Clinical nurse competence and its effect on patient safety culture: A Systematic Review

doi:10.21203/rs.3.rs-2097082/v1

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Clinical nurse competence and its effect on patient safety culture: A Systematic Review

https://doi.org/10.21203/rs.3.rs-2097082/v1

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published 19 May, 2023

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Background: Unsafe health practices are one of the leading causes of disability and even death. Competent nurses are crucial to ensure safe and high-quality health care services. The patient safety culture is concerned with internalizing safety beliefs, values, and attitudes, translating them into health care practices, and committing to maintain an error-free health environment. A high level of competence ensures the achievement and compliance with the safety culture goal. Objective This systematic review aims to identify the relationship between the level of nursing competence and the safety culture score and perception among nurses at their workplace.

Methods: Four international online databases were searched to find relevant studies published between 2018 and 2022. Peer-reviewed articles using quantitative methods, targeting nursing staff, written in English were included. After reviewing 117 identified articles, 16 full-text studies were included. The PRISMA 2020 checklist for systematic reviews was used.

Results: Evaluation of the articles indicates safety culture, competency, and perception are assessed using a wide variety of instruments. Safety culture was generally perceived as positive. No unique and standard tool has been developed to investigate the effect of safety competency on the perception of the safety culture in a standardized way.

Conclusions: Existing research provides evidence of a positive correlation between the nursing competence and patient safety score. Future research is recommended to investigate ways to measure the effect of nursing competency level on safety culture in health care institutions. Relevance for Clinical Practice Clinicians and leaders in the clinical setting may consider applying the findings of this study to address nursing competence as a component of addressing the patient safety culture in their practice setting.

Unsafe health practices are highly regarded to cause disability and death. It is estimated that the chance that unsafe practice can cause harm for the patient is 1 in 300 chance (World Health Organizaion, 2019b). Nearly 400,000 deaths occur annually in the United States due to several reversible adverse events, such as medication error, infection transmission, and fall events (Armando Nahum, 2021). In addition, poor quality care can cause death and a global health burden (Kruk et al., 2018). Patient safety is a health care discipline that evolved as a result of the increasing sophistication of health care systems and the increasing in adverse outcomes in health-care facilities. Its goal is to avoid and decrease risks, mistakes, and harm to patients while providing health care. Therefore, reliable, safe, equitable, effective, and highly standardized patient-centered care has become the ultimate goal of all health care institutions worldwide (World Health Organizaion, 2019a). Besides that, patient safety culture focuses on organizational culture issues related to patient safety, , patient safety culture is concerned with internalizing safety beliefs, values, and attitudes, translating them into health care practices and commitment to maintaining an error-free health setting and emphasizing reporting culture (Khoshakhlagh et al., 2019).

Competent nurses are key contributors to maintaining safe and effective health care services by integrating knowledge, skills, and attitudes that enable them to adapt to dynamic health environments (Fukada, 2018). Patient safety competencies are a core competency in the continuum of professional development activities that protect patients from unnecessary risks and hazards (Ayoung Huh & Juh Hyun Shin, 2021). A high level of competence promotes the achievement and compliance with the patient safety goal.

Several studies found that patient safety culture and nurse safety competency are affected by many factors. For example, workplace regulations and climate, nursing fatigue, satisfaction, stress, demographics, type of health institution type, teamwork and learning opportunity, specialty, degree of bedside involvement, and job description are all factors that affect safety culture (Al Ma'mari et al., 2020; Halabi et al., 2021; Khoshakhlagh et al., 2019; Wang et al., 2019; Yan et al., 2021).

Any improvement strategies to modulate these factors are unnegotiable. However, a better understanding of nurse competence and patient safety culture is essential to improve safe practice and professional development and minimize adverse events (Wami et al., 2016). Therefore, this study aims to address the gap in knowledge between nursing competencies and the perception of patient safety among nurses in their workplace. This knowledge may be used to providing in-depth explanation to the following research questions:

Is there a valid and reliable international tool that helps nurses self-report their core competencies, especially in the safety domains?
How does the competency level affect the patient safety culture among nurses?

Study Design

We conducted a systematic review of the published literature from April 1, 2022, and April 11, 2022, by the electronic search from January 1, 2018, through May 1, 2022.

