Patient safety was defined by the US Institute of. Current assessment of patient safety education. Abstract. Mansour Mansour

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1 Current assessment of patient safety education Mansour Mansour Abstract The purpose of this literature review was to examine current evidence on how student nurses and nursing faculty members perceived the integration of patient safety education in preregistration/undergraduate nursing training. Databases searched from January 2000 to April 2011 included CINAHL, PsycINFO, British Nursing Index, PubMed, AMED, Academic Science, Midline, Cochrane Library Database, Web of Knowledge, Ovid Nursing Database, Wiley Online Library and Science Direct. In total, 77 articles were initially found, although only 15 were included in the author s review. Of these, 5 papers were researchbased articles that examined aspects of patient safety education in undergraduate/pre-registration nursing training, and 9 papers were literature review and discussion based, which provided insight into the experience, assessment, evaluation or implementation of patient safety education curriculum in nursing education. The author s literature review highlights the continuing lack of research on patient safety education in undergraduate/preregistration nursing training and, in particular, outlines areas in nursing education which need to be addressed to develop patient-safety-friendly nursing curricula. Key words: Patient safety education Undergraduate preregistration nursing Nursing curricula Patient safety was defined by the US Institute of Medicine as the freedom from accidental injury due to medical care or from medical error (Committee on Quality of Health Care in America Institute of Medicine, 2000: 58). On the other hand, a near miss has been defined as the incident that didn t reach the patients (Kessels- Habraken et al, 2010: 1302). Growing appreciation of the increasing burden of unsafe practice, primarily in human cost, but also in financial implications, means that ensuring safe health care and service delivery is one of the key issues for healthcare organisations and education providers. It has been estimated that unsafe practice costs the NHS around 2 billion per year (Department of Health, 2000a).To prevent errors, adverse event and near misses in health care, it was suggested that Mansour Mansour is Senior Lecturer in Acute Care Department, Faculty of Health and Social Care, Anglia Ruskin University, Chelmsford Accepted for publication: March 2012 improving patient safety education for health professionals requited improvement (National Steering Committee on Patient Safety, 2002; Greiner and Knebel, 2003; House of Commons Health Committee, 2009; Pearson et al, 2009). It is now widely accepted that single events or errors often occur owing to the convergence of multiple contributing factors in the system, and preventing errors and improving safety for patients requires a systems approach in order to modify the conditions that contribute to them (Reason, 2000). However, nursing education is regarded as the bridge to quality and the link to creating the changes needed in the health care system (Sherwood, 2011). This review examines the current evidence on the views of student nurses and faculty members with regards to the quality, content and delivery of patient safety education in undergraduate/ preregistration nursing training and curricula. Search strategy The search terms and strategies covered three main areas: patient safety education, undergraduate/preregistration nursing and nursing curriculum (Figure 1). Articles were included in the review if they were written in English in peerreviewed journals, published between 2000 to 2011, and were primary research or discussion articles that contributed to the overall analysis of patient safety education in undergraduate/ preregistration nursing training. All titles and abstracts found were assessed for relevance to the purpose of this review. Twelve databases were included in the electronic search, including CINAHL, PsycINFO, British Nursing Index, PubMed, AMED, Academic Science, Midline, Cochrane Library Database, Web of Knowledge, Ovid Nursing Database, Wiley Online Library and Science Direct. The initial electronic search resulted in 77 papers; however, 16 of these were excluded because they focused on patient safety education as a constant developmental practice, as opposed to education being delivered in academic settings to the undergraduate/preregistration nursing education. It was felt that continuous development of patient safety education is less structured, and has less impact on the initial student experience with patient safety education. In addition, 41 papers were excluded as they were not relevant to the scope of the review, or narrowly focused on certain aspects of patient safety education in undergraduate/preregistration nursing training (i.e. use of simulation and reporting of unsafe practice), with little emphasis on the overall nursing education and curriculum development for nursing students. Finally, five papers were excluded because they were editorial and/or non-peer reviewed. 536 British Journal of Nursing, 2012, Vol 21, No 9

