In . J. En i on. Res. Public Heal h 2021, 18, 1429. h ps://doi.o g/10.3390/ije ph18041429 www.mdpi.com/jou nal/ije ph
A icle
A i udes o Unde g adua e Nu sing S uden s owa ds Pa ien
Sa e y: A Quasi-Expe imen al S udy
Nu ia Can e o-López 1, Víc o M. González-Cho dá 1,*, Ma ía Jesús Vale o-Chille ón 1, Desi ée Mena-Tudela 1,
Lau a And eu-Pejó 1, Ra ael Vila-Candel 2,3 and Águeda Ce e a-Gasch 1
1 Depa men o Nu sing, Facul y o Heal h Sciences, Uni e si a Jaume I, 12071 Cas ellón, Spain;
[email protected] (N.C.-L.); [email p o ec ed]s (M.J.V.-C.); dmen[email p o ec ed] (D.M.-T.); pej[email p o ec ed] (L.A.-P.);
ce e [email protected] (Á.C.-G.)
2 Depa men o Obs e ics and Gynaecology, La Ribe a Uni e si y Hospi al, FISABIO, C a. Co be a km 1,
46600 Valencia, Spain; ila_ a can@g a.es
3 Depa men o Nu sing, Facul y o Nu sing and Podia y, Uni e si y o Valencia, Jaume Roig, s/n,
46010 Valencia, Spain
* Co espondence: cho d[email p o ec ed]; Tel.: +34-964-387-744
Abs ac : Imp o ing nu sing s uden s’ a i udes owa ds pa ien sa e y is a cu en and ele an
opic. This s udy aims o e alua e he e ec i eness o an educa ional in e en ion based on c i ical
inciden and oo cause analysis (RCA) echniques ega ding a i udes owa ds pa ien sa e y in
nu sing s uden s. A quasi-expe imen al be o e and a e s udy was de eloped be ween Janua y
2018 and Decembe 2019 in a sample o 100 nu sing s uden s a Uni e si a Jaume I (Spain). The
in e en ion was de eloped in wo phases. Phase I was a uni e si y, whe e s uden s applied he
RCA echnique in a eal case. Phase II ook place du ing clinical p ac ice. S uden s used c i ical
inciden s o iden i y a isk si ua ion o he pa ien s and applied RCA o de ec i s oo causes. The
measu emen o a i udes was pe o med wi h he A i udes o Pa ien Sa e y Ques ionnai e (APSQ-
III). The global sco e o he ques ionnai e in he baseline measu emen was 3.911 (±0.335), in he
in e media e measu emen i was 4.031 (±0.337) and in he inal measu emen i was 4.052 (±0.335),
wi h signi ican di e ences (p = 0.03). Howe e , in a-g oup di e ences we e obse ed in he inal
measu emen (p = 0.021). The eamwo k dimension had he highes mean sco e on all h ee
measu es and he no i ica ion dimension had he lowes mean sco es. An educa ional in e en ion
combining c i ical inciden and RCA echniques can imp o es nu sing s uden s’ a i udes owa d
pa ien sa e y.
Keywo ds: nu se educa ion; pa ien sa e y; compe ence; a i ude; c i ical inciden echnic; oo cause
analysis
1. In oduc ion
Since he beginning o he cen u y, he e has been g owing conce n wi h he educa-
ion o u u e heal h p o essionals ega ding he knowledge, skills and a i udes necessa y
o imp o e hei compe encies in pa ien sa e y. The Wo ld Heal h O ganiza ion (WHO)
[1] and di e en agencies in he Uni ed S a es [2,3], Aus alia [4], Canada [5] and Eu ope
[6] ha e de eloped compe ency p o iles o pa ien sa e y ha heal h science s uden s
mus acqui e, including nu sing s uden s.
Howe e , a ound he wo ld nu sing deg ee cu icula do no assign he necessa y
impo ance o compe encies ela ed o pa ien sa e y [7–10] and i is necessa y o ad ance
he design and e alua ion o mo e e ec i e educa ional in e en ions o imp o e
knowledge, skills and a i udes ega ding pa ien sa e y [7,11], bo h in uni e si y class-
ooms and clinical se ings [12,13].
Ci a ion: Can e o-López, N.;
González-Cho dá, V.M.;
Vale o-Chille ón, M.J.; Mena-Tudela,
D.; And eu-Pejó, L.; Vila-Candel, R.;
Ce e a-Gasch, A; A i udes o
Unde g adua e Nu sing S uden s
owa ds Pa ien Sa e y: A Quasi-
Expe imen al S udy. In . J. En i on.
