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Measuring Patient Safety knowledge and

competences as perceived by nursing students:
an Italian validation study

ARTICLE in NURSE EDUCATION IN PRACTICE AUGUST 2015

DOI: 10.1016/j.nepr.2015.08.006

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 Nurse Education in Practice xxx (2015) 1e8

Contents lists available at ScienceDirect

Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

Measuring patient safety knowledge and competences as perceived by

nursing students: An Italian validation study
Valentina Bressan a, Simone Stevanin b, Giampiera Bulfone a, Antonietta Zanini a,
Angelo Dante c, Alvisa Palese a, *
a
University of Udine, Udine, Italy
b
University-Hospital of Padova, Padua, Italy
c
University of Trieste, Trieste, Italy

a r t i c l e i n f o a b s t r a c t

Article history: The study sought to validate the Italian version of the Health Professional Education in Patient Safety Survey
Accepted 7 August 2015 (H-PEPSS), an instrument used to assess the perceptions of health professionals regarding patient safety
competence. The H-PEPSS was administered to a sample of 574 bachelor degree nursing students in two
Keywords: north-eastern Italian universities. Its factor structure, validity and reliability were examined using
Patient safety explorative factor analysis. The internal consistency of the Italian version of H-PEPSS (H-PEPSSIta) measured
Nursing education
with Cronbach's alpha (a) was higher for both classroom (.938) and clinical training (.942) dimensions. The
Clinical learning
six factors that emerged from the analysis were composed of three to ve items loading
.55 and explaining
Knowledge
Competence
69.344% of the classroom total variance and 70.425% of the clinical training total variance of the H-PEPSSIta.
Student perception The H-PEPSSIta is a valid tool capable of evaluating the self-perception of nursing students regarding patient
safety knowledge and competence. Therefore, the instrument could be adopted in educational settings as a
periodic nursing student report. This may help students reect on PS related-issues, and evaluate gaps in
knowledge and competences; furthermore, data emerging from periodic self-reports may offer the op-
portunity to tailor educational strategies to ll the gaps in PS knowledge and competences that emerge.
2015 Elsevier Ltd. All rights reserved.

Introduction Ginsburg et al., 2012) as recommended also by the WHO, which

since 2001 has proposed a European strategy aimed at harmonizing
The need to ensure safety in the health sector is driving the nursing and midwife educational programs (WHO, 2001) a state-
development of policies aimed at improving the clinical practice as ment that was reinforced in 2009 (WHO, 2009). Furthermore, some
well as health care professionals education on a global scale European countries such as the UK (Steven et al., 2014) and Finland
(Sherwood, 2011; World Health Organization, 2012). According to (MSAH, 2009) have established programs aiming at improving PS
these strategies, risk management (RM) and patient safety (PS) is- content in undergraduate nursing education. In accordance with
sues have attracted interest world-wide (World Health the priorities of common basic and continuing nursing education
Organization, 2010; World Health Organization, 2011). Although on PS, there is a need to validate instruments capable of detecting
PS is both a concern and a responsibility of all health care pro- knowledge and competences as perceived by students and health
fessionals, Registered Nurses (RNs) are largely recognized as having care professionals. The aim of the study was, therefore, to validate
a key role (Butterworth et al., 2011; Vaismoiradi et al., 2012) given an instrument capable to detect the PS knowledge and compe-
their constant presence at the bedside which enables them to tences as perceived by students and, potentially, the effects of
recognize conditions exposing patients to risk at an early stage. educational strategies offered at the nursing academic level.
The knowledge and expertise of RN's is considered a milestone
among the factors affecting PS. Therefore both academic and
continuing education is needed (Abbott et al., 2012; Cooper, 2013; Background

It is widely acknowledged that academic education should

* Corresponding author. Tel.: 39 (0)432552806. include PS (Mansour, 2012; Slater et al., 2012) as a core content of
E-mail address: [email protected] (A. Palese). basic nursing education. A multi-level learning process on PS is

http://dx.doi.org/10.1016/j.nepr.2015.08.006
1471-5953/ 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Bressan, V., et al., Measuring patient safety knowledge and competences as perceived by nursing students: An
Italian validation study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.08.006
2 V. Bressan et al. / Nurse Education in Practice xxx (2015) 1e8