2 LITERATURE REVIEW In total, 15 papers were included in the review. The process for culling the literature included asking questions for each citation (e.g. does the paper explore the patient safety education strategy, content, method for delivery and the academic staff, and the student nurses involvement in the research questions? Is the paper a review containing data, a case study, a research study or guideline?). Findings Five primary research papers (as shown in Table 1) were identified in the literature search that addressed patient safety education in undergraduate/preregistration nursing training from different perspectives. These studies used a range of research methods (quantitative, n=2; qualitative, n=2; mixed methods, n=1), which are described in more detail below. CINHAL n=29 Online Wiley Library n=4 Patient safety education Preregistration/undergraduate nursing Nursing curriculum Psychinfo n=6 Ovid Nursing Database n=7 Science Direct n=6 Academic Science n=18 PubMed n=22 Web of Knowledge n=21 British Nursing Index n=26 Medline n=22 ERIC n=4 Cochrane Library n=0 Organisational case study Attree et al (2008) used an organisational case study approach to explore the patient safety aspects of English preregistration nursing degree curricula. The study used various data collection methods, including analysis of the current preregistration nursing degree curriculum, focus group interviews with 15 students and 10 educators on the course, and semistructured interviews with 6 key informants responsible for education provision. The findings suggested that, while the students conceptualised patient safety as a specific patient-focus theme, the educators and key education stakeholders focused on broader aspects of safe practice and risk assessment strategies. However, there was a shared perception among all participants that the organisational culture of the practice setting was defensive, concealing and blaming. Examining the curriculum revealed that there was a lack of explicit patient safety learning objectives in the curriculum, with little emphasis on the system approach and its relation to modern awareness of patient safety (Reason, 2000) However, these study findings should be considered in terms of the limited sample size of the participants. More research is needed to validate the study findings using a larger, more representative sample. Qualitative study Vaismoradi et al (2011) conducted a qualitative study to explore Iranian nurses perspectives on patient safety and the role of nursing education. They conducted 17 face-toface, semi-structured interviews with undergraduate nursing students from various academic semesters enrolled in one university in Tehran. Data was analysed using content analysis. The authors findings suggested that the participants perceived patient safety as seeking patient comfort, but also not being knowledgeable enough to deliver safe patient care. Moreover, the participants expressed deep dissatisfaction with the way patient safety issues were discussed in the classroom. For example, many felt that teaching time was spent on addressing teaching with the medical domain, such as the pathopysiology of disease and prognosis of treatment, and that the nursing tutors spoke only generally on the basic principles of patient safety, such as using bedside rails, preventing patient falls or changing patients positions. The n=165 (includes duplicates within and across database Exclusion criteria: Duplicate =77 Overall, not focusing on undergraduate/preregistration nursing training =16 Not relevant to the purpose of the review =41 Editorial/non-peer reviewed papers =5 Total number of papers included in the review n=16 (includes duplicates within and across database) Figure 1. Flowchart of the strategy for literature search and paper selection students were struggling to make the connection between patient safety principles provided in the theoretical courses and their applications in nursing practice. However, it should be noted that the transferability of the findings in this study can only be considered in the context of Iranian culture, values and educational systems. Consequently, more research may need to be carried out to ascertain these findings in different contexts. Survey Smith et al (2007) carried out a survey to assess how far the six competencies of Quality and Safety Education for Nurses (QSEN) were addressed in Schools of Nursing in the USA. The six competencies were defined according to the Institute of Medicine report Bridge the Quality (Greiner and Knebel 2003). A national online survey was distributed to the 572 USA Baccalaureate Schools of Nursing, and to a convenience sample of 57 associate degree programmes. The survey instrument was developed and piloted with nursing faculty and administrators from four schools of nursing. In total, 30% of the Baccalaureate schools and 40% of the associate schools of nursing responded to the survey. The schools reported patient centred care as the competency most frequently threaded in the curriculum (95%), followed by safety (89%) and teamwork (82%). The three lowest ratings were for evidence-based practice (73%), quality improvement British Journal of Nursing, 2012, Vol 21, No 9 537

