Does problem-based learning education improve knowledge, attitude, and perception toward patient safety among nursing students? A randomized controlled trial

Patient safety is a priority issue for all health care systems worldwide [1, 2]. Providing safe and error-free care is the ultimate goal of all healthcare systems [3]. Nurses are leading healthcare team members [4], and they have a fundamental responsibility to ensure patient safety [5]. It is estimated that there are 421 million hospital admissions worldwide every year. Meanwhile, approximately 7.42 million cases of adverse events occur during these hospitalizations, making patient harm is the 14th leading cause of global deaths [6]. Furthermore, one in every ten patients is harmed while receiving hospital care as the world health organization (WHO) considers patient safety as an endemic and epidemic concern [7]. Annually, more than 400,000 premature deaths occur due to preventable adverse events, and the incidence of serious harm is 10 to 20 times higher than the mortality rate [8]. In clinical settings, nursing students sometimes participate directly in unsafe care, errors, adverse events, and poor patient care. For that reason, like other healthcare team members, they should use their knowledge, attitude, and perception of patient safety while caring for the patient [9]. Lack of patient safety knowledge is one of the nursing students’ educational problems that lead to unsafe practice [10]. Mansour and Francis (2013) stated that graduate nurses should have sufficient knowledge to identify potential safety risks, and they should have the confidence to protect patients against preventable harm or adverse events [11, 12].

On the other hand, an unsafe attitude is a precursor to adverse events because it shapes and influences the behavior, so any change in attitude has a significant effect on people’s safety behavior [13]. Nowadays, it is widely accepted that optimal patient safety development is not possible without a safe attitude in health care facilities [14]. Therefore, nurses’ attitude toward patient safety is very important to promote a safe environment for patients [15]. Nurses’ perceptions are the foundation of any behavior and lead to actions that affect patient safety and are vital for all hospitals and healthcare providers [16].

Hence, evaluating nursing and medical students’ knowledge, attitude, and perceptions toward patient safety is necessary because they are future healthcare professionals [17]. Most universities around the world are looking for teaching methods through which they would be able to enhance students’ clinical decision-making capabilities and self-centered learning [18]. In recent decades, the use of new and active student-centered learning methods has been trending strongly with educational systems [19]. The PBL is an innovative educational method that focuses on one problem, either assigned by the students or by the teacher [20], and it has been adopted in medical sciences such as nursing, midwifery, dentistry, and medicine in many universities around the world [21]. The PBL is a student-centered pedagogy in which students and professors are responsible partners in the learning-teaching process, and teaching is a way to facilitate learning [22]. The purpose of this method in medical education is to acquire basic clinical knowledge, make progress in personal learning skills, and evolve in dealing effectively with challenges at the patient’s bedside, and ultimately improve dynamism and motivation for learning [23].

As members of the healthcare team, nurses play a vital role in improving patient safety, originating from their attitudes, knowledge, and skill in patient safety [15, 24]. Also, the WHO emphasizes teaching patient safety to medical and nursing students, and the ministries of health focus on patient safety programs [25]. Given the widespread adoption of PBL in medical and nursing schools worldwide and many nursing education, experts believe that PBL can bridge the gap between theory and practice [26, 27]. Thus, this study aimed to determine the effect of patient safety education through PBL on nursing students’ knowledge, attitude, and perceptions toward patient safety.

Seventy-eight nursing students entered the analysis, with no attrition in this study. The results indicated no statistically significant difference between the two groups in terms of age, gender, semester, marital status, residency, interest in the nursing major, clinical work experience, and grade point average (GPA), indicating that the two groups were homogeneous (Table 2).

The results of the paired t-test indicated that the mean score of patient safety knowledge in the control group did not differ significantly before and after the intervention (p = 0.279). However, the mean score of patient safety knowledge in the intervention group increased significantly after the intervention (p = 0.001) (primary outcome). Moreover, based on the paired t-test result, the mean score of students’ attitudes toward patient safety was not significantly different in the control group after the PBL education (p = 0.529). However, the difference was statistically significant in the intervention group after the PBL education as the mean score of students’ attitudes about patient safety increased significantly after the intervention (p = 0.016) (secondary outcome). The paired t-test also showed no significant difference in the mean score of the students’ perception of patient safety in the control group before and after PBL education (p = 0.122). Nevertheless, the mean score of students’ perception of patient safety increased significantly in the intervention group after PBL education (p = 0.037) (secondary outcome) (Table 3).

A significant difference was found in the mean score of patient safety knowledge between the control and the intervention group before and after the intervention (p = 0.001). No statistically significant difference was revealed in the mean score of students’ attitudes toward patient safety between the two groups before the intervention (p = 0.152). However, the difference was statistically significant between the two groups after the PBL education (p = 0.006). Consequently, the PBL positively affected students’ attitudes about patient safety in the intervention group. The independent t-test demonstrated that the difference in the mean score of the students’ perception of patient safety was not statistically significant between the two groups before the intervention (p = 0.264). Moreover, after the intervention, the mean score of students’ perception toward patient safety increased significantly in the intervention group compared to the control group (p = 0.001). Accordingly, the PBL had a positive effect on the mean score of students’ perceptions of patient safety in the intervention group.