recommended throughout the academic path, especially in the from a .81 to .85. According to the nature of PS knowledge,
early years when students establish their clinical practice founda- which is both theoretical and practical, factors and items are
tions (Walton et al., 2010). Nursing students should be prepared reproduced for two different dimensions (classroom and clinical
through theoretical and practical sessions, including lessons and training): respondents are asked to indicate their agreement for
clinical practice experience, laboratories and simulation scenarios each item regarding contents learned in the classroom and
(Killam et al., 2012; Tella et al., 2014), aimed at developing appro- during their clinical experience. Each item is reported as a
priate knowledge and competences on PS. Nurse educators are statement, and uses a 5-point Likert scale for each item with
required to monitor the breadth of PS nursing knowledge needed possible responses that ranges from strongly disagree (1) to
within the clinical practice settings (Killam et al., 2013), while strongly agree (5) and includes a don't know option (3).
students should be considered active learners capable of offering a 2) The second section (composed of ve items) is focused on how
subjective understanding of PS acquired in the classroom and the broader PS issues are addressed in health professional educa-
clinical environment (Killam et al., 2012). According to available tion, and aims to gain an overall understanding of student per-
literature on PS, nursing faculties have the mission to prepare ceptions regarding their PS education.
students through evidence-based knowledge helping them to 3) The third section (composed of four items), is dedicated to
develop consistent knowledge, skills, and competencies to use also licensed health care professionals regarding how able and
in interdisciplinary and inter-professional teams, which are needed comfortable they feel speaking up about PS.
to continuously improve the quality and the safety of care offered to
patients (Abbott et al., 2012; Nrgaard et al., 2013). However, evi- According to its authors (Ginsburg et al., 2012, 2013), H-PEPSS
dence about how nursing students improve their PS knowledge and may be used by health professional educators as well as a self-
competence has been limited (Vaismoiradi et al., 2011), while evaluation tool by students and new graduates.
health care environments demand increasing PS competence. In In the context of Italian nursing education, which involves a
addition, increasingly available data available on unsafe nursing signicant focus on PS in its theoretical and practical core-
students, shows that errors and lack of PS awareness could be a curriculum (Decreto Interministeriale, 2009), it is necessary to
result of a lack of knowledge, skills and professional relationships support the learning process appropriately. Validating an instru-
with patients and educators (Killam et al., 2011). This suggests the ment like H-PEPSS in languages other than English may create a
need to revise academic education and curricula (Gregory et al., basis for international comparisons with regard to the nursing
2007; Steven et al., 2014), and continually evaluate learning goals. student perceptions of PS knowledge and competence across
In the eld of PS competence evaluation, few assessment in- different educational settings, countries and professional cultures.
struments are available (Sullivan et al., 2009). In a systematic review
by Okuyama et al. (2011) it emerged that there are 34 instruments Aim of the study
devoted to health care professionals, few of which are capable of
measuring the breadth of competences involved in PS. In the specic The aim of this study was to assess the validity and the reliability
eld of health care students, Madigosky et al. (2006) and Flin et al. of the H-PEPSS tool in the context of Italian nursing education.
(2009), have developed questionnaires aimed at measuring PS
knowledge and aptitudes, documenting explorative psychometric Methods
data. More recently, the US Health Care Professionals Patient Safety
Assessment Curriculum Survey (HPPSACS) questionnaire was vali- Study design and rationale
dated and introduced in the UK (Chenot and Daniel, 2010; Mansour,
2014) with the aim of investigating nursing student awareness, A validation study using a cross-sectional design was under-
skills, and attitudes concerning PS. Cooper (2013) has developed a taken. Initially, researchers debated the appropriateness of the tool
tool measuring pre-licensing nursing students basic information (Herdman et al., 1998; Sidani et al., 2010) with regard to a) the
regarding the use of error and near-error reporting tools and how underlying concept of PS and its consistency with what is consid-
they perceive safety reporting in the clinical setting. Christiansen ered in Italian nursing education; b) the pertinence of the items to
and colleagues (Christiansen et al., 2010) have also developed an the knowledge and competences expected in Italian nursing edu-
instrument devoted to measuring key aspects of student PS cation (Palese and Dalponte, 2007); c) the population involved in
knowledge and attitudes aimed at improving learning outcomes. the validation (newly graduated nurses, among others), and its
Seeking to ll the knowledge gap, Ginsburg et al. (2012) similarity to the target population expected; and d) the relevance
developed the Health Professional Education in Patient Safety and acceptability of the items included in the tool.
Survey (H-PEPSS), involving 1247 newly graduated Canadian
nurses, doctors and pharmacists in a cross-sectional survey. The Instrument translation and face/content validation
tool measures newly graduated health professionals self-reported
PS competence, based on 38 items, divided into three sections: Having obtained authorization from the authors (Liane Gins-
burg, 17/06/2013), the instrument was translated into Italian
1) The rst section of the questionnaire (composed of 27 items) is (Gjersing et al., 2010; Sidani et al., 2010; Suosa and Rojjanasrirat,
focused on learning about specic PS content areas. Its structure, 2010). The Italian version was then translated into English (back-
conrmed through factor analysis (CFA) (Ginsburg et al., 2012, translation) aimed at verifying its cross-cultural adaptation
2013), is based on six factors, reecting the key areas of PS (Gjersing et al., 2010). A native English-speaking expert nurse and a
competence: (a) Contributing to a culture of patient safety certied translator independently undertook the forward and
(items no. 4); (b) Working in teams for patient safety (items backward translation (Sousa and Rojjanasrirat, 2010). The two En-
no. 6); (c) Communicating effectively for patient safety (items glish versions obtained were analyzed and compared indepen-
no. 3); (d) Managing safety risks (items no. 3); (e) Opti- dently by two other translators (Sousa and Rojjanasrirat, 2010) and
mizing human and environmental factors (items no. 3); and any discrepancies were discussed with the previous translators.
(f) Recognizing, responding to and disclosing adverse events A panel of ve faculty and clinical nursing experts were involved
and close calls (items no. 4). The internal consistency of the in the analysis of the nal version of the tool with the aim of
documented instrument (Ginsburg et al., 2012, 2013) ranges evaluating its pertinence, clarity of wording, face, and content

