Patient Safety Competency and its Related Aspects in Professional Education among Nursing Students of Two Nursing Schools in Iran: A Comparative Study

Background: The importance of patient safety competency in nursing students to enter the clinical environment has made continuous studies necessary. However,


Introduction
Changes in science and technology along with modern conceptions of professionalism suggest quality improvement and patient safety in healthcare settings as the professional responsibilities of all medical practitioners, notably nurses and nursing students (Karami et al., 2017). Patient safety is defined as the prevention of harm to patients and has long been a topic of discussion around the world (Lee et al., 2016). According to a growing body of evidence, improving patient safety competency and reforming health professionals' curriculum are happening slowly in the health professions (Torkaman et al., 2022).
Nurses, due to their unique position, can ensure successful implementation of patient safety strategies because they spend a majority of their time with patients. To improve healthcare

Research design
The present study employed a cross-sectional descriptive-analytical study to compare patient safety competency and its related aspects among undergraduate nursing students.

Setting and samples
This study was carried out in two nursing schools, one is affiliated to the University of Medical Sciences in the Southeastern (Group A) and the other is affiliated to the University of Medical Sciences in the center of Iran (Group B). Group A represents a new university that is located near the northwest and center of Iran and next to the political capital of Iran, Tehran, and this has caused many volunteers to study there. Meanwhile, Group B represents a university with a long history (about half a century) in the southeast of Iran. Therefore, the main question of researchers in this study is whether there is a difference in patient safety competency among nursing students in two universities that are different in terms of geography and age.
The target population included all undergraduate nursing students studying in the second, third and fourth year in two aforementioned nursing schools. Inclusion criteria included nursing students who successfully had passed the "Fundamentals of Nursing Course", had started learning in clinical settings, and not employed in a hospital. Therefore, students in the first year were not considered as the target population. The exclusion criteria included those failing to complete the questionnaires. Given that the sample size was equal to the target population, all eligible nursing students were included in the study by a census method. According to the inclusion criteria, 240 undergraduate nursing students were enrolled from group A and 200 ones from group B. Among 240 eligible nursing students in group A, 40 questionnaires were not completed, which resulted in a response rate of 83.33%. Out of 200 eligible nursing students in group B, 63 questionnaires were not completed due to the participants' lack of cooperation, which resulted in a response rate of 68.50%. As a result, a total of 337 undergraduate nursing students participated in the study. The overall response rate was 76.60%.

Measurement and data collection
The study questionnaires included a demographic questionnaire and the Health Professional Education in Patient Safety Survey (H-PEPSS) (Ginsburg et al., 2012). The demographic questionnaire comprised of questions on the students' age, gender, attendance at patient safety training, observation of medical and nursing errors in clinical practices, and experiences of reporting errors to clinical educators, hospital staff, and peer students.
The H-PEPSS (with 38 items) was developed to assess patient safety competency in the sociocultural dimensions of patient safety and its related aspects such as broader patient safety issues in health professional education and comfortable speaking up about patient safety. The H-PEPSS consists of three parts. The first part, which investigates "learning about specific patient safety content areas" (27 items), contains seven domains, namely, (1) issues related to clinical safety, for example safe medication, hand hygiene, infection control , and safe clinical practice in general (four items), (2) working in teams (six items), (3) communicating effectively (three items), (4) management of safety risks (three items), (5) optimizing human and environmental factors (three items), (6) recognizing, responding to, and disclosing adverse events and close calls (four items), and (7) contributing to a safety culture (four items). Considering the theoretical and practical nature of patient safety, items were designed for in two classroom and clinical training settings. The participants were required to answer the items individually according to what they had learned about patient safety in the classroom and clinical settings. Therefore, scores of the domains were calculated for the classroom and clinical settings separately. 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 "don't know". Mean scores are calculated from the items in each dimension for each learning setting.
The second and third parts of the H-PEPSS investigate aspects related to patient safety in professional education, such as "how broader patient safety issues are examined in health education" (seven items) and "comfortable speaking up about patient safety" (four items), respectively. The second and third parts are scored based on the scale value of one (strongly disagree) to five (strongly agree). Higher scores indicate better positive perceptions about patient safety competency, broader aspects of patient safety, and comfortable speaking up about patient safety.
The original H-PEPSS had confirmed internal consistency (Cronbach's alpha=0.81-0.85) (Ginsburg et al., 2012;Ginsburg et al., 2013). In a study in Iran, the H-PEPSS was used with the developers' permission. The cross-cultural adaptation and translation of the H-PEPSS involved forward 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 nursing students' perception and understanding of the items. The Persian version of the H-PEPSS received content validity confirmation from 10 nursing faculty members. The Content Validity Index (CVI) of the questionnaire and items was 90%. In addition, its reliability was corroborated using Cronbach's alpha coefficients of 0.72-0.83 and 0.78-0.85 for the class and clinical settings, respectively (Torkaman et al., 2022).
The data in this study were collected from September to October 2020. In order to collect data, two WhatsApp groups were created and the participants were added to each related group. Later, participants were provided with the required instructions to complete the questionnaires as well as the links of the study questionnaires via e-mail and WhatsApp groups. The questionnaires were sent back to the researchers automatically.