Because there was a significant difference in the mean score of patient safety knowledge between the two groups before the intervention (Table 3), we used ANCOVA analysis to ensure that the significant difference in the mean score of patient safety knowledge after the intervention is due to the PBL educational approach, not the effect of the pre-interventional knowledge in the intervention group. After checking Levene’s test to confirm the homogeneity of variance between the two groups, we used ANCOVA analysis and confirmed the effect of PBL on the mean score of knowledge differences between the two groups after intervention (f = 40.90, p < 0.05) (Table 4).

The results showed that the students’ knowledge about patient safety increased significantly after PBL educational approach. The results of the following studies are consistent with our study results. Meo (2013) showed that the students who were educated through the PBL method acquired significantly higher knowledge and skill compared to the students who were educated through lecture-based learning [33]. A study conducted by Yew and Goh (2016) showed that PBL is an effective teaching and learning approach, especially when evaluated for long-term knowledge retention and applications [34]. PBL is a preferential method for both the long-term retention of course content and the use of clinical skills [35]. It plays an important role in improving the knowledge horizons and learning skills and enriching the teamwork experience. Moreover, the tutor’s role as facilitators and motivators for appropriate activities is one of the main reasons for improving knowledge in PBL sessions [36]. PBL can improve nurses’ education by teaching them how to apply theory to clinical practice and develop their problem-solving skills [37]. It encourages students to be self-centered and promotes their critical thinking, leadership, and teamwork skills [38]. Dring (2019) revealed that PBL prepares students to work together and effectively communicate to provide more patient-focused care [39]. Contrary to our findings, Arpanantikul and Luecha (2010) reported that engaging in collaborative learning is considered a challenge, and the PBL method has failed to improve learning processes and knowledge acquisition. They concluded that nursing students in the PBL method discuss non-specific issues, fail to create group ideas, and obtain incomplete and superficial knowledge [40].

Our result revealed that nursing students’ attitudes toward patient safety increased significantly after the intervention. In line with our findings, Terashita et al. (2016) concluded that plain radiography practical training through PBL promoted students’ attitudes toward self-efficacy and increased their self-efficacy through self-centered learning [41]. Furthermore, Park and Choi’s (2015) study showed that PBL plays a considerable role in improving learning attitude, critical thinking disposition, and problem-solving skills in nursing students [42]. PBL improves learning by constructing an understanding of the interrelationship between basic science concepts and medical knowledge [43]. Limited studies have investigated the effect of PBL on nursing students’ knowledge and attitude toward patient safety. Liu et al. (2009) reported that the PBL approach is an effective way for nursing students to improve patient safety knowledge and enhance the integrative capacity [44]. Sahota (2020) stated that PBL promotes learners’ knowledge and skills in non-technical subjects, including patient safety, and enhances their ability to cope with the challenges they encounter in clinical environments [45].

Our findings also showed that the perception of patient safety increased significantly in nursing students after PBL education. High nursing students’ perceptions of patient safety were reported in a similar study [25]. This increased students’ perceptions of patient safety through implementing the PBL method can be explained by its significant effect on students’ learning, motivation, and experience [46]. Penjvini and Shahsawari (2013) found that students in the PBL group acquired more knowledge and had a higher level of motivation towards learning, and provided better care for patients than students in the lecture group [47]. Kim and Han (2016) showed that education programs that are implemented to strengthen critical thinking, self-efficacy, and problem-solving promote patient safety competence among clinical nurses [48]. Despite the many benefits of the PBL method, it can stress students by creating frustration, anxiety, uncertainty, and fear [49, 50]. PBL is also known as a time-consuming educational method [40, 49].

In general, Liu et al. (2019) concluded that problem-based learning is superior to the conventional teaching methods in areas such as interest in learning, teamwork spirit, problem-solving ability, analysis, knowledge attainment and application, and communicational skills [51]. Another study reported that problem-based learning enhances active learning and students’ innate motivation, which improves deep learning among students [52]. Khatiban et al. (2019) conducted a study to compare the effect of two methods of lecture-based and problem-based learning in ethics education among nursing students. They recommended problem-based learning to be used in other nursing areas since it is an effective tool for developing moral reasoning [53]. In a recent systematic review, authors have shown the effectiveness of problem-based learning in nursing education and student empowerment, so that they called for a widespread acceptance and use of this method for education in nursing schools [54].

Patient safety is of great significance in various nursing education areas, including nursing education and practice. Like other healthcare team members, nursing students have the opportunity to improve the quality of patient safety. Meanwhile, nursing instructors play a vital role in improving the students’ required knowledge, attitude, and perception of patient safety. They can ensure that nursing graduates are well prepared to provide a safe environment and care for patients. Based on this study’s findings, PBL significantly impacted students’ knowledge, attitude, and perception toward patient safety compared to conventional teaching methods. Considering the PBL positive outcomes, including learning improvement, continuous and self-centered learning, concentration on understanding concepts, and innovation, it is recommended that nursing professors apply this teaching method in some courses to promote students’ clinical and cognitive capabilities to ensure safe patient care.