INTRODUCTION

Patient safety has turned into a key priority for health systems around the world since the publication of the seminal reports To Err is Human and an Organization with a Memory^1,2. Patient safety as a challenging discipline in health care quality was defined by the Institute of Medicine (IOM) as “the prevention and avoidance of any harm to patients in providing healthcare services’’. It also defined as” minimizing a patient’s exposure to hazards and near-misses and, likewise, reducing the risk of unnecessary harm associated with healthcare to an acceptable minimum’’^1,3. Assessing, identifying, managing risks, and errors, incident reporting and analysis in addition to learning from errors and how to disclose and manage them are important elements in patient safety⁴. To reduce these errors, and adverse events in healthcare, expanded accentuation on patient safety in the healthcare education is imperative, including transforming of the nursing curriculum⁵.

Investing in improving patient safety is one of the most brilliant opportunities for having a safe and effective health care system. Hence, nursing education has a substantial role in securing and enhancing patient safety in a complicated healthcare surrounding ^5,6. The primary aim of nursing education system is to prepare nursing professionals who are competent in delivering safe care to meet changing needs of patients and society ⁷. Undergraduate education has a great role in developing the knowledge, skills, and attitudes that promote patient safety among the healthcare providers⁸. Nursing education entails theoretical knowledge integrated with clinical training and practice furnished to college students with the reason to set them up for their future obligations as nursing care specialists⁹. The shift between traditional instructional methods and student-centered teaching challenges nursing faculty to create learning experiences that will develop safe and competent graduates ¹⁰. Patient safety education and training is a needed learning for all levels and degrees of training especially amid the early years when nursing students are building the ground for their clinical practice. They require supporting information about patient safety in addition, knowing the way to follow and apply the principles and concepts at the bedside¹¹.

Moreover, educational literature stresses the significance of early engagement and exposure of college students in patient safety and error reduction learning to develop the ability, skill, and competence and be ongoing throughout Nursing education ^3,8,12.Learning through clinical practice has been the gold standard of professional healthcare education because experience grows through multiple patient encounters. Students retain 5% of the information given to them by lecture, but 75% retention is evident if they practice after 6 months ^3,8. Tingle (2011)¹³stated, in the early years, students can be impacted, and their behaviors can be attuned, yet with time they might be less inclined to adapt to changes and more set in their approaches. Once healthcare providers are educated about patient safety in the early years of their education, they might act as superb advocators and agents for change toward the improvement ¹³.

The literature on patient safety education in nursing colleges indicates that patient safety teaching is various and extends from single-session intervention to educational programs incorporated throughout years of college-based training¹⁴. The degree of nursing students’ confidence in their classroom and clinical experience as well as their attitude and skills in providing care for the patient found to be affected by the excellence of patient safety education. Prior study contended that educational experience differs in the classroom and clinical settings. Inconsistencies on how patient safety issues are conferred to the students in the classroom and clinical settings were recognized⁸.

An important study was conducted by was done by Colet et al., (2015)⁸ found that the Saudi nursing students reported varying levels of competence in the dimensions of patient safety which reflected gap in their self-reported competences. Another investigation was done by Lukewich et al., (2015)¹⁵demonstrated that students’ patient safety confidence in the clinical setting diminishes during the year preceding graduation. Moreover, Steven et al., (2014)¹⁶, and Tella et al., (2014)⁵ highlighted that nursing education does not give enough concern to patient safety; consequently, a theory and practice gap exists. In this context, Burke (2013)¹⁷ reported that Nursing educators has been challenged in their endeavors to enhance the patient safety culture and attitude of students because there is a lack of empirical evidence as to which teaching strategies positively affect students’ attitudes toward patient safety.

Problem statement and significance of the Study

In the Kingdom of Saudi Arabia (KSA), patient safety and medical errors have become a vital national issue discussed and getting consideration by the media in the past decade. Pressure to improve patient safety in the Kingdom is evident and studies focusing on it are essential⁸. However, patient safety topics are not formally included as academic subjects in undergraduate curricula ¹⁸ and there is very limited local information on nursing students’ knowledge and attitude regarding these concepts and few research studies in Saudi Arabia have been directed toward measuring patient safety among health care providers^18-22.