3 (54%) and informatics (48%). However, these relatively high scores were questioned when the results of 9 concurrent focus groups conducted in 9 conferences assessed the faculty members perceptions of the new competencies (Cronenwett et al, 2007). The results showed that participants had different perceptions of the meaning of each competency, which cast Table 1. Summary of research papers identifying aspects of patient safety education in undergraduate/preregistration nursing training. Author(s) Purpose Methods/sample Key findings Limitations Attree, To identify patient safety An organisational case study Patient safety was not explicitly Student participants Cooke themes in the curriculum, used to identify aspects of the addressed in the curriculum, were a small, self-selected Wakefield and where and how educational milieu that affect which focused on the related sample, from one case study (2008) they are taught. Also, to teaching and learning about concepts of safe practice, site. The findings of this small, examine the assessment patient safety. Curriculum fitness for practice and risk. exploratory study may need of patient safety in theory analysis was used to investigate The educational milieu was validating using larger, more and practice, and to explore patient safety within one pre- characterised as defensive representative samples factors in the educational registration nursing degree and closed, and as having milieu that affect the curriculum. Focus group an individual versus system development of students interviews with 15 students from approach to safety knowledge, attitudes and all three years of the programme, behaviour in relation to and 10 educators who teach on patient safety the programme were used in the study Chenot and To examine current Phase I: Healthcare Professionals Measurement integrity The HPPSACS was adapted from Daniel patient safety education Patient Safety Assessment studies indicated that patient an instrument developed for use (2009) for nursing students and Curriculum Survey (HPPSACS) safety awareness can be with medical resident, and even investigate nursing was piloted on a group of 400 measured validly and with pilot testing of this survey student awareness, skills, scholarly professional nurses. reliably. A content analysis on a group of registered nurses, and attitudes about patient Phase II: the HPPSACS was found that all of the the tool may have still safety distributed to nursing students participating nursing schools shortcoming in addressing the at seven universities and included at least three of the intended outcomes. Moreover, community colleges. six core competencies of the the survey is a self-report Phase III: qualitative content Quality and Safety Education instrument subject to weaknesses analysis of the patient safety for Nurses (QSEN) (Cronenwett of all such instruments in that curricula from the participating et al, 2007) in their curriculum; participants answers were institutions was carried out one school exhibited all six subjective and could have been influenced by social desirability. A low rate of return was observed from some of the participating institutions which may limit the generalisability of the findings.finally, the HPPSACS was administered at only a few universities and colleges. The awareness, skills, and attitudes about patient safety among the schools nursing faculty are unknown Smith, To assess current levels A national online survey distributed Patient centred care was The majority of schools Cronenwett of integration of quality to the 572 baccalaureate schools reported as the competency investigated chose not to and Sherwood and safety content in of nursing and a convenience most frequently threaded in respond, so the conclusion that (2007) pre-licensure nursing sample using the 57 associate the curriculum (95%), followed the responses of this sample may curricula degree nursing programmes in by safety (89%) and teamwork not be representative of nursing North Carolina. The overall return collaboration (82%). The three education programmes rate was 31% (n=195) lowest rating were evidence- throughout the country. based practice (73%), quality Moreover, the results for improvement (54%) and community college informatics (48%) programmes were based on one geographical area, and may not be reflective of national trends, and diploma programmes were not represented at all 538 British Journal of Nursing, 2012, Vol 21, No 9

4 LITERATURE REVIEW Table 1. Summary of research papers identifying aspects of patient safety education in undergraduate/preregistration nursing training (continued) Author(s) Purpose Methods/sample Key findings Limitations Sullivan, To assess student Electronic QSEN Student With response rate of 35% Low response rates and response Hirst and perspectives of quality Evaluation (n=565), the students rates that differed significantly Cronenwett and safety content in Survey (SES) was distributed reported exposure to QSEN across participating schools (2009) their nursing programmes to 1665 knowledge areas, more often limit the generalisability of the along with self-reported students via . The survey in classroom and clinical study findings. In addition, levels of preparedness consists of 3 primary questions learning settings than in skills the sample was comprised and perceived related to knowledge, skills, and lab/simulation settings. of schools already highly importance of the six attitudes. The knowledge scale of Clinical experience outside motivated to improve quality QSEN competencies the survey included 19 knowledge formal education was and safety education and objectives from the QSEN associated with perceptions