NURSING STUDENTS’ KNOWLEDGE OF PATIENT SAFETY AND DEVELOPMENT 
OF COMPETENCES OVER THEIR ACADEMIC YEARS: FINDINGS FROM  
A LONGITUDINAL STUDY 
Valentina BRESSAN
1
, Giulia CAUSERO
1
, Simone STEVANIN
2
, Lucia CADORIN
1
, 
Antonietta ZANINI 1, Giampiera BULFONE
1
, Alvisa PALESE
1*
1
University of Udine, Department of Medical Science, Viale Ungheria 20, 33010 Udine, Italy
2
University Hospital of Padova, Via Nicolò Giustiniani, 2, 35128 Padova, Italy
3
University of Rome “Tor Vergata”, Department of Biomedicine and Prevention,  
Via Montpellier 1, 00133 Rome, Italy
Received: Jun 17, 2020
Accepted: Feb 3, 2021 
 *Corresponding author: Tel. + 39 33 38276 621; E-mail: alvisa.palese@uniud.it
10.2478/sjph-2021-0017 Zdr Varst. 2021;60(2):114-123
114
KAKO SE Z AKADEMSKIMI LETI STOPNJUJETA ZNANJE IN 
STROKOVNOST ŠTUDENTOV ZDRAVSTVENE NEGE O VARNOSTI 
PACIENTA: REZULTATI LONGITUDINALNE RAZISKAVE
 ABSTRACT
Keywords: 
competences, 
knowledge, longitudinal 
studies, nursing 
education, nursing 
students, patient safety
 usposobljenost, 
znanje, longitudinalne 
raziskave, zdravstvena 
nega, študentje 
zdravstvene nege, 
varnost pacientov Introduction: Future nurses should possess the knowledge and competences necessary to ensure patient safety. 
However, little evidence is available on the way in which students learn patient safety-related principles over 
time. This study explored the progress of a cohort of Italian undergraduate nursing students as they acquired 
patient safety knowledge and competences from time of enrolment to graduation. 
Methods: A longitudinal study carried out between 2015 and 2018 enrolled a cohort of 90 nursing students 
from two Italian Bachelor of Nursing Science Degree Courses at the Udine University, Italy. The students were 
followed-up on an annual basis and data collection was performed three times: at the end of the 1st, 2nd and 
3rd years. The validated Italian version of the Professional Education in Patient Safety Survey tool was used to 
collect data. 
Results: At the end of the 1st year, students reported an average 4.19 out of 5 patient safety knowledge 
acquired in classrooms (CI 95%, 4.11–4.28), which was stable at the end of the 2nd (4.16; CI 95%, 4.06–4.26) and 
3rd years (4.26; CI 95%, 4.16–4.32) and no statistical differences emerged over the years. With regard to the 
competences acquired in clinical settings, at the end of the 1st year the students reported an average 4.28 
 p=0.02) and increased at the end of the 3rd year (4.37; CI 95%, 4.27–4.47; p<0.01). 
Conclusions: Nursing students’ competences in patient safety issues increases over time, while their knowledge 
 about patient-safety issues. 
 podatkov ob koncu prvega, drugega in tretjega letnika. Ti podatki so bili izbrani na podlagi italijanske verzije 
raziskave Professional Education in Patient Safety Survey.  
 © Nacionalni inštitut za javno zdravje, Slovenija. 