Search Strategy

Four international online databases, MEDLINE (via PubMed), CINHAL (via EBSCOhost), Scopus (via Elsevier), and Embase were searched for published studies that describing the relationship between nurse competencies and patient safety culture. Search terms were developed based on experience and keywords from similar research. The search was structured using Boolean operators (AND, OR) and consisted of MeSH terms and free terms related to nursing, patient safety, competency, and safety culture. The term 'OR' was used between keywords or comparable MeSH phrases; meanwhile, the Boolean operator ‘AND’ was used to connect phrases or keywords with different meanings to refine the search (see Appendix A). The search approach used for PubMed-MEDLINE is described in detail Appendix A. For the other databases, the strategy was essentially the same but adapted as appropriate to the characteristics of each. The review process was presented using the PRISMA statement 2020 (Page et al., 2021) (Fig. 1).

Inclusion and Exclusion Criteria

Each retrieved study was evaluated by title and abstract and included according to the following criteria: studies using the quantitative approach; targeting nursing staff; published in English from January 1, 2018, through May 1, 2022, and full free full text available. The following studies were excluded: studies in the form of letters, editorials, essays, case studies, comments or narrative, systematic reviews, and conference abstracts; articles published in other languages than English; studies with nursing students, and studies using qualitative approach; and studies of pre-hospital and ambulatory care.

Data Extraction And Management

Risk of Bias Assessment

The methodological quality of the studies was evaluated by two reviewers (LZ and RZ). Disputes about the risk of bias were resolved through discussion and consensus between the two reviewers, with any remaining disagreements addressed to a third author (ES).

After applying the inclusion and exclusion criteria and removing duplicate studies, the remaining retrieved articles were examined thoroughly for further refinement of the results and review of the inclusion criteria. The net result of this thorough approach was sixteen articles qualifying for systematic qualitative analysis.

The design of the reviewed studies

Of the 16 qualifying articles, 15 were cross-sectional descriptive studies, and only one applied a quasi-experimental, pretest-posttest design (Letourneau & McCurry, 2019). Three out of the sixteen articles were conducted in South Korea (Han & Roh, 2020; Han et al., 2020; A. Huh & J. H. Shin, 2021). Three studies originated from Saudi Arabia (Abdualrahman Saeed Alshehry, 2022; Halabi et al., 2021; Mahsoon & Dolansky, 2021). Two studies from Iran (Aghil Habibi Soola et al., 2022; Edris Kakemam et al., 2021). In addition, a study was conducted in each Australia (Connell et al., 2021), Palestine (Najjar et al., 2018), Brazil (Lousada et al., 2020), Jordan (Abdullah Khamaiseh et al., 2020), Spain (Peñataro-Pintado et al., 2022), England (Letourneau & McCurry, 2019), and China (Yan et al., 2021). Finally, one study had an unidentified setting or country of origin.

The sampling technique

Given the sampling technique, eight articles used the convenience sampling technique (Abdualrahman Saeed Alshehry, 2022; Connell et al., 2021; Aghil Habibi Soola et al., 2022; Halabi et al., 2021; A. Huh & J. H. Shin, 2021; Mahsoon & Dolansky, 2021; Son et al., 2019; Yan et al., 2021). The highest sample size was 2,836 participants in the study by Najjar et al. (2018), while the least was 56 participants in (Lousada et al., 2020) study.

Measurement Tools For Safety Culture And Nursing Competency

The construct concepts of patient safety culture, safety climate, and patient safety competency were operationally measured using various tools or instruments throughout the sixteen studies. Nursing safety competency was measured using the Patient Safety Competency Self-Evaluation Tool, the Health Professional Education in Patient Safety Survey (H-PEPSS) (Han et al., 2020), and the Nurses’ Attitudes and Skills Safety scale, the latest version of NASUS (Mahsoon & Dolansky, 2021). Furthermore, Abdualrahman Saeed Alshehry (2022) used the Health Professional Education in Patient Safety Survey ‘ (H-PEPSS) to assess safety competency. Halabi et al. (2021) used the short version of Nurse Professional Competence (NPC).The self-reported Patient Safety Competency Nurse Evaluation Scale (PSCNES) was used by Yan et al. (2021).