contained an over-representation competencies. Skills scale consists of a higher level of of BSN students. The results of the survey with 22 items Self- preparedness for QSEN reported here may not reported levels of preparedness. skills in several be representative of all US to perform skills in all six QSEN competencies. In general, schools of nursing. Variation in competencies. The Attitude scale students reported the timing and focus of Learning of the survey consists of 22 skill relatively high levels of Collaborative schools curricular items. The survey pilot tested on preparedness in all types of may also limit the generalisability 5 pre-licensure students pre-licensure nursing of the findings programmes and endorsed the importance of quality and safety competencies to professional practice Vaismoradi, To explore Iranian Qualitative, semi-structured Three main themes emerged The study provides the Salsali and nursing students interviews with 17 bachelor s from the data analysis: perspectives of one group of Marck perspectives regarding degree nursing students (7 male Safety as patient comfort, nursing students within the (2011) patient safety and the and 10 female) from various not being knowledgeable or Iranian culture and context, and, role of nursing academic semesters enrolled at a experienced enough, being therefore, the transferability of education in developing large medical sciences university helped to internalise the findings should be considered their capabilities to in a large city in Iran principles and values of with caution in comparison with provide safe care patient safety by adopting a those of similar studies humanistic approach conducted in other contexts towards patients and practising conscientiously in the workplace doubts on the participants interpretations of the questions presented in the survey. In the same study, 2 additional focus groups were held with senior nursing students and newly-qualified nursing graduates on their nursing training. The results suggested that, not only did participants not learn the content of six competencies,, but also the School of Nursing could not have actually taught them. Although the study does not clarify in more detail the number of the participants in the focus groups, or how they were recruited, the discrepancies in the participants responses in the online survey and focus groups nonetheless suggest that one must exhibit caution in assuming that curricula are addressing the six competencies as the online survey suggested. Indeed, Smith et al (2007) implied that there is a mismatch between the actual content of the current nursing curriculum and the definitions of the six competencies advocated by the QSEN. Programme leaders, such as the Dean, Directors and Chairs, may be too far removed from the actual curriculum in use to accurately respond to the survey, which raises questions on the validity of the answers obtained from it. Mixed-methods study Chenot and Daniel (2010) carried out a mixed-methods study to gain insight into the current status of patient safety awareness among pre-license nursing students. First, the researcher developed the Health Care Professionals Patient Safety Assessment Curriculum Survey (HPPSACS), which was adopted from the Patient Safety/Medical Fallibility Assessment Pre and Post Curriculum Survey (Madigosky et al, 2006). After the pilot stage, the survey was distributed to a sample of 618 to students in seven universities in the southeast of the USA. Qualitative content analysis of patient safety curriculum and instructional methodologies was also carried out to examine the pre-licensure nursing curriculum in the 7 universities which were participating in the study. In total, 51% of the questionnaires were returned from the main study (n=318). Demographic variables were correlated with patient safety awareness variables among the participants. The researchers argued that measurements integrity studies used in this research indicate that patient safety awareness can be measured validly and reliably. For example, Alpha estimates for scores on items of HPPSACS were above or British Journal of Nursing, 2012, Vol 21, No 9 539

5 Table 2. Summary of literature review papers identifying aspects patient safety education in preregistration/undergraduate nursing training Author(s) Purpose Key findings Wakefield, The review examines to what extent Although patient safety issues feature prominently in many UK Government and public Attree, patient safety is addressed within policy documents, this is not reflected within the formal curricula guidelines issued Braidman, medical and nursing curricula by the Nursing and Midwifery Council and General Medical Council. The researchers Carlisle, argue that learning how to manage errors effectively would enable trainee practitioners Johnson and to improve patient care, reduce the burden on an overstretched healthcare system and Cooke engage in dynamic as opposed to defensive practice. (2005) near the range of the recommended level of 0.7 (Nunnally, 1978; Cortina, 1993), which demonstrated the reliability and internal consistency of the HPPSACS survey tool. The survey results also presented analysis of the relationships between various students perceptions of their awareness, skills and attitudes toward patient safety. Detailed presentation of such correlation is beyond the scope of this