The scarcity of studies among undergraduate nursing students indicates that more studies on patient safety are required in the provision of health‑care; specifically with respect to the attitude toward this issue ought to be explored. A developing body of literature recommends that student self-evaluation of attitudes towards patient safety is essential for addressing the educational needs and preparing students to provide high-quality care ^23-25. As future nurses and leaders, nursing students must be prepared to practice safe healthcare ¹¹. Since nursing students have direct contact with patients during their clinical obligations, they expected to have sufficient knowledge level and inspirational attitude towards promoting patient safety. Negative or poor attitude will bring about unpleasant compliance and application of such knowledge to their clinical practice ²⁶.

Assessing attitude towards patient safety is crucial and particularly important in the light of evidence that attitudes can considerably influence safety behaviors²⁷. Attitudes represent beliefs, feelings and action tendencies towards things, ideas or people and frequently is used in describing individuals and explaining their behavior²⁸. Attitudes drive behavior, if a person's attitude changes, his or her conduct may change. Also, it's miles vital to assess nursing students’ attitude regarding the patient safety to have a baseline information to outline and actualize pertinent educational programs and intervention¹⁸.

What is more and significant to be investigated also, is that many factors may be associated with attitude towards patient safety and it is important to identify these factors from the students’ perspectives. Nursing students as future nurses must be aware of the multiple factors that influence healthcare outcomes particularly patient safety and act to reduce the opportunities for errors¹¹.

Thus, the present study intended to assess the attitudes of undergraduate nursing students towards patient safety. Further to identify the factors that influence their attitude towards patients safety. The findings may offer important insights into the current gap in knowledge and practice about patient safety. It is imperative to describe students’ patient safety attitude at their academic level in both classroom and clinical settings purposely to determine the aspect needed for change while they are still undergoing education and training. This could help nursing educators, leaders, and students to understand the current situation and act accordingly based on students’ learning needs for improvement. Dimness in patient safety can be easily remedied while they are still nursing students than those who are already practicing⁸. In addition, using a qualitative data approach to obtain the students’ perspectives of factors that could influence their attitude toward patient safety could help nurse educators and practitioners to identify the problem areas and solutions based on students’ views are likely to be more realistic and effectiveto enhance patient safety and improve the quality of care²⁹.

AIM OF THE STUDY

The main aim of this study was to assess the attitudes of undergraduate Saudi nursing students towards patient safety at the College of Nursing- Jeddah. Further, to identify the factors that influence their attitude towards patient safety.

SPECIFIC RESEARCH OBJECTIVES

To assess the attitudes of Saudi nursing students towards patient safety at the College of Nursing- Jeddah.

To identify the factors nursing students perceived that influence their attitude towards patient safety.

RESEARCH QUESTIONS

-How do Saudi nursing students report their attitudes towards patient safety?

-What are the factors that nursing students perceived to influence their attitude towards patient safety?

MATERIAL AND METHODS

Research Design

A “concurrent triangulation”mixed methods research design was used, in which both quantitative and qualitative data were simultaneously collected for combination and merging among them. A quantitative study part was carried out with a cross-sectional outline while the qualitative investigation was guided by the in-depth interview. A qualitative study approach was chosen to elicit in-depth insight and enhance ‎understanding of the context, personal experiences, and interpretations of the participants’ experiences.

Research Setting

This study was conducted at the College of Nursing- Jeddah (CON-J), which affiliated to King Saud bin Abdul-Aziz University for Health Sciences, National Guard Health Affairs- Jeddah, Saudi Arabia. CON-J admits female Saudi national only and awards a Bachelor of Science in nursing (BSN) after four years of academic studying and one year of internship.

Target Population/ Participants

The target population of the study represented all undergraduate nursing students at (CON-J) with Inclusion criterion of nursing students who registered for levels 4 to 8 per the academic year 2017/2018. Nursing students start their core nursing courses in the second academic year by the fourth level at CON-J where the study was conducted after finishing their three preparatory semesters.

Sampling Technique

- For the quantitative part, a non-probability sampling technique using a convenience sample of all undergrduate nursing students enrolled in the academic year 2017-2018 at CON-J and willing to participate in the study were included (N=296).

- For the qualitative part, 14 nursing students were interviewed based on purposive sampling until data saturation was reached. Participants were chosen to include all academic levels (4^th- 8^th) to capture a range of students’ perspectives.

