Challenges of integrating patient safety into nursing curricula: An integrative literature review

Abstract

Introduction

The World Health Organization's Multi-Professional Patient Safety (PS) Curriculum (WHO-MPSC) was introduced in 2011, which made PS content easily available for nursing educators to integrate into their own curricula. With the exception of a few developed countries that have their own PS frameworks, many countries have yet to fully integrate PS concepts in pre-licensure healthcare education. The literature reveals numerous challenges when attempting to integrate new patient safety (PS) concepts. Due to the lack of updated synthesis and appraisal of these challenges, a synthesis of findings from the literature was deemed timely and significant. Hence, a literature review was carried out to comprehensively understand the challenges.

Methods

An integrative review was conducted by searching electronic databases for the years 2011–2022. The Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE databases and Google Scholar were searched. The search terms were barriers, challenges, nursing students and PS education.

Results

Twenty reviews met the inclusion criteria. Through this review, investigators were able to identify 5 major categories of challenges (educators’ characteristics, administration, programme structure, curriculum, theory–practice gap) and 17 individual challenges of PS education implementation.

Conclusion

The theory-practice gap, curriculum development, and programme structure are areas that should be targeted by curriculum developers in nursing education. Furthermore, it was revealed that there is a need for further research on topics such as resistance to change and individual innovativeness among nurse educators.

1. Introduction

Ensuring patient safety (PS) has been erroneously centralized on the notion of improving individual performance and absolute correctness. ¹ This was challenged by ‘The quality chasm’, a series of reports on healthcare safety in the United States by Institute of Medicine. In 2000, the first report, ‘To Err is human’, shifted the approach to solving PS issues from ‘naming and shaming’ the individual to making robust systems that could prevent human error. ² This report insisted on the need to accept human fallibility in healthcare workers, which can be considered the cornerstone of the PS paradigm shift. Since then, many studies have shown the importance of introducing these new concepts and competencies of PS into healthcare professional education.^3–6 The abovementioned new PS concepts include but are not limited to human factors (HFs), system factors in error, learning from error, reporting adverse events and root-cause analysis.

Since the early 2000s, PS has been a priority in healthcare education, which can be largely attributed to the quality chasm series, mandates from healthcare professional bodies and the World Health Organization (WHO). There has been a common agreement to add PS concepts in healthcare curricula. Gradually, some countries have developed their own PS education frameworks, such as Quality and Safety Education for Nurses (QSEN) ⁷ in the United States and the Canadian Patient Safety Education Programme (PESP). ⁸ The World Health Organization's Multi-Professional Patient Safety Curriculum (WHO-MPSC) ⁹ was introduced in 2011, and this made PS content easily available for anyone to refer and integrate into their own curricula. However, it became apparent that the integration of PS content has not achieved the momentum as expected, particularly in low- and middle-income countries. ¹⁰ With the exception of a few developed countries having their own PS frameworks, many countries have yet to fully integrate PS concepts in pre-licensure healthcare education. Hence, PS education is still considered an emerging trend. ¹¹

It is important to understand why some countries are facing challenges when trying to integrate PS concepts. Challenges are described as something new and difficult that requires great effort and determination to overcome. ¹² There is an inherent resistance to change or adopt a new movement. ¹³ There can be numerous challenges to change a particular behaviour and gain acceptance of a new practice. Some of the challenges highlighted in the literature regarding the adoption of PS concepts include a saturated curriculum, lack of training for nursing educators and theory-practice gap. It is vital to identify what are the challenges and why those challenges arise, in order to mitigate these challenges. Most importantly, for institutions which are planning to integrate PS, this understanding will provide a proactive understanding of what to anticipate. Hence, a literature review was planned to comprehensively understand the challenges.

Fink ¹⁴ defines literature review as ‘a systematic, explicit, and reproducible method for identifying, evaluating and synthesizing the existing body of completed and recorded work produced by researchers, scholars, and practitioners’. We could identify three (3) such literature reviews done on PS education. Sheehan et al. ¹⁵ identified both barriers and opportunities related to HF implementation through a systematic review on HF and PS in undergraduate education in health care . Barriers identified were, the lack of shared safety language, lack of faculty expertise in PS as well as the lack of an appropriate HF-based competency framework to guide curriculum development. Opportunities included increased organizational collaboration between academic and clinical settings with respect to PS teaching. An integrative literature review conducted by Tella et al. ¹⁶ has identified which PS content is being taught to nursing students at both clinical and academic settings. Her study reiterated that curriculum content is fragmented, and highlighted the importance of nurse educators’ response towards students’ errors at clinical placements. Mansour, ¹ claimed that according to nursing students and faculty members’ perception, there is a need for PS friendly nursing curricula and there is a vacuum in existing curricula that need to be filled with PS content. He also highlighted the existence of theory-practice mismatch with regard to PS education. Wu & Busch ¹⁷ has listed out challenges of PS implementation, including but not limited to, all the challenges mentioned above.

All the systematic literature reviews on PS have been conducted before the WHO-MPSC was published about ten years ago. New synthesis of evidence remains due. After the publication of WHO-MPSC, many countries initiated integrating PS in their healthcare curricula. It can be hypothesized that new challenges might have emerged during the last decade. In all three literature reviews mentioned above, the main objective has not been to identify challenges of PS implementation; nevertheless, during the course of analysis, they have identified certain challenging issues related to PS education.

Due to the lack of updated synthesis and appraisal of the aforesaid challenges, a synthesis of findings from the literature was timely and significant. Through this review, the research team was able to identify 5 major categories and 17 challenges of PS education implementation. This will be explained in detail in the results section. We were able to further analyse the most reported challenges and propose means to mitigate these challenges. We could also identify areas for future research. The evidence gathered can be utilized by individuals or educational institutions to develop a proactive strategic plan to overcome these challenges.