Please cite this article in press as: Bressan, V., et al., Measuring patient safety knowledge and competences as perceived by nursing students: An
Italian validation study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.08.006
 V. Bressan et al. / Nurse Education in Practice xxx (2015) 1e8 3

validity (Herdman et al., 1998). In two meetings, the panel dis- process. The completed questionnaires were collected immediately
cussed each item of each section, and the following decisions were after their completion, assuring the condentiality of the data
adopted: collected.
A total of 573 students (92.2%; 199 from degree no. 1, and 375
- The rst section of the tool (Learning about specic patient safety from degree no. 2) agreed to participate in the study. Over thirty-
content areas, 27 items): the panel agreed to consider it in the ve per cent (35.4%) were attending the 1st academic year, 188
validation process. However, according to the authors (Ginsburg (32.8%) the 2nd year, and 181 (31.6%) were attending the 3rd year
et al., 2012), four items included in the original tool solely to (missing data .2%). The majority of the respondents were female
help respondents distinguish between clinical and socio- (434; 75.7%). The average age was 23.5 4.5 years (median 22,
cultural aspects of PS, and not included in the CFA (Ginsburg range 19e51).
et al., 2012), were not considered in the Italian version.
- The second section of the tool (How broader PS issues are
addressed in health professional education, 7 items): data Data analysis
collected was not considered in this study according to Ginsburg
et al. (2012, 2013) who did not consider these items in their CFA. Data was analyzed using Microsoft Excel 2010 and SPSS Statis-
- The third section of the tool (Comfort speaking up about patient tical Package version 22.0. Having measured the position index of
safety, 4 items): the panel agreed to omit the four items (e.g., If each item (Mean, and Standard Deviation [SD]), the internal con-
I see someone engaging in unsafe care practice in the clinical sistency of the tool was measured with Cronbach's alpha. Aiming to
setting, If I make a serious error I worry that I will face disci- identify the contribution of each item to the internal consistency,
plinary action) because they were focused on newly graduated the variation in the values of a deleting each item (Pett et al., 2003)
professionals. These items were omitted even by the authors was evaluated. The correlation among items was calculated eval-
(Ginsburg et al., 2012) in their CFA of the original tool. uating the corrected item-to-total correlation. Correlation values
<.30 were considered unacceptable and therefore removed (Polit
Therefore, a total of 23 items of the H-PEPSS were considered in and Beck, 2008).
our study. In addition, socio-demographic data was also collected. Explorative factor analysis (EFA) was performed in two phases:

Sampling, setting and data collection process 1) The suitability of the data for factor analysis was ascertained.
The KaisereMeyereOlkin (KMO) measure of sampling adequacy
Following a convenience criteria, two bachelor's degree courses and Bartlett's test of sphericity were executed for both class-
in nursing located in northern Italy were selected. According to room and clinical training items. A KMO measure of sampling
Italian Law (Decree of 3 November, 1999), the bachelor's degrees adequacy higher than .30, and a Bartlett's test of sphericity
have to be 3 years in length and the curriculum based on a block lower than .05 were considered appropriate (Tabachnick and
system model, offering theoretical courses in the rst ve months Fidell, 2012).
of each academic year (from October to February), and in the 2) The EFA was performed using a Varimax rotation. Values greater
following six months, clinical practice experience mainly in than .30 were considered (Di Iorio, 2005). In accordance with
teaching hospitals. Students start to learn PS issues in the rst se- the theoretical framework established by authors for the orig-
mester of their 1st year, before approaching clinical practice. inal version of the instrument (Ginsburg et al., 2012) six xed
The homogenous theoretical content of the degrees were based factors were extracted through the analysis of the principal
on: (a) the concept of healthcare workers' safety; (b) integrated RM components (PCA). Researchers considered the recommenda-
approaches in healthcare environments; (c) prevention and pro- tions made by Pett et al. (2003), regarding the item-to-factor
tection strategies (PPE) in the context of health care activities; (d) loading: therefore, loadings from .45 to .55 which are fairly
principles of ergonomics; and (g) the standard precautions and good (less than 30% of that item's variance is shared with the
mandatory protocols to be adopted in case of injury exposure (e.g. factor) were removed. Item analysis was performed in order to
who to report to and how). During their clinical training, students facilitate the researchers' understanding of the characteristics of
were supervised by an expert nurse in a 1:1 student-to-supervisor the items and their association with other features so that
ratio. The supervisor had legal responsibility for both student safety informed decisions could be made regarding retaining or de-
and that of the patient cared for by the student. leting individual items (Di Iorio, 2005). The researchers worked
Initially, the deans of the nursing degree courses were independently, prior to sharing and agreeing upon their con-
approached and authorizations to contact students were obtained. clusions regarding the factors that emerged and their in-
According to Pett et al. (2003), 10e15 participants per item were terpretations (Di Iorio, 2005). Conceptual qualitative analysis
considered appropriate for a target sample-size. In addition, in line was performed on the items in order to evaluate their consis-
with the theoretical assumption that PS should be a crucial tency with the CFA performed by Ginsburg et al. (2012). In
component of nursing education, and would therefore be further accordance with the ndings of the factor analyses conducted,
developed throughout the degree, a maximum variation of the the internal consistency of the tool was re-evaluated using
sample was sought, involving students attending the 1st, 2nd and Cronbach's alpha; the level of acceptability was xed at a
0.60
3rd years of the course. (Di Iorio, 2005).
Therefore, all students (n 201 bachelor degree 1; n 420
bachelor degree 2; total N 621) attending the 1st, 2nd and 3rd Four researchers were involved in each step of the EFA and re-
academic years were eligible and contacted at the end of September sults were agreed upon through discussion and open dialogue.
2013, having nished their annual clinical competence examina- Discussions regarding the ndings were agreed with the remaining
tion. Thereafter, the Italian version of the H-PEPSS (H-PEPSSIta) was researchers. Finally, the total-to-total correlation (Pearson, r)
administered in a dedicated room on three different index days, among the two dimensions (classroom, clinical training) was
according to the academic year attended by eligible students. A calculated and the stability of the tool over time was assured,
researcher initially explained the aims of the study to the students administering the H-PEPSSIta at an interval of one week to a con-
as well as giving details on the data collection instrument and venience sample of 34 students attending the 2nd year.

Please cite this article in press as: Bressan, V., et al., Measuring patient safety knowledge and competences as perceived by nursing students: An
Italian validation study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.08.006
4 V. Bressan et al. / Nurse Education in Practice xxx (2015) 1e8

Ethical issues p 0.000; clinical training: c2 5594.32; df 253; p 0.000) and

the KMO test was >.60 (classroom .93; clinical training .94).
The study was approved by the Internal Review Board of Udine As reported in Tables 2 and 3, the six factors that emerged were
University, Italy. The participants were informed about the aims of composed of three to ve items, loading
.55. Only item no. 4
the study, the voluntary participation not affecting the academic Engaging patients as a central participant in the healthcare team
outcomes and the condentiality of collected data management. was removed in both classroom and clinical training dimensions
Return of the questionnaire was considered as willingness to due to its loading <.55.
participate in the study project. Researchers independently performed a qualitative analysis of
the items as categorised in the six factors according to the original
version of the instrument, attributing the same conceptual deni-
Results tion to each factor that emerged (Ginsburg et al., 2012). The six
factors extracted have explained 69.344% of the H-PEPSSIta-class-
The internal consistency of the H-PEPSSIta measured with room total variance, and 70.425% of the total variance of the clinical
Cronbach's alpha was higher both for classroom (.938) and clinical training dimension (Tables 2 and 3). The main explanatory factor
training (.942) dimensions. The emerging item-to-item correlations was Working in teams for the classroom dimension (explained
were
.30. In the descriptive data in Table 1, the overall internal variance 13.99%) and Communicating effectively for clinical
consistency of the tool's dimensions (as well as of each item if training (explained variance 13.60%).
deleted) and the item-to-total correlation index are reported. Among the clinical training dimension, item no. 6 (Table 3),
The basic criteria for performing EFA were satised in both di- Encouraging team members to speak up, question, challenge,
mensions (classroom and clinical training). The Bartlett test was advocate, and be accountable as appropriate to address safety is-
statistically signicant (classroom: c2 5348.72; df 253; sues showed a higher loading in the factor Communicating

Table 1
Position index, item-to-total correlation and Cronbach's alpha of H-PEPSSIta (classroom N 447; clinical training N 440).