Three studies applied the Hospital Survey on Patient Safety Culture (HSOPSC) developed by the Agency for Healthcare Research and Quality to measure safety culture (Han et al., 2020; E. Kakemam et al., 2021; Najjar et al., 2018). The safety climate was measured using the Safety Attitudes Questionnaire (SAQ) and the Safety Climate Survey (SCS); (Connell et al., 2021; A. Khamaiseh et al., 2020; Lousada et al., 2020)

The Patient Safety Culture

Patient safety culture was mentioned in the title of six studies (Han et al., 2020; E. Kakemam et al., 2021; A. Khamaiseh et al., 2020; Lousada et al., 2020; Mahsoon & Dolansky, 2021; Najjar et al., 2018). The was considerable variation of how this concept was perceived among nurses for example, (Lousada et al., 2020) study found that professionals working in home care services perceived higher scores related to safety culture compared with those working in primary care services. The accredited primary center in Jordan had an average positive response rate in some safety cultures ranging from 58.54–75.63% (A. Khamaiseh et al., 2020), A total of 32 Iranian teaching hospitals out of 150 reported poor patient safety culture (E. Kakemam et al., 2021). On the other hand, and with regard to the safety climate, the study by Connell et al. (2021) revealed that novice-competent nurses in Australian emergency departments rated the safety climate higher than expert nurses in all domains except stress recognition.

Patient Safety Competency

Six studies examined patient safety competency and several connected safety competencies with the domain of safety culture. For example, Yan et al. (2021) assessed the safety competence of Chinese associate degree nurses and found it moderate. Aghil Habibi Soola et al. (2022) found a positive correlation among Iranian emergency between safety competence nurses with teamwork, psychological safety, leadership, communication, mutual support, situation monitoring, and team structure. Han and Roh (2020) found that the night shift among emergency nurses in Korean hospitals negatively affected safety competence and was significantly and positively correlated with the experience of the emergency department and reported adverse events by others.

In a medical city in Saudi Arabia, A. S. Alshehry (2022) studied the correlation between the conflict between nurses and the patient, and safety competencies. The study revealed that nurses were highly competent in effective communication, but they had the lowest competency in ‘working in teams with other health professionals.’ Nurses perceived ‘mistrust of motivations’ and “contradictory communication” got the poorer self-reported safety competency.

The purpose of this study was to provide a systematic review of the literature investigating the relationship between nursing competencies and perception of patient safety among nurses in their workplace. In this systematic review, and after a thorough analysis of the entire manuscript of the retrieved articles, we selected and discussed sixteen articles based on their conformity with the inclusion criteria.

Relationship between Nursing Competencies and Safety Culture

None of the reviewed articles explicitly explored the relationship between nursing competencies and the safety culture dimensions and how they affect each other. Furthermore, studies identified no specific comprehensive tool specifically to assess the relationship between nursing safety competency and the dimension of culture or safety climate safety. Rather, the included articles examined patient safety culture, health care safety climate, and other nursing competencies that influenced or affect safety climate independently.

Measurement of patient safety culture

In this review, two self-reported questionnaires were found to have been applied to understand the dimensions and scores in health institutions. The Safety Attitude Questionnaire (SAQ) (A. Khamaiseh et al., 2020; Lousada et al., 2020) and the Hospital Survey on Patient Safety Culture (HSOPSC) (Han et al., 2020; E. Kakemam et al., 2021; Mahsoon & Dolansky, 2021; Najjar et al., 2018) were two assessment tools that employed Likert scales. However, in their study, Alsalem et al. (2018) revealed that five instruments are used to assess the patient safety culture and climate in health institutions. Furthermore, these tools vary in their psychometric properties and scope.

The most common study design among the studies was a questionnaire-based descriptive quantitative approach. Using different study designs, such as qualitative research and a variety of data collection methods, could help improve understanding of the safety culture and health care provider perceptions and would be required to address the existing relationship between safety culture and nursing competency (Alqattan et al., 2019)

Measurement of safety nursing competency

Eight of the studies, or 50% of the literature, in this review showed that nurses were more competent in communicating effectively than working in teams with colleagues, and their overall safety culture score was positive. Likewise, Zabin et al. (2022) found that both organizational learning and continuous improvement, as well as cooperation within units, received the highest composite frequency of patient safety perception.