2. Methods

2.1. Design of the study

Aveyard ¹⁸ recommends incorporating a review question, specific methods or strategies in the literature search, appraisal and analysis of the literature, results of the review, and a discussion with recommendations for practice to develop a comprehensive literature review. Booth et al. ¹⁹ reiterate the same by suggesting that a literature review should be carried out systematically in 4 steps, which they acronym as ‘SALSA’, Search, Appraisal, Synthesis and Analysis.

The question leading this review was, ‘what are the common challenges faced by individuals and institutions when attempting to integrate PS concepts in nursing curricula?’. The purpose of this review was to synthesize existing knowledge on the challenges of PS education for nursing students. The ultimate aim was to systematically identify the challenges of integrating PS into nursing education to provide direction for future action and investigation.

An integrative review (IR) was conducted because the purpose of the review resonated well with the intention of conducting an IR rather than other available literature review models. The IR is a distinctive form of research that uses literature to create new knowledge. ²⁰ As elucidated by Toronto & Remington, ²¹ ‘the term IR is often used interchangeably with systematic review; however, there are distinct differences between them … A systematic review has a single narrowly focused clinical question, usually formulated in a PICO (P = population, I = intervention, C = comparison, O = outcomes) format and may include meta-analysis. An IR looks more broadly at a phenomenon of interest than a systematic review and allows for diverse research, which may contain theoretical and methodological literature to address the aim of the review … An IR does not include statistical synthesis methods whereas a systematic review statistically synthesizes data’.

2.2. Search methods and strategies for the identification of studies

IRs combine data from theoretical and empirical literature as well as experimental and non-experimental research to understand a phenomenon of concern holistically. This study utilized a systematic approach to database searching as emphasized by Aveyard. ¹⁸

The data search and screening were performed from October to December in 2022. The databases searched for related literature included MEDLINE, CINAHL and Google Scholar. Search limitations included were, by year 2011–2022 (10 years post introduction of WHO-MPSC), English language, and academic journal articles. The reference lists of the included studies were also reviewed to find additional articles. Google Scholar was used as a complimentary database to find literature with the support of ‘Publish or Perish’ software. ²² Keywords for the search included challenges, barriers, PS, and nursing education. To increase precision in the search process, the Boolean term AND was used to separate the keywords.

Covidence, a web-based collaboration software platform for literature reviews, was used to manage the screening process. ²³ The system mandated that the two reviewers independently screen the titles and abstracts of all the retrieved documents to check the inclusion criteria. A full-text review was performed independently by two reviewers, and studies were excluded based on mutually agreed exclusion criteria.

2.3. Inclusion and exclusion criteria

Inclusion criteria

Original research papers (positivistic, hermeneutic and mixed methods), literature reviews, editorials and discussions about PS education and the challenges of integrating safety education into nursing curricula were included.

Exclusion criteria

• i)

  Articles that generally addressed PS education without identifying challenges or barriers.

  ii)

  Articles published without peer review.

  iii)

  Research abstracts that did not provide access to the full text of the article.

  iv)

  Studies that are not related to polished undergraduate education.

  v)

  Studies that have not been within the time limit (2011–2022)

  vi)

  Research was only on medical education or any other allied health discipline.

  vii)

  Nursing education-related articles that are not without any relevance to PS

  At each review cycle, Covidence synthesized the overall outcome and presented the articles with conflicts for further discussion and resolution.

  2.4. Data extraction and synthesis

  Twenty (20) full-text papers were retrieved and included in the study. Eighteen (18) studies were from the keyword search and two (2) were included by manual searching of the references in relevant full-text articles (Figure 1). The list of articles was exported into an excel sheet. Themes emerging while reviewing articles were documented against the articles. First, the researcher reviewed each article several times to identify potential and actual barriers or challenges mentioned. An excel matrix was created to record the basic study details such as author, title, published year, etc. Challenges are listed in a ‘findings or conclusions’ column. Results were then analysed inductively to identify major categories and subcategories.

  
  Figure 1.

  PRISMA flow diagram for article selection. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. Doi: 10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/ ( ²⁴ ).

2.5. Quality appraisal

Literature reviews and expert opinion papers selected for retrieval were assessed for methodological validity using The Joanna Briggs Institute's (JBI) quality assessment tools.^25,26 Qualitative studies, quantitative studies, mixed method studies were assessed using Mixed Methods Appraisal Tool (MMAT), version 2018. ²⁷ Two reviewers (AD and KD) conducted quality appraisal of the manuscripts independently and blinded to each other's ratings. Disagreements were discussed and resolved by consensus. No article was excluded due to lack of quality.

3. Results

3.1. Characteristics of the included studies

Twenty studies were finalized for the thematic analysis. These consisted of a vast range of study designs, which included surveys, interviews, focus group discussions, editorials, discussion papers, evaluation reports, literature reviews, systematic reviews and multi-method descriptive studies (Table 1). Five (5) major themes and seventeen (17) sub-themes emerged from these studies (Table 2). Table 3 provides an overview of the challenges identified in each article.

Table 1.

