Program Evaluation

International Quarterly of
Community Health Education
The Effect of Patient Safety Education on 2022, Vol. 42(2) 219­–224
! The Author(s) 2020
Undergraduate Nursing Students’ Patient Article reuse guidelines:
sagepub.com/journals-permissions
Safety Competencies DOI: 10.1177/0272684X20974214
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Mahya Torkaman1,2, Amirreza Sabzi1, and Jamileh Farokhzadian2*

Abstract
Patient safety is influenced by a set of factors in various levels of the healthcare system. One of the factors affecting patient safety is
safety competencies of the nursing students. The current study aimed to evaluate the effect of patient safety education on patient
safety competencies of the nursing students. This quasi-experimental study was conducted with a pretest-posttest deign. The levels of
patient safety competencies of 50 nursing students were investigated in a nursing school affiliated to large university of medical
sciences in the south of Iran in 2019. Data were collected using Health Professional Education in Patient Safety Survey (H-PEPSS). The
data were analyzed in SPSS 21 using descriptive statistics and repeated measures ANOVA. The three investigated intervals were
significantly different in terms of the total H-PEPSS dimensions, while the lowest was attributed to the dimension “managing safety”.
Mean scores of “how broader patient safety issues are addressed in health professional education” and “comfort speaking up about
patient safety” significantly increased during the follow-up periods. The educational intervention was partially effective in improving
patient safety competencies of the nursing students over long term.

Keywords
patient safety, education, nursing student, safety, patient safety competency

