Anglia Ruskin University. Evaluation of World Health Organisation (WHO)’ Multi-Professional Patient Safety Curriculum Guide Dr Mansour Mansour Alice Skull Michael Parker Acute Care Department, Faculty of Health, Social Care and Education Anglia Ruskin University.

Patient Safety Heart of high quality healthcare Nursing Education Patient Safety Education in nursing curriculum: Implicit vs. explicit (Atree at al 2008) Competencies need to better reflect practice preparation The need for Frameworks for patient safety education (House of Commons Health Committee 2009, Greiner, and Knebel 2003)

Frameworks for patient safety education Quality and Safety Education for Nurses (QSEN) (Cronenwett et al 2007) WHO Multi-Professional Patient Safety Curriculum Guide (WHO 2011)

Multi-professional Patient Safety Curriculum Guide (WHO 2011) 1.1. 1. What is patient safety? 2. Why applying human factors is important for patient safety. Understanding systems and the effect of complexity on patient care. 4. Being an effective team player 5. Learning from errors to prevent harm 6. Understanding and managing clinical risk 7. Using quality improvement methods to improve care 8. Engaging with patients and carers 9. Infection prevention and control 10. Patient safety and invasive procedures 11. Improving medication safety

International project to evaluate the impact of educational intervention related to the WHO Multi-Professional Patient Safety Curriculum Guide. Anglia Ruskin University approved as WHO complementary testing site.

Research aim To evaluate the impact of teaching related to two selected patient WHO Patient Safety topics on the pre-registration student nurses’ knowledge and attitudes toward patient safety. Two topics tested: What is patient Safety ? Learning from error to prevent harm.

Methods Pre-test, post-test, non- experimental design. Convenient sample of final year pre-registration nursing students Three branches of Nursing: Adult, Child and Mental Health . Pre-test sample: 181, Post-test sample: 141 Education intervention: two face-to-face lecture, One Group work discussion Delivered through Nursing Management module. (April – May 2012) Study Approved by Anglia Ruskin Faculty Research Ethics Panel. Paired t-test, McNemar's test and frequencies measures were used for data analysis.

Patient Safety Education Questionnaire Pre-Test Instrument (26-items) Attitudes toward understanding Patient Safety (23 Likert items) Error and Patient safety subscale Safety of Health Care systems subscale Personal Influence over Safety subscale Personal Attitudes to Patient Safety subscale Knowledge Questions on Patient Five multiple choice questions related to the two selected topics Post-Test Instrument (42-items) Attitudes toward understanding Patient Safety (23 Likert items) Error and Patient safety subscale Safety of Health Care systems subscale Personal Influence over Safety subscale Personal Attitudes to Patient Safety subscale Knowledge Questions on Patient Five multiple choice questions related to the two selected topics 3. Feedback section Perception about the Patient Safety Topics. Effectiveness of the Patient Safety Topics Qualitative free text comments on Patient Safety teaching

Results (pre-test) Students characteristics Frequency measure Results 3rd year students 98.3 % (n=173) Patient safety has been taught in their university 87.5 % (n =154) Have previously taken designated patient safety course. 24 % (n =42)

Students response rate Frequency measure Results Pre-test response rate 94% (n=171) Post- test response rate 51% (n=72) Matched pre-test and post test cases 71

Differences in Attitudes toward understanding patient safety Factor/ subscale Pre test Average Mean Scores Post Test Average Means Score Difference (SD) 95% Confidence Interval for the Difference   Cohen’s d Lower Upper Error and Patient safety 3.491 3.873 * 0.382 (0.77) 0.200 0.560 0.62 Safety of the Healthcare System 3.380 3.490 0.110 (0.49) -0.004 0.224 0.26 Personal Influence over Safety 3.404 3.561 * 0.157 (0.52) 0.034 0.279 0.28 Personal Attitudes to Patient Safety 4.268 4.310 0.042 (0.59) -0.079 0.181 0.10 * p< 0.05

Knowledge questions on patient safety topics   Question n Number of correct answers Relative difference (95% confidence limits) p Pretest Posttest What is Patient Safety? What multiple factors can lead to the delivery of unsafe care? 48 35 (72.9%) 40 (83.3%) 38.5% (-7.3%, 84.3%) 0.302 A nurse fails to practice hand hygiene between patients because hey feel they are too busy even if there 5 (10.4%) 9 (18.8%) 9.3% (-4.4%, 23.0%) 0.344 How we understand and learn from errors to prevent harm? Wrong diagnosis leads to an inappropriate treatment plan. What type of error is it? 49 29 (59.1%) 26 (53.1%) -15.0% (-63.2%, 33.2%) 0.664 A patient was being treated for non-Hodgkin's lymphoma. A Syringe containing vincristine for another patient has been accidently delivered to patient's bedside. The physician administered vincristine via a spinal route, believing it was a different medication. The error was not recognized and the patient died three days later. What are the major factor(s) that caused the error in this case? 30 (62.5%) 0% (-46.2%, 46.2%) 1.000 5. What are the best ways to learn from errors? 41 (85.4%) 0% (-88.5%, 88.5%)