In the current findings, the reviewed literature mentioned four self-reported measurement tools. Despite that, there was no consensus on the best tool for measuring safety competencies, and the lack of a key self-reported tool for measuring safety culture and linking it to nursing safety competency limited the ability to directly assess the effect of nursing competency on safety culture (Arzahan et al., 2022). As a result, more research is needed to enrich the literature, improve the understanding of the effect of safety competency on safety culture scores among nurses, and help in providing more clear operational definition of safety culture and nursing safety competency (Kalteh et al., 2021).

Although we used broad keywords to search different online databases, the retrieved articles did not specifically discuss the relationship between the dimensions of the safety culture, perception, and competency in nursing safety. Additionally, the lack of a standardized tool to measure the concepts of safety culture and nursing safety competency made it difficult to find a robust number of targeted studies and limited our ability to find specific operational definitions to the concepts of safety culture and nursing safety competency that was used consistently across the literature.

Moreover, using self-reported surveys and relying on convenient sampling eased data collection and provide more objective data for many of the studies in this review. However, there were drawbacks that limited the generalizability and might not cover all aspects of the studies’ content. Therefore, future use of mixed designs with the use of qualitative methods is highly recommended to deepen the study issue and explore the unique relationship between the dimensions of the safety culture and nursing competency that can play a pivotal role in improving safety practices.

This review study recognizes the importance of conducting additional searches and reviews and broadening the scope of keywords used to search online databases to focus on the core of this study. In addition, it is recommended to investigate the effect of nursing competency on perceptions of dimensions of safety culture and to make valid comparisons between demographics and cultures.

More research would provide a better understanding and may have a greater clinical impact and aid in improving and delivering highly effective, safe, and efficient care. Furthermore, the findings would support synchronicity between academic clinical programs and nursing staff safety practices. For example, nursing students receive competency-based training that allows them to live in a safe environment and directly implement the dimension of safety culture (Debourgh, 2012).

Limitations

This systematic review study has several limitations. First, we restricted the databases to four primary resources considered suitable for gathering eligible articles for the study purpose. The second is that the delimiters of this review included only articles in English, so some related articles may not have been included. Another limitation that should be highlighted is that we reviewed articles published between 2018 and 2022 to include the most recent data, but this also restricted the number of retrieved studies.

Another potential limitation was that the results of the reviewed studies could not be generalized. The articles were only published in peer-reviewed journals to ensure the high quality of evidence and the reported findings, which omitted many worthwhile studies such as grey and unpublished studies. Additionally, the study designs of the majority of the retrieved papers were descriptive, which restricts the generalizability of their findings and prevents access to many relevant studies. Therefore, it is recommended to conduct further systematic or integrative reviews that might include qualitative and descriptive studies as well as expand the inclusion criteria for other types of literature.

This systematic review draws several conclusions from the sixteen reviewed articles. First, the study showed no specific tool to measure the safety culture and nursing safety competency dimensions. Additionally, no study explicitly discussed the effect of nursing safety competency on safety culture scores among nursing staff. However, most of the studies employed a questionnaire-based descriptive approach. Conducting more research with different study designs such as the experimental, qualitative, and longitudinal approaches may enhance the understanding and assist in constructing a valid and more reliable tool to measure the effect of nursing safety competency on safety culture. Second, rigorous research needed to establish a well-designed competency-based training program to improve safety scores among more diverse demographics and cultures is needed. Finally, the findings can motivate administrators to promote safety culture in different health care facilities, as well as increase professional awareness of the factors that impact safety culture and, consequently, patient safety.

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Table 1. Summary of articles.

