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The Role of Undergraduate Nursing Education in Patient Safety

Joan Stanley, PhD, NP, FAAN, FAANP; Bryan M. Gale, MA; Sarah E. Mossburg, RN, PhD | November 27, 2023 
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Introduction

Nurses are a linchpin of patient safety within the healthcare system. Their responsibilities encompass a wide spectrum of care tasks that can impact safety, including administering medications correctly, monitoring vital signs for deterioration, and identifying and reporting errors and near misses. Because of this expansive role, they wield a large influence on patient outcomes and safety, as mentioned in the landmark Institute of Medicine report Keeping Patients Safe: Transforming the Work Environment of Nurses. That report, and numerous studies since, found that patient safety outcomes are improved if there are (1) lower nurse-to-patient staffing ratios; (2) a highly educated, professional nurse workforce; and (3) work environments that enable nurses to care for patients effectively. While the quantity of nurses and the environment of care are important, the quality of each nurse’s education forms the bedrock for their clinical reasoning and execution of daily tasks that impact each patient’s safety.

In 2022, 71% of currently practicing nurses in the workforce have earned a baccalaureate degree or higher.1 Within the classroom and clinical settings of these baccalaureate nursing programs, students acquire the knowledge, skills, and abilities necessary to become not only healthcare providers but also patient safety advocates. Therefore, the standards, curricula, and execution of undergraduate nursing education must be of high quality and include a particular focus on safety topics.

Nursing Curricula

Several organizations have published educational standards related to undergraduate nursing, including the World Health Organization in 2000,2 the Quality and Safety Education for Nurses project (QSEN) starting in 2005,3 and most recently updated, the American Association of Colleges of Nursing (AACN) Essentials in 2021.4 All of these standards include components focusing on patient safety, quality of care, teamwork, and evidence-based practice. For example, the AACN included “Quality and Safety” as one of its 10 domains of competence, which is described as a “core value of nursing practice, enhancing quality and minimizing risk of harm to patients and providers through both system effectiveness and individual performance.”4

Nursing curriculum standards are shifting toward competency-based education (CBE) and away from a traditional knowledge-based instructional model.5 In the traditional model of learning, the focus is on the learner showing the instructor what they know generally through a graded written assignment or test at the end of a fixed period of time. CBE, by contrast, is focused on the use of knowledge, skills, and competencies to demonstrate application of what they know. There are multiple opportunities for feedback to students across the curriculum, as well as a summative assessment for determining competency attainment. The goal of transitioning to this model of education is to produce more competent and confident nurses who are better prepared to meet the dynamic challenges of the modern healthcare environment.

Instructional Strategies

Nursing students are first introduced to patient safety concepts in the classroom and by simulated experiences. These concepts are reinforced later in their education during their clinical rotations. Both of these settings provide students with essential knowledge and skills. A recent literature review suggested that it can be difficult to bridge the gap between theory and practice and to instill the values of safety culture in students.

Classroom Instruction

In the classroom, educators use a plethora of pedagogical strategies, including lectures, case studies (both one-time use and unfolding scenarios), skills labs, and simulation exercises. Safety concepts can be integrated into lessons to instill patient safety as a core competency in students from the beginning, starting with introducing safety concepts explicitly in lectures and readings. Faculty can weave core safety concepts into lectures focused on the fundamentals of nursing, and gradually introduce specific population or disease-based safety risks as the curriculum progresses. Faculty can build on concepts introduced in lectures through case studies. Case studies, including both one-time and unfolding scenarios, present students with complex patient cases that involve safety-related challenges and compel students to consider patient safety principles and best practices in their decision-making process. Skills labs support and facilitate psychomotor learning while offering the students the opportunity to openly apply safety concepts. Similarly, simulation allows students to apply skills in a realistic scenario and, importantly, learn through failure without the risk of negative impact to a patient. Post-simulation debriefing enables instructors to coach students through an analysis and evaluation of the impact of individual behaviors, clinical reasoning processes, team dynamics, and communication, on outcomes. To aid educators and administrators, QSEN has a repository of teaching strategies with a wide array of evidence-based teaching materials and strategies specifically designed to instill patient safety competencies.6

Clinical Rotations

One of the most difficult parts of a nurse’s education is translating the theory learned in the classroom to the practice of working in a clinical setting, both during their education and after they have graduated. Exposure to patient safety concepts outside of the classroom setting is critical for each student’s feeling of preparedness to transition to the clinical setting after graduation.7 While the classroom provides a structured and controlled environment for theoretical knowledge acquisition, the clinical setting introduces dynamic and unpredictable real-world context to their decision making. Schools can help students bridge the gap by making sure that safety competencies are an explicit part of the curriculum for the clinical rotation and clearly communicating expected safety competencies to both students and preceptors. This alignment ensures that students are aware of their learning objectives and that preceptors are well-prepared to guide and evaluate their progress.

