A major challenge for nurse educators is to teach prelicensure nursing students to perform safe nursing care using a systems thinking approach. Systems thinking is an approach to assist health care professionals to improve patient safety (Dolansky & Moore, 2013; Schyve, 2005). Nursing practice has long viewed patient safety through a narrow lens of avoiding medication errors and preventing patient falls, with causes for errors identified at both system and practice levels (Dolansky & Moore, 2013). Although having students acknowledge personal responsibility is essential to ensure patient safety, systems thinking enables new and productive approaches to address patient safety within health care organizations.
Miltner, Patrician, Dawson, and Jukkala (2012) noted that, historically, education about quality and safety focused on the knowledge, skill, and vigilance of individual practitioners. A shift occurred partly in response to the Institute of Medicine's (2003) Health Professions Education: A Bridge to Quality report. Schyve (2005) stated that, as recently as two decades ago, the health care system reacted to preventable patient harm as an anomaly and sought to blame and punish individual practitioners. Opportunities to review conditions in which an error occurred were hampered because focus centered on blame and punishment as opposed to understanding the context in which the error occurred and the interconnectedness to individuals or disciplines within a system.
In the past decade, a paradigm shift occurred within health care with the introduction of systems thinking (Dolansky & Moore, 2013; Schyve, 2005). Schyve suggested that systems thinking provides a less threatening platform to move beyond assigning blame. It offers opportunities to examine a combination of design and environmental failures while systematically reviewing how individuals, program structures, and processes may be contributing to errors and undermining patient safety. Dolansky and Moore stated that health professionals have rudimentary knowledge of systems thinking and its usefulness when tackling complex problems within the health care system.
Finkelman and Kenner (2012) challenge nursing schools to move safety and quality improvement approaches, more specifically systems thinking, from the background to the forefront in all parts of nursing curricula (Dolansky & Moore, 2013). There is a gap in the literature examining knowledge and skills of systems thinking in prelicensure curricula (Dolansky & Moore, 2013). This article describes the design and evaluation of a pilot study to determine the effect of an on-campus educational strategy on nursing students' knowledge and skills associated with systems thinking in a prelicensure, four-year baccalaureate nursing program in the mid-Atlantic region of the United States.
EDUCATIONAL STRATEGY
The goal of this pilot study was to design a learning strategy that prepares future professional nurses to use systems thinking approaches in the delivery of safe patient care. Vygotsky's (1978) theory, grounded in social constructivism, emphasizes that learning takes place in social interactions. Central to this theory is the zone of proximal development, described as the difference between what a learner can do independently and what a learner can do when collaborating with experienced teachers and/or peers (Handwerker, 2012; Vygotsky, 1978). Vygotsky states that new knowledge and skills can be co-constructed within the zone of proximal development when interactions occur in a social learning environment. Faculty purposely combined sophomore students with juniors, who had more clinical practice, in groups of five to six to facilitate an interactive learning environment. These collaborative groups explored the nurse's role in creating safe practice environments. Two course faculty built experiential learning activities to enhance clinical reasoning through the lens of systems thinking.
The strategy encompassed a three-pronged approach. The first prong consisted of an introduction to patient safety risks using a video, The Josie King Story (King, 2001), and continued with a patient safety slide presentation. Using a medication error case study, the second prong included students' discussion of their reaction to making an error. Students completed a flow chart on how the error occurred, created a mock adverse event report, and role-played how to communicate an error to a professional nurse in a supervisory role.
As the last prong, student groups examined a medication error case study from a systems perspective. They completed a root cause analysis by using a quality improvement tool, fishbone diagram, and then identified potential causes for a medication error. This prong supports the benefits of systems thinking in identifying and understanding the larger picture. Student discussion centered on how leadership within organizations establishes a framework for improvement and can subsequently identify priority areas for enhancement.
PILOT STUDY DESIGN AND EVALUATION
The design of the study was a descriptive, pretest-posttest design. A convenience sample of 84 undergraduate nursing students, composed of 47 sophomores and 37 juniors, volunteered to participate in the study. Sophomore and junior students attending a prelicensure, four-year baccalaureate nursing program were the study participants. The sample size exceeded the minimum requirement of 28 identified in the power analysis using Faul, Erdfelder, Lang, and Buchner's (2007) G*Power 3.1 technique with alpha ([alpha];) = p = .05, medium effect size, with power of .80. The pilot study proposal was approved by the university's institutional review board.
The author of the 20-item Systems Thinking Scale instrument granted approval prior to this study (M. Dolansky, personal communication, August 15, 2012). Before the start and at the conclusion of the four-hour on-campus educational strategy, participants completed the Systems Thinking Scale instrument. No identifying information was included on this instrument.
RESULTS AND DISCUSSION
Inferential statistics, a paired t-test, was used to test significant differences between the pre- and posttests for the research question: Is there a change in prelicensure baccalaureate nursing students' systems thinking scores from pre- to posttest for students who participate in an on-campus educational strategy? The alpha ([alpha]) level for all analyses as appropriate was p <= .05. Statistical significance was noted with students' systems thinking from pretest (M = 60.0, SD = 9.86) to posttest (M = 65.6, SD =11.02), t(-4.65), p = .000.
The on-campus educational strategy positively impacted a systems thinking approach to patient safety with prelicensure baccalaureate nursing students. The findings were consistent with previous studies, which found that nursing programs may benefit from curricular activities to improve understanding of systems thinking (Dolansky & Moore, 2013; Phillips, Stalter, Dolansky, & Lopez, 2016). The on-campus educational strategy may have broadened thinking about medical errors with a change in the focus of error from the individual to possible multiple causes and sequence of events. If nurse educators hope to develop students' ability to engage in systems thinking, faculty must expand nursing curricula to consistently incorporate learning strategies on systems thinking.
Limitations
Using a convenience sample from one location limits generalizability of results. This study occurred with a homogeneous student population of traditional-aged college students, 18-24 years, from the mid-Atlantic region of the United States, which may differ from other prelicensure nursing programs. Administering a pre- and posttest within an activity is another limitation. It is difficult to discern if knowledge changes are related to the educational strategy or reinforced existing knowledge. Using the same test for both pre-and posttest, students may absorb knowledge just from taking the test. A randomized control study with a diverse student population from multiple universities and retesting students at a later time in their education may strengthen the study and generalizability of test results.
CONCLUSION
This study suggests that integrating systems thinking principles in prelicensure nursing curricula has the potential to improve future practitioners' application of systems thinking in the clinical environment. Within a social learning environment, students explored the meaning of systems thinking to gain a better understanding of their role as future practitioners in creating safe practice environments. This type of learning environment supports Vygotsky's (1978) theory that construction of knowledge occurs when students work collaboratively rather than independently. Integrating teaching strategies in didactic and clinical education throughout nursing curricula will elucidate the principles of systems thinking and shape a broader understanding of how all parts of a system connect in the delivery of safe patient care.
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