Patient safety (PS) is an international issue since health pro-
fessionals are ethically responsible to ensure PS within the
healthcare system.1 Patient safety is the absence of prevent-
able harm to a patient during the process of health care.2 PS
can be achieved by reducing and mitigating unsafe measures,
and using best practices that can lead to optimal patient out-
comes.3 Nurses can ensure PS through monitoring and super-
vision. Therefore, they should provide patient-centered care,
work in interdisciplinary teams, use evidence-based practices,
improve safety and quality, and meet needs of patients in the
21st century.2 Nurses must be equipped with PS competen-
cies either in their studentship or their working periods.4
Despite the emphasis of international and national guide-
lines.3 nursing education does not address PS deeply, and it
is unable to bridge the gap between theory and practice with-
out integrating PS into the nursing education.5
In 2006, the Canadian Patient Safety Institute (CPSI)
designed The Safety Competencies for health professionals.
The Safety Competencies has six core domains: 1) contribute
to a culture of patient safety, 2) work in teams for patient
safety, 3) communicate effectively for patient safety, 4)
manage safety risks; 5) optimize human and environmental
factors, and 6) recognize, respond to, and disclose adverse
events.6 The fundamentals of PS and risk management skills
should be trained to nurses to develop their PS competency.3
Ginsburg et al. designed the Health Professional Education
in Patient Safety Survey (H-PEPSS) for reflecting the six key
domains of PS competency.7 Educational innovations and PS
competency evaluation have been recommended to enhance
PS among nurses.2 Although the importance of PS training
has been acknowledged for over a decade, it is still underu-
tilized and undervalued in most countries.8
The PS curriculum focuses on clinical processes that are
related directly and indirectly to the patient, and includes the
1
Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
2
Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran
Corresponding Author:
Jamileh Farokhzadian, Kerman University of Medical Sciences, PO Box:
7716913555, Haft-Bagh Highway, Kerman, Iran.
Email: j.farokhzadian@kmu.ac.ir
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structures, processes, tools, and activities used by hospital
staff to identify, analyze, control, and manage risks during
healthcare delivery.9 Such a curriculum is suitable for both
patients, and the health care team and organizations, and can
minimize the risks to patients.4 However, due to the wide
range of patient safety aspects, it is not possible for all coun-
tries to include all the principles of PS competency in the
curriculum of students. Students should be aware of the con-
ditions, which predispose to medical errors, especially during
their studentships, respect the patients’ safety principles, and
receive the necessary training to obtain PS
competencies.10Lee et al. emphasized on the need to revise
the nursing curriculum and to use various teaching methods
to deliver PS education more comprehensively and effective-
ly. Furthermore, researchers reported a need to develop an
integrated approach to ensure students’ PS competencies.2
However, the process of enhancing PS competency and
restructuring the nursing curriculum is very slow.11 A
number of studies examined trainees’ PS knowledge, skills,
and attitudes, but most of them assessed either the impact of
specific PS curriculum or training interventions.12,13 Tella
et al. reported that only few studies investigated promotion
of PS competencies among nursing students.14 A systematic
review found no surveys on the broad content reflected in PS
competencies of healthcare professionals based on H-
PEPSS.15 In most of these studies, research instruments
were designed and used to measure the impact of specific
PS curriculum. However, such studies have not used H-
PEPSS. In Iran, nursing schools have incorporated PS con-
tent into their curriculum, but to the best of our knowledge,
little has been published so far about these efforts.
Considering that assessment is central to all educational pro-
grams, curriculum designers should ensure that the registered
nurses are safe and competent. To provide effective and safe
care services, nursing graduates need to attain the vital com-
petencies set by the CPSI. Furthermore, assessment of the
students’ self-perceived competencies after an educational
program can help adjust curricula to students’ needs.16
Therefore, the current study aimed to investigate the effec-
tiveness of PS education on PS competencies of the under-
graduate nursing students in Iran.
Methods
Study Design and Setting
This quasi-experimental study was carried out among under-
graduate nursing students with a pretest-posttest design, in
which the students were followed up after one, three, and six
months. The participants included 50 students selected from
the nursing school of Kerman University of Medical Sciences
in southeast of Iran. According to the academic law in Iran,
the bachelor’s degree includes four years of study and the
curriculum is based on a semester system. Students have to
pass theoretical and clinical units in university and
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educational hospitals, respectively. The students experience
clinical learning opportunities, such as long-term care,
family/community health, and critical care setting (e.g.,
medical-surgical, pediatrics, maternity, mental health).
The participants of this study were students who received
no PS education.
According to the curriculum, a 4-hour mandatory work-
shop on PS is held at the beginning of the third semester in
Razi School of Nursing and Midwifery. However, we con-
ducted an eight-hour program with more comprehensive con-
tents, and explained it in details in the data collection
procedure and intervention section.
Sample
The target population of this study included all undergradu-
ate nursing students in the third semester of the second year.
Sixty-three participants were recruited from January to June
2019. Given the small size of target population, all students
were selected as the study participants using census sampling
method. Finally, 50 students completed the questionnaires
(response rate ¼ 79.36%).
Inclusion and Exclusion Criteria
Inclusion criteria were the nursing students who had not
passed any PS training courses, those who passed the credit
of “Fundamentals of Nursing”, those who started learning in
the clinical setting, and those who were not employed. The
exclusion criteria included failing to complete the question-
naires and being absent in one or more sessions.