Characteristics and key findings of included studies

	Author (s) (Year)	Title	Purpose and Aims of the Study	Research Methods/ Instrument/Sample	Key findings- challenges identified	Limitations
1	Debourgh (2012)	Patient safety manifesto: a professional imperative for pre-licensure nursing education.	To suggest teaching and learning strategies to build students’ capabilities, using the rubric of human and systems factors implicated in medical error.	Text and Opinion: discussion paper.	Placing students in interactive settings with dynamic variables that mimic the complexity of contemporary health care environments remains difficult. Contextual, action-oriented learning activities during formative education is not an option but essential to bridge the theory–practice gap. Meaningful academic–service partnerships: Health care agencies, as employers of new graduate nurses, often feel disconnected and powerless to influence pre-licensure nursing curricula. Curricula are lacking effective quality and safety content because faculty are unclear on what or how to teach these concepts. Nurse educators struggle with the challenge to add a n ever-increasing amount of knowledge and skill content to the already full nursing curricula.	Not applicable.
2	Farley (2015)	Field Test of the World Health Organization Multi-Professional Patient Safety Curriculum Guide.	Evaluation report of WHO developed the Multi-professional Patient Safety Curriculum Guide, to assess its effectiveness for teaching patient safety to undergraduate and graduate students in a global variety of settings.	Mixed method: prospective/retrospective design to get formative information on the experiences of working with the Guide and summative information on the impacts of the Guide stakeholder interviews and student surveys, data were gathered from each participating school(n = 12) at three times.	The teaching faculties at many schools were found to have limited patient safety knowledge, suggesting that faculty may need more extensive training. Most faculties were enthusiastic, and those who resisted initially were often motivated by workload issues. Integrating the guide into existing curricula helped schools to deal with work- load issues, but it lowers the visibility of patient safety. Therefore, in the long run, some schools prefer to teach it as separate course(s).	1. This study had a number of limitations due in part to the worldwide nature of the project. 2. The tight timescale and resources did not allow detailed testing of all evaluation tools prior to the study. 3. Only 12 universities/ schools were able to participate in this study, which could affect the generalizability of the results, and the sample of each location is not sufficient to allow comparison between different locations and professions. 4. In addition, the risk of self-report bias, which always is a consideration in interview or survey work, was reduced by the findings of strong consistency in responses to questions across multiple stakeholder groups.
3	Ginsburg (2017)	What stage are low-income and middle-income countries (LMICs) at with patient safety curriculum implementation and what are the barriers to implementation? A two-stage cross-sectional study.	To address the gaps in knowledge on what topics are included, what stage are countries at with patient safety curriculum implementation and what are the barriers to implementation.	Quantitative descriptive: Two cross-sectional surveys were carried out. First, 88 technical officers in Ministries of Health and WHO country offices were surveyed to identify the pattern of patient safety curricula at country level. A second survey followed that gathered information from 71 people in a position to provide institution-level perspectives on patient safety curriculum implementation.	1. Insufficient training to enable faculty to implement the patient safety curriculum. 2. Lack of organisation-level commitment to implementation of the patient safety curriculum. 3. Lack of governmental commitment to the patient safety curriculum (e.g., providing ongoing financial support) * Lack of buy-in from stakeholders internal to the organisation. * Poor fit between the patient safety curriculum and the broader political and economic context (such as regulation of health professionals and how faculty are paid) * Lack of faculty enthusiasm/meaningful participation in implementation of the curriculum. * Lack of faculty cooperation and collaboration to address implementation challenges. * Poor fit between the patient safety curriculum and the assessment system in training settings (e.g., the university. * Poor coordination between the ministry and other organizations around implementation of the patient safety curriculum.	1. Study limitations pertain largely to the sample size. While survey response rates of 42% and 52%, our results are based on two, fairly small, respondent groups. *2. We solicited and received information via email from non-responders to try to understand the nature of our non-response bias. 3. Neither the European nor African WHO regions participated in the study, and the African region has the highest proportion of low-income countries.
4	Gomes (2021)	Safe cardiovascular care in nursing education: perspective of teachers, students and graduates.	To analyse nursing teaching in the field of safe cardiovascular care.	Qualitative: hermeneutic study carried out in the nursing course of a public university in the interior of Northeastern Brazil with teachers, students, and graduates. Sampling was by convenience. The inter-views and focus groups were submitted to thematic categorical analysis with theoretical reference of the Curricular guide of patient safety of the World Health Organization. The final sample was 46 participants.	Personal and political- institutional challenges refer to interpersonal and power relations inside and outside the university. The lack of structure, teaching processes focused on the content, and the difficulty in reconciling teaching, research, and extension activities and time. Nonspecific and fragmented way in the teaching-learning processes. Insecurity in the approach to the theme by teachers and students.	The limitations of this study are that it was conducted in a single HEI and in only one health course.
5	Headrick (2012)	Results Of An Effort To Integrate Quality And Safety Into And Nursing School Curricula And Foster Joint Learning.	The purpose of this demonstration project was to stimulate US nursing and medical schools to work together to integrate healthcare improvement and patient safety content into existing required curricula.	Text and Opinion: programme evaluation data were collected through monthly reports from the sites and their coaches, site visit results, and final site reports: descriptions of educational activities; the number of medical and nursing students involved in the activities; the percentage of new learning activities that were inter-professional; evaluation strategies; and challenges and solutions.	Faculty unfamiliarity with quality improvement and patient safety content. Creating meaningful clinical experiences in quality improvement and patient safety for more than a few students. The lack of a critical mass of clinically based faculty members who were ready to teach about the improvement of care.	By design, the initiative encouraged each site to develop its own innovations in quality and safety education, taking advantage of local resources and strengths. This limited the analysis of results across sites.
6	Jang (2017)	Patient safety competency and educational needs of nursing educators in South Korea.	To assess nursing educators’ competencies and educational needs for patient safety in hospitals and nursing schools.	Mixed method: A mixed-methods sequential explanatory design employed a survey and focus group inter- view with nursing educators (school clinical instructors and hospital nurse preceptors). Thirty-eight questionnaires filled out by clinical instructors from six four-year nursing universities and 106 questionnaires from nurse preceptors from three high-level general hospitals in the Seoul metropolitan area were analysed to obtain quantitative data. Focus group inter- views were conducted among six clinical instructors from one nursing school and four nurse preceptors from one high-level general hospital in Seoul.	Ambiguous and extensive PS- non explicit. PS topic is not explicitly linked with each subject and/or content area in the undergraduate nursing program- non explicit. Burden of PS education in a fully saturated curriculum. Lack of confidence in providing education about PS. Current education system in which we cannot be actively involved in hospital. practice, because we are not affiliated with the hospital. Need for education for educators. Need for collaboration with the hospital Difficulty of satisfying PS standards in clinical practice-theory -practice mismatch.	Generalization of findings requires caution because the participants were not representative of all nursing educators in South Korea. The measured level of competencies may somewhat vary from the actual level, since PS competencies were assessed with a self-report scale.
7	Kirwan (2019)	Regulation and current status of patient safety content in pre-registration nurse education in 27 countries: Findings from the Rationing - Missed nursing care (RANCARE) COST Action project.	To examine the concept and relevance of rationing of nursing care across countries within a context of patient safety. To examine the current nature of patient safety training in nurse education and the implications for the profession and for patients.	Mixed method: It was conducted using an online cross-sectional survey, which aimed to gather both qualitative and quantitative data. The survey was developed by members including nurse educators and practicing nurses. The resulting instrument was intended to gather general information such as country, nurse regulatory body, and HEI type, etc. Sample-representatives from 83 HEIs from 27 countries participated in this process. Twenty-two partially completed the consultation survey, and 61 respondents completed the entire survey. At institutional level, 63 universities and 12 other nurse education colleges provided data, 8 did not identify the HEI type.	Inclusion in the curriculum continues to be as an ‘integrated’ or ‘hidden’ topic across the programme, with little or no consistency about timing or subject matter. The WHO Multi-professional Patient Safety Curriculum Guide (World Health Organization, 2011) is an underutilized resource in pre-registration nurse education. For nurse educators who may lack confidence in teaching patient safety to pre-registration nurses it would appear that the WHO Multi- professional Patient Safety Curriculum Guide provides a ready-made solution.	Small sample size in this consultation impacted the likelihood of relationships being identified where they might have been expected. This consultation does not provide us with detail on how different approaches to patient safety in nurse curricula impact student learning.