*Corresponding author: Tel. + 39 33 38276 621; E-mail: alvisa.palese@uniud.it
1 INTRODUCTION 
There is an increasingly recognized need to prepare future 
healthcare professionals for Patient Safety (PS) (1), and 
different policies have been developed internationally 
establishing that PS should be included as a major area of 
nursing education (e.g., 2, 3). As a consequence, in recent 
years healthcare faculties have reviewed their programs 
by introducing theoretical and clinical educational 
interventions aimed at increasing PS awareness, 
knowledge, and competences among students (1, 4). These 
interventions aim at ensuring that graduated healthcare 
professionals are capable of performing at the entry level 
 tools capable of assessing PS knowledge and competences 
acquired both for educational and research purposes have 
been developed and validated (5, 6). However, no data on 
PS programs introduced in the nursing curricula in recent 
years has been assessed from the students’ perspective 
(7), and to date no data with regard to the progression over 
time of their PS competences has been documented (8).
According to their professional role and closeness to 
patients, nurses need to be prepared to recognize, 
respond to, and disclose possible safety risks, protecting 
patients from close calls, adverse events and avoidable 
risks (9). The nurses’ adherence to PS principles has 
 attitudes and perceptions of safety issues (10). Therefore, 
nurse educators in both academic and practical settings 
are crucial in helping students acquire and implement 
evidenced-based safe practices during their clinical 
experiences (1, 5, 11). However, despite pioneer research 
 in 1973 (12), little knowledge is still available on how 
students learn PS principles and the progression of such 
knowledge and competences over time (1). 
Several cross-sectional studies have been performed 
reporting sensitivity, accountability, and awareness of PS 
principles among nursing students (e.g., 13, 9). However, 
only Lukewich and collegues (14) have measured the 
progression over time of the perceived PS knowledge and 
competence among a cohort of undergraduate nurses 
by adopting a repeated (annual basis) cross-sectional 
study design. Despite the novelty of this study, a paired 
analysis involving a cohort study design embracing the 
entire nursing program and offering a comprehensive 
 is still lacking. Therefore, this study aims: (a) to explore 
PS knowledge and competences as perceived by nursing 
students, and their progression over time, from the 1st to 
 how PS concepts are integrated and enacted in the nursing 
curriculum, as perceived by students.
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2 METHODS
2.1 Study design 
A longitudinal study was conducted between September 
2015 and September 2018, and reported here according to 
the Strengthening the Reporting of Observational Studies 
in Epidemiology recommendations (15).
2.2 Participants 
Two Bachelor of Nursing Science (BNSc) Degree Courses at 
the Udine University (Italy) were approached: these were 
homogenous in terms of theoretical courses and clinical 
placements; students were offered a homogeneous PS 
 to the national guidelines for Italian nursing education (16), 
 course on PS composed of three modules was delivered. 
 evaluation were admitted to clinical training. Four modules 
 mandatory in order to improve students’ knowledge about 
risk management and PS issues. More details regarding the 
 the nursing program are reported in Table 1.
In the approached settings, all nursing students (n=140) 
 participate were those who: (a) had obtained positive 
 semester of the 1st academic year; (b) were admitted to 
clinical rotations; (c) attended the expected theoretical 
courses and clinical rotations in each academic year; and 
(d) consented to be included in the study. The cohort 
of students was followed-up on an annual basis up to 
graduation, as reported in Diagram 1.
Students were excluded if they: (a) reported academic 
 period, thus not progressing in their education as a nursing 
student; (b) withdrew from the nursing program (e.g., for 
health and family reasons); (c) experienced their clinical 
learning abroad and therefore were exposed to different 
aspects and rules of PS; and (d) submitted incomplete 
questionnaires. 

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Admission and 
enrolment
Program duration 
Theoretical and 
practical clinical 
learning model 
 
Lectures  
Clinical training
 
 
 
 
 