Instrument
Data were collected using two questionnaires: a demographic
questionnaire containing the participants’ age and gender,
observation of medical and nursing errors in clinical practi-
ces, reporting errors to clinical educators, hospital staff, and
peer students, as well as PS quality in the university educa-
tion, and a modified version of the Health Professional
Education in Patient Safety Survey (H-PEPSS) . The latter
is a self-reporting tool on PS competency. H-PEPSS can be
used by health professional educators, the students and new
graduates as a self-evaluation tool.7,17
The H-PEPSS is composed of 38 items divided into three
sections. The first section deals with “Learning about specific
PS domains” (27 items). These items begin with the stem ‘I
feel confident in what I learned about and are categorized
under seven dimensions:
1. Clinical safety issues such as safe medication practices,
hand hygiene, etc. (four items). These items are included
in the H-PEPSS to help respondents distinguish between
clinical and socio-cultural aspects of PS.
2. The six sociocultural domains of PS competencies such as
“Working in teams” (six items).
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3. Effective communication (three items).
4. Safety risks’ management (three items).
5. Human and environmental factors (three items).
6. Recognition of and response to adverse events (four
items).
7. Culture of safety (four items).
In the first section, participants were asked to respond
each item regarding contents learned in the classroom and
during their clinical experience. According to the purpose of
this study, we asked the participants to respond each item
regarding contents learned in the classroom (workshop). All
27 items of the first section were scored on the scale value of
one (strongly disagree) to five (strongly agree), and the
option of “no idea”. The mean and standard deviation of
items in all seven domains was calculated on a Five-point
Likert scale.
The second section of the H-PEPSS containing seven
items considered “How broader PS issues are addressed in
health professional education”.
The third section of the H-PEPSS included “Comfort
speaking up about PS” and had four items. The second
and third sections were scored on the scale value of one
(strongly disagree) to five (strongly agree).
The H-PEPSS was developed to assess the levels of clinical
safety and six core domains of CPSI Competency framework
in newly graduated students. Three PS experts involved with
the training of health professionals in medicine and nursing
were asked to give feedback on the draft questionnaire. Its
construct validity was confirmed through factor analysis
(CFA). The internal consistency was calculated using
Cronbach’s alpha coefficient; Cronbach’s alpha was between
.81 and .85 indicating a good reliability.7,17
In this study, the H-PEPSS was used with the developers’
permission. The cross-cultural adaptation and translation of
the questionnaire involved forward accurate translation of
the original H-PEPSS into Persian. Later, a proficient
English translator conducted the backward translation of
the Persian version into English. Next, the translated version
was matched with the original version. Face validity of the
instrument was also examined and confirmed by students’
perception and understanding of the items. For a pilot
study on the Persian version of the H-PEPSS to be con-
ducted, 30 students not involved in the study process were
asked to complete the questionnaire.
Furthermore, 10 nursing faculty members confirmed the
content validity of Persian version of the H-PEPSS, and the
Content Validity Index (CVI) was 90% for the entire instru-
ment and more than 86% for all the items. Furthermore, the
reliability of the questionnaire was calculated through inter-
nal consistency method, in which Cronbach’s alpha coeffi-
cient ranged from 0.73 (clinical safety) to 0.86 (effective
communication and safety risks management) the whole
instrument was 0.89.
2213
Data Collection Procedure and Intervention
The participants were followed up from the second year of
study (January 2019) to the next six months (June 2019). The
co-researchers collected data from defined groups of students
in the classroom. The participants were asked to complete the
questionnaires that took ¼ 15–20 min. The participants com-
pleted the questionnaire one week before the educational
intervention (pretest), one month (posttest), three months
(follow-up), and finally six months after the educational
intervention (follow-up). Changes in the PS competencies
were compared at pretest posttest, three-month follow-up,
and six-month follow-up using the H-PEPSS.
At the beginning of the third semester, a safety-training
workshop was performed for 4 hours. The intervention group
was divided into two groups to increase the opportunity for
participation in the workshop, and an eight-hour workshop
was held in two days. Contents of these training sessions and
several educational videos and PowerPoints were then
uploaded on the Nursing School website, so that students
can continue their education virtually. The authors and a PS
expert conducted the training program. The educational con-
tent of the sessions and modality are presented in Table 1.18
Statistical Analysis
The data were analyzed in SPSS 20 using descriptive statistics
(frequency, percentage, mean and standard deviation) and
inferential statistics (repeated measures ANOVA). The
Kolmogorov Smirnov test showed that the data followed a
normal distribution. The significance level was set at �0.05.
Results
Demographic Information
Thirteen eligible nursing students did not complete the ques-
tionnaires in the three follow-ups. Our results showed that
the mean age of participants was 20 years; 50% were women.
About 96% of the participants reported medical errors, 80%
reported errors to their clinical instructors, 42% reported
them to hospital staff, and 84% reported them to peer stu-
dents. Furthermore, 50% of the participants believed that the
nursing curriculum covered PS issues.
Patient Safety Competency
As Table 2 represents, PS competency, and its domains were
evaluated at four time points. Results showed that the par-
ticipants’ PS competency and its domains significantly
increased after the training program (p < 0.001). With
regard to the first part of the questionnaire, the highest
mean score difference was related to “working in teams”,
while the lowest one was attributed to “managing safety”.
In the second and third parts of the questionnaire, “how
broader PS issues are addressed in health professional
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Table 1. Patient Safety Curriculum Content and Educational Modality.