8	Lee (2020)	Patient safety education in pre-registration nursing programmes in South Korea.	How patient safety is currently taught in preregistration nursing programmes across South Korea. nurse educators’ perspectives on curriculum change.	Quantitative descriptive: This descriptive study used data collected during a 2019 accreditation workshop provided by the Korean Accreditation Board of Nursing Education. A paper-and-pencil survey was completed by 80 nurse educators working in 16 regions throughout Korea.	Patient safety education is limited in hours of instruction and breadth of content, and delivered in a fragmented approach. Overcrowded curriculum. Lack of awareness of the importance of teaching patient safety. Lack of support for faculty, including funding and resources. Lack of faculty preparation to teach patient safety concepts; the burden of new curriculum development. The difficulty of collaboration between academicians and practitioners. Little attention to systems, workplace design or human issues that are necessary for developing the critical reasoning and skills to support patient safety.	The use of self-report data collection and risk of self-selection bias Collected limited data on the demographic characteristics of study participants and school characteristics. It is possible that unmeasured characteristics (e.g., nurse educators’ years of experience or school sizes) may have affected the study results. The use of descriptive statistics due to the design of the original survey
9	Li (2021)	Major educational factors associated with nursing adverse events by nursing students undergoing clinical practice: A descriptive study.	To examine the status quo of nursing adverse events and to discuss the major educational factors concerned in different regions of China.	Quantitative descriptive: A descriptive study design was undertaken in 2018. Participants and setting: A convenience sample of 1173 nursing students undergoing clinical practice was recruited from 22 hospitals in different regions of China. Methods: The Chinese version of the Medical Student Safety Attitudes and Professionalism Survey (MSSAPS) was administered to and demographic and professional data were collected from clinical nursing students after obtaining informed consent.	1. Cooperation between nursing colleges and hospitals should be strengthened to promote patient safety in clinical nursing students.	The sample size from third-tier or fourth-tier cities was much smaller than in other parts. In this study, the region of hospitals was a major influencing factor of nursing adverse events. The imbalance of sample size distribution may affect the result. More influencing factors need to be considered. The cross-sectional design is unable to illustrate the causality between nursing adverse events and influencing factors such as patient safety attitudes.
10	Mansour (2012)	Examining patient safety education in pre-registration nursing curriculum: Qualitative study.	How student nurses and nursing faculty members perceived the integration of patient safety education.	Literature review: Databases searched from January 2000 to April 2011 included CINAHL, PsycINFO, British Nursing Index, PubMed, AMED, Academic Science, Midline, Cochrane Library Database, Web of Knowledge, Ovid Nursing Database, Wiley Online Library and Science Direct. In total, 77 articles were initially found, although only 15 were included in the author's review. Of these, 5 papers were research-based articles that examined aspects of patient safety education in undergraduate/ pre-registration nursing training, and 9 papers were literature review and discussion based, which provided insight into the experience, assessment, evaluation or implementation of patient safety education curriculum in nursing education.	Lack of any teaching material to address the importance of HFs and the contributions of system complexities toward unsafe practice. The focus on the individual contribution towards unsafe practice, without taking into account the system approach toward patient safety. Discrepancies between the theoretical teaching of patient safety in the UK, and the context of clinical learning for nursing students. Fragmented, non-explicit PS content/link to PS, lower visibility.	1. Papers published before the year 2000 were not included. 2. Only papers deemed to explicitly focus on patient safety education in nursing training, with academic relevance (i.e., including nursing students’ and faculty members’ views), were included. This might have excluded other papers that addressed patient safety education from different perspectives. 3. The key words used in the search strategy included ‘patient safety’. The use of such exclusive term may have overlooked other issues, which might be considered important constituents of patient safety research, but were not labelled explicitly as patient safety.
11	Mansour (2013)	Current assessment of patient safety education.	To examine the views of nursing students and faculty members on patient safety education in a pre-registration adult nursing curriculum in relation to the WHO’ patient safety themes.	Qualitative: utilizing 20 semi-structured interviews with pre-registration adult nursing students and faculty members (10 students and 10 faculty members). The data were analysed thematically.	The participants expressed a range of views in relation to how their nursing education was related to patient safety themes……ranged from not addressed at all, to being addressed but not linked to patient safety and to being implicitly linked to patient safety. Patient safety education needs to be more visibly taught in nursing education. Mismatch between theory and practice. Many students in this study suggested that there were disparities between what they were taught in the university and what they practiced in clinical settings in relation to patient safety agenda. The role of the mentor in practice. Several students suggested that their clinical mentors were seen by students as inspiring role models for practicing patient safety. some students expressed their scepticism concerning the patient safety practices of their mentors.	1. The study was carried out in one UK academic institution, and although the findings may be transferable beyond this context, caution needs to be exercised in doing so. 2. The researcher who conducted this study was employed by the academic institution where this study took place, and this may have inhibited some participants from expressing their views. However, the views expressed in the findings suggest that this concern was minimised, but might have not been fully neutralised. 3. This study focused on the student nurses and faculty members’ views only. The inclusion of the clinical mentors’ in the research sample might have enriched the data analysis, and provided fresh perspectives of the students’ experiences of patient safety education in practice.
12	Mbuthia and Moleki (2018)	Perspectives on patient safety education in the Kenyan preregistration nursing curriculum.	Identifying explicit patient safety concepts in the Kenyan nursing curriculum and exploring the perspectives of the nursing faculty members and clinical nurses on the integration of patient safety in the curriculum.	Qualitative: A qualitative content analysis was conducted on the relevant curriculum documents from two universities. In- depth, semi-structured interviews were conducted on a purposive sample of 13 staff members of the nursing faculty from the university and 14 clinical nurses from the hospitals where the students undergo clinical instruction.	Lack of explicit patient safety content. Inadequate faculty preparation. Lack of emphasis on patient safety. Role strain of faculty.	Not identified.
13	Robson (2013) 28	Teaching patient safety and HF in undergraduate nursing curricula in England: a pilot survey.	To explore the degree to which patient safety and HFs were being introduced into current nursing curricula. The survey explored how much time was being devoted to patient safety and HFs, what topics were being covered and what teaching methods were being used to deliver the teaching.	Quantitative descriptive: An electronic survey was sent to 20 schools of nursing in England. A convenience sample of schools were selected by the authors. The survey was sent electronically to three faculty members at each institution who were involved with the pre- registration adult nursing programmes. Moreover, reminder emails were sent to non-responders. In all, 13 universities responded (65% response).	Knowledge of the WHO multi-professional patient safety curriculum (2011) was poor, with only three respondents being aware of it. The mentor relationship affects how confident they feel to challenge unsafe practice by other staff.	1. The schools were a convenience sample and were not selected at random. There may therefore have been some selection bias. Another limitation is that only schools who considered themselves to be at the fore of undergraduate teaching may have responded. 2. The sample was very small and all 13 schools of nursing were located in England. Hence, the results are not generalizable. A much larger survey of schools of nursing is required along with in-depth interviews or focus groups of nursing faculty, student nurses and mentors.