review. However, the statistical results showed some variations on the students responses on the 34-item scale survey and subscale. The content analysis showed that all participating nursing schools included at least three of the six core competencies of QSEN (Cronenwett et al, 2007) in their curriculum, and one school exhibited all six competencies. This demonstrated that, despite the set of core competencies of patient safety education, many schools were still not addressing the required education, at least as understood in relation to the perceived QSEN definition of competencies. Non-primary research Other literature published since 2000, although not primary research, supports the increasing need to address the patient safety education in undergraduate/preregistration nursing training (Tables 2 and 3), although there seem to be variations on how this issue is being addressed. As a response to the Institute of Medicine s quality and safety challenge (Greiner and Knebel, 2003), Cronenwett et al (2007) proposed a conceptual framework to integrate QSEN, whereby prelicensed nursing students would be exposed to six core competencies, including patient-centred care, teamwork and collaboration, evidence-based practice quality improvement, safety and informatics, with related knowledge, skills and attitudes (KSA) to be met by student nurses to qualify. This was a key paper in driving patient safety education for prelicensed nursing students in the USA, and several subsequent studies in this context drew on this paper to discuss their views and experiences of implementing the QSEN in nursing education. For example, Brown et al (2010) described the integration of QSEN in their school of nursing s associate nursing degree programme. The faculty adopted the QSEN competencies and the related KSAs in their curriculum, by using the Train the Trainer model. This model advocates a system of training based on principles of cognitive learning in which the student forms an explicit mental template of a particular practice through rehearsal of steps before physically completing the task (Raven Department of Education, 2007; Murphy et al, 2008). Twelve faculty members were allocated the task of encouraging the integration of the QSEN project by integrating the teaching strategies into classroom, simulation and clinical learning experience. The implementation of the QSEN project was reported to initiate a dramatic shift in the faculty from traditional content-based to conceptbased curriculum. The faculty developed a toolkit for each competency of the QSEN to guide clinical discussion, promote reflective thinking and linking theory concepts of the QSEN competencies with the clinical situation, and created opportunities for the students to think at the application and analysis level. Moreover, Wakefield et al (2005) carried out a literature review to examine if medical and nursing curricula are addressing patient safety themes in UK. The authors found that the ability to learn from near misses is an underdeveloped attribute in the healthcare curriculum, and there is little evidence that nursing programmes equip students with the skills necessary to examine patient safety issues. The authors argued that, although the patient safety issues have been featured prominently in many public documents and Government White Papers (Department of Health, 2000a; 2000b), this has not been reflected in the formal curricula guidelines issued by the Nursing and Midwifery Council, who are responsible for approving nursing curricula. This literature review, however, was published in 2005, and it is likely that patient safety education has gone through some changes since then. The review, however, does not state the search strategy or the inclusion/exclusion criteria, so it is difficult to affirm the scope of the authors research. Furthermore, Gregory et al (2007) reported on patient safety education in Canada. They argued that, in the Canadian context, there is still a tendency in nursing education to take an individual approach to nursing student errors, and that the nursing educators are still missing the broader systematic factors in nursing education, as well as the clinical environment. The authors called for a culture shift in nursing education, whereby educators need to identify system flaws and highlight them in curriculum courses, programmes and models of instructions. Moreover, the authors suggested that the theoretical education of nursing students is still largely supportive of the individual approach to unsafe practice. While this may be a valid argument for shifting the culture to a system approach in educational settings, it does not, however, specify the means for doing so, nor is there an explicit vision on how to integrate this notion into nursing curricula in a practical manner. 540 British Journal of Nursing, 2012, Vol 21, No 9

