Table 1
General and specific features on PS of the BNSs involved in the study
| BNSc: general features | |
|---|---|
| Admission and enrolment | A nationwide entry exam is mandatory for all BNSc candidates. Candidates must have at least 12 years of prior education to applying. The candidates-to-places ratios in the involved nursing program were 2.7 to 1. |
| Program duration | 180 university credits; 5,400 hours; 3 years. |
| Theoretical and practical clinical learning model | According to the block system model, 5 months/year are dedicated to lectures and 6 months/year to clinical training. One month/year is dedicated to a mandatory holiday. |
| Lectures | Approximately 30 credits/year, 36–40 hours per week. It is compulsory for students to attend at least 70% of the scheduled lectures. |
| Clinical training | Approximately 20 credits/year, 36 hours/ week. Attendance is mandatory for 100% of the scheduled hours of learning. These hours are as follows: |
| 1. 1st year: 30 hours of skill labs and 480 hours of clinical training (two periods of practical experience in medical and surgical units); | |
| 2. 2nd year: 30 hours of skill labs and 600 hours of clinical training (three periods of practical experience in specialised medical and surgical units); | |
| 3. 3rd year: 30 hours of labs and 840 hours of clinical training (seven periods of practical experience in acute [intensive care, stroke unit], sub-acute [medical, surgical care], maternal and childcare and community care [mental health, nursing home, home care]. | |
| Number of examinations | Total = 20 exams. Students may progress from one year to the next after having obtained positive results in the theoretical and practical examinations. |
| Final examination | The BNSc ends with one exam consisting of a professional license and thesis discussion. The commission is composed of Faculty and members of the Nursing Board. |
| PS: specific features of the knowledge and competences developed | |
|---|---|
| Theoretical courses | PS: specific features of the knowledge and competences developed. |
| Two PS courses are offered: | |
| 1) Safety in the clinical environment | |
| Three modules (four credits, 120 hours) in the first semester of the 1st year based on the following core contents: a) the concept of healthcare workers’ safety; b) integrated risk management approaches in healthcare environments; c) Italian legislation on safety and health prevention/protection in healthcare environments with specific reference to the responsibility of nursing roles; d) main risk factors in the clinical environment for nursing students; e) PPE in the health-care context; f) principles of ergonomics; g) the standard precautions and mandatory protocols to be adopted in case of injury exposure (e.g. whom to report to and how); h) safe management of hospital waste. Students who have achieved a positive evaluation in the examination can be admitted to clinical training; | |
| 2) Risk management | |
| Four modules (four credits, 120 hours) in the first semester of the 3rd year. The course is focused on the following core contents: a) risks to patients and issues of PS in hospital and community settings; b) strategies at the system, team work and individual levels aimed at monitoring and protecting PS; c) standards for PS and effective strategies/methods to develop/improve PS; d) how to interpret reports on adverse events/ risks monitored in the health care system; e) organizational and nursing care factors affecting PS; f) the role of clinical documentation and incident reporting in PS; and g) ethical and medicolegal implications of PS. | |
| Clinical rotation | The main competences to be achieved from clinical rotations are as follows, and the complete list is available from authors: |
| 1. 1st year: identifying the risk of patients associated with healthcare practices; environmental factors such as workflow, ergonomics and resources which may affect PS; applying strategies to ensure safety at the patient and healthcare levels (e.g. wearing Personal Protective Equipment [gloves, glasses], checking patient identity); recognizing an adverse event and a close call; communicating adverse events or close calls; identifying the role of human factors in PS (e.g., fatigue due to shift work); | |
| 2. 2nd year: assessing the risk of healthcare associated infection, falls, pressure sores and other adverse events sensitive to nursing care; recognizing situations in which safety issues may arise; preventing adverse events with appropriate evidence-based interventions; administering medication safely; monitoring effects of medication administration; documenting nursing care; | |
| 3. 3rd year: preventing medication errors; identifying team dynamics and authority/power differences; managing interprofessional conflicts; enhancing PS through consistent and effective communication with patients and healthcare providers; recognizing an adverse event or close call; disclosing an adverse event to the patient; developing a questioning attitude and speaking up when the clinical environment and practices are unsafe. |
Diagram 1
Participant flow recruitment and inclusion.