Res. Public Heal h 2021, 18, 1429.
h ps://doi.o g/10.3390/
ije ph18041429
Academic Edi o : Paul B.
Tchounwou
Recei ed: 4 Janua y 2021
Accep ed: 1 Feb ua y 2021
Published: 3 Feb ua y 2021
Publishe ’s No e: MDPI s ays neu-
al wi h ega d o ju isdic ional
claims in published maps and ins i-
u ional a ilia ions.
Copy igh : © 2021 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and con-
di ions o he C ea i e Commons A -
ibu ion (CC BY) license (h p://c e-
a i ecommons.o g/licenses/by/4.0/).
In . J. En i on. Res. Public Heal h 2021, 18, 1429 2 o 11
In he li e a u e, di e en app oaches can be ound o imp o e he compe encies in
pa ien sa e y o nu sing s uden s. Some au ho s use adi ional app oaches wi h mas e
classes [14] o s uc u ed cou ses [15]. O he au ho s in oduce digi al eco dings in hei
cou ses [16,17] o use ins uc ional me hods such as he lipped class oom [18,19]. On he
o he hand, Lee and Quinn [13] conclude ha clinical simula ion, echnological aids and
online lea ning modules imp o e he sa e y compe encies o nu sing s uden s. Howe e ,
mo e esea ch is needed o iden i y which educa ional s a egies a e he mos app op ia e,
in eg a ing heo e ical and clinical lea ning [11,12].
Du ing clinical p ac ices, nu sing s uden s may wi ness si ua ions ha pu pa ien
sa e y a isk and may make e o s ha cause damage o hei pa ien s [20]. The mos
equen e o s a e ela ed o medica ion adminis a ion, he imp ope handling o equip-
men and biological acciden s [21,22]. Despi e he impo ance o knowing hese e o s o
imp o e heal hca e p ocesses [23], nu sing s uden s a e eluc an o epo hese si ua ions
o ea o he consequences [24], and i is necessa y o imp o e hei a i udes owa ds
eamwo k and open communica ion o e o epo ing [25]. In ac , Kong e al. [26] ound
an associa ion be ween a o able a i udes o nu sing s uden s owa ds pa ien sa e y and
he execu ion o ela ed beha io s— o example, e o no i ica ion—which also occu s
when hey a e p o essionals [27].
The e o e, i is impo an o imp o e he a i udes o nu sing s uden s owa ds pa-
ien sa e y, al hough a i udes a e p obably one o he mos complex componen s o in-
oduce and e alua e in he eaching–lea ning p ocess [28]. S uden mis akes du ing p ac-
ice can be conside ed lea ning oppo uni ies; echniques ini ially de eloped in he ield
o enginee ing and indus ial sa e y, such as c i ical inciden [29] o oo cause analysis
(RCA) [30], can be used as eaching s a egies o imp o e he a i udes o unde g adua e
nu sing s uden s owa ds pa ien sa e y.
In 1950, Flanagan de ined a c i ical inciden as “any obse able human ac i i y ha
is comple e enough in i sel o allow in e ences and p edic ions abou he pe son pe o m-
ing he ac ” and de eloped his e ospec i e echnique o analysis o human beha io
[31]. Since hen, he c i ical inciden echnique has been used in nu sing educa ion o op-
imize lea ning om eal expe iences li ed by s uden s— o example, in he de elopmen
o c i ical hinking, cul u al and e hical aspec s [29], o lea ning om e idence-based p ac-
ice [32].
On he o he hand, oo cause analysis (RCA) is a eac i e echnique based on he
assump ion ha p oblems a e bes sol ed by ying o co ec o elimina e oo causes,
a he han simply ying o sol e immedia e consequences [33]. Se e al au ho s p opose
he use o RCA as a echnique o each pa ien sa e y o nu sing s uden s [3,30], and o he
au ho s [34] conclude ha his echnique p omo es c i ical hinking and a posi i e a i ude
in s uden s when eal cases a e analyzed.
These echniques show a o able esul s when hey a e used as eaching me hods,
bu a limi ed numbe o s udies ha e e alua ed he ela ionship be ween hei e ec on
a i udes and pa ien sa e y in nu sing s uden s. Thus, he main objec i e o his s udy was
o e alua e he e ec i eness o an educa ional in e en ion based on c i ical inciden and
RCA echniques ega ding a i udes ela ed o pa ien sa e y in unde g adua e nu sing
s uden s a he Uni e si a Jaume I (Spain).
2. Ma e ials and Me hods
2.1. Design and Se ings
A quasi-expe imen al be o e and a e s udy was ca ied ou in hi d-yea s uden s
o he deg ee in nu sing a Uni e si a Jaume I (Spain). The s udy was conduc ed be ween
Janua y 2018 and Decembe 2019.