6 LITERATURE REVIEW Table 3. Summary of discussion papers identifying aspects patient safety education in preregistration/undergraduate nursing training Author(s) Purpose Key findings Armstrong, To describes how one university is The COPA model offers clear direction for standardised evaluation of competency. Some Spencer and using the QSEN competencies to nursing programmes that shifted the curricular framework to COPA concepts, outcomes, Lenburg enhance its competency outcome and validation methods may raise concerns about the emerging implementation of the (2009) performance assessment (COPA)- QSEN initiative. The relevance of the COPA model and value system is increased in the based curriculum, and updating and context of QSEN, in which not only clinical competency is necessary to protect patient strengthening its graduates skills in safety, but systems competency also is equally vital. Nursing faculty whose teaching is quality improvement and safety focused in a competency-based curriculum are well positioned to respond to the call to integrate QSEN competencies into their curricula Brady To describe a course redesign and The QSEN competencies provide a systematic structure for course redesign and course (2011) restructure for nursing education content. Applying the competencies using best practices in education involves active which incorporated a wide variety of learning strategies, technology-rich experiences, and assignments that incorporate multiple active learning modalities and learning modalities. Simulation is an ideal education technique to implement QSEN since simulation to implement and the multiple levels of knowledge, skills and attitudes (KSAs) in each competency can be integrate the QSEN competencies. practiced and evaluated Brown, To describe the three-phased The faculty adopted the QSEN competencies and the related Knowledge, Skills and Feller and initiative of integrating the QSEN in Attitudes (KSA) in their curriculum, by using train the trainer model. The faculty developed Benedict the school of nursing, associate a toolkit for each competency of the QSEN to guide clinical discussion, promote reflective (2010) nursing degree programme as one of thinking and linking theory concepts and the QSEN competencies with the clinical two associate degree pilot schools situation, and created opportunities for the students to think at the application and analysis involved in the early phases of level. The implementation of the QSEN project was reported to initiate a dramatic shift in QSEN development the faculty from traditional content-based to concept-based curriculum Cronenwett The article presents the rationale, The collective accomplishments of the collaboration provided a foundation for spread of Sherwood and design, activities, and outcomes of innovations toward the goal of making quality and safety competency development a Gelman the collaborative initiative to improve reliable outcome of pre-licensure nursing education programmes (2009) quality and safety education in prelicensure nursing programmes, 15 schools participated in a 15-month learning collaborative Cronenwett, Discussion held with faculty members To ensure that the new graduate competencies in the six QSEN-advocated competencies, Sherwood, and pre-licensure nursing students to all of nursing education must embrace the need for change. These competencies cannot be Barnsteiner, find if the six QSEN competencies for mastered through a didactic approach nor developed in a single course or web-based Disch, nursing education are appropriate module. Every clinical instructor will have to engage differently with the inter-professional Johnson, goals for students preparing for basic team on patient care units where they are teaching Mitchell, practice as a registered nurse Sullivan and Warren (2007) Day and To describe an innovative approach to Suggested strategies include shifting the focus to system approach in learning in the Smith integrating quality and safety content acute care clinical environment requires a shift in the attention rather than changes in (2007) into existing clinical practical. The core course content and can be included in any clinical rotation in an acute care setting. New competencies identified by the QSEN graduate nurses need to start seeing themselves as powerful members of a larger team project serve as the framework for the and as capable of influencing patient care delivery in a larger sense through their work at teaching/learning exercises the bedside and as part of an interdisciplinary team Gregory, M To discuss the current trend of patient The authors argued that in the Canadian context, there is still a tendency in nursing Guse, L Dick, D safety education in nursing training in education to take an individual approach to nursing student errors, as opposed to system Russell, C the Canadian context approach. They also called for culture shift in nursing education, whereby educators need (2007) to identify system flaws and highlight them in curriculum courses, programmes and model of instructions Neudorf, K To describe the integration of patient Nursing education can provide the catalyst for safe care delivery by providing leadership Dyke, N safety core curriculum modules for to improve health education systems and patient safety. Graduate who have the Scott, D competency development. The foundation competencies relevant to system approach are likely to contribute mostly to Davidson, D process for students reporting adverse the quality and safety of patient care (2008) events and near misses is also outlined, and the processes used to engage faculty are addressed Walsh, To provide a preliminary report of the The CPET consists of three components: Checklist of recommended practice, key and Jairath, process of developing a Clinical guidelines for educators and students. The CPET can be used to more accurately appraise Paterson and Performance Evaluation Tool (CPET) clinical capabilities of nursing students by focusing on quality and safety in health care, and Grandjean to accurately measure the Quality and it permitted the evaluation of critical thinking skills and team communication (2010) Safety Education for Nurses (QSEN) competencies in the undergraduate programme of a school of nursing British Journal of Nursing, 2012, Vol 21, No 9 541