Measuring tools

For quantitative data: Attitude Towards Patient Safety Questionnaire (APSQ). A structured questionnaire was developed by the researchers based on the related and relevant literatures ^{11, 18, 30-32} to achieve the quantitative objective of this study. It is a self-administered questionnaire consists of two main parts:

Part 1: Students’ demographic characteristics.This part included five questions related to students’ demographic characteristics and academic profile such as (age, academic level, previous information on patient safety, the source of this information and learning experience affect positively on their attitude towards patient safety).

Part 2: Attitude towards patient safety: This part consists of 30 items to measure participants’ attitudes towards patient safety issues. Six main issues were addressed as follow: The importance of patient safety reflects participants’ attitude towards the percived importance of patient safety in health care (5 items). Errors disclosure responsibility represents participants’ attitude towards error disclosure and their sense of responsibility and willingness to openly report errors to staff, instructor and patient/ family, regardless of whether harm occurs or not (6 items). Errors management denotes participants’ willingness to foster good behaviors to manage an error and learn from mistakes and experience in a clinical/work setting (10 items). Team functioning mirrors participants’ attitude towards cooperation and work within the team to reduce error and promote patient safety (3 items). Patient involvement reflects participants’ attitude towards involving the patient in care decisions and preventing the risk for errors (2 items). Teaching patient safety indicates participants’ attitude towards the continuous teaching and learning of patient safety in education and practice (4 items). Responses were measured using a 5-point Likert scale. Participants rated each item on the scale, that transposed into numerical values ranged from 1 to 5 (from low to high score, 1= strongly disagree, 2=disagree, 3= neutral, 4= agree, 5= strongly agree). The total score ranged from 30 to 150. Score values higher than (91) reflected a positive attitude towards patient safety.

For qualitative data: Face-to-face in-depth interviews using a developed guide were conducted to collect the qualitative data related to the perspectives of nursing students of factors influencing their attitude towards patient safety. The interview guide was developed by the researchers based on the related literatures ^29,33 and it was based on two overarching questions: 1-What do you believe as the most important factors that positively influence and improve the attitude towards patient safety? 2-What do you believe as hinders/barriers for improving patient safety? In addition, two demographic questions were also included about age, academic level, and an open-ended question asking the respondents to describe their previous knowledge or experience in situations related to patient safety. Appropriate Probing questions were used to stimulate more information about factors that influence attitude towards patient safety to get more elaborating answers.

Validity and Reliability

For quantitative part, the APSQ Questionnaire was tested for content validity by the principal investigator (PI) (PI= the main author) and expert academic members in the field of study. Accordingly, the needed modification was done (some rewording). Also, it was tested for internal reliability using Cronbach’s alpha correlation coefficient and was reliable, see table (1) for overall and dimensions reliability coefficient. In addition, a pilot study was conducted on 5% of nursing students who excluded from the study subjects to ensure the clarity and applicability of tools, identify obstacles that may be encountered during data collection and estimate the time required to complete the study questionnaire.

Table (1): Reliability Statistic for Attitude towards Patient Safety Questionnaire (APSQ)

Dimensions	No of items	Cronbach's alpha*
Importance of patient safety	5	0.700
Error Disclosure Responsibility	6	0.803
Error Management	10	0.711
Team functioning	3	0.854
Patient role and involvement	2	0.797
Teaching patient safety issues	4	0.894
Overall (APSQ)	30	0.905

*Statistically significant at p ≤ 0.65

For qualitative part, the interview guide was sent to principal investigator’s peers to review to establish its face validity with a result of all agreement on the interview guide. All criteria of academic Rigor and trustworthiness including; credibility, transferability, dependability, and conformability were considered. To enhance the credibility of the findings, Member checking was undertaken by student participants with the PI. Transcript and data analysis report was read by them, to ascertain that the interviewer representing the students’ perspectives. Transferability achieved by providing a rich and thick description of study processes and data in the final research report. Dependability considered by giving a detailed methodological description. To ensure the reliability, conformability, and accuracy of the data analysis, consistency checks (Inquiry audit) was performed through a peer researcher to ensure congruent opinions between two independent researchers about the data’s accuracy, relevance or meaning.

Data Collection

- For qualitative data: After obtaining the required approval, the APSQ was distributed in its English form by the student researchers to nursing students who agreed to participate in the study.

