2011). Students have perceived that they learn most of their patient safety knowledge in academic settings, whereas training skills such as recognizing patient safety problems, implementing safety solutions, and anticipating and managing high-risk situations are learned in clinical settings (Ginsburg, Tregunno, & Norton, 2013; Sullivan et al., 2009). This may arise from the reality that students have not had an opportunity to acquire the competences in academic settings since the discipline of patient safety is new and has not necessarily been a part of the curricula. On the other hand, it seems that academic settings are perceived as a safe environment in which to learn about working in multiprofessional teams, communicating effectively, discussing errors, and understanding the system-based nature of patient safety problems. Overall, nursing students were also more confident to speak up in academic settings (Ginsburg et al., 2013). A safe and supportive culture with a systems approach advances learning about how to communicate professionally regarding errors and makes it easier to identify and respond to problems and challenges (Barnsteiner & Disch, 2012). In addition, nursing students seem to have affirmative attitudes toward patient safety. Nursing students consider patient safety and reporting incidents as high priorities in healthcare systems (Pearson et al., 2010; Sullivan et al., 2009). It is essential to learn about patient safety, transformative integration of knowledge, skills, and attitudes in order to build professional competence. This requires critical self-reflection and an openness to change (Baartman & de Bruijn, 2011).

Gap Between Education in Academic and Clinical Settings Research on nursing students’ perceptions about nursing education stresses the importance of developing patient safety education. Overall, students perceive a gap between learning in academic and clinical settings. (Steven et al., 2014; Vaismoradi, Bondas, Jasper, & Turunen, 2014). Simulation education is one evidence-based method that can narrow the perceived gap (Gantt & Webb-Corbett, 2010; Ironside, Jeffries, & Martin, 2009; Shearer, 2013). For example, rigorously implemented simulation education can decrease medication errors by providing a clinical experience for nursing students.

155

Learning Patient Safety in Academic Settings

Simulation may also improve students’ knowledge and attitudes related to safety (Shearer, 2013). Lewis, Strachan, and Smith (2012) found positive effects of high fidelity simulation starting with significantly improved interpersonal communication skills and team behavior. Students were more prepared for crisis situations; they gained leadership experience and had a chance to develop critical thinking and reasoning skills. Simulation education can potentially equip nursing students with affirmative patient safety knowledge, skills, and attitudes before encountering real-life clinical situations.

PURPOSE The purpose of this study was to determine the current state of patient safety education in nursing programs from preregistration nursing students’ perspectives in order to inform nursing and healthcare education faculty about designing future curricula. The study explores and compares Finnish and British nursing students’ perceptions of their learning about patient safety in academic settings. The specific objective was to determine the potential predictive factors that explain differences between Finnish and British students’ perceptions of teaching and learning about patient safety.

METHODS Design This study was a cross-sectional, nonexperimental survey. It was conducted in a Finnish–British research group as part of a larger patient safety in a nursing education research project.

Settings and Sample The European Union (EU) regulates European nursing education, requiring that theoretical education encompass at least one third and clinical practice at least one half of the entire nursing program. The scope of general nurse education is 180 ECTS (European Credit Transfer and Accumulation System) credits (Council Directive 2013/55/EC, 2010). In the United Kingdom, the NMC (2010) recommends that the proportion of theoretical education cover 50% of the 4,600-hour program. In Finland, the current nursing education encompasses 210 ECTS credits and, thus, the theoretical portion covers more than one half of the nursing program, as clinical practice does not exceed 90 ECTS credits (ME, 2006). The study took place in two Finnish universities of applied sciences and in two English, United Kingdom, universities. Power analysis was performed using G* Power software (Faul et al., 2007). The Wilcoxon-Mann-Whitney test was used with significance level 0.05 and power 80%. Three hundred questionnaires were distributed in each country, with the expectation of 150 questionnaires per country being returned. The total amount of returned responses was 353, of which 195 were from Finland and 158 were from England, United Kingdom. Thus, it was possible to detect a 0.33 effect size. The inclusion criteria for respondents were full time, final year preregistration nursing students, completing a bachelor’s

156

degree in 3 years in the United Kingdom and in 3½ years in Finland. The Finnish students filled out the Patient Safety in Nursing Education Questionnaire (PaSNEQ) in Finnish and British students in English. Written instructions with detailed explanations about filling out the PaSNEQ were provided to the respondents in a class room setting. The data were collected in 2012.