Mean and SD Likert (1e5)* Corrected item-to-total correlation Cronbach's alpha if item deleted

Classroom Clinical training Classroom Clinical setting Classroom Clinical training

5 Team dynamics and authority/power differences 4.12 .790 4.20 .814 .523 .507 .936 .941
6 Managing inter-professional conict 3.84 .835 3.87 .872 .542 .604 .936 .940
7 Debrieng and supporting team members after an 3.89 .883 3.96 .828 .584 .606 .935 .940
adverse event or close call
9 Sharing authority, leadership and decision-making 4.10 .731 4.04 .808 .668 .700 .934 .938
10 Encouraging team members to speak up, question, 4.12 .802 4.04 .879 .636 .632 .934 .940
challenge, advocate, and be accountable as appropriate
to address safety issues
11 Enhancing patient safety through clear and consistent 4.48 .693 4.43 .735 .619 .656 .935 .939
communication with patients
12 Enhancing patient safety through effective 4.38 .719 4.31 .769 .654 .694 .934 .939
communication with other healthcare providers
13 Effective verbal and nonverbal communication abilities 4.31 .743 4.23 .785 .672 .696 .934 .939
to prevent adverse events
14 Recognizing routine situations in which safety problems 4.20 .732 4.26 .738 .669 .611 .934 .940
may arise
15 Identifying and implementing safety solutions 4.15 .745 4.15 .747 .617 .662 .935 .939
16 Anticipating and managing high risk situations 3.98 .823 3.99 .816 .617 .639 .935 .939
17 The role of human factors, such as fatigue, which effect 4.23 .780 4.33 .750 .567 .590 .936 .940
patient safety
18 The role of environmental factors such as work ow, 4.14 .763 4.18 .777 .608 .609 .935 .940
ergonomics and resources, which effect patient safety
19 Safe application of health technology 4.27 .738 4.23 .793 .594 .656 .935 .939
20 Recognizing an adverse event or close call 4.16 .715 4.13 .740 .642 .655 .934 .939
21 Reducing harm by addressing immediate risks for 4.14 .696 4.13 .746 .680 .685 .934 .939
patients and others involved
22 Disclosing an adverse event to the patienta 4.08 .831 4.03 .877 .597 .595 .935 .940
23 Participating in timely event analysis, reective practice 4.10 .770 4.05 .828 .631 .633 .935 .939
and planning in order to prevent recurrence
24 The ways in which healthcare is complex and has many 4.08 .761 4.11 .760 .622 .601 .935 .940
vulnerabilities (e.g., workplace design, stafng,
technology, human limitations)
25 The importance of having a questioning attitude and 4.37 .694 4.38 .696 .627 .556 .935 .941
speaking up when you see things that may be unsafe
26 The importance of a supportive environment that 4.36 .690 4.27 .765 .534 .588 .936 .940
encourages patients and providers to speak up when
they have safety concerns
27 The nature of systems (e.g., aspects of the organization, 4.10 .761 4.05 .781 .598 .621 .935 .940
management or the work environment including
policies, resources, communication and other
processes) and system failures and their role in adverse
events
Total H-PEPPSIta a .938 .942

* From 1 strongly disagree to 5 strongly agree.

SD standard deviation; a Cronbach's alpha.
a
Item left in this factor according to the original version of the instrument.

Please cite this article in press as: Bressan, V., et al., Measuring patient safety knowledge and competences as perceived by nursing students: An
Italian validation study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.08.006
 V. Bressan et al. / Nurse Education in Practice xxx (2015) 1e8 5

Table 2
Factor loadings for EFA with six xed factors (classroom N 468).

Factors and loadings

Working in Recognizing Communicating Culture of Managing Understanding

teams and responding effectively safety safety risk human and
to adverse events environmental
factors

Working in teams (a .829) (6 items)