Number of 
examinations 
Final examination 
Theoretical courses 
Table 1. Legend: BNSc, Bachelor of Nursing Students course; Bachelor Nursing Students; PS, Patient Safety; PPE, prevention and protection strategies
A nationwide entry exam is mandatory for all BNSc candidates. Candidates must have at least 12 years of 
prior education to applying. The candidates-to-places ratios in the involved nursing program were 2.7 to 1.
180 university credits; 5,400 hours; 3 years.
According to the block system model, 5 months/year are dedicated 
to lectures and 6 months/year to clinical training. 
One month/year is dedicated to a mandatory holiday.
Approximately 30 credits/year, 36–40 hours per week. It is compulsory for 
students to attend at least 70% of the scheduled lectures.
Approximately 20 credits/year, 36 hours/ week. Attendance is mandatory for 
100% of the scheduled hours of learning. These hours are as follows:
1. 1
st
 year: 30 hours of skill labs and 480 hours of clinical training (two periods 
of practical experience in medical and surgical units);
2. 2
nd
 year: 30 hours of skill labs and 600 hours of clinical training (three periods 
of practical experience in specialised medical and surgical units);
3. 3
rd
 year: 30 hours of labs and 840 hours of clinical training (seven periods of practical 
experience in acute [intensive care, stroke unit], sub-acute [medical, surgical care], maternal 
and childcare and community care [mental health, nursing home, home care].
Total = 20 exams.
Students may progress from one year to the next after having obtained 
positive results in the theoretical and practical examinations.
The BNSc ends with one exam consisting of a professional license and thesis discussion. 
The commission is composed of Faculty and members of the Nursing Board. 
 Two PS courses are offered:
1) Safety in the clinical environment
 core contents: a) the concept of healthcare workers’ safety; b) integrated risk management approaches 
in healthcare environments; c) Italian legislation on safety and health prevention/protection in 
 factors in the clinical environment for nursing students; e) PPE in the health-care context; f) principles 
of ergonomics; g) the standard precautions and mandatory protocols to be adopted in case of injury 
exposure (e.g. whom to report to and how); h) safe management of hospital waste. Students who 
have achieved a positive evaluation in the examination can be admitted to clinical training; 
2) Risk management
 following core contents: a) risks to patients and issues of PS in hospital and community settings; b) strategies 
at the system, team work and individual levels aimed at monitoring and protecting PS; c) standards for PS 
and effective strategies/methods to develop/improve PS; d) how to interpret reports on adverse events/
risks monitored in the health care system; e) organizational and nursing care factors affecting PS; f) the role 
of clinical documentation and incident reporting in PS; and g) ethical and medicolegal implications of PS. 
The main competences to be achieved from clinical rotations are as 
follows, and the complete list is available from authors:
1. 1st year: identifying the risk of patients associated with healthcare practices; environmental factors 
 at the patient and healthcare levels (e.g. wearing Personal Protective Equipment [gloves, glasses], 
checking patient identity); recognizing an adverse event and a close call; communicating adverse 
events or close calls; identifying the role of human factors in PS (e.g., fatigue due to shift work);
2. 2nd year: assessing the risk of healthcare associated infection, falls, pressure sores and other 
adverse events sensitive to nursing care; recognizing situations in which safety issues may arise; 
preventing adverse events with appropriate evidence-based interventions; administering medication 
safely; monitoring effects of medication administration; documenting nursing care; 
3. 3rd year: preventing medication errors; identifying team dynamics and authority/power differences; managing 
 healthcare providers; recognizing an adverse event or close call; disclosing an adverse event to the patient; 
developing a questioning attitude and speaking up when the clinical environment and practices are unsafe.
BNSc: general features 
 Clinical rotation 

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Diagram 1. Legend: n, number.
 
t1-second data collection, academic year 2013-2014;  
t2-third data collection, academic year 2014-2015.
2.3 Variables, instruments and data collection 
The concept of PS as a patient’s freedom from unnecessary 
harm or close call miss associated with healthcare (17) was 
adopted in the study protocol. Data was collected using the 
Italian version of Health Professional Education in Patient 
Safety Survey (H-PEPSSIta) tool (18). Like the original 
tool H-PEPSS (19, 20), the Italian version is validated and 
capable of evaluating the nursing students’ self-perception 
of patient safety knowledge and competence (8, 18). 
Namely, the tool explores two dimensions measuring PS 
knowledge as learned in the classroom and PS competence 
as acquired in clinical settings, and it is based on the 
same six factors with a total of 22 items (“Working in a 
 events”, four items; “Communicating effectively”, 
three items; “Culture of safety”, four items; “Managing 
safety risks”, three items; and “Understanding human 
and environmental factors”, three items) (18). For both 
 0.936 (8, 18), scores are required to be ranked on a Likert 
scale from 1 (strongly disagree) to 5 (strongly agree). 
Moreover, students were required to express their 
agreement or disagreement about how broader PS issues 
were addressed in their entire nursing program by scoring 
seven items on a 5-point Likert scale (1, strongly disagree; 
5, strongly agree) translated from the original version of 
H-PEPSS (19). 
Data collection, via paper and pencil, was performed 
three times: at the end of the 1st year, by administering 
the H-PEPSSIta tool including items to gather demographic 
data, and at the end of the 2nd and 3rd years, by 
administering the questionnaire only. 
2.4 Bias control 
Strategies to prevent selection, interviewer, and 
 programs were included; (b) the same data collection 
procedures were followed over the years and performed 
by a faculty member trained in the research protocol; (c) 
the study excluded students reporting academic failure 
and thus with performance concerns; and (d) the study 
excluded also students who experienced their clinical 
learning abroad as these were exposed to different 
aspects and rules of PS. All incomplete questionnaires 
were also excluded. 
2.5 Data analysis 
SPSS Statistical Package version 22.0 was used for data 
analysis. Categorical variables were summarised in 
frequencies and percentages. Continuous variables were 
displayed as averages, standard deviations (SD, ±), and 
 assessed through the Pearson test (r); progression in 
the PS knowledge and competence over the years was 
evaluated using the paired matched t-test. The level of 
 2.6 Ethical issues Permission to conduct the study was granted by the 
Bachelor of Nursing Degrees Board. The study participation 
was voluntary and written consent was obtained from each 
student before data collection. In order to track potential 
variations over time, questionnaires were not anonymous, 
and this was highlighted when providing information to 
eligible students. After having tracked the same student 
 and then data analysis performed. 

