Development of a clinical learning model to enhance patient safety awareness competency among Thai nursing students

Background

The recovery from illness and safety from adverse events or preventable complications during the medical process is the expectation of the patients and reflects the quality of patient care. Nurses play an essential role in managing risks and protecting patients, and nursing practice must be based on safety principles and do not cause any harm or risk to patients (World Health Organization, 2011). Nursing organizations, therefore, place importance on patient safety by defining them as part of competencies in nursing practice. It also deals with issues of ethics and professional law. Nevertheless, the errors in patient care leading to adverse events are mostly preventable (World Health Organization, 2011).

Patient harm in healthcare facilities is the leading cause of morbidity and mortality internationally that affects the significant outcomes of patient care, cost burden, and health care system (Pangh et al., 2019). In Thailand, patient safety is integrated into the quality development process and set as one of the criteria for quality assurance in hospitals, which must be the first awareness of the medical personnel (Yoelao et al., 2014). Therefore, it is essential for health care education to focus on the importance of healthcare professionals to have a foundation in knowledge, skill, behavior, and attitude relevant to patient safety in all actions (Tella et al., 2014).

In terms of the nursing context, patient safety problems are related to human factors and work processes, such as infection control procedures, medication errors, infection control procedures, medication errors, and communication failure. Therefore, raising awareness requires the development of a safe patient care management system and the human factor related to individual nurses due to the high workload, negligence, lack of knowledge or skill, and miscommunication (Tella et al., 2014; Yetti et al., 2021). Thus, the cultivation of patient safety in nursing students must be from nursing theory and learning from experiences in nursing practice. These will shape nursing students to keep patient safety in mind and make it a part of normal behavior. According to the study of Bandansin et al. (2020), the patient safety awareness competency of nursing students refers to students protecting patients or reducing the likelihood of injury, complications, or adverse events due to limitations in terms of knowledge, skills, lack of harm prevention, neglect and making a mistake. Additionally, nursing students’ patient safety awareness competency consists of two components: (1) management to ensure patient safety and (2) solving the hazard problem in patient care. However, nursing students, the future professional nurses, must participate with the healthcare team in reducing or eliminating the risk of harm to patients (Lee et al., 2014; Usher et al., 2017).

Developing nursing students into professional nurses with competence in patient safety awareness will help them recognize the potential risks of the cognitive misunderstandings that lead to medical care errors. However, this competence is achieved by focusing on managing learning experiences in classrooms and clinics to foster awareness of patient safety care. Literature review indicated that applying the Metacognitive Experiential Learning Model to design the learning processes establishes a body of knowledge from learners’ own experiences and practice (Kolb & Kolb, 2009; Tanaka et al., 2016). Therefore, this model is appropriate for patient safety practice by using questioning to inquire about nursing problems that could be solved rationally. In addition, questioning encourages thought, linking experiences with theoretical knowledge, monitoring and controlling their cognition, behavior, and problem-solving during operations to achieve the targeted results (Torabizadeh et al., 2018).

Questioning is a tool for students to develop higher-order thinking skills and desirable attributes. Higher cognitive questioning is conducted to achieve a deep awareness and a reflection of what will be done, such as carefully understanding the role, responsibility, and appreciation of the value of nursing practice (Lakdizaji et al., 2013). In addition, the integration of patient safety into clinical practice bridges the traditional learning gap that lacks a connection of the theoretical knowledge learned in the classroom and the real world by teaching risk-based thinking to emphasize situational awareness and learning from errors (Fore & Sculli, 2013).

In this study, the clinical learning model is developed to enhance patient safety awareness competency among nursing students, which applied metacognitive thinking through experiential learning (using a questioning strategy as a tool for patient safety learning, which the learners think critically and question their experiences related to the safety of nursing activities with patients) and reflective learning (the teacher's questions encourage the nursing students to criticize the experience associated with the patient hazard, near miss situations to improve their doing in other conditions). This clinical learning model aims to enhance patient safety awareness among nursing students to build a culture of quality and safety in nursing practice.

Methods

Data Collection

Quantitative strand

The quantitative data on the effectiveness of the DUIR clinical learning model were collected among 24 nursing students who practiced fundamental nursing in the second semester of the 2018 Academic Year for four weeks.