In . J. En i on. Res. Public Heal h 2021, 18, 1429 3 o 11
2.2. Popula ion and Sample
The nu sing deg ee a Uni e si a Jaume I has 360 s uden s. The s udy popula ion
was made up o hi d-yea s uden s en olled in he subjec “Managemen o ca e in he
socio-sani a y ield” in he academic yea s 2017–2018 and 2018–2019 (N = 108). This subjec
has a o al o six c edi s wi hin he Eu opean C edi T ans e Sys em (ECTS). The heo e -
ical con en s deal wi h aspec s ela ed o managemen models, leade ship, quali y o ca e
and pa ien sa e y. The pe iod o clinical p ac ice is ca ied ou in adul hospi aliza ion
uni s, whe e s uden s ca y ou an ac i i y ha allows applying he heo e ical con en s o
he subjec in he heal hca e eali y.
Th ough a con enience sampling, all he s uden s en olled in his subjec we e in-
cluded. Those who did no comple e he clinical p ac ice pe iod and hose who did no
ag ee o pa icipa e in he s udy we e excluded.
2.3. Educa ional In e en ion
The educa ional in e en ion was based on RCA and c i ical inciden echniques and
was ca ied ou in wo phases, de eloping in he same way in he wo academic yea s
conside ed (Figu e 1). Phase I was ca ied ou in he class oom by he eache esponsible
o he subjec and a membe o he esea ch eam. The du a ion was 120 min. Wi h no
p io s uc u ed knowledge abou pa ien sa e y, g oups o i e s uden s applied he RCA
echnique in a eal case ela ed o e o s in he adminis a ion o medica ion known as
“The case o he Den e nu ses” [35]. This case is based on eal e en s and deals wi h he
chain o human e o s and sys em ailu es ha occu ed om he admission o a p egnan
woman o he dea h o he baby due o an e o in he adminis a ion o medica ion. The
exe cise was based on eaching ma e ials on pa ien sa e y p epa ed by he Spanish Min-
is y o Heal h, Social Se ices and Equali y [36]. In addi ion, he exe cise included a se ies
o ques ions o del e in o he basic p inciples ela ed o pa ien sa e y (e.g., whose aul
was i ?). The case was esol ed and a guided e lec ion was ca ied ou on he basic p in-
ciples o pa ien sa e y.
Figu e 1. S udy sequence.
Phase II was ca ied ou du ing clinical p ac ice. Indi idually, each s uden used he
c i ical inciden echnique o analyze a si ua ion expe ienced du ing clinical p ac ices ha
posed a isk o pa ien sa e y and applied he RCA echnique o ha si ua ion. Examples
o c i ical inciden s ela ed o pa ien sa e y du ing clinical p ac ices include e o s in he
adminis a ion o medica ion, he all o a pa ien du ing mobiliza ion o a ailu e o es-
cue. Likewise, each s uden ca ied ou a bibliog aphic sea ch o p opose measu es ha
could educe o elimina e he oo causes o his si ua ion. The s uden s had a guide o
p epa e he wo k and he suppo o he eaching s a o he subjec .
In . J. En i on. Res. Public Heal h 2021, 18, 1429 4 o 11
2.4. Da a Collec ion Ins umen
A i udes owa ds pa ien sa e y we e assessed wi h he A i udes o Pa ien Sa e y
Ques ionnai e (APSQ-III). The o iginal e sion o he APSQ-III was de eloped by Ca -
u he s e al. [37] o medical s uden s and Lamponi e al. [38] alida ed i in Spanish. In
his s udy, a e sion o nu sing s uden s adap ed and alida ed in a p e ious s udy pend-
ing publica ion was used. This e sion is composed o 22 i ems measu ed wi h a 5-poin
Like scale (1, s ongly disag ee; 5, s ongly ag ee) dis ibu ed in six dimensions ha ex-
plained 53.82% o he a iance in he explo a o y ac o analysis (Responsibili y; O gani-
za ion and communica ion; Teamwo k; T aining; No i ica ion; Awa eness). A con i ma-
o y ac o analysis indica es an adequa e i be ween he model and he da a (χ2 = 366; p
< 0.001; χ2/d = 1.886; RMSEA = 0.07; 95% Cl = 0.059–0.081; CFI = 0.885). The ques ionnai e
o e ed an adequa e in e nal consis ency (α = 0.808) and a good in a-obse e eliabili y
(ICC = 0.792). A highe sco e on he ques ionnai e means be e a i udes owa ds pa ien
sa e y.