Author /Citation	Research title	Research question or aim		Sample			Sample number	Setting			Country	Design		Questionnaire /data collection			Level of evidence
(Habibi Soola et al., 2022)	Predictors of patient safety competency among emergency nurses in Iran: a cross-sectional correlational study.	Assess predictors of patient safety competency among emergency nurses.		The convenience sampling method was used to recruit emergency department nurses			254	Five emergency departments of Ardabil Teaching Hospitals, northwest of Iran			Iran	Cross-sectional correlational research		Patient Safety in Nursing Education Questionnaire			VI
(Huh & Shin, 2021)	Person-Centered Care Practice, Patient Safety Competence, and Patient Safety Nursing Activities of Nurses Working in Geriatric Hospitals	Investigate the relationships between person-centered care practice, patient safety competence, and patient safety during nursing activities in geriatric hospitals.		Convenience sampling was used to recruit geriatric nurses			186 in 12 geriatric hospitals	12 geriatric hospitals			Canada	a descriptive survey design		Patient Safety Competence Assessment Tool for Nurses.			VI
(Khamaiseh et al., 2020)	Patient safety culture in Jordanian primary health-care centers as perceived by nurses: a cross-sectional study	Determine nurses’ attitudes towards patient safety culture in primary health centers in Jordan.		All nurses who were willing to participate in the study at the time of data collection and had at least 1 year of experience in governmental health settings; having worked in the center concerned for a minimum of 6 months; having Jordanian nationality;			644	91 accredited primary health care centers in Jordan d in 12 governorates			Jordanian	A cross-sectional descriptive study		SAQ			VI
(Alshehry, 2022)	Nurse–Patient/Relatives Conflict and Patient Safety Competence Among Nurses		To assess self-reported nurse and patients/relatives’ conflicts among nurses and investigate its association with the nurses’ confidence in patient safety competencies.		Registered nurse in Saudi Arabia; employed in the university hospital for at least 6 months; and provided direct care to patients;	320			King Saud University Medical City (KSUMC) in Riyadh City, Tertiary	Saudi Arabia			descriptive and cross-sectional		“Health Professional Education in Patient Safety Survey” (H-PEPSS)	VI
(Connell et al., 2021)	Measuring the safety climate in an Australian emergency department	Measure perceptions of the safety climate in an Australian metropolitan emergency department and examine relationships between safety climate perceptions and staff characteristics		The convenience sampling method was used to recruit the survey participants who were all medical and nursing personnel who were working in the ED of the study site at the time of the study.			127	a mixed metropolitan emergency department (adult and pediatric) metropolitan ED in Australia			Australia	Not mentioned		The Safety Climate Survey (SCS)
(Kakemam et al., 2021)	Nurses’ perception of patient safety culture and its relationship with adverse events: a national questionnaire survey in Iran	Assess the association between nurses’ perception of patient safety culture and their perceived proportion of adverse events.		Nurses employed in 32 teaching hospitals in Iran			2295	32 teaching hospitals in Iran			Iran	A nationwide cross-sectional study		Persian version of the Hospital Survey of Patient Safety Culture (HSOPSC),			VI
(Halabi et al., 2021)	Professional Competence Among Registered Nurses Working in Hospitals in Saudi Arabia and Their Experiences of Quality of Nursing Care and Patient Safety	Assess nurses' self-reported professional competence and illuminate experiences of the quality of nursing care and patient safety.		Nurses working in different unit			469	Two public hospitals and Regions			Kingdom of Saudi Arabia	cross-sectional design		The Nurse Professional Competence Scale			VI
(Han & Roh, 2020)	Teamwork, psychological safety, and patient safety competency among emergency nurses	This study aimed to identify the levels of teamwork, psychological safety, and patient safety competency, and determine the associations among these variables in emergency nurses.		Nurses with more than 12 months of ED experience in. New graduate nurses with less than one year of experience were excluded from the study			200	15 tertiary or secondary hospitals located in Seoul and the metropolitan areas of South Korea			Korea	A descriptive, correlational study used cross-sectional survey methodology.		Patient safety competency' self-evaluation tool.			VI
(Letourneau & McCurry, 2019)	The Effect of Transition to Practice Programs on the Self-Assessment of Newly Licensed Registered Nurses’ Confidence in Quality and Safety Competency Attainment	To evaluate the effectiveness of transition to practice programs (TPPs) in self-assessment of quality and safety competency development in newly licensed registered nurses (NLRN).		nurses who graduated from an accredited prelicensure nursing program within the last 12 months; were licensed as RNs; and currently practiced in a hospital setting, with no more than six months of experience			Sixty-four	Participants were recruited from three acute care institutions.			England	A quasi-experimental. Pretest-posttest design		The Nursing Quality and Safety Self Inventory (NQSSI)			III