To measure the effectiveness of the DUIR clinical learning model, we employed a quasi-experimental method using repeated measures design, divided into three phases, 1) a preparation phase, 2) a ward practice phase, and 3) an expansion of the knowledge and experience phase. Each phase used the four steps of the DUIR clinical learning process. The performance of patient safety awareness was assessed in week 1 (pre-test), weeks 2, 3, 4 (during learning), week 4 (post-test), and week 8 (after the end of learning), as shown in Figure 1. In addition, the effectiveness of the clinical learning model was measured by researchers, preceptors, and nursing students using scoring rubrics for patient safety awareness competency.

Qualitative strand

We collected qualitative data in 24 students through a reflection. The researchers with the teachers asked the students three questions to write the answer on a blank paper: 1) What was your learning-related patient safety experience? 2) How did you manage the incident? 3) What did you do to protect the harm or prevent the risk if you confronted the new experience? The students described their answers thoroughly. In addition, for two instructors and one preceptor, we conducted in-depth interviews about the clinical learning models’ benefits and obstacles. All interviews were audio-recorded and transcribed verbatim.

Results

Phase 1: DUIR Clinical Learning Model Development

In this phase, the DUIR clinical learning model was established to enhance patient safety awareness among nursing students, which consisted of the principles and the purposes of the clinical learning model, learning process, content, teaching materials, and measurement and evaluation. The four steps of the DUIR process begin with Doubt (D), a step of the risks and harm spotlight. A clinical instructor asks the questions for students to inquire about the risk and the harm related to the patient care process. The second step is Understanding (U), an action to discuss risk and harm prevention in the patient care process. The third step, Insight (I), is a risk and harm checkpoint step before taking procedures or patient care. The fourth step, Reflected value (R), is a step of experience sharing. A clinical instructor asked the reflective questions for students to criticize their risk experiences to improve patient safety performance. It encouraged the students to report their near-miss activity of process care. They had got feedback that made them feel comfortable to report near misses or errors. The DUIR process was a cycle model run in each learning activity (Figure 2).

Discussion

Many patient safety educational interventions proved that patient safety awareness is required for qualified nurses' characters in clinical settings (Tregunno et al., 2014). WHO encouraged healthcare faculties to use the WHO patient safety curriculum guide-multi-professional edition (World Health Organization, 2011) to teach healthcare students, which differ in many ways from the context of preregistration students nurses, the curriculum in each discipline, the policy of clinical workplace, and previous clinical experiences of the clinical instructors. In fact, in the context of this study, there is still a gap in the nursing curriculum in which patient safety content is limited or unclear to be integrated into practice, thus unable to connect to the real-world situation (Mansour et al., 2015).

The DUIR clinical learning model was developed from a competency-based concept and a metacognitive experiential learning model to effectively enhance student patient safety awareness competency. This clinical learning model promotes learning outcomes, which demonstrate nursing students' patient safety awareness competency in two components: patient safety management (risk detection, safety nursing practice, awareness, and compassionate response to patient needs, communication for effective nursing care) and problem-solving to provide safe care (exchanging experiences learned about patient safety, improving nursing plans to prevent patient risks, and participating in solving safety problems into patient care). These components, however, are in accordance with the patient safety competency framework of The Quality & Safety Education for Nursing (QSEN), which states that patient safety competency is based on patient-centered care that focuses on the risks that affect the body and takes into account the emotions of the patient and their relatives to promote compassionate care for the patient based on respect for the patient's values, beliefs, values or needs.

Additionally, instilling a safety culture among nursing students as part of the nursing care team can protect their patients' safety and promote efficient communication with patients, the nursing team, and the multidisciplinary (Cresswell et al., 2013; DeBourgh, 2012). The learning model is also consistent with the components of patient safety performance measurement of registered nurses in Thailand regarding individual factors affecting patient safety, emphasizing examination of readiness or limitation of knowledge and skills in working. Furthermore, there are good attitudes of following the patient safety principles and practices protocol, including participating in safety cultures, such as communicating with the nursing team about warning signs of the patients, reporting errors or near-miss incidence (Panthulawan et al., 2016). Hence, the learning outcomes are determined to relate to nursing sensitivity outcomes (DeBourgh, 2012; Gravina, 2017; Lee et al., 2014), and Thailand Safety Goals (SIMPLE - Safe surgery, Infectious control, Medication error, Process care, Line and tube safety, Emergency response) (Limpanyalert, 2018; Panthulawan et al., 2016).