1 Team dynamics and authority/power differences .666 .048 .136 .306 .068 .206
2 Managing inter-professional conict .753 .170 .051 .034 .109 .232
3 Debrieng and supporting team members after an adverse .756 .244 .163 .065 .102 .094
event or close call
4 Engaging patients as a central participant in the healthcare .491 .184 .467 .112 .146 .009
teama
5 Sharing authority, leadership and decision-making .698 .210 .178 .223 .252 .081
6 Encouraging team members to speak up, question, .572 .211 .341 .235 .205 .019
challenge, advocate, and be accountable as appropriate to
address safety issues
Recognizing and responding to adverse events (a .838) (4 items)
7 Recognizing an adverse event or close call .118 .664 .117 .228 .324 .211
8 Reducing harm by addressing immediate risks for patients .217 .717 .182 .180 .247 .174
and others involved
9 Disclosing an adverse event to the patient .194 .748 .163 .126 .145 .131
10 Participating in timely event analysis, reective practice and .184 .745 .166 .241 .084 .170
planning in order to prevent recurrence
Communicating effectively (a .881) (3 items)
11 Enhancing patient safety through clear and consistent .163 .141 .822 .145 .156 .217
communication with patients
12 Enhancing patient safety through effective communication .186 .170 .774 .217 .161 .210
with other healthcare providers
13 Effective verbal and nonverbal communication abilities to .240 .199 .747 .177 .206 .180
prevent adverse events
Culture of safety (a .813) (4 items)
14 The ways in which healthcare is complex and has many .179 .314 .178 .585 .173 .195
vulnerabilities (e.g., workplace design, stafng, technology,
human limitations)
15 The importance of having a questioning attitude and .258 .125 .184 .762 .148 .153
speaking up when you see things that may be unsafe
16 The importance of a supportive environment that .102 .113 .198 .794 .153 .073
encourages patients and providers to speak up when they
have safety concerns
17 The nature of systems (e.g., aspects of the organization, .154 .377 .050 .674 .107 .195
management or the work environment including policies,
resources, communication and other processes) and system
failures and their role in adverse events
Managing Safety Risk (a .840) (3 items)
18 Recognizing routine situations in which safety problems .223 .237 .208 .177 .724 .206
may arise
19 Identifying and implementing safety solutions .210 .163 .159 .166 .811 .151
20 Anticipating and managing high risk situations .138 .242 .194 .162 .752 .179
Understanding human and environmental factors (a .765) (3 items)
21 The role of human factors, such as fatigue, which effect .179 .062 .221 .230 .179 .733
patient safety
22 The role of environmental factors such as work ow, .178 .289 .171 .129 .200 .705
ergonomics and resources, which effect patient safety
23 Safe application of health technology .144 .332 .166 .152 .158 .680
% of Variance 13.998 12.948 11.597 11.558 10.309 8.935
Total % of Variance of the factor model 69.344
Total H-PEPSS Cronbach's a .939

a Cronbach's Alpha.
a
Item removed according to its loading <.55 in all factors.

effectively. However, according to the conceptual structure of the weak (r .319, p 0.000). Weak correlations also emerged among
original instrument (Ginsburg et al., 2012) the item was included in factors measured for the classroom and clinical training di-
the factor Working in teams. mensions: 1) Working in teams, r .227 (p .000); 2) Recog-
After having removed item no. 4, the total internal consistency nizing and responding to adverse events, r .354 (p .000); 3)
of the instrument remained higher in both dimensions (classroom Communicating effectively, r .264 (p .000); 4) Culture of
a .939; clinical training a .936) (Tables 2 and 3). In the class- Safety, r .336 (p .000); 5) Managing Safety Risk, r .372
room dimension, the a values ranged from .765 for Understanding (p .000); and 6) Understanding human and environmental fac-
human and environmental factors to .881 for Communicating tors, r .323 (p .000).
effectively factor. In the clinical training dimension, the a values The instrument stability obtained within one week using a
ranged from .799 to .860 in the same above-mentioned factors. The convenience sample of 34 students was good: the total-to-total
total-to-total score correlation between the two dimensions was correlation between the classroom dimensions was r .67

Please cite this article in press as: Bressan, V., et al., Measuring patient safety knowledge and competences as perceived by nursing students: An
Italian validation study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.08.006
6 V. Bressan et al. / Nurse Education in Practice xxx (2015) 1e8

Table 3
Factor loadings for EFA with six xed factors (Clinical Training N 454).

Factors and loadings

Working Recognizing and Communicating Managing Culture Understanding

in teams responding to effectively safety risk of safety human and
adverse events environmental
factors

Working in teams (a .820) (6 items)