- For qualitative data: The face-to-face, audio-recorded, in-depth interviews using the developed guide were conducted individually with 14 nursing students who agreed to be contacted by the principal investigator. Before conducting the interviews, students were provided with information about the aim of the study, the duration estimated for the interview, confidentiality of data and the voluntary participation. Students’ consent to participate in the study and to be quoted along with information was granted. The interviews were audio-taped upon their permission and transcribed literally verbatim prior to the data analysis. The length of the interview ranged from 15-30 minutes for each student. All types of data were collected in students’ break time to fit their academic schedules and enable them to freely express their opinions. The concurrent collection of quantitative and qualitative data was conducted from January 2018 until April 2018.

Ethical considerations

Approval was obtained from the Students Research Unit (SRU) at CON-J then submitted to King Abdullah International Medical Research Center (KAIMRC) to get the Institutional Review Board (IRB) approval No (H-01-R-005). The researchers explained the aim of the research to all participants. The privacy and confidentiality of data were maintained and assured by obtaining participants’ informed consent to participate in the research before data collection. The anonymity of participants and the right to withdraw from the study at any time were granted.

Data analysis and management

- For quantitative data: Data coded by the researchers and fed to the computer and analyzed using IBM SPSS software package version 20.0. Cronbach’s alpha correlation coefficient was used to test the study’s tool for internal reliability. Frequency and percentages were used for describing demographic characteristics. Descriptive statistics such as mean and standard deviation were applied to summarize the data. For comparison between numerical data, Analysis Of Variance (ANOVA) F test was applied. The P value of <.05 considered as the level of significance.

- For qualitative data: Content analysis of in-depth interviews was performed. Tape recorded in-depth interviews were transcribed verbatim. Next, the familiarization stage in which the audio recording of each interview was listened to whilst the transcription being read. The Transcript was read through several times to obtain the sense of the whole and to get the general sense of the content then subjected to content analysis to identify the emerged themes.

- Both quantitative and qualitative data were brought together to guide the analysis and interpretation of findings. See diagram 1 representing the study design.

Diagram 1: The Study Design.

RESULT:

Findings from the Quantitative Data

Demographic Characteristics

Table 2 illustrates that mean age for nursing students was 21.35±1.28 ‎years old with the highest percentage (53.7%) belonged to the age group ≤ 21 years. About one third (33.8 %) of them we enrolled in the fourth academic level and the rest of the students were distributed across the other academic levels. The largest proportion of nursing students (94.9%) reported that they had previous information about patient safety. The most frequently reported sources of this information were; program lecture (82.4%), and self-reading (25.0%). The highest proportion of nursing students (78.7%) perceived clinical learning experience as learning experience affects ‎their attitude toward patient safety more positively compared to each of classroom learning experience (8.1%) and both classroom and clinical experiences together (13.2%).

Table (2): Distribution of Saudi Nursing Students According to Demographic and Academic Characteristics (N =296)

Demographic and Academic Characteristics	No.	%
Age (years)
≤ 21	159	53.7
> 21	137	46.3
Min. – Max.	19.0 – 25.0
Mean ± SD.	21.35 ± 1.28
Current Academic Level
Fourth level	100	33.8
Fifth level	49	16.6
Six level	48	16.2
Seventh level	42	14.2
Eighth level	57	19.3
Do you have previous information about patient safety?
Yes	281	94.9
No	15	5.10
*If yes, what is the source of this information?
Self-reading	74	25.0
Training courses	30	10.1
Program lecture	244	82.4
Scientific Conference	14	4.70
Workshops	28	9.50
* Which of the following learning experience do you think that it affects your attitude toward patient safety more positively?
Classroom Learning Experience	24	8.10
Clinical Learning Experience	233	78.7
Both classroom and clinical Experience	39	13.2

*Multiple responses; SD: Standard Deviation.

Mean Score and Level of Saudi Nursing Students' Attitude towards Patient Safety

Table 3 reveals the mean percent score of nursing students’ overall attitude towards patient safety ‎as (74.63 ± 8.80) with the highest mean for teaching patient safety issues (84.63 ± 15.35) followed by team functioning dimension (79.11 ± 13.84), patient involvement (76.39 ± 18.08), and perceived importance of patient safety (75.07 ± 12.75). While the lowest mean scores were given to error management (69.74 ± 10.65) and error disclosure (72.90 ± 13.26). In addition, table 3 indicates that the majority of students (98.6%) had high attitude level towards patient safety compared to only 1.4% of them had low attitude level.

