Driven by the Institute of Medicine's call for transformation in health care professionals' education,1 the Quality and Safety Education for Nurses (QSEN) Institute led efforts to develop 6 competencies identifying the knowledge, skills, and attitudes needed for graduate nurses to provide safe, quality care.2 To promote the transfer of learning into clinical practice, competencies related to patient safety should be incorporated early in nursing curricula using active teaching strategies that promote student engagement.3

There is a lack of empirical studies exploring the impact of the QSEN safety competency on prelicensure nursing students' outcomes. Only 1 study has explored knowledge and comfort related to patient safety among nursing students who received didactic and clinical integration of QSEN safety tools during a first-semester fundamentals course.4 Results from studies regarding student perceptions of preparedness related to patient safety vary.5,6 The purpose of this study was to determine the effect of active, student-centered teaching strategies on baccalaureate nursing students' knowledge, skills, perceptions, and comfort related to patient safety.

Methods

Following institutional review board approval, a convenience sample of sophomore baccalaureate nursing students (n = 161) in a midsized, Catholic university in the mid-Atlantic region of the United States was recruited. Six males and 150 females participated in the study (5 individuals did not identify gender). The majority of participants were 19 (n = 105 [65.2%]) or 20 (n = 41 [25.5%]) years old with an age range from 18 to 29 years (mean, 19.46 years).

Instruments

The Safety Knowledge Assessment (SKA), developed by the co-principal investigators, is a 15-item multiple-choice test that assesses patient safety knowledge. Content validity was determined by 6 patient safety experts (scale content validity index [S-CVI] = 0.93). Cronbach's [alpha] for this study was low, ranging from .155 at pretest to .429 at posttest.

The Healthcare Professionals Patient Safety Assessment (HPPSA) is an existing tool that measures attitudes and comfort related to patient safety.7 Part 1 was used to assess participants' perceptions of patient safety; Part 2 was used to assess their comfort related to patient safety. The original developer reported a Cronbach's [alpha] reliability of .71 for parts 1 and 2.7 For the current study, Cronbach's [alpha] for part 1 ranged from .336 to .608, and Cronbach's [alpha] for part 2 ranged from .778 to .833.

The Clinical Evaluation Instrument (CEI) for clinical practica at the study school consists of 10 objectives, one of which specifically addresses patient safety. For each objective, students earn a score from 1 to 4 (1 = failing, 2 = basic, 3 = advanced, 4 = superior). Participant scores on the safety objective in the Practicum in Essentials of Nursing Practice clinical course were used to assess skill competence related to patient safety.

Procedure

Subjects were recruited in class at the end of the semester before their Essentials of Nursing Practice course. At this time, participants completed a voluntary written consent, demographic data, HPPSA parts 1 and 2 pretest, and SKA pretest. Subjects were posttested using the HPPSA parts 1 and 2, and SKA during the last class period of their Essentials of Nursing Practice course. Scores on the CEI safety objective for the Practicum in Essentials of Nursing Practice course were obtained at the end of the semester.

Several active, student-centered teaching strategies including a preassigned learning module, an unfolding case study, online discussion boards, and a formative capstone simulation-based learning experience (SBLE) were implemented to enhance delivery of patient safety content.8 Students viewed the preassigned learning module, which discussed patient safety, safety culture, and preventable medical errors,9 and completed a study guide prior to the first day of the Essentials of Nursing Practice class.8 This strategy allowed faculty to address safety content through interactive discussion rather than lecture.8

The unfolding case study was integrated throughout the semester. Students received weekly updates about the case study patient along with related safety-focused discussion questions specifically associated with weekly course content.8 Students worked in small groups outside class to answer the discussion questions. The same student groups also completed a WebQuest,10 in which they reviewed patient safety Web sites and responded to related discussion questions.8 Both of these assignments were completed on online discussion boards on the university's course management system to foster student interaction and peer learning.

In the associated laboratory course, students participated in a safety-focused formative capstone SBLE prior to beginning their first clinical practicum.8 Students used the QSEN 60-second situational awareness11 to identify safety concerns, performed a safety assessment, and provided safe nursing care to a standardized patient.8 The CEI was introduced during debriefing to familiarize students with safety expectations in clinical.8

Study participants were divided into 4 groups based on graduation year and course section. The multiple intervention groups allowed the researchers to explore various combinations of teaching strategies. The control group (n = 18) learned patient safety information using traditional teaching strategies only (textbook readings and didactic lecture). Intervention group 1 (n = 28) completed the preassigned learning module and SBLE. Intervention group 2 (n = 90) completed the unfolding case study, WebQuest, and SBLE. Intervention group 3 (n = 25) participated in all the teaching strategies discussed above.

Data Analysis

The pretest/posttest scores on the SKA and HPPSA parts 1 and 2 were analyzed using repeated-measures analysis of variance. Scores on the safety objective of the CEI were analyzed using cross tabulations and [chi]² test.

Results

There was a statistically significant difference in CEI safety objective scores among the groups ([chi]²₆ = 41.308, P < .001). Intervention group 3 had the highest percentage in the "superior" column (88%), followed by intervention group 1 (76.9%), intervention group 2 (65.5%), and finally the control group (56.3%). There were no statistically significant differences among the groups between pretest and posttest scores on the SKA (F_3,111 = 0.427, P = .734), HPPSA part 1 (F_3,102 = 0.673, P = .570), or HPPSA part 2 (F_3,102 = 2.138, P = .10).

Discussion

There is insufficient nursing education literature exploring the impact of the QSEN safety competency on nursing students' outcomes. The findings of the current study support the use of active, student-centered teaching strategies to promote patient safety skill competence in the clinical setting, which provides objective support to previous qualitative findings that nursing students feel prepared to perform QSEN-related skills.5,6 The findings of this study, though, did not show a change in knowledge, perceptions, or comfort related to patient safety; this is contrary to existing literature that demonstrated an improvement in patient safety knowledge and comfort with integration of QSEN safety concepts through SBLEs.4

There were several limitations to the current study. The single-site, homogeneous age, and lack of ethnic background information limit generalizability. The SKA tool had low internal reliability, indicating the tool should be revised with further psychometric testing before being used again.

More research is needed related to the educational integration of the QSEN safety competency on nursing students' knowledge, perceptions, and skills related to patient safety to address the gap in the nursing education literature. Specifically, the current study should be replicated with a larger sample and at multiple sites. Furthermore, the SKA tool should be revised and retested to gain more information about psychometrics and increase reliability.

Acknowledgment

The authors acknowledge the Villanova Institute for Teaching and Learning (VITAL) for the mini grant support for this project.

References