Abstract
Existing research into learning about patient safety focuses on identifying how educational interventions improve educational outcomes but few studies offer evidence that inform educators about the mechanisms involved in learning about patient safety. The current evidence based in undergraduates is also limited to outcomes that relate to knowledge and skills. A realist approach involving three cycles of data collection in a single cohort of students over 5 years used different outcomes in Kirkpatrick’s framework to identify the mechanisms that influence students learning about patient safety. Data source 1. Focus groups identified an overarching theoretical model of the mechanisms that influence patient safety learning for medical students. Data source 2 Identified if the mechanisms from data source 1 could be demonstrated at the outcome level of knowledge and attitudes. Data source 3 Established associations between mechanisms and outcomes at skills and behavioural level, in a standardised simulated ward setting. Data source 1: The interpretation of data from seven focus groups involving sixty students identified reflection at two levels of Mezirow’s descriptions; reflection and critical reflection as mechanisms that influence learning about error. Data source 2: Sixty-one students participated. The associations found, reflection and knowledge of actions to take for patient safety, r = 0.44 (P = 0.00) and critical reflection and intentions regarding patient safety, r = 0.40 (P = 0.00) Data source 3: Forty-eight students participated. The correlation identified associations between critical reflection and planned changes following feedback was, r = 0.48 (P = 0.00) and reflection and knowledge based errors r = −0.30 (P = 0.03). A realist approach identified two different levels of reflection were associated with different patient safety outcomes for this cohort of students. Critical reflection was associated with attitudes and reflection was associated with knowledge of actions and error behaviours. These findings give educators greater depth of information about the role of reflection in patient safety.
Similar content being viewed by others
References
Altman, D. (1991). Practical statistics for medical research. London: Chapman and Hall.
Azjen, J. (1991). The theory of planned behaviour. Organizational Behavior and Human Decision Processes, 50, p179–p211.
Barr, H., Freeth, D., Hammick, M., Koppel, I., & Reeves, S. (2000) Evaluations of interprofessional education. A United Kingdom review for health and social care. Retrieved 10th October 2012 from http://www.caipe.org.uk/silo/files/evaluations-of-interprofessional-education.pdf.
Bland, J. M., & Altman, D. G. (1995). Multiple significance tests: The Bonferroni method. British Medical Journal, 310, p170.
de Feijter, J. M., de Grave, W. S., Dornan, T., Koopmans, R. P., & Scherpbier, A. J. (2011). Students’ perceptions of patient safety during the transition from undergraduate to postgraduate training: An activity theory analysis. Advances in Health Sciences Education, 16(3), p347–p358.
Dixon-Woods, M., Suokas, A., Pitchforth, E., & Tarrant, C. (2009). An ethnographic study of classifying and accounting for risk at the sharp end of medical wards. Social Science in Medicine, 69(3):362–369.
Gould, B. E., Grey, M. R., Huntington, C. G., et al. (2002). Improving patient care outcomes by teaching quality improvement to medical students in community-based practices. Academic Medicine, 77:1011–1018.
Halbach, J. L., & Sullivan, L. L. (2005) Teaching medical students about medical errors and patient safety: Evaluation of a required curriculum. Academic Medicine, 80(6):600–606.
Hall, L. W., Scott, S. D., Cox, K. R., Gosbee, J. W., Boshard, B. J., Moylan, K., & Dellsperger, K. C. (2010). Effectiveness of patient safety training in equipping medical students to recognise safety hazards and propose robust interventions. Quality and Safety in Health Care, 19(1):3–8.
Health and Safety Executive HSE. (1999). Reducing error and influencing behaviour. HSG48, London: HSE books.p2.
Iedema, R. (2011). Creating safety by strengthening clinicians’ capacity for reflexivity. BMJ Quality and Safety, 20(Suppl 1), i83–i86.
Institute for Healthcare Improvement. (2012). SBAR technique for communication: A situational briefing model. Retrieved 6 December 2012 from http://www.ihi.org/knowledge/Pages/Tools/SBARtechniqueforCommunicationAsituationalBriefingModel.aspx.
Jackson, F. (2009). In World Health Organisation. Human factors in patient safety. Review of topics and tools. Retrieved November 20, 2012 from http://www.who.int/patientsafety/research/methods_measures/human_factors/Human_factors_review.pdf.
Kember, D., Leung, D., Jones, A., Yuen Loke, A., Mckay, J., Sinclair, K., et al. (2000). Development of a questionnaire to measure the level of reflective thinking. Assessment & Evaluation in Higher Education, 25(4), p381–p395.
Ker, J. S. (2013). Simulation in practice. Chapter 13. In K Forrest, J McKimm, & S. Edgar (Eds.), Essential simulation in clinical education. New Jersey: Wiley-Blackwell.