7 Discussion This review has focused on patient safety education in undergraduate/preregistration nursing training. Research in North America appears to have taken advanced steps in integrating this education in undergraduate/preregistration nursing training. This is exemplified by the development of the QSEN (Cronenwett et al, 2007) and the subsequent testing and implementation of its competencies in nursing curriculum. Apart from one study conducted by Attree et al (2008), there seems to be little evidence of similar work undertaken in UK. Previous literature reviews conducted in the UK on patient safety education in undergraduate healthcare education, including nursing, concluded that, in comparison to other disciplines, there is currently limited evidence to show how nurse educators are incorporating patient safety into programmes and what effect such training has on practice (Pearson et al, 2009). The examination of selected papers has suggested that most of research in patient safety in undergraduate/preregistration nursing training have followed the competency-based approach in reforming the patient safety education curricula, including nursing ones. Competency-based education focuses on making the learning outcomes for courses more explicit, and evaluating how well the students have mastered these outcomes or competencies (Harden, 2002; 2007). It was argued that a competency based approach would result in improving the students education, because educators would have to benchmark the outcome for student performance, and would provide an impetus for faculty development, curricular reform and leadership activities (Greiner and Knebel, 2003). However, few empirical studies have been carried out to support this suggestion, and its impact of the on addressing all aspects related to patient safety remains to be seen. Evidence from this review has highlighted that there is a mismatch between the student perception and educator conceptualisation of patient safety (Attree et al 2008; Vaismoradi et al 2011), and the focus on the individual contribution towards unsafe practice, without taking into account the system approach toward patient safety (Vaismoradi et al, 2011). Person et al (2009) supported this notion, and suggested that there are some discrepancies between the theoretical teaching of patient safety in the UK, and the context of clinical learning for nursing students, and that there is a tension between being taught the safe performance of skills (such as moving and handling) in the university, and being exposed to numerous variations in the performance of these skills in their placements. There has been an increasing drive in healthcare settings to adopt some of the training skills that are not related directly to technical expertise, but crucial for maintaining safety. Such training is often called crew resource management (CRM), which is designed to reduce human error by enhancing nontechnical skills, such as communication, teamwork, situation awareness, and decision making (Baker and Dismukes, 2002; Flin et al, 2003). The initial results of integrating such non-technical skills in the training of operating-room nurses have demonstrated reduced errors and changed attitudes and behaviour towards teamwork and patient safety (Powell and Hill, 2006). Integrating such training in preregistration nursing education was said to provide the students with a common vocabulary and facilitate discussion of unsafe behaviours, improve team communication, and help to develop solutions for reducing risks to patients (Flin and Patey, 2009); although the benefits of applying these skills in the context of preregistration nursing education has not yet been systematically tested, particularly given that a considerable proportion of preregistration nursing education is delivered through student clinical supervision (Ramprogus et al, 2003). The case for integrating the non-technical skills in healthcare education has become more powerful since the publication of the Parliamentary Report into Patient Safety (House of Commons Health Committee, 2009), which suggested that the NHS lags unacceptably behind other safety-critical industries, such as aviation, and that human factor education must be fully integrated into the undergraduate and postgraduate healthcare education. Flin and Patey (2009) supported this notion and argued that it might be too late to start delivering this training after undergraduate education has been completed and professional attitudes are almost fully formed. The QSEN (Cronenwett et al, 2007) appears to have addressed some of the aspects of non-technical skills teaching, such as teamwork and the interdisciplinary communication. Several other aspects of such non-technical skills, however, appear to be largely missing from the QSEN framework. For example, there seems to be a lack of any teaching material to address the importance of human factors and the contributions of