14	Sheehan (2022)	HFs and patient safety in undergraduate healthcare education: a systematic review.	to capture the extent to which HF is currently reported in the context of undergraduate healthcare curricula, and to characterize how it is reported using SEIPS 101.	Systematic review: Using a publication timeframe from 2016–2021. A systematic search was conducted using the following databases: Embase, PubMed, Scopus, CINAHL and Eric. Relevant websites were searched for grey literature. The PETT (People, Environments, Tools and Tasks) component of SEIPS 101 was chosen as framework for data extraction and analysis	Findings of this review point to a disconnect between academic and clinical settings in the context of PS education. The importance of how educators work with practice providers to ensure patient safety skills are appropriately developed’ . Connectivity could yield benefits for both academic and clinical preceptors. In addition to supporting the formal curriculum, such collaboration holds potential to positively impact both the informal and hidden curricula.	1. Only published studies were included in the review, therefore this work does not include a comprehensive curricular overview of health-care programmes and HF. Coding of data to the PETT Scan headings was conducted by the first author and reviewed by the research team. 2. Inter-rater reliability was not conducted as part of the PETT Scan data extraction process, representing a limitation. This review has however looked across all healthcare disciplines and contributes to the potential to use IPE as an educational opportunity to address HF and PS in healthcare curricula.
15	Steven (2014)	Patient safety in nursing education: Contexts, tensions and feeling safe to learn.	The study from which the findings of this paper are drawn aimed to investigate the formal and informal ways pre-qualification nursing students from a range of healthcare professions learn about keeping patients safe from errors, mishaps and other adverse events.	Qualitative: Scoping of nursing curricula from four UK university programmes was followed by in-depth case studies of two programmes. Analysing curriculum documents and interviews with 8 programme leaders. Case-study data collection included focus groups (24 students, 12 qualified nurses, 6 service users); practice placement observation (4 episodes = 19 h) and interviews (4 Health Service managers).	In curriculum documents examined in stage 1I, patient safety was not visible as a separate theme, but as a series of statements about safety. Practice learning mainly took place by observing qualified staff who varied as role models. Students and newly qualified nurses had to contend with the harsh reality of the practice culture and the positional power of those further up the hierarchy.	Not identified.
16	Tella (2014)	What Do Nursing Students Learn About Patient Safety? An Integrative Literature Review.	To critically analyse peer-reviewed studies focusing on patient safety in nursing education and to synthesize the findings.	Literature review: An integrative literature review was conducted to synthesize the research literature related to the content of patient safety, the teaching and learning methods used, and nursing students’ learning of patient safety. This IR uses Whittemore's and Knafl ‘s (2005) five stages as a framework for data collection, analysis, and synthesis.	Content of patient safety education varies within the nursing education field. If patient safety was not evident as a subject in the nursing curricula but rather integrated in several modules, it could disappear. Nurse educators should respond to the errors that nursing students make in their clinical practice placements and thus develop better educational methods and curricula to improve patient safety competencies. Understanding the importance of the interactive connection between academic and clinical education is essential.	1. The studies selected in this review included participants from different levels and phases of nursing education. 2. The implementation of primary studies varies and can influence the reliability of this IR. Some studies shared the same data, which could have biased the results of this IR. 3. The IR method itself has some limitations, such as the combination of diverse methodologies, which can lead to inaccuracy and bias (Whittemore & Knafl, 2005 29 )
17	Tella (2015)	Learning Patient Safety in Academic Settings: A Comparative Study of Finnish and British Nursing Students’ Perceptions.	To explore and compare Finnish and British nursing students’ perceptions of learning about patient safety in academic settings to inform nursing educators about designing future education curriculum.	Quantitative descriptive: A purpose-designed instrument, Patient Safety in Nursing Education Questionnaire(PaSNEQ) was used to examine the perceptions of Finnish (n = 195) and British (n = 158) nursing students prior to their final year of registration. Data were collected in two Finnish and two English nursing schools in 2012. Logistic regressions were used to analyse the differences.	Learning about a system-based approach and paying more attention to system failures rather than an individual's errors was not considered by the respondents to be realized in real-life contexts. Nursing faculty need to pay special attention to equipping their students with competences in communicating clearly, identifying and reporting incidents, understanding a systems-based approach, forming a supportive environment…etc.	1. This study was undertaken in two higher education institutes in Finland and two in England, UK. This choice may have reduced the generalizability of the results, since nursing curricula may vary within countries. 2. In addition, the results may reflect cultural diversities in Finnish and British students’ perceptions. Thus, the transferability of findings needs to be carefully considered and critically appraised. 3. The results are based on a sample collected with a purpose-designed PaSNEQ instrument. The strengths of this study lie in the carefully built and translated instrument and rigorously implemented analysis. In addition, the PaSNEQ displayed good internal consistency as measured by Cronbach's alpha.
18	Vaismoradi (2011)	Patient safety: nursing students’ perspectives and the role of nursing education to provide safe care.	The aim of this study was to explore Iranian nursing students’ perspectives regarding patient safety and the role of nursing education in developing their capabilities to provide safe care.	Qualitative: A purposeful sampling strategy was used to recruit 17 junior and senior nursing students for qualitative, semi-structured interviews. Content analysis of the interview transcripts was conducted to identify several relevant themes.	Medical section of nursing education curriculum consumed more class time than sections on nursing cares and interventions. In other words, students felt that instructors spent the majority of classroom hours teaching the pathophysiology of diseases, prognosis and treatment. More opportunities to be mentored by experienced nurses in super-vised clinical placements. Experienced nurses therefore need to be actively engaged in mentoring the next generation of nurses in patient safety.	The present qualitative study only provides the perspectives of one group of nursing students within the Iranian culture and context. Therefore, the transferability of findings should be considered with caution and critiqued and compared with those of similar studies conducted in other contexts. Further studies in different cultures and contexts should be conducted to help us recognize various aspects of patient safety and improve our comprehension of factors influencing patient safety in nursing education and practice.
19	Vaismoradi (2014)	Nursing students’ perspectives and suggestions on patient safety implications for developing the nursing education curriculum in Iran.	This study explores nursing students’ perspectives and suggestions on developing patient safety aspects of the nursing curriculum in the context of Iranian culture.	Qualitative: A qualitative methodology involving three focus groups with a purposive sample of 18 nursing students from a large Iranian nursing school, utilizing directed semi-structured interviews generated data, which was analysed using the content analysis process.	Building a Trustful Relationship Between Education and Practice. Clinical nurses only mentor students at times of faculty member shortage – yet formalizing this method of teaching would offer students access to first-hand experience, thus strengthening the quality of learning in practice. There is no agreed ratio of clinical nurses providing support to students in clinical practice. As a result, they were not involved as mentors and instructors in patient safety education. Students recognised that realities of practice were outdated, and often shortcuts in nursing care were taken to save time. This suggests that nursing students are falling between the concrete world of hospital and the theoretical world of university.	This study was conducted with nursing students in an Iranian educational setting. Therefore, the study's findings can be considered transferable with caution and after conducting similar studies in other cultures and contexts. The perspectives of faculty members may draw a more complete picture of patient safety in nursing curricula.
20	Wu (2019)	Patient safety: a new basic science for professional education.	The aim of this study was to explore Iranian nursing students’ perspectives regarding patient safety and the role of nursing education in developing their capabilities to provide safe care.	Text and Opinion: Editorial.	Patient safety should be regarded as a new basic science for health professions education. However, the translation of patient safety science into safe practice is also a highly applied activity. Major reforms will be needed to incorporate patient safety into the curricula of professional schools and training programmes. These organizations will need to redirect their focus away from the mere acquisition of knowledge to developing competencies and changing behaviour.	Not applicable.