Table 2
PS knowledge acquired in the classroom and PS competence developed in the clinical settings as perceived by students (=90) over the years.
| BNSc: general features | PS knowledge developed in the classroom | |||||||
|---|---|---|---|---|---|---|---|---|
| Factors and items, mean, 95% CI | 1st year P* | 2nd year P** | 3rd year P*** | 1st year P* | 2nd year P** | 3rd year P*** | ||
| Working in team | 4.1 (4.0-4.2) | 4.05 (3.93-4.18) | 4.02 (3.90-4.15) | 4.18 (4.07-4.29) | 4.11 (3.99-4.23) | 4.22 (4.09-4.35) | ||
| 1. Team dynamics and authority/ power differences | 4.13 (3.99-4.27) | 4.18 (4.04-4.31) | 4.13 (3.99-4.28) | 4.31 (4.18-4.44) | 4.31 (4.18-4.44) | 4.40 (4.26-4.54) | ||
| 2. Managing interprofessional conflicts | 4.10 (3.93-4.27) | 3.99 (3.82-4.16) | 3.88 (3.71-4.05) | 4.10 (3.94-4.26) | 4.02 (3.86-4.18) | 4.13 (3.97-4.29) | ||
| 3. Debriefing and supporting team members after an adverse event/close call | 4.16 (3.99-4.32) | 4.01 (3.82-4.20) | 3.91 (3.74-4.08) | 4.21 (4.04-4.38) | 4.06 (3.88-4.23) | 4.22 (4.04-4.41) | ||
| 4. Sharing authority, leadership, decision-making | 4.14 (3.99-4.28) | 4.16 (4.00-4.31) | 4.10 (3.97-4.23) | 4.13 (3.98-4.29) | 4.20 (4.06-4.34) | 4.28 (4.13-4.43) | ||
| 5. Encouraging team members to speak up, question, challenge, advocate, and be accountable as appropriate to address safety issues | 4.13 (3.97-4.30) | 4.08 (3.91-4.25) | 4.10 (3.97-4.28) | 4.24 (4.08-4.41) | 4.03 (3.85-4.21) | 4.13 (3.95-4.32) | ||
| Communicating effectively | 4.38 (4.25- 4.51) | 4.33 (4.18-4.47) | 4.50 (4.27-4.72) | 4.43 (4.27-4.58) | 4.33 0.027 (4.21-4.45) | 4.51 (4.38-4.64) | ||
| 6. Enhancing PS through clear and consistent communication with patients | 4.42 (4.28-4.56) | 4.45 (4.31-4.59) | 4.44 (4.32-4.57) | 4.61 (4.48-4.73) | 4.43 (4.30-4.56) | 4.52 (4.38-4.66) | ||
| 7. Enhancing PS through effective communication with healthcare providers | 4.41 (4.28-4.54) | 4.38 (4.23-4.53) | 4.40 (4.27-4.53) | 4.45 (4.31-4.58) | 4.41 (4.29-4.54) | 4.54 (4.41-4.68) | ||
| 8. Effective verbal/nonverbal communication abilities to prevent adverse events | 4.43 (4.16-4.48) | 4.21 (4.06-4.37) | 4.66 (4.01-4.70) | 4.38 (4.22-4.54) | 4.22 (4.08-4.36) | 4.48 (4.33-4.66) | ||
| Managing safety risk | 4.12 (3.98-4.25) | 4.19 (4.04-4.34) | 4.27 (4.15-4.38) | 4.18 (4.05-4.31) | 4.07 <0.01 (3.91-4.22) | 4.38 <0.01 (4.26-4.51) | ||
| 9. Recognizing routine situations in which safety problems may arise | 4.26 (4.12-4.39) | 4.32 (4.19-4.44) | 4.31 (4.18-4.44) | 4.36 (4.22-4.49) | 4.30 (4.16-4.44) | 4.47 (4.33-4.60) | ||