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3 RESULTS 
A cohort of 90 students agreed to participate. Their 
average age at study enrolment was 22.2 years (SD=4.7). 
The majority were female (66; 73.3%). Only four students 
(1.1%) had previously obtained a degree (in economics and 
biology).
Factors and items, 
mean, 95% CI
 
1. Team dynamics 
and authority/
power differences
2. Managing 
interprofessional 
 supporting team 
members after an 
adverse event/close call
4. Sharing authority, 
leadership, 
decision-making
5. Encouraging 
team members to 
speak up, question, 
challenge, advocate, 
and be accountable 
as appropriate to 
address safety issues
Communicating 
effectively
6. Enhancing PS through 
clear and consistent 
communication 
with patients
7. Enhancing PS 
through effective 
communication with 
healthcare providers
8. Effective 
verbal/nonverbal 
communication 
abilities to prevent 
adverse events
 
9. Recognizing routine 
situations in which safety 
problems may arise
10. Identifying 
and implementing 
safety solutions
11. Anticipating 
and managing high-
risk situations
Table 2. PS knowledge acquired in the classroom and PS competence developed in the clinical settings as perceived by students (=90) 
over the years.
1st year 
4.1  
(4.0-4.2)
4.13  
(3.99-4.27) 
4.10  
(3.93-4.27) 
4.16  
(3.99-4.32) 
 
4.14  
(3.99-4.28) 
4.13  
(3.97-4.30) 
 
 
 
 
4.38  
(4.25- 4.51)
4.42  
(4.28-4.56) 
 
4.41  
(4.28-4.54) 
 
4.43  
(4.16-4.48) 
 
 
4.12  
(3.98-4.25)
4.26  
(4.12-4.39) 
4.15  
(4.00-4.29) 
4.06  
(3.85-4.26) 
2nd year 
4.05  
(3.93-4.18)
4.18  
(4.04-4.31) 
3.99  
(3.82-4.16) 
4.01  
(3.82-4.20) 
 
4.16  
(4.00-4.31) 
4.08  
(3.91-4.25) 
 
 
 
 
4.33  
(4.18-4.47)
4.45  
(4.31-4.59) 
 
4.38  
(4.23-4.53) 
 
4.21  
(4.06-4.37) 
 
 
4.19  
(4.04-4.34)
4.32  
(4.19-4.44) 
4.31  
(4.20-4.43) 
4.18  
(4.04-4.32) 
3rd year  
4.02  
(3.90-4.15)
4.13  
(3.99-4.28) 
3.88  
(3.71-4.05) 
3.91  
(3.74-4.08) 
 
4.10  
(3.97-4.23) 
4.10  
(3.97-4.28) 
 
 
 
 
4.50  
(4.27-4.72)
4.44  
(4.32-4.57) 
 
4.40  
(4.27-4.53) 
 
4.66  
(4.01-4.70) 
 
 
4.27  
(4.15-4.38)
4.31  
(4.18-4.44) 
4.28  
(4.16-4.40) 
4.22  
(4.09-4.35)
 
1st year 
 
4.18  
(4.07-4.29)
4.31  
(4.18-4.44) 
4.10  
(3.94-4.26) 
4.21  
(4.04-4.38) 
 