1 Team dynamics and authority/power differences .766 .020 .071 .150 .243 .137
2 Managing inter-professional conict .755 .201 .145 .127 .140 .184
3 Debrieng and supporting team members after an adverse .640 .355 .299 .069 .014 .142
event or close call
4 Engaging patients as a central participant in the healthcare .543 .072 .509 .127 .197 .087
teama
5 Sharing authority, leadership and decision-making .564 .212 .395 .184 .180 .225
6 Encouraging team members to speak up, question, .353 .323 .571 .087 .027 .213
challenge, advocate, and be accountable as appropriate to
address safety issuesb
Recognizing and responding to adverse events (a .853) (4 items)
7 Recognizing an adverse event or close call .039 .623 .098 .403 .248 .325
8 Reducing harm by addressing immediate risks for patients .138 .641 .105 .387 .286 .232
and others involved
9 Disclosing an adverse event to the patient .251 .769 .149 .130 .137 .091
10 Participating in timely event analysis, reective practice and .123 .782 .242 .096 .213 .166
planning in order to prevent recurrence
Communicating effectively (a .860) (3 items)
11 Enhancing patient safety through clear and consistent .129 .085 .739 .304 .217 .174
communication with patients
12 Enhancing patient safety through effective communication .221 .116 .737 .256 .239 .160
with other healthcare providers
13 Effective verbal and nonverbal communication abilities to .182 .216 .680 .302 .148 .210
prevent adverse events
Managing Safety Risk (a .823) (3 items)
14 Recognizing routine situations in which safety problems .174 .077 .248 .756 .185 .187
may arise
15 Identifying and implementing safety solutions .216 .237 .277 .749 .107 .133
16 Anticipating and managing high risk situations .090 .284 .220 .744 .154 .207
Culture of safety (a .809) (4 items)
17 The ways in which healthcare is complex and has many .233 .264 .095 .163 .608 .253
vulnerabilities (e.g., workplace design, stafng, technology,
human limitations)
18 The importance of having a questioning attitude and .125 .085 .164 .177 .818 .143
speaking up when you see things that may be unsafe
19 The importance of a supportive environment that .107 .223 .488 .003 .643 .052
encourages patients and providers to speak up when they
have safety concerns
20 The nature of systems (e.g., aspects of the organization, .228 .287 .144 .199 .620 .175
management or the work environment including policies,
resources, communication and other processes) and system
failures and their role in adverse events
Understanding human and environmental factors (a .799) (3 items)
21 The role of human factors, such as fatigue, which effect .165 .133 .116 .227 .230 .744
patient safety
22 The role of environmental factors such as work ow, .217 .179 .176 .168 .136 .766
ergonomics and resources, which effect patient safety
23 Safe application of health technology .189 .240 .305 .138 .136 .718
% of Variance 12.300 12.397 13.601 11.181 10.781 10.166
Total % of Variance of the factor model 70.425
Total H-PEPSS Cronbach's a .936

a Cronbach's Alpha.
a
Item removed according to its loading <.55 in all factors.
b
Item left in this factor according to the original version of the instrument.

(p < .001) while between the clinical training dimensions it was instruments that evaluate learning progression (Sullivan et al.,
r .58 (p < .006). The total score correlation was r .63 (p < .001). 2009). This aim is pursuit also in nursing education established in
Italy since 2001 at the academic level (Inter-ministerial Decree,
Discussion 2001). However, to the best of our knowledge, no studies intro-
ducing and validating tools that evaluate PS knowledge and
According to the available literature (Vaismoiradi et al., 2011), competence are available in the Italian nursing education context.
faculties should pursue greater preparation of future generations of Different instruments evaluating health care professionals'
nursing students in order to develop appropriate PS theoretical (Okuyama et al., 2011), new graduates' (Ginsburg et al., 2012, 2013)
knowledge (through lessons) and competence (knowledge-based and nursing students (Christiansen et al., 2010; Cooper, 2013;
application at the bedside) (Tella et al., 2014), and introduce Madigosky et al., 2006; Tella et al., 2014) knowledge and

Please cite this article in press as: Bressan, V., et al., Measuring patient safety knowledge and competences as perceived by nursing students: An
Italian validation study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.08.006
 V. Bressan et al. / Nurse Education in Practice xxx (2015) 1e8 7