| 10. Identifying and implementing safety solutions | 4.15 (4.00-4.29) | 4.31 (4.20-4.43) | 4.28 (4.16-4.40) | 4.24 (4.10-4.37) | 4.10 (3.97-4.23) | 4.36 (4.22-4.49) | ||
| 11. Anticipating and managing high- risk situations | 4.06 (3.85-4.26) | 4.18 (4.04-4.32) | 4.22 (4.09-4.35) | 4.06 (3.8-4.26) | 4.02 (3.85-4.19) | 4.34 (4.20-4.49) | ||
| Understanding human and environmental factors | 4.21 (4.10-4.33) | 4.18 (4.04-4.31) | 4.27 (4.13-4.40) | 4.36 (4.25-4.47) | 4.27 (4.16-4.38) | <0.01 | 4.48 (4.36-4.60) | |
| 12. The role of human factors (fatigue) affecting PS | 4.20 (4.05-4.35) | 4.26 (4.09-4.42) | 4.27 (4.10-4.44) | 4.43 (4.30-4.56) | 4.49 (4.35-4.62) | 4.41 (4.26-4.56) | ||
| 13. Safe application of health technology | 4.12 (3.67-4.27) | 4.06 (3.89-4.22) | 4.19 (4.04-4.34) | 4.27 (4.10-4.44) | 4.09 (3.95-4.23) | 4.46 (4.31-4.60) | ||
| 14. The role of environmental factors, such as workflow, ergonomics, and resources, which effect PS | 4.33 (4.18-4.49) | 4.28 (4.15-4.40) | 4.36 (4.21-4.50) | 4.40 (4.24-4.56) | 4.26 (4.12-4.39) | 4.41 (4.26-4.56) | ||
| Recognizing and responding to adverse events | 4.12 (4.00-4.24) | 4.16 (4.04-4.28) | 4.25 (4.13-4.37) | 4.19 (4.06-4.32) | 4.06 (3.95-4.18) | <0.01 | 4.27 (4.13-4.41) | |
| 15. Recognizing an adverse event or close call | 4.16 (4.03-4.28) | 4.19 (4.06-4.32) | 4.32 (4.19-4.45) | 4.18 (4.03-4.33) | 4.16 (4.02-4.29) | 4.33 (4.18-4.49) | ||
| 16. Reducing harm by addressing immediate risks for patients and others involved | 4.16 (4.02-4.29) | 4.19 (4.03-4.35) | 4.27 (4.13-4.40) | 4.31 (4.17-4.46) | 4.08 (3.93-4.22) | 4.35 (4.21-4.49) | ||
| 17. Disclosing an adverse event to the patient | 4.12 (3.95-4.30) | 4.19 (4.04-4.34) | 4.12 (3.96-4.28) | 4.13 (3.96-4.31) | 4.08 (3.83-4.19) | 4.17 (3.98-4.35) | ||
| 18. Participating in timely event analysis, reflective practice, and planning in order to prevent recurrence | 4.07 (3.92-4.21) | 4.13 (3.99-4.28) | 4.30 (4.15-4.45) | 4.16 (3.99-4.32) | 4.03 (3.87-4.20) | 4.29 (4.13-4.45) | ||
| Culture of safety | 4.24 (4.14-4.34) | 4.06 (3.86-4.25) | 4.26 (4.09-4.44) | 4.38 (4.28-4.47) | 4.06 (3.88-4.25) | <0.01 | 4.38 (4.21-4.55) | |
| 19. The ways in which healthcare is complex and has many vulnerabilities | 4.08 (3.93-4.23) | 4.02 (3.86-4.19) | 4.19 (4.05-4.34) | 4.29 (4.13-4.45) | 4.07 (3.91-4.22) | 4.36 (4.23-4.50) | ||
| 20. Having a questioning attitude and speaking up when you see things that may be unsafe | 4.40 (4.26-4.54) | 4.36 (4.21-4.50) | 4.56 (4.43-4.68) | 4.50 (4.39-4.61) | 4.49 (4.37-4.62) | 4.69 (4.58-4.80) | ||