Ker, J. S., Hesketh, E. A., Anderson, F., & Johnston, D. A. (2006). Can a ward simulation exercise achieve the realism that reflects the complexity of everyday practice junior doctors encounter? Medical Teacher, 28(4), p330–p334.
Kerfoot, B. P., Conlin, P. R., Travison, T., & McMahon, G. T. (2007). Patient safety knowledge and its determinants in medical trainees. Journal of General Internal Medicine, 22(8):1150–1154.
Kirkpatrick, D. L. (1967). Evaluation of training. In R. Craig & L. Bittel (Eds.), Training and development handbook (pp. 87–112). New York: McGraw-Hill.
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington: National Academy Press.
Leape, L. L. (1994). Error in medicine. Journal of the American Medical Association, 272(23), 1851–1857.
Madigosky, W. S., Headrick, L. A., Nelson, K., Cox, K. R., & Anderson, T. (2006). Changing and sustaining medical students' knowledge, skills, and attitudes about patient safety and medical fallibility. Academic Medicine, 81(1):94–101.
Mann, K., Gordon, J., & MacLeod, A. (2009). Reflection and reflective practice in health professions education: A systematic review. Advances in Health Sciences Education; Theory and Practice, 14(4), p595–p621.
McCulloch, P., Mishra, A., Handa, A., Date, T., Hirst, G., & Catchpole, K. (2009). The effects of aviation style non-technical skills training on technical performance and outcome in the operating theatre. Quality and Safety in Health Care, 18, p109–p115.
McIlwaine, L. M., McAleer, J. P. G., & Ker, J. S. (2007). Assessment of final year medical students in a simulated ward: Developing content validity for an assessment instrument. International Journal of Clinical Skills, 1, p33–p35.
Mezirow, J. (2000). Learning as transformation: Critical perspectives on a theory in progress. San Francisco: Jossey-Bass.
Morey, J. C., Simon, R., Jay, G. D., Wears, R. L., Salisbury, M., Dukes, K. A., et al. (2002). Error reduction and performance improvement in the Emergency Department through Formal Teamwork training: Evaluation Results of the MedTeams Project. Health Services Research, 37(6), p1553–p1581.
National Patient Safety Foundation. (2012). Ask me 3™. Retrieved November 20, 2012 from http://www.npsf.org/for-healthcare-professionals/programs/ask-me-3/.
Patey, R., Flin, R., Cuthbertson, B. H., MacDonald, L., Mearns, K., Cleland, J., et al. (2007). Patient safety: Helping medical students understand error in healthcare. Quality and safety in Health Care, 4, p256–p259.
Pawson, R., & Tilley, N. (1997). Realistic evaluation. London: Sage Publications.
Reason, J. (2008). The Human Contribution: unsafe acts, accidents and heroic recoveries. Aldershot: Ashgate Publishing Limited.
Ritchie, J., & Spencer, L. (1994). Qualitative data analysis for applied research. Chpt 9. In A. Bryman & R. Burgess (Eds.), Analysing qualitative data. London: Routeledge.
Vincent, C., Neale, G., & Woloshynowych, M. (2001). Adverse events in British Hospitals: Preliminary retrospective record review. British Medical Journal, 322, 517–519.
Vira, T., Colquhoun, M., & Etchells, E. (2006). Reconcilable differences: Correcting medication errors at hospital admission and discharge. Quality and Safety in Health Care, 15, p122–p126.
Wittich, C. M., Lopez-Jimenez, F., Decker, L. K., Szostek, J. H., Mandrekar, J. N., Morgenthaler, T. I., et al. (2011a). Measuring faculty reflection on adverse patient events: Development and initial validation of a case-based learning system. Journal of General Internal Medicine, 26(3), p293–p298.
Wittich, C. M., Reed, D. A., Drefahl, M. M., West, C. P., McDonald, F. S., Thomas, K. G., et al. (2011b). Relationship between critical reflection and quality improvement proposal scores in resident doctors. Medical Education, 45(2), p149–p154.
Wong, B. M., Etchells, E. E., Kuper, A., Levinson, W., & Shojania, K. G. (2010). Teaching quality improvement and patient safety to trainees: A systematic review. Academic Medicine, 85(9), p1425–p1439.
World Health Organisation (2009). Conceptual Framework for the International Classification of Patient safety. Retrieved June 24, 2013 from http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf.
Acknowledgments
The authors would like to acknowledge the cohort of medical students from the University of Dundee who participated in this study over the 5-year period. The authors would also like to acknowledge Mr Kevin Stirling who assisted in the data collection for data source 3 and Professor Peter Donnan and Dr. Douglas Murphy who contributed statistical advice for data sources 2 and 3.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Ambrose, L.J., Ker, J.S. Levels of reflective thinking and patient safety: an investigation of the mechanisms that impact on student learning in a single cohort over a 5 year curriculum. Adv in Health Sci Educ 19, 297–310 (2014). https://doi.org/10.1007/s10459-013-9470-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10459-013-9470-8