4.13  
(3.98-4.29) 
4.24  
(4.08-4.41) 
 
 
 
 
4.43  
(4.27-4.58)
4.61  
(4.48-4.73) 
 
4.45  
(4.31-4.58) 
 
4.38  
(4.22-4.54) 
 
 
4.18  
(4.05-4.31)
4.36  
(4.22-4.49) 
4.24  
(4.10-4.37) 
4.06  
(3.8-4.26) 
2nd year 
4.11  
(3.99-4.23)
4.31  
(4.18-4.44) 
4.02  
(3.86-4.18) 
4.06  
(3.88-4.23) 
 
4.20  
(4.06-4.34) 
4.03  
(3.85-4.21) 
 
 
 
 
4.33  
(4.21-4.45)
4.43  
(4.30-4.56) 
 
4.41  
(4.29-4.54) 
 
4.22 
(4.08-4.36) 
 
 
4.07  
(3.91-4.22)
4.30  
(4.16-4.44)
 
4.10  
(3.97-4.23) 
4.02  
(3.85-4.19) 
3rd year 
4.22  
(4.09-4.35)
4.40  
(4.26-4.54) 
4.13  
(3.97-4.29) 
4.22  
(4.04-4.41) 
 
4.28  
(4.13-4.43) 
4.13  
(3.95-4.32) 
 
 
 
 
4.51  
(4.38-4.64)
4.52  
(4.38-4.66) 
 
4.54  
(4.41-4.68) 
 
4.48  
(4.33-4.66) 
 
 
4.38  
(4.26-4.51)
4.47  
(4.33-4.60) 
4.36  
(4.22-4.49) 
4.34  
(4.20-4.49) 
P*** P*** P**
0.027
<0.01 <0.01
P** P* P*
BNSc: general features At the end of the 1st year, students reported an average 
4.19 out of 5 of PS knowledge acquired in the classroom 
(CI 95%, 4.11–4.28), which was stable at the end of the 
2nd year (4.16; CI 95%, 4.06–4.26) and 3rd year (4.26; CI 
95%, 4.16–4.32). Both at the factor and item levels, no 
statistical differences emerged over the years (Table 2).

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Understanding human 
and environmental 
factors
12. The role of human 
factors (fatigue) 
affecting PS
13. Safe application 
of health technology
14. The role of 
environmental 
factors, such as 
 and resources, 
which effect PS
Recognizing and 
responding to 
adverse events
15. Recognizing 
an adverse event 
or close call
16. Reducing harm by 
addressing immediate 
risks for patients and 
others involved
17. Disclosing an adverse 
event to the patient
18. Participating in 
timely event analysis, 
 planning in order to 
prevent recurrence
Culture of safety 
19. The ways in 
which healthcare 
is complex and has 
many vulnerabilities 
20. Having a questioning 
attitude and speaking 
up when you see things 
that may be unsafe
21. The importance of a 
supportive environment 
encouraging patients 
and providers to speak 
up when they have 
safety concerns
22. Systems, system 
failures, and their role 
in adverse events
Total
Note: Scores from 1 (strongly disagree) to 5 (strongly agree)
 Bachelor Nursing Science course
4.21  
(4.10-4.33) 
4.20  
(4.05-4.35) 
4.12  
(3.67-4.27)
4.33  
(4.18-4.49) 
 
 
 
4.12  
(4.00-4.24) 
4.16  
(4.03-4.28) 
4.16  
(4.02-4.29) 
 
4.12  
(3.95-4.30)
4.07  
(3.92-4.21) 
 
 
4.24  
(4.14-4.34)
4.08  
(3.93-4.23) 
 
4.40  
(4.26-4.54) 
 
 
4.29  
(4.16-4.42) 
 
 
4.20  
(4.04-4.36) 
4.19  
(4.11-4.28)
4.18  
(4.04-4.31) 
4.26  
(4.09-4.42) 
4.06  
(3.89-4.22)
4.28  
(4.15-4.40) 
 
 
 
4.16  
(4.04-4.28) 
4.19  
(4.06-4.32) 
4.19  
(4.03-4.35)
 
 
4.19  
(4.04-4.34)
4.13  
(3.99-4.28) 
 