| 21. The importance of a supportive environment encouraging patients and providers to speak up when they have safety concerns | 4.29 (4.16-4.42) | 4.37 (4.21-4.52) | 4.38 (4.22-4.53) | 4.46 (4.33-4.59) | 4.30 (4.15-4.45) | 4.51 (4.38-4.65) | ||
| 22. Systems, system failures, and their role in adverse events | 4.20 (4.04-4.36) | 4.07 (3.91-4.23) | 4.33 (4.18-4.48) | 4.28 (4.11-4.44) | 3.98 (3.82-4.13) | 4.36 (4.21-4.51) | ||
| Total | 4.19 (4.11-4.28) | 4.16 (4.06-4.26) | 4.26 (4.16-4.32) | 4.28 (4.20-4.37) | 4.15 (4.07-4.23) | <0.01 | 4.37 (4.27-4.47) | |
[i] Note: Scores from 1 (strongly disagree) to 5 (strongly agree)
Legend: CI, confidence interval; p*, p value-paired matched t-test comparing 2nd year vs. 1st year; p**, p value-paired matched t-test comparing 3rd year vs. 2nd year; p***, p value-paired matched t-test comparing 3rd year vs. 1st year; PS, patient safety; BNSc, Bachelor Nursing Science course
Table 3
How PS concepts are integrated and actualized in the nursing curriculum as perceived by students.
| Items, mean (95% CI) | 1st year | 2nd year | 3rd year | p* | p** | p*** |
|---|---|---|---|---|---|---|
| 1. As a student, the scope of practice was very clear to me | 4.02 (3.88-4.17) | 4.15 (4.03-4.27) | 4.34 (4.22-4.46) | - | 0.007 | <0.001 |
| 2. There is consistency in how PS issues were dealt with by different preceptors in the clinical setting | 3.94 (3.77-4.12) | 3.87 (3.70-4.05) | 4.13 (3.96-4.29) | - | 0.005 | - |
| 3. I had sufficient opportunity to learn and interact with members of interdisciplinary teams | 3.94 (3.78-4.11) | 4.16 (4.02-4.30) | 4.25 (4.13-4.38) | 0.019 | - | <0.001 |
| 4. I gained a solid understanding that reporting adverse events and close calls can lead to changes and reduce the reoccurrence of such events | 4.22 (4.08-4.37) | 4.22 (4.08-4.37) | 4.30 (4.15-4.44) | - | - | - |
| 5. PS was well integrated into the overall program | 4.39 (4.26-4.52) | 4.43 (4.31-4.55) | 4.60 (4.48-4.72) | - | 0.021 | 0.007 |
| 6. Clinical aspects of PS (e.g., hand hygiene, transferring patients, medication safety) were well covered in our program | 4.37 (4.23-4.50) | 4.48 (4.36-4.61) | 4.60 (4.49-4.72) | - | - | 0.002 |
| 7. “System” aspects of PS were well covered in our program | 4.01 (3.85-4.17) | 4.06 (3.90-4.21) | 4.30 (4.16-4.43) | - | 0.002 | 0.002 |
[i] Note: Scores from 1 (strongly disagree) to 5 (strongly agree)
Legend: CI, confidence interval; p*, p value-paired matched t-test comparing 2nd year vs. 1st year; p**, p value-paired matched t-test comparing 3rd year vs. 2nd year; p***, p value-paired matched t-test comparing 3rd year vs. 1st year; PS, patient safety.