Table (3): Mean Score and Level of Saudi Nursing Students Attitude towards Patient Safety

Dimensions of attitude towards patient safety	Min. – Max.	Mean Percent Score ± SD.
Importance of patient safety	15.0 – 100.0	75.07 ± 12.75
Error Disclosure Responsibility	16.67 – 100.0	72.90 ± 13.26
Error Management	40.0 – 95.0	69.74 ± 10.65
Team functioning	41.67 – 100.0	79.11 ± 13.84
Patient role and involvement	25.0 – 100.0	76.39 ± 18.08
Teaching patient safety issues	31.25 – 100.0	84.63 ± 15.35
Overall attitude towards patient safety	39.17 – 95.0	74.63 ± 8.80
Overall attitude level towards patient safety
Levels	No.	%
Low (score 30-90) ‎	4	1.4
High (score 91-150)	292	98.6

SD: Standard Deviation.

Mean Score of Saudi Nursing Students’ Attitudes towards Patient Safety by the Current Academic Level and Learning Experience

Table 4 reveals no significant difference was found among nursing students across the different academic levels regarding their overall mean score of attitudes towards patient safety (F = 0.857, p <0.490) as well as their perception of the related safety dimensions. Also, table 4 reveals no significant difference among the mean score of the classroom ‎learning ‎experience, clinical ‎learning ‎experience and both experiences regarding nursing students’ overall attitude towards patient safety (F=1.381‎, p<0. ‎253‎). The same trend of result was reflected in the related safety dimensions. Additional values see table 4.

- Patient teaching about safety measures (F, B)

Another patient-related factor that could affect attitude towards patient safety is providing the patient/family/ the visitors with teaching, knowledge, awareness and enough instructions related to safety measures such as hand hygiene, side rails, slippery floor, using masks...etc. Participants said:

"Maybe, when I can teach the patient to take precautions in all care aspects and how to keep himself safe and more independent this affect me and my patient positively” (P #7). "It is essential in the hospital that nurses give adequate information and instructions to the patient, family and visitors about safety measures such as hand hygiene, side rails, slippery floor, using masks...etc.” (P #10).

On the other hand, lack of knowledge among patients and visitors about infection control, patient safety and risk factors are reported by students as a barrier towards patient safety and students recommended conducting workshops to teach them:

“When patient and family lack the knowledge and information about infection control or not follow them, of course, this caused negative attitude toward safety, if you need to succeed, you should make sure that the patient and his family being aware of safety measures. Also, I recommend conducting awareness sessions for visitors about patient safety” (P #10).

- Patient’s culture, customs, wrong ideas and over demands (B)

Students mentioned that patient’s culture, customs, and wrong ideas and over demanding attitude are barriers that could affect their attitude towards patient safety. Students stated:

“Maybe patient customs and traditions or religious affects attitude toward patient safety. Some patients refuse care because of their wrong beliefs and ideas. Some patients refuse female nurses to care for them, some husbands refuse that male physician to follow wife pregnancy and birth …. etc. I think that could also affect my attitude toward safety” (P #7).

“I think that one of the factors that could affect me is the patient himself, maybe the patient is hard to deal with because of his beliefs and customs especially if coming from a particular city or rural area. Some patients are over demanding and asking for many requests. So, the nurse should be patient with him and have enough information about patient cultural and religious background to know how to deal with him effectively, and this I will try to do when enrolled in the clinical training” (P #8).

Theme II: Staff (Healthcare Professionals) Factors

The second theme that was apparent when analyzing the findings was staff factors which refers to various personal characteristics and behaviors of the nurses and other health care professionals the students perceived to influence the attitude toward patient safety. This theme comprised of eight sub-factors which are explained as follow:

- Knowledge and awareness of patient safety (F, B)

Participants pointed to this factor as the most important for patient safety. Many respondents believed that nurses, nursing students, physicians, healthcare professionals' knowledge and awareness of patient safety measures such as (risk of infection, medication errors, patient fall, patient identification, patient safety goals, hand hygiene, wearing PPE …etc.) are the most important factors that influence their attitude positively towards patient safety. Students verbalized:

"First of all, having adequate knowledge of staff about safety goal, safety precautions and safety measures and how to keep the patient safe and away from the risk of infection, medication errors or fall is an important factor for patient safety"(P #9). Other participants pointed to their opinions, “From my point of view that increased knowledge about safety between nurses also between physicians is a factor if adequately present could affect positively our attitude toward patient safety” (P #11).