Data analysis
The data were analyzed by using version 21 of Statistical Package for the Social Science (SPSS, Inc., Chicago, IL). Descriptive statistics were expressed as mean and standard deviation for continuous variables and as frequencies and percentages for categorical variables. The independent samples t-test was applied to compare nursing students' H-PEPSS scores in two groups as well as investigate the difference of H-PEPSS scores with respect to demographic characteristics. The significance level was set at p<0.05.

Ethical considerations
This research with No. 98000996 was approved by the Ethics Committee of Kerman University of Medical Sciences (IR.KMU.REC.1399.030). In addition, the necessary permissions were presented to the Nursing and Midwifery Schools. The participants were explained about the study purpose, study process, and voluntary participation in the study. They were also assured that they could withdraw from the study at any time without any negative consequences and about the confidentiality of information they would provide.

Demographic characteristics of the respondents
Based on the results of this study, in group A, about 59.3% of the participants (n=121) were female, and 90% (n=180) were younger than 25 years old. About 70.9% (n=144) of the participants had no attendance at patient safety training; 92.2% (n=188) had observed medical and nursing errors in clinical practices; 80.9% (n=165) had reported errors to clinical educators; 57.4% (n=117) had not reported errors to hospital staff; and 81.9% (n=167) had reported errors to peer students.

Comparison of H-PEPSS domains and self-reported PS competency in different learning
settings Table 2 shows results on comparison of two groups regarding H-PEPSS domains and patient safety competency. Results showed that nursing students' total scores of patient safety competency in classroom (3.43(0.60)) and clinical setting (3.32(0.62)) were statistically significant higher in group A compared with total scores of patient safety competency in classroom (2.66(0.90)) and clinical setting (2.39(0.9)) in group B (p=0.001).  Table 3 shows results on comparison of two groups in terms of nursing students' perceptions of broader aspects of patient safety and comfortable speaking up about patient safety. The results showed that the means of the broader aspects of patient safety (3.58(0.71)) and comfortable speaking up about patient safety (3.31(0.59)) were significantly lower in group A compared with group B (3.79(0.71) and 3.55(0.72), respectively), (p=0.008, p=0.001, respectively).  Table 4 shows the scores of H-PEPSS domains in different learning settings, perceptions of broader aspects of patient safety, and comfortable speaking up about patient safety with respect to nursing students' demographic information. The scores of patient safety competency of nursing students who attended patient safety training (p=0.001) and reported errors to educators (p=0.001) and peer students (p=0.04) were significantly higher in the classroom setting. In addition, it was revealed that the scores of patient safety competency of nursing students who observed medical and nursing errors (p=0.005) and reported errors to clinical educators (p=0.007) and peer students (p=0.001), were significantly higher in the clinical settings.

Comparison of patient safety competency, broader aspects of patient safety and comfortable speaking up about patient safety with respect to demographic data
Moreover, the score of broader aspects of patient safety was significantly higher in female students (p=0.03) who did not observe medical and nursing errors (p=0.006). Moreover, the score of comfortable speaking up about patient safety was significantly higher in students who did not observe medical and nursing errors (p=0.03) and did not report errors to clinical educators (p=0.004) based on the results of this study.