Table 2.

Major themes and sub-themes.

Major themes	Sub-themes
1. Educators’ characteristics.	1. Lack of awareness of PS curriculum components/ WHO-MPSC, underutilized. 2. Lack of engagement and involvement by faculty members in resolving issues at clinical practice. 3. Resistance to change, resistance to innovation adoption, lack of cooperation, lack of enthusiasm. 4. Competing work pressures and lack of time, burden of new workload. 5. Lack of know-how, confidence to teach PS content, insecurity. 6. Teacher's lack of recognition for PS, less attention on important PS content.
2. Administration.	7. Lack of leadership. 8. Lack support for educators, including funding, training.
3. Programme structure.	9. The discipline-based structure of medical science and health care, vs interdisciplinary. 10. Historical focus on content-based learning, treating diseases. 11. Lack of real-world PS practice opportunities-scope of students’ involvement.
4. Curricula.	12. Overcrowded curricula. 13. Important PS competencies are not included. 14. Fragmented, non-explicit PS content/link to PS, lower visibility.
5. Theory-practice gap.	15. Evidence gaps in best practices. 16. Lack of agreement, including the hidden curriculum, theory practice mismatch. 17. Mentor in practice, lack of mentors and mentors’ characteristics.

Table 3.

An overview of challenges identified.