Conversely, lack of nurses, physicians and students’ knowledge about patient safety or inappropriate application of this knowledge or inadequate awareness of safety measures among the students could act as barriers to patient safety. Students stated:

"Lack of staff knowledge about patient safety or may have knowledge but they don’t apply it in a serious way affect negatively on patient safety"(P #1,14). "Many physicians had inadequate knowledge about patient safety, they only care about medical orders and medications which are very wrong, and the patient safety is not only the care plan or medication."(P #10). “Insufficient knowledge or inadequate awareness of safety measures among the students could affect their attitude toward patient safety and become fearful of participation in any care even if it is simple" (P #6).

- Clinical Exposure and Learning from Others’ Errors (F, B)

Many students reported that applying theoretical knowledge, clinical exposure and training as well as learning from others’ experiences, errors and mistakes at the hospital are interrelated factors that also play role as facilitators or barriers to patient safety. Students reflected:

"Also…. clinical exposure and training can help me to apply my theoretical knowledge in the clinical setting. for example, I read before about patient safety goal in the theoretical part of my course, so when I went to an elderly patient, I saw the side rails not up and the theoretical knowledge always encouraging me to make the patient safe and I raise the side rails up. Also, when I was in clinical training area in pediatric oncology, there were two nurses that they previously violated patient safety by making medication error. What is good, that they come to the oncology ward to make a workshop about their mistakes and how they learned from their experience and they come to transfer this learning to others" (P #4).

Other students clarified; “Clinical experience at the hospital is important to the student in addition to the educational background. The hospital experience has an effective role to learn from experience or mistakes. One of the primary nurses told us; when you give injections wear 2 gloves. The role of the medical team is important because they teach us about things students do not pay attention" (P #6).

In contrast, students indicated that a lack of clinical experience and non-exposure to others’ mistake could affect their attitude towards patient safety. A student stated:

"Unfortunately, as I am still not exposed to clinical training and experience, I hope in the near future to go to the clinical to see the cases and gain experience and advice from others about their mistakes and learn from them, this of course will improve my attitude toward patient safety” (P #8).

- Clinical Supervision (F, B)

Another staff factor related to clinical exposure reported by the students is the provision of adequate clinical supervision from the unit manager in addition to teaching staff’ supervision and guidance. Students stated:

“I think that the unit manager’s supervision for all personnel in the unit including nurses, physicians, and students are desirable to be sure that they follow safety practices and not break infection control measures. For me, as a student if I provided with adequate supervision and guidance in the unit from my teaching assistant and manager my attitude toward patient will be enhanced"(P #1). "If my teachers/ Teaching Assistants (TAs) support me with guidance and supervise me adequately in the clinical training, I will gain self-confidence, I will learn, and I will be better, in turn, improve patient safety” (P #8).

Conversely, inadequate clinical supervision from Teaching Assistants (TAs) for students verbalized by the students as a barrier to enhance their attitude toward patient safety. Students verbalized:

“Inadequate supervision from TAs affect negatively on our attitude especially when students prepare and give medications also when they do the physical assessment on the patient” (P #5). "Sometimes we suffer from inadequate supervision in the clinical area, especially from TAs. For example, me and my pregnant friend enter the patient room and we don’t know the patient was isolated and no one told us, that will harm my friend and her fetus and me. Also, some of TAs let us prepare and give medications without enough supervision. I prefer if there is balance in supervision, not close not-open so, we can learn to be confident and independent" (P #6).

- Nurses Skills, Competency, and Experience (F, B)

Students verbalized that nurses’ skills, competency, and experience are vital factors that influence their attitude towards patient safety and act either facilitators or barriers. Students stated:

" Observing skills of the experienced nurses of course improve safety practice and influence my attitude toward patient safety, what does it mean a care without nurses' experience?" (P #7). "Nurses skill and competency will lead to improved patient safety"(P #9).

On the other hand, lack of necessary nurses' skills and being a nurse student who lacked experience with safety measures was mentioned as a barrier and affect negatively on their attitude. Students highlighted the necessity of continues training and learning to be skillful. Students pointed to:

“Lack of necessary skills and experience for providing patient care hinders improving safety ‎"(P #2,14). 'I think that lack of experience as a student with safety measures will affect me negatively and on my patient safety, we need continues training and learning to be skillful" (P #8).

