Patient safety in nursing education: Contexts, tensions and feeling safe to learn

Summary

Education is crucial to how nurses practice, talk and write about keeping patients safe. The aim of this multisite study was to explore the formal and informal ways the pre-registration medical, nursing, pharmacy and physiotherapy students learn about patient safety. This paper focuses on findings from nursing.

A multi-method design underpinned by the concept of knowledge contexts and illuminative evaluation was employed. Scoping of nursing curricula from four UK university programmes was followed by in-depth case studies of two programmes.

Scoping involved analysing curriculum documents and interviews with 8 programme leaders. Case-study data collection included focus groups (24 students, 12 qualified nurses, 6 service users); practice placement observation (4 episodes = 19 hrs) and interviews (4 Health Service managers).

Within academic contexts patient safety was not visible as a curricular theme: programme leaders struggled to define it and some felt labelling to be problematic. Litigation and the risk of losing authorisation to practise were drivers to update safety in the programmes. Students reported being taught idealised skills in university with an emphasis on ‘what not to do’.

In organisational contexts patient safety was conceptualised as a complicated problem, addressed via strategies, systems and procedures. A tension emerged between creating a ‘no blame’ culture and performance management. Few formal mechanisms appeared to exist for students to learn about organisational systems and procedures.

In practice, students learnt by observing staff who acted as variable role models; challenging practice was problematic, since they needed to ‘fit in’ and mentors were viewed as deciding whether they passed or failed their placements. The study highlights tensions both between and across contexts, which link to formal and informal patient safety education and impact negatively on students' feelings of emotional safety in their learning.

Introduction

Improving patient safety is a global concern. In 2001 the UK National Patient Safety Agency (NPSA) was established followed by the World Alliance for Patient Safety in 2004 (WHO, 2004). However UK inquiries continue to highlight safety issues; children's heart surgery at Bristol (Kennedy, 2001); the Maidstone and Tonbridge Wells investigation into Clostridium difficile (Healthcare Commission, 2007); and the recent inquiry into care provided by Mid Staffordshire National Health Service (NHS) Foundation Trust (Francis, 2013, Hornett, 2012). Issues included: teamwork, workplace culture, leadership, communication, staffing levels, training, difficulties in reporting concerns; and information monitoring. The increased profile of patient safety resulted in numerous campaigns and collaborations across UK universities, the NHS and beyond (Slater et al., 2012, Burston et al., 2011). Developments include the Safer Patients' Initiative (Health Foundation, 2011a), Scottish patient safety programme and research network (Haraden and Leitch, 2011), and patient safety research centres. Thus considerable research and development have been stimulated in areas including, adverse events (Jordan, 2011), medication issues (Wulff et al, 2011), non-technical skills (Gordon et al., 2012, White, 2012), organisational factors (Dodds and Kodate, 2011) and human factors (WHO, 2009). Despite some progress, unnecessary patient harm remains a key issue for nursing and health care (The Health Foundation, 2011b, Jordan, 2011). Education is recognised as playing a major role in developing safe, high quality, nursing and health care (Francis, 2013, Mansour, 2012, Slater et al., 2012, Pearson and Steven, 2009). However a recent review of evidence on perceptions of patient safety in pre-registration and undergraduate education revealed a continued lack of research and the need for ‘patient-safety-friendly nursing curricula’ (Mansour, 2012, p.536).