 
4.06  
(3.86-4.25)
4.02  
(3.86-4.19) 
 
4.36  
(4.21-4.50)
 
 
 
4.37  
(4.21-4.52)
 
 
 
4.07  
(3.91-4.23)
 
4.16  
(4.06-4.26)
4.27  
(4.13-4.40) 
4.27  
(4.10-4.44) 
4.19  
(4.04-4.34)
4.36  
(4.21-4.50) 
 
 
 
4.25  
(4.13-4.37) 
4.32  
(4.19-4.45) 
4.27  
(4.13-4.40) 
 
4.12  
(3.96-4.28)
4.30  
(4.15-4.45) 
 
 
4.26  
(4.09-4.44)
4.19  
(4.05-4.34) 
 
4.56  
(4.43-4.68) 
 
 
4.38  
(4.22-4.53) 
 
 
4.33  
(4.18-4.48) 
4.26  
(4.16-4.32)
4.36  
(4.25-4.47) 
4.43  
(4.30-4.56) 
4.27  
(4.10-4.44)
4.40  
(4.24-4.56) 
 
 
 
4.19  
(4.06-4.32) 
4.18  
(4.03-4.33) 
4.31  
(4.17-4.46) 
 
4.13  
(3.96-4.31)
4.16  
(3.99-4.32) 
 
 
4.38  
(4.28-4.47)
4.29  
(4.13-4.45) 
 
4.50  
(4.39-4.61) 
 
 
4.46  
(4.33-4.59) 
 
 
4.28  
(4.11-4.44) 
4.28  
(4.20-4.37)
4.27  
(4.16-4.38) 
4.49  
(4.35-4.62) 
4.09  
(3.95-4.23)
4.26  
(4.12-4.39) 
 
 
 
4.06  
(3.95-4.18) 
4.16  
(4.02-4.29) 
4.08  
(3.93-4.22) 
 
4.08  
(3.83-4.19)
4.03  
(3.87-4.20) 
 
 
4.06  
(3.88-4.25)
4.07  
(3.91-4.22) 
 
4.49  
(4.37-4.62) 
 
 
4.30  
(4.15-4.45) 
 
 
3.98  
(3.82-4.13) 
4.15  
(4.07-4.23)
4.48  
(4.36-4.60) 
4.41  
(4.26-4.56) 
4.46  
(4.31-4.60)
4.41  
(4.26-4.56) 
 
 
 
4.27  
(4.13-4.41) 
4.33  
(4.18-4.49) 
4.35  
(4.21-4.49) 
 
4.17  
(3.98-4.35)
4.29  
(4.13-4.45) 
 
 
4.38  
(4.21-4.55)
4.36  
(4.23-4.50) 
 
4.69  
(4.58-4.80) 
 
 
4.51  
(4.38-4.65) 
 
 
4.36  
(4.21-4.51) 
4.37  
(4.27-4.47)
<0.01
<0.01
<0.01
<0.01
BNSc: general features 