Ethical Considerations A favorable statement on the ethical acceptability of the study was granted by the University Committee on Research Ethics. Approvals for the study were obtained from the participating organizations in the United Kingdom and in Finland. The cover letter of the questionnaire included statements about participants’ anonymity throughout the research process and the voluntary nature of their participation. Completing the questionnaire served as informed consent (Burns & Grove, 2009). The cover letter also included information about the details of the study, including its purpose, data collection and analysis, names of the researchers, and contact information.

The Development of the PaSNEQ The PaSNEQ was designed to gain understanding of nursing students’ learning about patient safety in nursing programs. The PaSNEQ contains questions regarding participants’ background information, students’ views about education in academic and clinical settings, and their patient safety competences. This paper focuses on didactic teaching in academic settings (e.g., face-to-face education, e-learning, or simulation). The study used two scales: the Included in Education in Academic Settings (INCa) and the Important for Students’ Own Learning of Patient Safety (IMPa). Responses were rated the same for both scales, using a 4-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). The validity and reliability of PaSNEQ was considered in several ways (Burns & Grove, 2009). The validity was confirmed in seven phases (Figure 1). First, the questionnaire was developed on the basis of relevant patient safety literature and international guidelines (EUNetPaS, 2010; WHO, 2011). An integrative literature review was carried out to summarize research literature from teaching contents and methods and to review nursing students’ learning patient safety in nursing education (Tella et al., 2014). The initial PaSNEQ was designed in Finnish (IQF1). Second, the PaSNEQ was assessed by an expert panel (n = 5) to evaluate the face and content validity of the instrument. The expert panel consisted of patient safety experts and nursing education faculty in Finland. Discussions with British authors supported the development phase. The expert panel evaluated the clarity and relevance of the instrument using content validity index (CVI) developed by Waltz and Bausell (1981). CVI was used to obtain the numerical value of the instrument with each item on a 3-point rating scale: 1 = not relevant; 2 = somewhat relevant, needs minor alteration; and 3 = relevant or very relevant (Burns & Grove, 2009). If an item was rated with 1 or 2, Worldviews on Evidence-Based Nursing, 2015; 12:3, 154–164.  C 2015 Sigma Theta Tau International

Original Article 1. Integrative literature review – Initial questionnaire in Finnish (IQF1) 2. Finnish expert panel (n = 5) estimation and discussions within Finnish-British research group (n = 5) 3. Forward-translation to English (FTE1) 4. Blind back-translation to Finnish (BTF2) 5. Blind back-translation to English (BTE2) 6. Comparing Finnish and English versions

7. Pilot testing – Finnish (n = 24) and English versions (n = 15)

Based on the pilot, changes to ensure the clarity of the questionnaire were made (Burns & Grove, 2009). The sum variables were formed from the INCa scale by using principal component analysis (PCA). The Kaiser–Meyer– Olkin (KMO) criteria with threshold ࣙ .6 were used to indicate if correlations were suitable for conducting PCA, eigenvalue >1 was set with Varimax rotation, and item loadings above .4 were accepted as significant values. A three-factor solution was found explaining 55.34% of the variance. The KMO was .938, which indicated that correlations were adequate. Based on the factor solution, mean sum variables were formed by counting together the values of items and dividing the outcomes with the total number of items. Two variables were left outside, as they did not meet the requirement to loadings over .4. The variables about the use of checklists (e.g., the surgical safety checklist) and learning systematically from errors are presented at the end of Table 1, but were not included in the sum variables. Furthermore, we formed equal sum variables from the IMPa scale and examined both scales with Spearman’s correlations (accepted ࣙ .3) varying from .311 to .618, and with Cronbach’s alphas varying from .784 to .853 (Table 2).