In addi ion, sociodemog aphic a iables we e collec ed, such as age, sex ( emale;
male), academic yea (2017–2018; 2018–2019), p e ious s udies ela ed o heal h sciences
(no; uni e si y; p o essional aining; o he s) and employmen s a us (unemployed; ac i e
in he heal h ield; no ac i e in he heal h ield).
2.5. Da a Collec ion P ocess
Da a collec ion ook place be ween Feb ua y and July, in he 2017–2018 and 2018–
2019 academic yea s. A baseline measu emen was pe o med, p io o he in e en ion,
whe e sociodemog aphic a iables we e also collec ed. Likewise, an in e media e meas-
u emen was made a e Phase I o he in e en ion and a inal measu emen a e Phase
II, a he end o he clinical p ac ices. In he baseline measu emen , he s uden s ecei ed
in o ma ion abou he objec i es and me hodology o he s udy, as well as i s olun a y
and anonymous na u e. In all h ee measu emen s, scheduled classes we e used o collec
da a.
2.6. Da a Analysis
A desc ip i e analysis o he a iables was ca ied ou acco ding o hei na u e. The
e ec i eness o he in e en ion was de e mined wi h he F iedman es o pai ed da a,
compa ing he global sco es o he ques ionnai e and i s dimensions in he h ee measu e-
men s (baseline, in e media e and inal) and wi h he Wilcoxon es o pai ed da a, com-
pa ing wo by wo a each measu emen .
In addi ion, a bi a ia e analysis was pe o med o de e mine i he e we e signi ican
di e ences in he global sco e o he ques ionnai e in he h ee measu emen s (baseline,
in e media e and inal) based on sociodemog aphic a iables. A e con i ming ha he
applica ion condi ions o he pa ame ic es s (homoscedas ici y and no mali y) we e no
me , he non-pa ame ic Mann–Whi ney U es was used o wo g oups and he K uskal–
Wallis es o h ee o mo e g oups. The quali a i e a iables we e analyzed wi h he Chi-
squa e es (X2). The s anda d de ia ion (SD) o he quan i a i e a iables’ mean was cal-
cula ed. S a is ical analysis was pe o med wi h SPSS p og am e sion 23.0 (IBM SPSS
S a is ics o Windows, IBM Co p., A monk, NY, USA). The signi icance le el was se a p
< 0.05.
2.7. E hical Conside a ions
This s udy was app o ed and au ho ized by he Nu sing Depa men Council o he
Uni e si a Jaume I (p ojec e e ence 19CO1/000156, 5 h Sep embe 2019). In he baseline
measu emen , he pa icipan s we e in o med o he s udy objec i es and i s olun a y
na u e. In o med consen was ob ained om all he subjec s in ol ed in he s udy. A dis-
socia ion code was used o ela e he h ee measu emen s and ensu e he anonymi y o
In . J. En i on. Res. Public Heal h 2021, 18, 1429 5 o 11
he pa icipan s. The s udy was designed and execu ed in acco dance wi h Spanish O -
ganic Law 03/2018 on P o ec ion Pe sonal Da a and Gua an eeing Digi al Righ s and he
e hical p inciples o he Decla a ion o Helsinki (bene icence, non-male icence, au onomy
and jus ice).
3. Resul s
3.1. Sample Cha ac e is ics
Eigh pa icipan s we e excluded because hey did no adequa ely ill in he dissoci-
a ion code in any o he h ee ounds. Thus, he inal sample consis ed o a o al o 100
s uden s. Fi y pe cen o he s uden s belonged o he 2017–2018 academic yea . The mean
age o he sample was 22.54 ± 5.92 yea s and 78.8% (n = 79) we e women. The e we e no
signi ican di e ences when compa ing he pa icipan s acco ding o academic yea (Ta-
ble 1).
Table 1. Sociodemog aphic a iables acco ding o academic yea (N = 100).
Va iables Academic Yea p 1
2017–2018% (n)
2018–2019% (n)
Employmen si ua ion
(n = 92)
No employed 34.8 (32) 37.0 (34)
0.224 No in he heal h a ea 10.9 (10) 7.6 (7)
In he heal h a ea 7.6 (7) 2.1 (2)
Sex (n = 99) Female 40.4 (40) 38.4 (38) 0.766
Male 10.1 (10) 11.1 (11)
P e ious s udies (n = 90)
No 36.7 (33) 37.8 (34)
0.182
Uni e si y 4.4 (4) 0 (0)
P o essional aining 11.1 (10) 8.9 (8)
O he 1.1 (1) 0 (0)
Va iables m (SD) m (SD) p 2
Age (
n
= 100) 22.50 (4.31) 22.58 (7.23) 0.122
1 Chi-squa e es ; 2 Mann–Whi ney U es .
3.2. E ec i eness o he Educa ional In e en ion
The global sco e o he ques ionnai e in he baseline measu emen was 3.91 ± 0.34
poin s, inc easing in he in e media e measu emen (4.03 ± 0.34) and in he inal measu e-
men (4.05 ± 0.34). The F iedman es con i med he o e all e ec i eness o he in e en-
ion when compa ing he h ee measu emen s (p = 0.03). Likewise, s a is ically signi ican
di e ences we e ound be ween he baseline and he in e media e measu emen (p =
0.008), bu no be ween he in e media e and he inal measu emen (p = 0.664).