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With regard to PS competence acquired during clinical 
rotations, at the end of the 1st year students reported 
an average 4.28 out of 5 (CI 95%, 4.20–4.37), which 
 CI 95%, 4.07–4.23; p=0.02) and increased at the end of 
the 3rd (average 4.37; CI 95%, 4.27–4.47; p<0.01). For what 
concerns each factor, only the perception of “Culture of 
 95% CI, 4.28–4.47) to the 2nd years (4.06; 95% CI, 3.88– 4.25) and from the 2nd to the 3rd years, while all other 
 of “Working in a team”, which remained stable. From 
the 1st to the 3rd years only the “Managing safety risks’” 
 of the 1st year to 4.38; 95% CI, 4.26–4.51 of the 3rd year). 
The overall perception of preparedness with regard to the 
PS knowledge and competences acquired in the classroom 
and in the clinical settings showed higher correlations at 
the end of the 1st year (r=0.639; p=0.01), as well as at the 
end of the 2nd (r=0.592; p=0.000) and 3rd years (r=0.429; 
p=0.01). 
Moreover, at the end of the 1st year, students reported 
that PS concepts were well integrated in the overall 
curriculum (4.39 out of 5; 95% CI, 4.26–4.52) and PS clinical 
factors were largely covered in the program (4.37; 95% CI, 
4.23–4.50) (Table 3). An improvement in the opportunities 
for PS learning was reported in the 2nd year (4.16; 95% 
CI, 4.02–4.30) compared to the 1st year (3.94; 95% CI, 
3.78–4.11). Furthermore, from the 2nd to the 3rd years 
 the scope of the practice (p=0.007), in the consistency 
with which the PS issue was handled by different clinical 
supervisors (p=0.005), in the integrity of the PS concepts 
in the curriculum (p=0.021), and in how system aspects 
of PS were covered in all programs (p=0.002). All aspects 
 the exception of the items measuring the consistency 
across clinical supervisors with regard to PS issues and the 
understanding that reporting adverse events/close calls 
may improve quality of care.
4 DISCUSSION
 enrolled in Italian nursing programs (22) and with the 
characteristics documented in previous studies in the PS 
 is considered suitable to assess students’ perceptions of 
PS at different levels of their education (19), and has been 
shown to have excellent internal consistency. 
The participants reported high scores in all H-PEPSSIta 
factors measuring PS knowledge acquired in the classroom. 
The factors “Communicating effectively” and “Culture 
of safety” achieved the highest scores at the end of the 
1st year. At the end of the 2nd year, the scores remained 
high, but a slight decrease emerged in all factors with the 
exception of “Managing safety risks”. At the end of the 
3rd year, the scores were higher in all factors as compared 
with those expressed at the end of the previous academic 
years, showing a slight increase in the PS knowledge the 
students possessed. This data suggests the PS course taken 
at the beginning of the nursing program may have affected 
1. As a student, the scope of 
practice was very clear to me
2. There is consistency in how PS 
issues were dealt with by different 
preceptors in the clinical setting
 interact with members of interdisciplinary teams
4. I gained a solid understanding that 
reporting adverse events and close 
calls can lead to changes and reduce 
the reoccurrence of such events
5. PS was well integrated into the overall program
6. Clinical aspects of PS (e.g., hand hygiene, 
transferring patients, medication safety) 
were well covered in our program
7. “System” aspects of PS were 
well covered in our program
Table 3. How PS concepts are integrated and actualized in the nursing curriculum as perceived by students.
Note: Scores from 1 (strongly disagree) to 5 (strongly agree)
 4.02 (3.88-4.17) 
3.94 (3.77-4.12) 
 
3.94 (3.78-4.11) 
4.22 (4.08-4.37) 
 
 
4.39 (4.26-4.52)
4.37 (4.23-4.50) 
 
4.01 (3.85-4.17)
4.15 (4.03-4.27) 
3.87 (3.70-4.05) 
 
4.16 (4.02-4.30) 
4.22 (4.08-4.37) 
 
 
4.43 (4.31-4.55)
4.48 (4.36-4.61) 
 
4.06 (3.90-4.21)
4.34 (4.22-4.46) 
4.13 (3.96-4.29) 
 
4.25 (4.13-4.38) 
4.30 (4.15-4.44) 
 
 
4.60 (4.48-4.72)
4.60 (4.49-4.72) 
 