system complexities toward unsafe practice, or acknowledgement that serious safety problems may occur in the hands of highly dedicated and competent health professionals. A recent review of top-ranked American nursing school curricula heavily criticised the absence of dedicated patient safety components, including human factor training and CRM (Howard, 2010). The review argued that the bridge between education and practice should be paved with required dedicate patient safety education, and should emphasise the study of human capability, and the fallibility of human within the systems-human interface. This implies that, even with the implementation of QSEN, some important aspects of patient safety remain inadequately addressed in nursing curricula. This review indicates that most patient safety education courses have not been formally and fully included in the undergraduate/preregistration nursing education system, even in those counties that are considered leading in this field. Also, there were some variations in course design and contents, teaching resources and methods of delivery, and no uniform criteria to evaluate the effect of teaching on nursing students. Such discrepancies made it difficult to systematically ascertain how patient safety education is perceived by the nursing students and academic faculty members There are some indications that non-technical skills are increasingly being addressed in the education of health professionals. This was noticed in the recently launched World Health Organization s (WHO) Curriculum Guide on Patient Safety for Medical Students (World Alliance for Patient Safety, 2009), and the recent publication of the updated version for multi-health professionals (World Alliance for Patient Safety 2011). WHO is currently conducting a global study to evaluate the effectiveness of this curriculum guide in the context of health education. The results of this study, in which the author s institution is participating, will hopefully provide some insight into how these skills can be used in health education. 542 British Journal of Nursing, 2012, Vol 21, No 9

8 LITERATURE REVIEW Limitations This review is not without limitations. For example, only papers published since 2000 were included, with an explicit focus on patient safety education in nursing training. Other papers published before the year 2000 were not included. Moreover, only papers deemed to explicitly focus on patient safety education in nursing training, with academic relevance (i.e. including nursing students and faculty members views), were included. This might have excluded other papers that addressed patient safety education from different perspectives. The key words used in the search strategy included patient safety. The use of such exclusive term may have overlooked other issues which might be considered important constituents of patient safety research, but were not labelled explicitly as patient safety. This might have lead to excluding an important research body that is relevant to the topic of patient safety education. Conclusion Patient safety education is changing rapidly, and by the time this review is published, new evidence and competencies of patient safety education could be tried and tested. However, there is little doubt around the need to integrate new thinking about patient safety in undergraduate/preregistration nursing curriculum and training. Most current hospital employees were educated in a time when quality and safety were not an obvious part of the curriculum (Hall et al, 2008), and this provides a strong impetus to rethink the nursing education so that future nurses are equipped with modern knowledge and skills which are compatible with a modern patient safety agenda. The findings from some of the papers which were addressed in the review have criticised the content of patient safety education, and the lack of explicit integration of important elements of patient safety education and training curricula of nursing, such as human factor, where there should be an emphasis on the human fallibility, and the recognition that errors will inevitably occur in certain circumstances. Although there is some newly emerging evidence in the literature in this regards, there is still a long way to go to achieve this goal. BJN Conflict of interest: none Armstrong GE, Spencer TS, Lenburg CB (2009) Using quality and safety education for nurses to enhance competency outcome performance assessment: a synergistic approach that promotes patient safety and quality outcomes. J Nurs Educ 48(12): Attree M, Cooke H, Wakefield A (2008) Patient safety in an english pre-registration nursing curriculum. 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(accessed 27 April 2012) KEY POINTS There is an increased awareness among education and health professionals that patient safety education is fundamental for delivering safe health care There seems to be a wealth of research from North America on integrating patient safety research in pre-registration/undergraduate nursing education, which is exemplified by the publication of the six competencies of Quality and Safety of Education for Nurses This literature review highlighted the lack of incorporating a modern patient safety agenda, training, systems thinking, and human fallibility to unsafe practice in nursing education British Journal of Nursing, 2012, Vol 21, No 9 543