- Teamwork communication and collaboration (F, B)

One of the interviewed students verbalized that teamwork, communication, and collaboration among students and staff in the unit can facilitate and improve overall attitude towards patient safety:

"I prefer to be trained and work in the future in teamwork with my colleague. Teamwork can help the staff to support each other and help the patient. If the unit staff is communicating well and collaborate with each other in planning and providing the patient care and ensure the safety practices, the overall attitude towards the patient safety will be promoted" (P #13).

On the contrary, another nursing student verbalized that poor communication and teamwork among healthcare providers could be a barrier affects their attitude towards the patient safety:

"We can say in another way, poor communication and teamwork among healthcare providers are harmful factors regarding the patient safety that of course affect our attitude” (P #10).

- Noncompliance of nurses and physicians of patient safety measures and standard precautions (B)

Students identified noncompliance of staff with infection control measures and standard precautions particularly physicians as a barrier that influences their attitude toward patient safety. A student verbalized:

"One of the bad experiences that affects my attitude toward patient safety and safety in general that I saw some nurses did not follow infection control measures and standard precautions, they didn’t wear gown or gloves when required in patient care. Also, sterilization technique not appropriate to maintain patient safety" (P #1).

Some students clarified that physicians did not show adequate concern or compliance to use or wear personal protective equipment (PPE). Students clarified:

“Some Healthcare Professionals particularly physicians did not give adequate concern or compliance to use or wear personal protective equipment (PPE) before entering patient isolation room or contacting HCV patient. Sometimes, physicians think if they touch the patient, they will not get the infection, and this is a wrong concept” (P #3). "Some physicians wear the PPE inside the patient room and go outside the room without getting it off or wear the same gloves for more than one patient. It is unbelievable that they do that! “(P #11).

Other students verbalized that nurses and physicians should lead by example and be role models to students and other staff members in their compliance with infection control measures and standard precautions:

"What can I say; the physicians themselves did not give adequate concern for patient safety. From my point of view that nurses and physicians as most frequently healthcare providers contacting the patient should lead by example and acts as role models in their compliance to infection control measures/ standard precautions, not to be bad examples for us” (P #13). “By the way, the physician should be a role model to nurses and other staff even nursing and medical students in their commitment toward safe practices to enhance the entire healthcare team attitude toward patient safety"(P #3).

- Nurse-patient relationship (F)

Another factor identified by the students is the mutual positive attitude toward the nurse-patient relationship, which could be a facilitator for enhancing their attitude towards patient safety. Students verbalized that positive attitude toward her as a nurse, trust, and caring attitudes as well as active communication with the patient are important elements in the nurse-patient relationship that influence their attitude towards patient safety:

"I think that nurse-patient relationship can affect patient safety if the patient trusts me and feels that the nurse is caring about his health and safety, he will show her a positive attitude and become an active participant in this relationship" (P #8). "When you are dealing with the patient as a one of your family…, you will give the best care for him and even when the patient has a positive attitude toward me as a nurse, I will give best of the best that I can do and make him safe"(P #3). "In my relationship with the patient, I have to make active communication with him and his relatives to understand his need and what he wants to avoid any complication that may happen to him and affect his safety" (P #9).

- Theory-practice gap (B)

The last negative factor in the staff category that could be a barrier to patient safety is the Theory-practice gap that reported as by one student:

"I feel there is a gap between the theory and practice, we learn a lot and gain theoretical knowledge, we trained well, we do competencies in the simulation lab in an ideal way then we go the clinical and find the nurses and physicians do other things or doing the same procedures in different ways. In addition to the felt gap between the nurses and the students in the clinical setting" (p# 11).

Theme 3: Work environment factors

Work environment factors is the third theme that derived from content analysis which relates to workplace conditions, staffing, facilities, and resources that the respondents perceived to influence patient safety. This theme included five subfactors which are explained as follow:

- Workshops, training courses and health events about patient safety (F)

Many students agreed that availability of adequate lectures, workshops, and training courses, campaigns, health events about patient safety and related issues in the work environment enhance attitude toward the importance of patient safety. Students verbalized:

“The hospital conducts many workshops and campaigns for nurses and students about infection control, hand hygiene, antibiotics use and patient safety. Also, in the college they provide us with workshop and lectures about patient safety in addition to students’ participation in some courses for healthy events in collaboration with the hospitals or schools. Participating in these activities, of course, helps the students to gain self-confidence in their knowledge and attitude towards patient safety” (P #10). “Also, attending workshops specifically for patient safety help to enhance my attitude towards patient safety, honestly, all nurse managers in the wards I enrolled during the clinical training encouraging nursing students to attend workshops and to listen to others’ information and experiences in these workshops” (P #4).