4.30 (4.16-4.43)
- 
- 
 
0.019 
- 
 
 
-
- 
 
-
0.007 
0.005 
 
- 
- 
 
 
0.021
- 
 
0.002
<0.001 
- 
 
<0.001 
- 
 
 
0.007
0.002 
 
0.002
Items, mean (95% CI) 1st year 2nd year 3rd year p* p** p***

the degree of knowledge perceived by students over the 
years, while the course offered in the 3rd year may have 
reinforced some theoretical principles with regard to PS (8). 
Therefore, while the nursing program seems to be unable 
of increasing students’ PS knowledge over the years, the 
combination of theoretical courses with clinical rotations 
may have hindered the inevitable decline in knowledge 
 and clinical staff are both responsible for teaching PS 
within the undergraduate nursing curricula (23).
Different trends emerged with regard to the PS competence 
acquired during the clinical placements: while at the 
end of the 1st year, students reported perceiving high 
competences, a slight decrease at the end of the 2nd 
 “Culture of safety” factor. In contrast, at the end of the 
3rd year, the scores increased in all factors as compared 
to those reported in the 2nd year.
The complexity of some learning tasks (e.g., administering 
medications), the increased independence from clinical 
supervisors, and the variability of the nurses’ behaviour 
across units attended by students may have jeopardized 
 by the 2nd year students (8). On the one hand, the low 
complexity of clinical competences expected at the end 
 students who reported higher scores; in contrast, 2nd 
year students might have a better understanding of the 
complexity of PS issues given that they are exposed to an 
increased complexity of clinical situations, and they are 
also more engaged with patient care, thus more aware of 
 the theoretical contents of the program in practice. At 
the end of the 3rd year students have developed more 
 Lukewich and collegues (14) and Usher and collegues (9), 
documented a decline in the “Working in team”, “Managing 
safety risks”, and “Recognizing and responding to adverse 
events” factors over the years: however, the cross-sectional 
study design adopted by these earlier studies suggests 
 Moderate correlations emerged in our study between PS 
knowledge and competences at the end of each academic 
year, and the strength of the correlations decreased over 
time. In accordance with Usher and colleagues (9), students 
increased their independence in clinical settings, and this 
allowed them to recognize possible gaps between their 
theoretical knowledge and the competences required in 
 regard to PS issues.
Students reported positive feedback on how PS concepts 
were integrated and actualized in the nursing curriculum, 
and this increased over the years, reaching the highest 
scores at the end of the 3rd year. Lower scores from the 
1st to the 3rd year were found with regard to how PS 
issues were dealt with by different clinical supervisors in 
the clinical settings. Previous studies (24-26) documented 
inconsistencies across settings that can affect the 
perception of curriculum integrity among students; 
this can also develop uncertainty among students that 
may arise for newly graduated nurses due to a lack of 
understanding of the complexity of PS in actual healthcare 
 on PS issues should be based on theoretical and clinical 
 which are capable of stimulating learning through 
experience (26-28), thus helping students to critically 
appraise the knowledge acquired in classrooms. According 
to Tella and colleagues (1), different teaching methods 
are needed to more effectively integrate the concept of 
PS within nursing curricula, while the learning activities 
undertaken during the clinical rotations should improve 
self-learning skills with regard to PS and critical events in 
real practice (29). 
4.1 Study limitations This study is affected by several limitations. First, around 
35.7% of students dropped out of the nursing program for 
different reasons. This academic failure rate is in line with 
that documented both at the national and international 
levels (30).
Second, data was not collected at baseline, at the day of 
BNSc course enrolment, therefore precluding the possibility 
of understanding the PS knowledge and competences 
already possessed by the students before their formal 
studies, and comparing these with those acquired while in 
the nursing education. Third, knowledge and competence 
progression were measured as perceived by students and 
not as performed. As documented by Yanes et al. (31), 
there is a discrepancy between students’ self-perception 
and their practical performance; therefore, future 
studies should also include objective measures aimed at 
 Fourth, data was collected at the end of the academic 
year as a comprehensive perception, and this might have 
affected the accuracy of the results. Finally, because 
of the longitudinal study design used in this work, the 
questionnaire was not anonymized, and this may have 
 5 CONCLUSIONS
Nursing students increase their PS competence over 
the years, while the related knowledge remains stable. 
Second year students seem to be more vulnerable as they 
perceive the lowest level of PS competence. 
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 included as learning aims at both the theoretical and 
clinical levels, as well as in didactical strategies aimed 
at linking the learning processes promoted in the 
classroom with the practical settings. Faculties and 
healthcare institutions should work together in offering 
consistent messages and supporting clinical supervisors in 
understanding the relevance of their role in developing 
and modelling PS competences for their students. 
Moreover, tailored policies at the national and international 
levels, aimed at harmonizing and supporting PS learning 
aims and teaching strategies undertaken in each nursing 
program, are recommended. Studies aimed at developing 
evidence on the most effective educational interventions 
capable of increasing PS knowledge and competence are 
also needed.
CONFLICTS OF INTEREST
 regard to this study. 
FUNDING
 ETHICAL APPROVAL
The protocols and procedures of this study were in 
agreement with the ethical guidelines on biomedical 
research on human subjects and the study was approved by 
the Bachelor of Nursing Degrees Board of the University of 
Udine. Written consent was obtained from all the subjects.
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