Table 2 shows he analysis o he sco es ob ained in he di e en dimensions. Re-
sponsibili y (p = 0.004), T aining (p = 0.001) and Awa eness (p = 0.047) showed s a is ically
signi ican di e ences when compa ing he mean sco es o he h ee measu emen s. How-
e e , no dimension showed signi ican di e ences when compa ing he mean sco e o he
in e media e and he inal measu emen (p > 0.05). On he o he hand, he Teamwo k di-
mension ob ained he highes sco e in he h ee measu emen s, while he lowes sco es
we e o he No i ica ion dimension.
In . J. En i on. Res. Public Heal h 2021, 18, 1429 6 o 11
Table 2. Analysis o he dimensions o he ques ionnai e (N = 100).
Dimensions
BM 1 IM 1 FM 1 p
m (SD) m (SD) m (SD) BM-IM-FM 2
BM-IM 3 IM-FM
3
Responsibili y 3.42 (0.58) 3.77 (0.62) 3.81 (0.68) 0.004 <0.001 0.868
O ganiza ion y com-
munica ion 4.32 (0.55) 4.38 (0.47) 4.41 (0.60) 0.341 0.517 0.830
Teamwo k 4.45 (0.48) 4.44 (0.51) 4.42 (0.57) 0.820 0.915 0.576
T aining 3.93 (0.49) 4.11 (0.50) 4.24 (0.53) 0.001 0.007 0.168
No i ica ion 3.36 (0.92) 3.18 (0.98) 3.25 (0.82) 0.377 0.090 0.864
Awa eness 4.02 (0.70) 4.28 (0.68) 4.18 (0.66) 0.047 0.001 0.055
1 BM: Baseline measu emen ; IM: In e media e measu emen ; FM: Final measu emen ; 2 F iedman
es ; 3 Wilcoxon es .
3.3. Analysis o he Global Sco e o he Ques ionnai e Acco ding o Sociodemog aphic Va iables
Table 3 shows he esul s o he ques ionnai e sco e acco ding o he sociodemo-
g aphic a iables. On he one hand, no signi ican di e ences we e obse ed as a unc ion
o sex in any o he h ee measu emen s (p > 0.05). On he o he hand, he s uden s who
wo ked in he heal h ield ob ained a signi ican ly lowe sco e in he h ee measu emen s
(p < 0.05) and his sco e dec eased h oughou he educa ional in e en ion, al hough no
signi ican ly (p = 0.223). In addi ion, s uden s wi hou p e ious s udies ela ed o heal h
sciences ob ained highe sco es in he h ee measu emen s, al hough signi ican di e -
ences we e only ound in he in e media e measu emen (p = 0.042). Finally, i was ob-
se ed ha he s uden s o he 2018–2019 academic yea ob ained sligh ly highe sco es in
he h ee measu emen s, al hough he e we e only s a is ically signi ican di e ences in
he inal measu emen (p = 0.021).
Table 3. Analysis o he global sco e o he ques ionnai e acco ding o he sociodemog aphic a i-
ables (N = 100).
Va iables
Measu emen s (m; SD)
Baseline In e media e Final
(m; SD) p (m; SD) p (m; SD) p
Employmen si ua ion 1 0.016 0.011 0.044
No employed 3.96 (0.32) 4.08 (0.33) 4.09 (0.40)
No in he heal h a ea 3.71 (0.37) 4.06 (0.35) 4.04 (0.47)
In he heal h a ea 3.80 (0.24) 3.70 (0.19) 3.46 (0.54)
Sex 2 0.524 0.527 0.639
Female 3.90 (0.32) 4.04 (0.34) 4.07 (0.37)
Male 3.96 (0.39) 3.99 (0.35) 3.99 (0.57)
P e ious s udies 1 0.490 0.042 0.229
No 3.93 (0.35) 4.10 (0.32) 4.11 (0.41)
Uni e si y 3.73 (0.15) 3.65 (0.14) 3.86 (0.0)
P o essional aining 3.92 (0.33) 3.93 (0.35) 3.86 (0.54)
O he 4.28 (0.0) 4.37 (0.0) 4.37 (0.0)
Academic yea 2 0.247 0.434 0.021
2017–2018 pe iod 3.87 (0.38) 4.009 (0.347)
3.94 (0.48)
2018–2019 pe iod 3.95 (0.28) 4.06 (0.33) 4.16 (0.32)