After expectations are set, many students will experience or witness a safety event during their clinical rotations. These events most commonly involve biological hazards (e.g., needlesticks) and medication errors (e.g., miscalculated dose). They happen more often when students lack appropriate supervision, further emphasizing the role of clinical preceptors in ensuring patient safety.8 Students are often afraid of speaking up about errors when they happen, usually due to fear of reprimand for calling out their preceptor or another clinician, or lack of confidence in their knowledge.9,10 This fear is certainly not exclusive to students. Many healthcare professionals are afraid to speak up about errors for similar reasons. A robust culture of safety within clinical sites can reduce the fear of speaking up, among both students and other healthcare professionals, by encouraging open communication and fostering an environment in which concerns are addressed promptly and effectively.10 While the prevailing culture of a clinical placement site may be beyond the control of nursing schools, faculty can educate and empower students to advocate for patient safety and support them when they experience or witness errors. For example, faculty can facilitate conversations about safety events in post-clinical group discussions and even among larger groups in the classroom when appropriate, specifically assessing safety risks, what occurred, as well as outcome trends. Faculty also could provide emotional support for students who experience events and temper expectations about the abilities of involved students to engage in this dialogue if they are uncomfortable.

Finally, it is worth mentioning that some, but not many, studies describe the characteristics of the ideal clinical learning environment for nursing students.11 Most of the published literature focuses on students’ perceptions of their clinical learning environment rather than on quantifiable outcomes of different environments on specific safety competencies. Some of the main facilitators mentioned by students are (1) experiencing a wide range of clinical learning settings, (2) being actively involved in clinical processes, (3) having strong interpersonal communication with their preceptor and the team, and (4) having adequate supervision and feedback.11 Barriers include a lack of time for teaching, discordant relationships within the clinical team, and clinicians practicing contrary to established conventions. Additional research would be beneficial in establishing evidence-based best practices for clinical nursing education.

Conclusion

Patient safety is heavily dependent on nurses in the U.S. healthcare system, and the quality of undergraduate nurse education is the foundation for their patient safety capability. To best prepare nurses to be patient safety advocates, nursing schools can leverage established standards like the AACN Essentials and evidence-based teaching strategies to integrate patient safety concepts into their undergraduate curriculum, encompassing both classroom instruction and clinical rotations. They can also maintain a commitment to introducing a culture of safety and cultivating mutually beneficial partnerships with clinical sites. Finally, nursing education is and must remain a dynamic discipline, perpetually adapting to the evolving landscape of modern healthcare and patient safety.


  1. U.S. Bureau of Labor Statistics. Occupational Outlook Handbook: Registered Nurses. U.S. Bureau of Labor Statistics; 2022. Accessed November 6, 2023. https://www.bls.gov/ooh/healthcare/registered-nurses.htm#tab-1
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  4. American Association of Colleges of Nursing. The Essentials: Core Competencies for Professional Nursing Education. American Association of Colleges of Nursing; 2021. Accessed November 6, 2023. https://www.aacnnursing.org/Portals/0/PDFs/Publications/Essentials-2021.pdf
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  8. García-Gámez M, Morales-Asencio JM, García-Mayor S, et al. A scoping review of safety management during clinical placements of undergraduate nursing students. Nurs Outlook. 2019;67(6):765-775. doi:10.1016/j.outlook.2019.06.003
  9. Bedgood AL, Mellott S. The role of education in developing a culture of safety through the perceptions of undergraduate nursing students: an integrative literature review. J Patient Saf. 2021;17(8):e1530-e1536. https://doi.org/10.1097/PTS.0000000000000548
  10. Hoffmann M, Schwarz CM, Schwappach D, Banfi C, Palli C, Sendlhofer G. Speaking up about patient safety concerns: view of nursing students. BMC Health Serv Res. 2022;22(1):1547. doi:10.1186/s12913-022-08935-x
  11. Bianchi M, Bressan V, Cadorin L, et al. Patient safety competencies in undergraduate nursing students: a rapid evidence assessment. J Adv Nurs. 2016;72(12):2966-2979. doi:10.1111/jan.13033
This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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