The influence of the clinical learning model or DUIR model on learners’ patient safety awareness competency in this study could be described from its learning process. For example, in Step 1 (Doubt) and Step 2 (Understanding focused on the thinking process by questioning related to risk or patient safety during clinical practice), the lessons learned from past mistakes influenced learners to think about how and why it happened and the chance of it happening in the future (Taitz et al., 2010; World Health Organization, 2017). At this point, nursing care plans and actions can be influenced by the ability to understand the risks or opportunities for the hazard. That ability predicts the outcomes if the nursing plans and standard practice guidelines are not followed. In addition, human factor errors can be reduced or eliminated by accepting and believing in standard operating procedures and analyzing various errors that have occurred in the past (Cresswell et al., 2013; Steven et al., 2019). In Step 3 (Insight, access to safety), compliance with standard practice, essential skills in performing tasks, and linking patient safety issues with ethical standards and professional ethics were emphasized. This will help nurture learners to realize the importance of the problem and its impact on patients and themselves. Meanwhile, in Step 4 (reflecting the value), the thinking process was the main focus by reflecting on work experiences, questioning and linking them to patient safety that will help learners realize the importance of actions to prevent or reduce the risk of danger with patients (Steven et al., 2019). Therefore, this clinical learning model affected the mean scores of the patient safety awareness competency among students, with a high level.

The patient safety awareness performance scores were consistent with the qualitative data from students' learning reflections and the instructors' experience sharing. They agreed with memorizing procedures and practicing each method until fluency skills are not enough to enrich safety performance. Students must reflect on what they have learned from errors or near-missed experiences and describe how to prevent that from happening again. These findings, however, were consistent with the study of patient safety competency among Bachelor's degree nursing students using an integrative literature review (Tella et al., 2014), and found that the strategies for learning management promoted patient safety competence, such as creating a conducive environment for learning, practical learning and reflection practice on patient safety in various situations (Tella et al., 2014).

In terms of critical reflection, in the DUIR model, the teachers acted as a coach or facilitator in learning by stimulating the thinking of learners by using questions to assess their understanding of knowledge or practice. After performing procedures with patients, reflective questions also allow the learners to explore and review their thoughts and then analyze them. According to Stoddard and O’Dell (2016), practice can change the attitudes and behaviors of learners. In addition, metacognition is used to develop ethics, and learners use situations to stimulate thinking and then express behavior or opinions by writing a description of their feelings or answering interview questions that reflect their beliefs, values, and ethical behavior (Seibert, 2014). However, this strategy is consistent with the study using questioning to reflect the feelings of emergency nurses, especially communication in their work, which affected emergency nurses in dealing with various patient safety situations (Pangh et al., 2019). So, it can be said that attitude and non-technical skills such as communication, critical thinking, problem-solving, empathy, and collaborative skills are essential to support patient safety performance.

Last, it is noteworthy that the DUIR learning process encouraged nursing students to reflect on mistakes or near misses, sharing problem-solving experiences, emotions, and feelings related to problems, risks, or hazards to patients. As a result, learners immersed themselves in problem processes, learning to transform their behaviors for quality and patient safety nursing outcomes (Colet et al., 2015; Steven et al., 2019). Therefore, the learning process stimulated a thought to criticize experience by questioning patient safety improvement.

Conclusion

The developed DUIR clinical learning model has four steps: (1) Doubt (D); (2) Understanding (U); (3) Insight (I); and (4) Reflected Value (R). This learning model used metacognitive thinking through experiential learning by using questioning strategies as a tool for patient safety learning and assists the learners to doubt and ask questions about their experiences related to the safety of nursing activities with patients. Therefore, the model can be considered effective. Furthermore, it can be applied in both classrooms and clinics, which the teachers and preceptors act as facilitators lead students to criticize their practice without judgments and encourage students to report the errors or near-misses in order to enhance patient safety awareness among nursing students with confidence and to be able to transform their practice focusing on the quality and safe patient care outcomes.