competence on PS are documented in the literature, although, in teams with other health professionals, Recognizing, responding to
light of the absence of recommendations regarding the best in- and disclosing adverse events and close calls and Managing safety
strument to adopt, researchers in Canada initially identied the H- risk reported a higher variance in the classroom dimension, while
PEPSS developed by Ginsburg et al. (2012, 2013) as the most Communicating effectively, Culture of safety and Understanding
appropriate instrument according to its pertinence, coherence and human and environmental factors reported higher values in the
appropriateness for the Italian nursing education context. In fact, clinical training dimensions. Student experience, the gap between
although the instrument was developed in a non-European theoretical knowledge and practice, as well as different priorities
context, the factors investigated were found to be compatible attributed in the classroom and in the clinical training may explain
with the suggestions of the European Network for Patient Safety these differences.
strategy (European Network for Patient Safety, 2010), reecting the
most critical aspects within health care education, such as learning
from mistakes, the patient safety-centered approach and the Limitations
importance of the environment (Tella et al., 2014). Therefore, in the
context of PS, which should be based on appropriate and early The study was conducted in Italy, therefore only the general-
education of professionals (Frank and Brien, 2008; European izibility of the ndings should be made with caution. Further
Network for Patient Safety, 2010), participants were selected from research may address the limitations of the present study, involving
nursing students attending their bachelor nursing degree in two a more diverse group of health care students, for example, con-
Italian universities. rming the factor structure of the tool, and analyzing its sensibility
The Italian version of the tool, H-PEPSSIta, reported high internal and specicity in predicting students' lack of PS knowledge and
consistency (from a .939 to .936), greater than was reported for the competence as evaluated through formal examinations.
original version (from a .81 to .85) (Ginsburg et al., 2013). Its sta-
bility, measured over a week, was good in both dimensions, ac-
cording to the continuing increases in PS knowledge and Conclusions and practical implications
competence in students continuously attending lessons and clinical
practice. In the EFA, only one item loading <.55 (Pett et al., 2003), The H-PEPSSIta is a valid instrument capable of evaluating
Engaging patients as a central participant in the healthcare team, nursing students self-perception of PS knowledge and compe-
was deleted given that this role is mainly performed by the clinical tence. Therefore, the instrument could be adopted in educational
tutors, who are expert nurses. Therefore, a total of 22 items were settings as a periodical nursing student report. This may help stu-
retained. The factorial structure of the instrument that emerged dents reect on PS issues, and evaluate gaps in knowledge and
was based on six factors as reported by Ginsburg et al. (2013) in competences; furthermore, data emerging from periodical self-
their CFA. Although in their CFA, the authors removed some items reports may offer the opportunity to tailor educational strategies
that were redundant and/or because they were distal in the to ll the gaps in PS knowledge and competences that emerge. In
construct (e.g., Team dynamics and authority/power differences; addition, the adoption of the instrument could also be used to
Debrieng and supporting team members after an adverse event evaluate the effectiveness of the adopted educational programs
or close call) in the Italian version these items obtained loadings both at the local, and at the national and international level.
>.55 and were therefore maintained. The item Encouraging team The validated tool may be used for nursing students PS knowl-
members to speak up, question, challenge, advocate, and be edge and competence comparisons across different care settings, as
accountable as appropriate to address safety issues was main- well as for competence development programs and curricula. At an
tained in the Working in a team factor in accordance with the individual level self-assessment by means of the H-PEPSSIta may
original version of the instrument and its signicance, which is contribute to an increased consciousness of students learning
related to teamwork instead of communication. It is possible, ac- needs.
cording to Tella et al. (2014), that despite educational efforts aimed For educators, analyzing the gaps between theoretical knowl-
at developing the ability to work individually and in a team, there edge and clinical competence, evaluating the scores obtained by
are still some limitations in clinical settings: nursing students are students in each dimension and the factors under evaluation, may
not always involved in the team due to their connection mainly offer the opportunity to develop critical aspects both in the theo-
with the clinical tutor who is responsible for their education, and retical and in the practical curriculum. In addition, there is the
for the standard of patient care delivered. In addition, students are potential to understand the hidden PS culture, expressed at both
not directly exposed to group dynamics aimed at focusing their the academic and clinical levels by analyzing student self-
attention on their learning aims. evaluations. The H-PEPSSIta may also contribute to address spe-
The instrument was based on two dimensions: classroom and cic educational programs for newly graduated nurses at their rst
clinical training, which express the perception of the theoretical employment.
knowledge gained and its practical application. Students were
asked to consider classroom and clinical settings as two separate
dimensions when answering. In fact, the correlations between the Conict of interest
two dimensions, and those reported by the factors composing each
dimension, were weak. This suggests that the tool is able to mea- There are no potential conicts of interest or any nancial or
sure the different dimensions, related each other in a non-linear personal relationships with other people or organizations that
manner (Valenti, 2007). could inappropriately bias the conduct and ndings of this study.
The explained variance was >60% in both dimensions and above
5% for each singular factor (Pett et al., 2003; Polit and Tatano-Beck,
2008) showing the ability of the instrument to evaluate PS Authors' contribution statement
knowledge and competence as perceived by nursing students. The
structure of the tool was based on six factors, as was the original BV, SS: research question; BV, SS, BG, ZA, DA, PA: research
tool (Ginsburg et al., 2012). A different explained variance emerged protocol, data collection; BV, SS, DA, PA: data analysis; BV, SS, DA,
from the two dimensions. In particular, factors such as: Working in PA: critical analysis of the ndings and manuscript preparation.

Please cite this article in press as: Bressan, V., et al., Measuring patient safety knowledge and competences as perceived by nursing students: An
Italian validation study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.08.006
8 V. Bressan et al. / Nurse Education in Practice xxx (2015) 1e8

Funding Mansour, M., 2012. Current assessment of patient safety education. Br. J. Nurs. 21
(9), 536e543.
Mansour, M., 2014. Factor analysis of nursing students' perception of patient safety
This research received no specic grants from any funding education. Nurse Educ. Today 35 (1), 32e37.
agency in the public, commercial or not-for-prot sectors. Ministry of Social Affairs and Health, 2009. Promoting Patient Safety Together.
Finnish Patient Safety Strategy 2009e2013, vol. 5. Publications of the Ministry
of Social Affairs and Health. Available from: http://www.julkari./bitstream/
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Please cite this article in press as: Bressan, V., et al., Measuring patient safety knowledge and competences as perceived by nursing students: An
Italian validation study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.08.006