Discussion
This study compared patient safety competency and patient safety-related aspects in professional education between Iranian undergraduate nursing students of two medical universities. The findings showed that the scores of patient safety competency (in the classroom and clinical settings) and its domains obtained by the nursing students of group A were significantly higher than those obtained by nursing students of Group B. Langari et al. (2017) also found that both Finnish and British nursing students had excellent overall patient safety competency scores; however, the overall patient safety competency score in British students was much higher than that of Finnish students. Similarly, two other studies reported considerable disparities in patient safety competencies among students from several Saudi universities (Alquwez et al., 2019;Colet et al., 2015). According to Shanty et al.'s (2018) study findings, patient safety competency scores significantly differed between the study groups. Patient safety competency was reported to be higher in postgraduate nursing and nuclear medicine students. Patient safety competency of nursing students was higher in the classroom than in the clinical setting according to findings of a study done by Amilia and Nurmalia (2020). In a nutshell, it seems that the level of patient safety competency is different among university students. This difference can be attributed to cultural and contextual varieties in patient safety education throughout the world (Langari et al., 2017). Günay and Kılınç (2018) reported that clinical learning is affected by different factors, including personal characteristics, clinical educators, academic educators, physical facilities, and environment.
Based on the findings, the scores of broader aspects of patient safety and perceptions of comfortable speaking up about patient safety in nursing students of group A were significantly lower than that of students in group B. No studies have been conducted in this regard yet. Therefore, a gap exists among the studies on how to address patient safety issues and perception of comfortable speaking up about patient safety. Since attitudes can influence behavior, assessing nursing students' attitudes towards patient safety is important (Robson et al., 2011). In this regard, researchers found that speaking of mistakes and filling out reporting forms were more effective in improving patient safety (Asem et al., 2019;Berman et al., 2018). Researchers also explained that the reasons that nurses and students speak less about patient safety issues may be fear of punishment, incorrect recognition of medical errors, lack of knowledge in the field, blame, and pressure from other colleagues (Asem et al., 2019;Robson et al., 2011;Safarpour et al., 2017). Usher et al. (2017) believed that nursing students must have the confidence to communicate with others to improve patient safety, especially to challenge unsafe practice, recognize, disclose, and respond to adverse events, including errors and malpractices, to reach significant improvements in patient safety and create a harmless environment for patients.
In total, our results showed that the scores of patient safety competency were statistically significantly higher in nursing students, who attended patient safety training, observed medical and nursing errors, and reported errors to clinical educators and peer students. Similarly, Torkaman et al. (2022) showed that educational intervention was somewhat effective in improving the patient safety competency in the long run. Gaupp et al. (2016) in line with the present study, indicated that e-learning improved students' attitudes toward patient safety competency. Two other studies also emphasized the role of education in understanding students' patient safety competency and their inclusion in the students' curriculum (Nie et al., 2011;Tom, 2016). Based on these findings, it can be concluded that students, who participate in workshops and training classes, gain more experience in patient safety. Observing and reporting medical and nursing errors allow students to become familiar with harmful cases to the patient. Consequently, reporting these errors and sharing them with other students and instructors, in addition to sharing self-experiences and observations, increase patient safety and may reduce errors in the clinical setting.
According to our results, score of broader aspects of patient safety was significantly higher in female students who did not observe medical and nursing errors. Moreover, mean of comfortable speaking up about patient safety was significantly higher in students who did not observe medical and nursing errors and did not report errors to clinical educators. One of the reasons why females were more concerned about patient safety issues than males may be the way they communicate with patients. Usually, women are more involved in conversations with the patient and their colleagues (Colet et al., 2015), which makes them more aware of patient safety concerns and issues, including medical errors. In addition, the more the students talk to their professors and instructors about patient safety in clinical setting, the less their fear of reporting errors and mistakes.

Implications and limitations
The results of the study implicate the importance of the attention to patient safety education among nursing students, suggesting a fundamental reform in the way novice nurses are prepared both in the classroom and in the clinical setting. Nursing professors are recommended to put more emphasis on the patient safety competency and its related aspects in educational curriculum. Results of the present study can guide nursing professors and managers to develop appropriate strategies in promoting nursing students' patient safety competency. These strategies may include reviewing the educational needs as well as modifying and developing the educational curricula.
This study had some limitations. The first limitation was related to its cross-sectional nature and gathering data at a single time period. The second limitation was the use of questionnaire to assess the safety competency and its related aspects in professional education, which may have resulted in exaggerative scores and personal bias. Future longitudinal studies are suggested to be done to collect detailed information on changes of patient safety competency over the time, from the students' entrance to the universities until they begin their clinical work. Moreover, future studies can be performed using different methods of competency evaluation, such as 360-degree evaluation method or other new and scientific methods, to help determine the actual competency.

Conclusion
According to the findings of the present study, nursing students from two different nursing schools had varied levels of patient safety competency in the classroom and clinical setting. In addition, it was found that the participants had different perspectives on larger aspects of patient safety and perceptions of speaking up about patient safety. The current findings can help policymakers align patient safety instruction with international standards in all nursing schools. Nursing professors are suggested to adopt new methodologies, such as realistic scenarios and role-playing. Researchers are recommended to undertake interventional and longitudinal studies to find out the efficacy of these strategies at improving students' patient safety competency.