Students perceptions about the Patient Safety Topics Items Median Rating ** (n= 71) The aims of this patient safety topic were clear to me. 4 It was important to incorporate this patient safety training in the educational curricula. I have improved my knowledge/skills as a result of this topic. I acquired new knowledge/skills that will be of value during my career. I will be able to readily apply the knowledge taught in the Curriculum Guide to actions during my professional work. My understanding of the importance of patient safety increased as a result of the patient safety training. My knowledge of patient safety principles and practices increased as a result of the patient safety training. This training increased my motivation to put patient safety practices to work in my professional roles. **Rating scale: 1 Strongly Disagree 2 Disagree 3 Neutral 4 Agree 5 Strongly agree.

Students’ evaluation of the effectiveness of the teaching related to Patient Safety Topics Items Median Rating * (n= 71) I found the style of teaching in this topic facilitated my learning. 4 The Instructors facilitated my understanding. The presentation of the topic was culturally appropriate. The teaching aids (e.g. audiovisual presentations or written materials) added to the session. Completion of the assignment(s) facilitated my understanding. N/A ** The time devoted to the topic was sufficient. The methods used to assess performance on the topic taught were effective. This stage in the overall Curriculum Guide is an appropriate time for this particular topic. **Rating scale: 1 Strongly Disagree 2 Disagree 3 Neutral 4 Agree 5 Strongly agree.

Discussion The results represent important indicator for shifting the students focus to system contributions toward unsafe practice (Reason 2000). The nature of the intervention (mostly classroom-based) may help to explain the uncertainty in the differences of the students’ knowledge acquired before and after the intervention. (Durham and Sherwood, 2008; Hamilton 2005). The QSEN framework is subject to more rigorous evaluation compared with the WHO Multi-Professional Patient Safety Curriculum Guide. (Chenot and Daniel 2010, Miller and LaFramboise 2009, Jones 2013)

Limitation Findings are based on self-report, with the potential of over or under reporting of the actual perceptions and attitudes toward patient safety education (Adams, et al. 1999, Van de Mortel, 2008). The non-experimental design meant that the study does not provide direct evidence that the training actually influence the student knowledge, or modified their attitudes and perceptions toward patient safety. Low response rate from the post-test survey.

Conclusion This study is the first published one to evaluate the impacts of teaching related to selected patient safety topics from the WHO Patient Safety Curriculum Guide in pre-registration nursing training. Considering using more robust, experimental design in future curriculum evaluation, with longer follow up to attribute more educational intervention will provide complementary insight into the findings of this study.

Thank you !

References Adams, A., Soumerai, S., Lomas, J., Ross-Degnan, D., 1999. Evidence of self-report bias in assessing adherence to guidelines. International Journal for Quality in Health Care, 11(3), 187-192. Attree, M. Cooke, H. Wakefield, A (2008) Patient safety in an English pre-registration nursing curriculum. Nurse Education in Practice 2008; 8(4): 239-248 Chenot, T.,Daniel, L., 2010. Frameworks for Patient Safety in the Nursing Curriculum. Journal of Nursing Education 49(10): 559–68 Cronenwett L, Sherwood G, Barnsteiner J, Disch J, Johnson J, Mitchell P et al (2007) Quality and safety education for nurses. Nursing Outlook 55(3): 122–31 Durham, C., Sherwood, G., 2008. Education to bridge the quality gap: A case study approach. Urologic Nursing, 28, 431-438, 453 Greiner, A. Knebel, E. (2003) Health Professions Education: A Bridge to Quality. Institute of Medicine Committee on the Health Professions Education Summit. Washington DC. Hamilton, R., 2005. Nurses’ knowledge and skill retention following cardiopulmonary resuscitation training: a review of the literature. Journal of advanced nursing, 51(3), 288-297.

House of Commons Health Committee (2009) Patient Safety: 6th Report of 9 sessions 2008-09. London: Stationery Office. Reason, J., 2000. Human error: models and management. British Medical Journal 320(7237): 768–70 Jones, A., 2013. The impact of integrating quality and safety education for nurses' safety competency in first-year associate degree nursing students. Teaching and Learning in Nursing, 8(4), 140-146. Miller, C., and LaFramboise, L., 2009. Student learning outcomes after integration of quality and safety education competencies into a senior-level critical care course. The Journal of nursing education, 48(12), 678-685. Van de Mortel, T., 2008. Faking it: social desirability response bias in self-report research. Australian Journal of Advanced Nursing, 25(4), 40. World Health Organisation (2011) Patient Safety Curriculum Guide: Multi-professional Edition. http://tinyurl.com/c6lbcsm (accessed 27 April 2012)