(Lousada et al., 2020)	Patient safety culture in primary and home care services	To evaluate safety culture in primary and home care settings and to verify relationships between the SAQ domains and variables related to gender, type of service (primary or home care) and time of professional experience		Professionals from nine districts covered by one home care program and six primary healthcare centers			56	One home care service and six primary care centers located in the metropolitan region of Fortaleza, Brazil.			Brazil	A cross-sectional study		The Safety Attitudes Questionnaire (SAQ)			VI
(Mahsoon & Dolansky, 2021)	Safety culture and systems thinking for predicting safety competence and safety performance among registered nurses in Saudi Arabia: a cross-sectional study.	Explore the relationships among systems thinking, educational level, safety culture, safety competence, and safety performance among registered nurses working in medical and surgical units in Saudi Arabia.		Convenience sampling was used to recruit registered nurses from inpatient medical and surgical units in a hospital.			84	Surgical units in a hospital.			Saudi Arabia	correlational cross-sectional design		Safety competence was measured using the nurse’s attitudes and skills safety scale the latest version of NASUS. Safety culture was measured by the hospital survey on patient safety culture (HSOPSC).			VI
(Najjar et al., 2018)	Similarities and differences in the associations between patient safety culture' dimensions and self-reported outcomes in two different cultural settings: a national cross-sectional study in Palestinian and Belgian hospitals.	Investigate the relationships between patient safety culture (PSC) dimensions and PSC self-reported outcomes of the PSC in different cultures and to gain insight into cultural differences regarding PSC.		Health care professionals.			2836	90 Belgian hospitals and 13 Palestinian hospitals.			Belgium and Palestine.	Observational, cross-sectional study		The HSOPSC			VI
(Peñataro-Pintado et al., 2022)	Development and Validation of a Questionnaire of the Perioperative Nursing Competencies in Patient Safety.	to design, validate and analyze the psychometric properties of the Perioperative Nursing Safety Competencies		Perioperative nurses from 55 hospitals			415	55 hospitals			Spain	An instrumental, quantitative and descriptive study divided into two phases		Questionnaire of Perioperative Nursing Safety Competencies			VI
(Son et al., 2019)	Association of Working Hours and Patient Safety Competencies with Adverse Nurse Outcomes: A Cross-Sectional Study	Identify the differences in PS competencies and adverse nurse outcomes in different working hour's groups; and to explore the association of working hours and PS competencies with adverse nurse outcomes as an indicator of organizational performance in South Korean nurses.		Convenience sampling. Participants were registered nurses of all levels.			364	Acute care hospital setting. Nurses working in three tertiary care hospitals affiliated with Soonchunhyang University in South Korea			South Korean	A cross-sectional descriptive design		‘Health Professional Education in PS Survey”			VI
(Han et al., 2020)	Cross Sectional Study on Patient Safety Culture, Patient Safety Competency, and Adverse Events	The study has the following objectives: (a) identify nurses’ perceptions of patient safety culture, patient safety competency, and adverse events; (b) examine associations between nurses’ perceptions of patient safety culture and adverse events; and (c) clarify associations between nurses’ perceptions of patient safety competency and adverse events.		Convenient sampling was used. Sample was nurses who had been employed for more than 1 year			212	Two university hospitals located in two provinces of South Korea.			Korea	A cross-sectional research design		The Hospital Survey on Patient Safety Culture (HSOPSC) Patient safety competency was measured using the Health Professional Education in Patient Safety Survey (H-PEPSS)			VI
(Yan et al., 2021)	Assessment and analysis of patient safety competency of Chinese nurses with associate degrees: A cross‐sectional study	Analyze patient safety competency (PSC) of Chinese nurses with associate degrees (ADNs) and explore factors.		A convenience sample			451	18 hospitals			China	Cross sectional		Patient Safety Competency Nurse Evaluation Scale (PSCNES).			VI

Note. ED: Emergency department. PS: Patient safety.

No competing interests reported.

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published 19 May, 2023

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Clinical nurse competence and its effect on patient safety culture: A Systematic Review

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Abstract

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Background

Methods

Study Design

Search Strategy

Inclusion and Exclusion Criteria

Data Extraction And Management

Risk of Bias Assessment

Results

The design of the reviewed studies

The sampling technique

Measurement Tools For Safety Culture And Nursing Competency

The Patient Safety Culture

Patient Safety Competency

Discussion

Relationship between Nursing Competencies and Safety Culture

Measurement of patient safety culture

Measurement of safety nursing competency

Limitations

Conclusions

References

Table

Additional Declarations

Supplementary Files

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Journal Publication

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