1 K uskal–Wallis es ; 2 Mann–Whi ney U es .
4. Discussion
The main indings o his s udy showed a signi ican inc ease in he global sco e o
he APSQ-III ques ionnai e adap ed o nu sing s uden s h oughou he h ee measu e-
men s, so ha i can be a i med ha his educa ional in e en ion based on he RCA and
c i ical inciden echniques signi ican ly imp o ed he a i udes owa ds pa ien sa e y.
In . J. En i on. Res. Public Heal h 2021, 18, 1429 7 o 11
O he au ho s [18,19,39] also ca ied ou educa ional in e en ions aimed a imp o ing
he pa ien sa e y compe encies o nu sing s uden s, bu i is di icul o compa e ou e-
sul s, as o he s udies wi h a simila educa ional in e en ion we e no ound and mos o
hem e alua e a i udes oge he wi h knowledge and skills and a e no speci ic. Fu he -
mo e, he e is a iabili y in he ins umen s used o e alua e he e ec i eness o educa-
ional in e en ions. Fo example, B ei k euz e al. [39] compa ed he use o ideos and
simula ion o imp o e nu sing s uden s’ a i udes owa ds pa ien sa e y, concluding ha
simula ion was mo e e ec i e. Kim e al. [19] compa ed he lipped class oom me hodol-
ogy wi h egula eaching in a sample o 75 nu sing s uden s. The au ho s concluded ha
hei in e en ion managed o signi ican ly imp o e knowledge and skills ela ed o pa-
ien sa e y, bu no a i udes, mainly in inal yea s uden s. Maxwell e al. [18] ob ained
simila esul s using he lipped class oom me hodology, al hough in hei s udy he e
was no con ol g oup and di e en ins umen s we e used o e alua e he e ec i eness o
he in e en ions.
Mansou e al. [14] e alua ed whe he knowledge and a i udes abou pa ien sa e y
imp o ed in a sample o 141 English nu sing s uden s a e wo mas e classes and acili-
a ed g oup wo k, bu he esul s o his p e-pos -in e en ion s udy we e no signi ican .
Ano he s udy wi h 59 Du ch nu sing s uden s ob ained sa is ac o y esul s a e applying
a s uc u ed p og am on pa ien sa e y, bu he au ho s used an ad hoc ques ionnai e o
globally assess he compe encies es ablished by he WHO and no he acquisi ion o
knowledge, skills and a i udes [15]. O he au ho s also did no ind signi ican di e ences
in a i udes owa ds pa ien sa e y when hey e alua ed di e en educa ional in e en-
ions [40,41].
In ou s udy, Phase I o he educa ional in e en ion ook place in he class oom,
while Phase II was ca ied ou du ing clinical p ac ice. I should be men ioned ha he
sco e o he ques ionnai e inc eased sligh ly be ween he in e media e and he inal meas-
u emen , al hough no signi ican ly, indica ing ha he clinical p ac ices did no nega-
i ely a ec s uden s’ a i udes. On he one hand, ou s uden s ecei e s uc u ed aining
on pa ien sa e y o he i s ime in he subjec whe e he in e en ion was ca ied ou ,
and his could explain why Phase I o he in e en ion signi ican ly imp o ed hei a i-
udes owa ds pa ien sa e y. On he o he hand, Lukewich e al. [42] obse ed ha a i-
udes owa d pa ien sa e y in nu sing s uden s dec eased as hei con ac wi h clinical
p ac ices inc eased. I is possible ha he le el o sa e y cul u e o he uni s whe e s uden s
ca y ou he clinical p ac ices [26], he quali y o he lea ning en i onmen [42] o he ole
played by clinical u o s as models o s uden s [43] may in luence hese esul s. In he
same way, hese ac o s can help o explain he signi ican di e ences ound in he inal
measu emen when compa ing he esul s be ween bo h cou ses, as p ac ice uni s a e
awa ded each yea acco ding o he cen e s’ add esses, and bo h he uni s and he clinical
p ac ice u o s may change. Fu u e s udies should conside he in luence o hese ac o s.
Despi e his, in eg a ing pa ien sa e y educa ion in o clinical p ac ice and educing
he gap be ween heo y and p ac ice is a common ecommenda ion o imp o e he pa ien
sa e y compe encies o nu sing s uden s. Al hough i is no clea wha he bes s a egies
o his a e [9,12,13], he esul s o ou s udy can help in his ega d.