Sections Contents Educational modality

Clinical safety Safe medication practice Lecture

issues Hand hygiene
Safe clinical practice in general
Infection control
Patient safety Epidemiology of medical errors Lecture & PowerPoints
overview Institution of medicine report To Error is human, and its recommendations
Definitions of error, adverse event, close call/near miss, and sentinel event
Ethical, educational, and policy aspects of patient safety Panel discussion, scenario
Error reporting How reporting can lead to improvement? Lecture
Characteristics of successful error reporting system
System vs. Human “Blame and shame” culture Lecture & PowerPoints
approach Socialization of perfection in medicine
Safety culture in other high-risk industries
Human factors engineering
Safety tools Interdisciplinary root cause analysis Lecture, interactive forum
System solutions that minimize reliance on human cognition and memory Modified root cause analysis,
interactive forum
Ethics/disclosure Ethical obligations surrounding medical fallibility and patient safety Lecture
Constructive responses to errors Panel discussion
Disclosure techniques Scenario, Role playing,

Table 2. Comparison of the Mean Scores of PS Competency and Its Dimensions at Pretest, Posttest, and Follow-Ups.

Dimensions Pretest (time1) time2 time3 time4 p.v*

Clinical safety skills 16.30  60.62 14.40  58.33 15.40  68.39 68.79  15.30 <0.001
Working in teams 14.67  20.40 48.30  16.60 34.26  20.60 22.39  21.50 <0.001
Communicating effectively 80.62  11.20 76.31  9.40 45.35  11.30 40.07  11.30 <0.001
Managing Safety 50.04  10.30 52.15  8.40 84.20  10.30 68.33  10.30 <0.001
Understanding human and environmental factors 42  10.30 64.99  8.30 36.58  10.30 60.82  11.02 <0.001
Recognizing and responding to adverse events 66.88  13.30 22.99  11.40 60.56  14.40 38.57  13.30 <0.001
Culture of safety 60.14  14.30 60.75  12.40 86.43  14.50 70.70  14.30 <0.001
Total patient safety competency 46.78  96.16 80.39  81.26 62.57  97.23 30.51  98.20 <0.001
*pretest (time 1)، posttest (time 2), a three-month follow-up (time 3) and a six-month follow-up (time 4)/repeated measures ANOVA.