Data Analysis Figure 1. Development Process of the PaSNEQ Instrument.

consensus was sought between the panel members and necessary changes were made into the instrument. Third, the PaSNEQ was translated from the Finnish language into English. Forward-translation from Finnish to English (FTE1) was conducted by a bilingual, native English speaking translator (Sousa & Rojjanasrirat, 2011). The WHO (2011) has considered patient safety as a highly important area in healthcare education around the world, which increases cultural understanding of basic patient safety concepts. Fourth, a blind back-translation to Finnish (BTF2) was completed (Sousa & Rojjanasrirat, 2011). The translator was a bilingual, native Finnish speaker fluent in English. Subsequently, the fifth step was to conduct a second blind back-translation from Finnish to English (BTE2). The sixth step was to compare the IQF1, FTE1, BTF2, and BTE2 versions of the instrument. In this phase, the researcher and two bilingual translators evaluated the conceptual equivalence of the translations (Sousa & Rojjanasrirat, 2011). Ambiguities and discrepancies of the first and second versions of Finnish and English were compared and resolved through consensus among the Finnish–British research group. The simplicity of the PaSNEQ was confirmed through piloting the Finnish and English versions. The seventh step included piloting the questionnaire with a group of Finnish (n = 24) and British (n = 15) preregistered nursing students to ensure that the questionnaire was understandable and logical. Open-ended questions were used to obtain information for the development of close-ended questions for the main study. Worldviews on Evidence-Based Nursing, 2015; 12:3, 154–164.  C 2015 Sigma Theta Tau International

Data were analyzed using Statistical Package for the Social Sciences (SPSS; Windows Version 19.0, IBM Corporation, Armonk, NY, 2010). The background variables were categorized as follows: Age 25 years or under, 26–35 years, and 36 years or over; work experience in health care and other sectors under 1 year, 1–4 years, and 5 years or over. Descriptive statistics, such as cross-tabulations and Pearson’s chi-square tests were used to compare Finnish and British data (Tables 1 and 2). In addition, means and standard deviations were calculated for the sum variables. The normality of the distributions of the sum variables was examined using the Kolmogorov–Smirnov test, indicating that all sum variables were skewed (p < .001). Thus, the Mann–Whitney U test was used to analyze differences between the groups. Binomial logistic regression analysis was used to examine the possible predictive factors in Finnish and British nursing students’ perceptions about teaching and learning patient safety in academic settings. Statistical significance was considered with p values ࣘ.05.

FINDINGS Background Variables There were significant differences between Finnish (n = 195) and British (n = 158) preregistration nursing students’ demographic characteristics related to age, work experience in health care, and work experience in other sectors (Table 3). Respectively, 29% and 34% of the students had participated in a separate patient safety course.

Comparing Perceived Inclusion and Importance of Patient Safety Issues. Overall, the results indicate that British students had significantly more positive perceptions of “patient safety included in nursing education” compared to Finnish

157

Learning Patient Safety in Academic Settings

Table 1. Finnish and British Preregistration Nursing Students’ Perceptions About Patient Safety (PS) Education at the Academic Settings, Percentages (%) Presented on the Likert Scale 1 = Strongly Disagree, 2 = Disagree, 3 = Agree, and 4 = Strongly Agree

INCa

IMPa

Finnish

British

Finnish

British

(n = 193–195)%

(n = 152–155)%

(n = 193–195)%

(n = 148–152)%

1

2

3

4

1

2

3

4

p

1

2

3

4

1

2

3

4

p

PS education has been a part of all phases of my nursing program

4

21

61

15

1

11

52

35

Learning Patient Safety in Academic Settings: A Comparative Study of Finnish and British Nursing Students' Perceptions.

Globalization of health care demands nursing education programs that equip students with evidence-based patient safety competences in the global conte...
275KB Sizes 0 Downloads 9 Views