The e sion o he APSQ-III used in his s udy o nu sing s uden s has 22 i ems o -
ganized in six dimensions (Responsibili y, O ganiza ion and Communica ion; Teamwo k;
T aining; No i ica ion; Awa eness) ha a e di ec ly ela ed o pa ien sa e y. The dimen-
sions Teamwo k and O ganiza ion and Communica ion a e ela ed o a undamen al p in-
ciple o pa ien sa e y, which is ha e o s in medical ca e depend mo e on ailu es in he
sys em and in he design o p ocesses han on human e o s [44]. This is also ela ed o
he Responsibili y and Awa eness dimensions, al hough he aim he e is o assess how
s uden s pe cei e esponsibili y o ad e se e ec s and he need o communica e undesi -
able esul s o pa ien s i hey occu [45]. The No i ica ion dimension e e s o he a i ude
o s uden s owa ds he epo ing o e o s o manage s, which is a undamen al aspec in
imp o ing pa ien sa e y [46]. Finally, he T aining dimension ocuses on he impo ance
In . J. En i on. Res. Public Heal h 2021, 18, 1429 8 o 11
o educa ion in unde s anding he causes o e o s and ad e se e ec s [1–6]. O he ques-
ionnai es on pa ien sa e y in nu sing s uden s p esen simila s uc u es and dimensions
ha add ess he same concep s [47].
The educa ional in e en ion e alua ed in his s udy began wi h he analysis o a eal
case ha a ec ed pa ien sa e y. This case ocuses on an e o in he adminis a ion o
medica ion, one o he main causes o ad e se e ec s [48], and ends wi h he dea h o he
pa ien . In he analysis o he case wi h he RCA echnique, a chain o sys em ailu es and
human e o s we e obse ed, mainly ela ed o communica ion p oblems, one o he main
oo causes o e o s [49]. The guided e lec ion a e he analysis o he case made i pos-
sible o add ess aspec s ela ed o he o ganiza ion o he p ocesses and esponsibili y o
e o s, conside ing ha ini ially he nu ses we e ound guil y and, a e he eal analysis
o he case wi h he RCA echnique, i could be shown ha hey we e no di ec ly espon-
sible o he dea h o he pa ien . In addi ion, du ing Phase II o he in e en ion, he s u-
den s elied on eal cases ha hey expe ienced du ing clinical p ac ice o e lec on pa ien
sa e y and apply he con en s and echniques add essed in he class oom. Thus, he edu-
ca ional con en used can in luence nu sing s uden s’ a i udes owa ds pa ien sa e y and
a e linked o he dimensions o he APSQ-III.
In ou s udy, he dimensions ha ob ained he highes sco es we e O ganiza ion and
Communica ion and Teamwo k, while he No i ica ion and Responsibili y dimensions
ob ained he lowes sco es. These esul s pa ially coincide wi h hose o o he au ho s
[50], whe e he bes esul s we e ob ained in aspec s ela ed o communica ion and he
wo s in aspec s ela ed o eamwo k. Howe e , s uden s ca y ou clinical p ac ice wi h
mo e expe ienced nu ses and hey a e expec ed o be able o wo k in eams and communi-
ca e p o essionally wi h hei colleagues and also wi h pa ien s. In addi ion, s uden s a e
expec ed o be cau ious, ask he nu ses when in doub and no i y hem i hey make a
mis ake. Howe e , nu sing s uden s a e unwilling o epo ad e se e ec s and hei mo-
i es need o be unde s ood in o de o imp o e hei a i udes owa ds epo ing [24–26].
Rega ding he in luence o sociodemog aphic a iables, se e al aspec s should be
discussed. On he one hand, only signi ican di e ences we e obse ed in he APSQ-III
sco e based on p e ious s udies in he in e media e measu emen . In addi ion, i was ob-
se ed how he sco e dec eased along he h ee measu emen s in s uden s wi h p e ious
p o essional aining and how s uden s wi h o he ypes o aining ( o example, i s aid
cou ses o aining as li egua ds) had he highes sco e. Howe e , i mus be aken in o
accoun ha he majo i y o s uden s did no ha e any ype o p e ious aining and ha
he o he subsamples o his a iable we e no e y ep esen a i e, which could a ec he
esul s. O he wise, he in luence o p e ious s udies o nu sing s uden s on hei a i udes
owa ds pa ien sa e y should be add essed in g ea e dep h in u u e esea ch, since no
p e ious s udies we e ound ha conside ed his a iable.