education”, and “comfort speaking up about PS” were exam-
ined at different time intervals. The results showed a signif-
icant increase in the participants’ knowledge of these
domains (p < 0.001) (Table 3).
Discussion
The current study examined the long-term effects of an edu-
cational intervention on the improvement of PS competen-
cies in nursing students. The educational intervention had a
significant effect on the overall PS competencies of nursing
students, which was similar to other studies.5,13,19 The overall
PS competencies scores of the students increased after the
education compared to the baseline. In other words, signifi-
cant positive changes were reported in PS competencies
scores over time after the intervention. However, such an
improvement may be resulted from education, maturity,
and experience in working conditions.20
Tom showed that staff’s perceptions of safety after PS
training were significantly different from those before the
intervention. In addition, the fall of patients has decreased
by 54%. They believe that the training of PS competencies is
necessary to clarify the roles, tasks, functions and responsi-
bilities of staff. It is also an economical and cost-effective
way to prevent the complications caused by non-
compliance with PS.21 Ignoring PS competencies of the stu-
dents seems to weaken the quality of care and does not solve
patients’ health-threatening problems. The results will be the
waste of economic capitals, decreased level of health and
social achievements in the long term.22 Nie et al. in China
studied the PS training to undergraduate medical students
and found that PS competencies were one of the important
issues that should be included in the student curriculum.23 In
addition, another study in the UK found no effective educa-
tion on PS in universities, and healthcare professionals
trained nursing graduates some safe care behaviors in the
Torkaman et
Torkaman et al.
al.
Table 3. Comparison of the Mean Scores of PS Education and Comfort in Speaking About PS at Pretest, Posttest, and Follow-Ups.
Pretest (time1)
Education on patient safety 96.09  21.50
Comfort speaking up about patient safety 46.70  12.20
*pretest (time 1), posttest (time 2), a three month- follow-up (time 3), and a six month- follow-up (time 4)/repeated measurement ANOVA.
clinical settings.24 The PS training is effective because PS
competency is a set of integrated capabilities in relation to
knowledge, attitude and skill that is a prerequisite for better
performance and problem solving in clinical settings.
With regard to “learning about specific PS domains”, the
results showed that the highest mean score was related to the
dimension “working in teams”; whereas, the lowest mean
score was attributed to the dimension “managing safety”.
Ginsburg et al. assessed safety competency of the nursing
and pharmacy students. Their results showed that “working
in teams” gained the highest score after the dimension
“effective communication with other members of the health-
care team”.16 This result may be due to the mediating role of
nurses in health care system; nurses learn and experience
teamwork skills from the outset. Gaupp et al. added that
the students’ participation increased after PS education.
Therefore, they hypothesized that this training activated stu-
dents’ systemic thinking and enhanced their engagement and
teamwork.5
In the present study, the lowest mean score difference was
related to “managing safety” because our participants includ-
ed first-year nursing students with no clinical experiences and
could not manage safety competencies effectively.16,18 As a
result, students need to acquire theoretical and practical
safety management skills to manage other positions.19
VanDenKerkh of et al. demonstrated that the score of
“managing safety” was higher among the clinically educated
nurses than the theoretically-educated nurses.6 It should be
noted that this study compared the newly graduated nurses in
clinical settings and those who were studying nursing in
theory; students will experience safety management skills
until they finish their education.
Results of the second and third parts of the questionnaire
(how broader PS issues are addressed in health professional
education, and comfort speaking up about PS) showed a
significant increase in the participants’ scores in different
time intervals. Lee et al. also indicated that PS education
had a positive impact on nursing students’ attitudes toward
PS2 because students involve in the clinical setting over time
and their experience of PS increases gradually.20
Furthermore, students’ attitudes towards PS changed after
the educational interventions, so that they considered it an
important issue for patients.5,21 Ginsburg et al. also showed
that students’ attitudes toward safety education were signif-
icant in the clinical setting.16 Moreover, safety education
becomes institutionalized in students in the clinical settings.25
Therefore, PS education should be involved in the students’
2235
time2 time3 time4 p.v*
32.29  23.60 70.50  25.70 92.50  25.50 <0.001
64.36  12.40 76.79  12.20 40.07  13.30 <0.001
curriculum, and nursing school administrators and faculty
members are recommended to continue safety training to
enhance the students’ PS competencies.
Limitations
The present study has some limitations. The number of par-
ticipants recruited in this study was limited; so, we could not
have any control groups to compare the results between the
intervention and control groups. Therefore, the pretest-
posttest design was used for the participants selected using
the convenience sampling method. Furthermore, we did not
have access to patients, and the results were specific to the
study population. The results would have been more com-
prehensive in the case that patients who received care from
the studied nurses had completed the questionnaire before
and after the intervention. Therefore, the results should be
generalized with caution.
Conclusions
The current study aimed to evaluate the effectiveness of PS
education on nursing students’ PS competencies. The results
showed a positive and significant effect of safety education
on all dimensions of students’ PS competencies. Therefore, it
seems necessary to consider PS training courses in nursing
schools after applying appropriate needs assessment.
Managing safety should be emphasized in the academic edu-
cation of PS formally and informally, so that students can
master safety management skills in the clinical settings.
Acknowledgements
The authors would thank all nursing students participated in this
study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
Ethical Considerations
This study was approved by the Ethics Committee of Kerman
University of Medical Sciences with the code of ethics of IR.
KMU.REC.1398. 053. In an open meeting, the first author invited
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the students to participate in the study and informed them about the
study goals and methods. The researcher emphasized that partici-
pation was voluntary and students could withdraw at any time. The
participants were reassured that their responses would be confiden-
tial and their identities would not be disclosed. Later, the partici-
pants were asked to sign written informed consent forms. Data were
maintained anonymous using unidentifiable student numbers.
ORCID iD
Jamileh Farokhzadian https://orcid.org/0000-0002-9621-3486
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Author Biographies
Mahya Torkaman, BSN, MSN,and phd student of nursin, is in
shiraz university of Medical Sciences in Iran. I have experiences
in conducting quantitative and qualitative research in quality
improvement, patient safety and organizational behavior.
Amirreza Sabzi, medical student, is in shiraz university of
Medical Sciences in Iran and have experiences in conducting
quantitative research in quality improvement.
Jamileh Farokhzadian, BSN, MSN, PhD, is an assistant pro-
fessor in department of community health nursing at Razi
nursing school affiliated with Kerman University of Medical
Sciences in Iran and have experiences in conducting quanti-
tative and qualitative research in quality improvement,
patient safety and organizational behavior.