Major themes	Sub-themes	Debourgh (2012)	Farley (2015)	Ginsburg (2018)	Gomes (2021)	Headrick (2012)	Jang (2017)	Kirwan (2019)	Lee (2020)	Li (2021)	Mansour (2012)
1. Educators’ characteristics.	1. Lack of awareness of PS curriculum components/ WHO-MPSC, underutilized.							✓
	2. Lack of engagement and involvement by faculty members in resolving issues at clinical practice.	✓					✓		✓	✓
	3. Resistance to change, lack of enthusiasm.
	4. Competing work pressures and lack of time, burden of new workload.		✓		✓				✓
	5. Lack of know-how, confidence to teach PS content, insecurity.	✓	✓			✓	✓	✓
	6. Teacher's lack of recognition for PS, less attention on important PS content.			✓					✓
2. Administration	7. Lack of leadership.			✓
	8. Lack support for educators, including funding, training.			✓			✓		✓
3.Programme structure	9. The discipline-based structure of medical science and health care, vs interdisciplinary.
	10. Historical focus on content-based learning, treating diseases.
	11. Lack of real-world PS practice opportunities-scope of students’ Involvement.	✓				✓	✓
4.Curricula.	12. Overcrowded curricula						✓
	13. Important PS competencies are not included.								✓		✓
	14. Fragmented, non-explicit PS content or link to PS, lower visibility.		✓		✓		✓	✓	✓		✓
5.Theory-practice gap.	15. Evidence gaps in best practices.
	16. Lack of agreement, the hidden curriculum, theory-practice mismatch.	✓					✓				✓
	17. Mentor in practice, lack of mentors, mentors’ characteristics.					✓

Table 3.

An overview of challenges identified continued.

Major themes	Sub-themes	Mansour (2013)	Mbuthia (2018)	Robson (2013)	Sheehan (2022)	Steven (2014)	Tella (2014)	Tella (2015)	Vaismoradi (2011)	Vaismoradi (2014)	Wu (2019)
1. Educators’ characteristics.	1. Lack of awareness of PS curriculum components/ WHO-MPSC, underutilized.			✓							✓
	2. Lack of engagement and involvement by faculty members in resolving issues at clinical practice.				✓		✓				✓
	3. Resistance to change, lack of enthusiasm.										✓
	4. Competing work pressures and lack of time, burden of new workload.		✓								✓
	5. Lack of know-how, confidence to teach PS content, insecurity.		✓								✓
	6. Teacher's lack of recognition for PS, less attention on important PS content.
2. Administration.	7. Lack of leadership.										✓
	8. Lack support for educators, including funding, training.										✓
3. Programme structure.	9. The discipline-based structure of medical science and health care, vs. interdisciplinary.										✓
	10. Historical focus on content-based learning, treating diseases.										✓
	11. Lack of real-world PS practice opportunities-scope of students’ involvement.
4. Curricula	12. Overcrowded curricula.										✓
	13. Important PS competencies are not included.							✓
	14. Fragmented, non-explicit PS content or link to PS, lower visibility.	✓	✓			✓
5.Theory-practice gap.	15. Evidence gaps in best practices.										✓
	16. Lack of agreement, the hidden curriculum, theory- practice mismatch.	✓	✓		✓			✓	✓	✓	✓
	17. Mentor in practice, lack of mentors, mentors’ characteristics.	✓		✓		✓			✓	✓

3.2. Educators’ characteristics

One of the common challenges identified in the literature is the tendencies of nurse educators to embrace or deviate from PS education. They almost act as the gatekeepers of deciding which PS concepts are reaching the students. Their awareness of the new PS concepts, readiness to embrace new ideas and confidence to teach are among the sub-themes identified.

3.3. Administration

The importance of support from administration to encourage PS education has been identified. Lack of leadership to embrace new PS content, funding and providing training opportunities have emerged from the literature as challenging administrative traits.

3.4. Programme structure

While acknowledging the importance given to simulations and their role as a medium of knowledge transfer, a lack of real-world opportunities to experience PS issues first-hand has been identified. In reality, healthcare teams work as teams and handle PS issues as teams. Due to the prevalence of disciplinary-based teaching, providing a realistic training experience has become a challenge.

3.5. Nursing curricula

One of the most frequently identified challenge is the non-explicit, fragmented nature of the PS content in nursing curricula. This challenge is worsening by the saturated curricula in use for pre-licensure nursing training.

3.6. Theory-practice gap

The existence of hidden curricula for PS, as with the rest of the clinical practices, and clinical mentors’ reluctance to endorse theoretical aspects of PS education has been identified as challenging. Hence, finding clinical mentors who are championing PS education is a need of the hour.

4. Discussion

The purpose of this IR is to synthesize existing knowledge on the challenges of PS education for nursing students.

This review identified seventeen (17) challenges from the literature that were categorized under educators’ characteristics, administration, programme structure, curriculum, and theory-practice gap. Out of the 17 challenges, the highest number of papers identified the following challenges,

Theory-practice mismatch, the hidden curriculum and lack of agreement

Fragmented, non-explicit PS content, lower visibility.

Lack of engagement and involvement by faculty members in resolving issues in clinical practice.

Lack of know-how, confidence in teaching PS content and insecurity of the faculty.

Mentors in clinical practice: lack of mentors and mentors’ characteristics

Several researchers^17,28–34 have found insufficient training of faculty members to be a major challenge in integrating PS education into nursing curricula. Wu & Busch ¹⁷ argue that existing faculty may feel uncomfortable with teaching material outside their own discipline and expertise. Similarly, Jang & Lee ³⁵ report that nursing educators express a desire for didactic lectures on PS concepts. To address this issue, Kirwan et al. ³³ highlight the WHO Multi-Professional Patient Safety Curriculum Guide as a ready-made solution for meeting the training needs of faculty members. The lack of trained faculty can also contribute to the non-explicit and fragmented nature of PS in the curriculum.

If faculty members were adequately trained, they would understand the importance of PS education and could make the PS content more visible in the curricula. The literature highlights two main issues in this regard:^36,37 First, when PS content is integrated into existing modules, it often lacks visibility and is overshadowed by other topics.^1,32,38 Second, when PS content is presented as a separate module, there is a fear among teachers that students might perceive it as separate from their other learning, thereby neglecting the importance of PS in all modules.^36,39 A possible solution to this dilemma is to introduce PS as a separate module or topic while clearly emphasizing to students that PS must be practised in all other modules and clinical settings. The objective of this module will be to consolidate fragmented PS concepts and practices to ensure visibility and comprehensiveness. If other modules already allocate considerable time to specific PS concepts, they can be briefly mentioned while focusing on unique concepts that require highlighting, such as HFs, error reporting, and root cause analysis.