On he o he hand, he a iable employmen si ua ion had a signi ican in luence on
he h ee measu es. Thus, s uden s who we e unemployed ob ained highe sco es han
hose who we e wo king, possibly due o a g ea e a ailabili y o ime o go o class and
dedica e hemsel es o s udying [41]. In addi ion, i is s iking ha he s uden s who al-
eady wo ked in he heal h ield ob ained signi ican ly lowe sco es han he es and i is
necessa y o highligh ha he sco e o hese s uden s who al eady wo ked in he heal h
ield dec eased o e he h ee measu emen s. These esul s dese e u he s udy and a e
p obably ela ed o a low cul u e o pa ien sa e y in hei wo k cen e s, al hough he e
a e ew s udies on sa e y cul u e in ou con ex [51]. These esul s ha e implica ions o
u u e educa ion i i is conside ed ha , a leas in ou case, pa ien sa e y educa ion is
a omized in o one subjec and his may be insu icien o an adequa e acquisi ion o com-
pe encies ela ed o pa ien sa e y and, speci ically, o de elop o modi y a i udes o-
wa ds pa ien sa e y. Meanwhile, di e en au ho s ecommend ha compe encies in pa-
ien sa e y be add essed h oughou he di e en academic cou ses and a e linked o ex-
pe iences ela ed o pa ien sa e y du ing clinical p ac ice [9,43]. Finally, he esul s o his
s udy should be iewed wi h cau ion due o hei limi a ions. On he one hand, i is a
In . J. En i on. Res. Public Heal h 2021, 18, 1429 9 o 11
quasi-expe imen al be o e and a e s udy, wi h a non- andomized sample and no con ol
g oup, which was ca ied ou in a single ins i u ion, limi ing he gene alizabili y o he
esul s. Fu he mo e, he long- e m e ec i eness o he in e en ion was no s udied, and
he esul s a e based on sel - epo by he s uden s, wi h a isk o in o ma ion bias. Despi e
hese limi a ions, he esul s o his s udy a e o in e es , as s udies e alua ing educa ional
in e en ions o imp o e a i udes owa ds pa ien sa e y in nu sing s uden s a e limi ed
and ew o hem epo a signi ican imp o emen in he a i udes o nu sing s uden s. In
addi ion, he implica ions o p ac ice should be conside ed, as imp o ing nu sing s u-
den s’ a i udes owa ds pa ien sa e y should imp o e ce ain beha io s, such as epo -
ing ad e se e ec s, eamwo k and communica ion wi h pa ien s when hey wo k as
nu ses. Thus, a di ec impac on imp o ing he quali y o heal hca e should be expec ed.
The in e en ion o e s an al e na i e wi h a o able esul s, al hough i is necessa y o
ca y ou s udies wi h mo e obus expe imen al designs and la ge samples o con i m
he esul s ob ained.
5. Conclusions
This quasi-expe imen al s udy e alua ed he e ec i eness o an educa ional in e -
en ion on a i udes owa ds pa ien sa e y in nu sing s uden s. The esul s showed a sig-
ni ican global imp o emen in he a i udes o he sample s udied and a i udes emain
posi i e when s uden s a e exposed o he eali y o clinical p ac ice. These esul s should
be con i med in u u e s udies wi h mo e obus designs ha conside ac o s such as he
quali y o he lea ning en i onmen , he le el o sa e y cul u e o he p ac ice uni s o he
in luence o he p ac ice u o s in he acquisi ion o skills ela ed o pa ien sa e y.
Au ho Con ibu ions: Concep ualiza ion, V.M.G.-C. and N.C.-L.; me hodology, D.M.-T., Á.C.-G.
and V.M.G.-C.; o mal analysis, N.C.-L. and M.J.V.-C.; w i ing—o iginal d a p epa a ion,
V.M.G.-C. and L.A.-P.; w i ing— e iew and edi ing, R.V.-C.; p ojec adminis a ion, V.M.G.-C.;
unding acquisi ion, V.M.G.-C. and N.C.-L. All au ho s ha e ead and ag eed o he published
e sion o he manusc ip .
Funding: This esea ch was unded by Minis e io de Educación y Fo mación P o esional, g an
numbe 19CO1/000156.
Ins i u ional Re iew Boa d S a emen : The s udy was conduc ed acco ding o he guidelines o he
Decla a ion o Helsinki and app o ed and au ho ized by he Nu sing Depa men Council o he
Uni e si a Jaume I (p ojec e e ence 19CO1/000156).
In o med Consen S a emen : In o med consen was ob ained om all subjec s in ol ed in he
s udy.
Da a A ailabili y S a emen : The da a p esen ed in his s udy a e a ailable on eques om he
co esponding au ho .
Con lic s o In e es : The au ho s decla e no con lic o in e es .
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