Insufficient training of faculty members can also lead to a lack of involvement in PS issues within clinical settings. To enable faculty members to champion PS in both academic and clinical settings, they need to be empowered with adequate knowledge and experience in PS. Another factor contributing to this distance between academia and clinical practice is the non-practicing state of some academics. This lack of clinical engagement diminishes their confidence and credibility in assuming clinical responsibilities. Researchers have called for improved connectivity between hospitals and academia.^15,40,41 Nurse educators have identified the difficulty of collaboration between academicians and practitioners as a barrier to incorporating PS into their curricula. ⁴² This issue has two facets: health organizations and clinical staff feeling powerless or disconnected in influencing nursing curricula ²⁸ and academic staff feeling limited due to a lack of affiliation with hospitals. ³² To address these challenges, the authors suggest officially appointing qualified clinical staff as extended faculty members and providing affiliations to academic staff at hospitals, thereby empowering them and providing legislative protection and coverage.

The theory–practice mismatch is a recognized issue not only in PS but also in other clinical subjects.^43,44 While clinical environments provide the ideal setting for practicing and refining competencies, the initial exposure to theory and procedural knowledge occurs in academic institutions. ²⁸ Nursing students have voiced concerns that theory lessons are often oversimplified and fail to consider the complexities of real clinical practice. ³⁸ While it is unrealistic to replicate actual clinical scenarios entirely in the university setting, attempts have been made through simulation to bridge the gap. It is crucial to clearly communicate this distinction to students, preparing them for the greater complexities they will encounter in the actual work environment.

The theory-practice mismatch leaves students feeling unprepared and low in confidence, as nurses doubt their abilities. ³⁸ To mitigate this, it is important to convey to them that nurses do not expect the same level of confidence from students as they would from registered nurses. Students are expected to learn through observation, assistance, and gradually performing tasks based on assessment by senior nurses. Students have also observed that the realities of practice can be outdated, with shortcuts taken in nursing care due to time constraints. ⁴⁵ Implementing evidence-based practice (EBP) in a realistic and context-specific manner is essential. Factors such as lack of resources, including water supply, waste segregation options, safety equipment, and limited hospital capacity, have been identified as hindrances and compromises to PS in hospitals. ³⁶ It is crucial to strike a balance between what is perfect and what is practical, selecting approaches that suit the needs and context of the situation.

Connectivity between academia and clinical practice can help bridge the theory–practice gap. Collaborative efforts not only support the formal curriculum but also have the potential to positively influence the informal and hidden curricula. ¹⁵ The characteristics of clinical mentors can either facilitate or hinder students’ inclination toward practicing PS. Challenges in this area include the lack of available clinical mentors and mentors who do not prioritize PS practices. ³⁴ Students expressed their enthusiasm to learn under the guidance of skilled nurses. ⁴⁵ However, not all clinical nurses are effective mentors.^39,46 Effective communication between academia and clinical staff is crucial in establishing mentoring support from experienced nurses. It is also important to have realistic expectations of mentors, and academic staff should be able to identify critical areas where a clinical mentor can provide support and guidance.

Wu & Busch ¹⁷ suggest that ‘resistance to change’ is a challenge when integrating PS content into curricula. However, there is a lack of in-depth studies specifically evaluating this aspect, particularly concerning faculty members. On the other hand, ‘innovation adoption’ is considered the opposite of resistance to change, as discussed by Rogers ¹³ and Hurt, Joseph & Cook. ⁴⁷ Hurt, Joseph and Cook's concept of individual innovativeness (II) refers to an individual's willingness to change. Previous research has shown a relationship between innovation adoption and individual innovativeness. Originally studied in the field of marketing and business to understand consumer behaviour in adopting new products, the concept of innovativeness has been expanded to higher education^48,49 and other contexts such as management. ⁵⁰

Given the highly personal nature of II, it is reasonable to assume that the level of II among educators could significantly impact PS education as well. Therefore, it is recommended to conduct an in-depth study to investigate how the individual innovativeness of nurse educators affects the integration of PS into curricula. Such a study would provide valuable insights into the role of educators’ willingness to change and innovate in promoting effective PS education.

5. Conclusion

This study aimed to systematically identify the challenges reported in the literature when integrating PS into existing nursing curricula. Our approach involved utilizing various databases, with a specific focus on the 10-year period following the introduction of the WHO-MPSC in 2011. The synthesis of international literature yielded highly insightful results.

However, it is important to acknowledge the limitations of this study. First, our search was restricted to MEDLINE, CINAHL, and Google Scholar, potentially overlooking relevant evidence present in other search engines. Second, the review only considered studies published in English, potentially excluding valuable evidence published in other languages. Additionally, the chosen search terms, such as ‘challenges’ and ‘patient safety education,’ may have inadvertently omitted studies using alternative terms such as ‘barriers’ to discuss similar phenomena.

Despite these limitations, the study demonstrates several strengths. Notably, we established specific inclusion and exclusion criteria to ensure a systematic approach to article selection and minimize bias. We employed validated appraisal tools and had two independent reviewers assess the data quality individually, thus enhancing the study's rigor. Furthermore, the adoption of a two-reviewer system for screening and appraising the selected articles further enhanced the reliability and objectivity of the findings.

This study contributes novel insights to the literature by synthesizing challenges related to the education of nurses in PS and proposing strategies to overcome these challenges. It also identifies the need for further research on topics such as resistance to change and individual innovativeness among nurse educators. Furthermore, it highlights areas such as the theory-practice gap, curriculum development, and programme structure that should be targeted by global nursing education curriculum developers.