- Regulations and policies regarding patient safety (F)

Having clear safety regulations and policies and infection control guidelines in the work/ clinical environment is another factor reported by students that facilitate their positive attitude and commitment towards patient safety. For examples, Students suggested:

“Having policy and regulation regarding safety measures in the unit, infection control, and medication safety guidelines help the staff to be compliant with them and also help me to be positive toward protecting my patient because it became clear to me what is required in this area” (P #1). “If the hospitals have regulations, policies and clear guidelines regarding patient safety, this will affect overall nurses or all health care providers as well as students’ attitude towards patient safety. This is the most affecting factor from my point of view for the student especially regulation should be clear to them to know how to deal with any situation related to patient safety.” (P #2).

-Attitude toward reporting errors, and fear of punishment for error reporting (F, B)

Positive attitude toward reporting errors, blame-free environment and non-punishing attitude for error reporting are considered by students as factors if present in the work environment, will improve the attitude toward safety:

“The response to reporting the error, in my previous example relating to learning from errors and other mistakes, the non-punishing attitude toward the two nurses when they are reporting their errors to their nurse manager and physician help them to be more experienced and do a workshop for other nurses to learn from their errors. Error reporting is important as it helps the staff to identify the root causes and play recommended action well accordingly” (P #4).

On the other hand, reporting system and fear of punishment mentioned as barriers to attitude toward patient safety. Students stated:

“Reporting system and fear of punishment are critical factors when making an error. Some nurse managers or TAs have a very negative attitude when they know that nurses and students made medication errors. Some managers try to catch the mistakes rather than improve the performance. So why I will report my error if I will be punished and not supported to learn from it?” (P #4).

- Shortage of nurses and the workload on nurses (B) clarified by students as barriers in the work environment. Students stated:

“Maybe workload and stress on nurses especially in case of in adequate staffing and staff shortage. Let me speak frankly, for example when I have many patients assigned to me to take care of all of them, I will become overwhelmed with doing the required tasks rather than patient safety. May not focusing on wearing PPE when required or washing hands for each patient or go outside and dealing with the other patient with the same gloves” (P #3). “The workload on nurses is among the factors that could be a barrier when I become a nurse to promote patient safety. Sometimes the nurse become task-centered rather than patient-centered, not all nurses can complete their assignment efficiently and safely especially if there is a shortage of staff or have a large number of patients assigned to care which in turn, affect nursing students in the clinical practice.” (P #13).

- Shortage of supplies and equipment

Another barrier could hinder the patient safety and makes the hospital/work environment unsafe mentioned by the students was the shortage of supplies and equipment:

‘I think that shortage of supplies and equipment is a barrier affects me negatively and makes me feel that the hospital/work environment unsafe. How can I feel safe and keep my patient safe if I did find simple things such as gloves, syringes, emergency drugs, isolation room, and everything patient need in his care, what can nurses do in such circumstances?” (P #12).

DISCUSSION

Today's students will be tomorrow's healthcare professionals and it is imperative to make them knowledgeable, competent and safe for patients and future generations. Investigating nursing students’ attitude towards patient safety and identifying factors influencing their attitude towards patient safety from their perspective is inevitable. Such information is essential for developing strategies to improve attitude toward patient safety, in turn, behaviors and performance could be boosted. Discussion of the current results will be presented by integration of the interrelated quantitative and qualitative findings.

The result of the current study indicated that Saudi nursing students had a high and positive attitude level towards patient safety. This result could be attributed to the college's education program which emphasized on patient safety as an important and integral part in students’ teaching-learning process and providing the students as much as possible with the theoretical knowledge related to this issue and stressed the role of the students, in turn students believe in the importance of patient safety. ‎In addition, their enrollment in clinical experience and exposure could make them more confident and having a positive attitude towards safety.

This goes in the same line with Mossey et al., (2012)³⁴and Vaismoradi et al., (2011)³⁵who indicated that nursing students were sensitive to their personal roles in clinical practice and considered patient safety to be a tremendous issue. Also, Tella et al., (2014)⁵underlined that the patient is the focal point of safe care, and nursing students can have an influential role through their behaviors by having a questioning approach and the confidence to work differently. However, some studies found that nursing students had low clinical patient safety competence⁸ as well as low knowledge and skills regarding patient safety³⁵. These conflicting findings might be clarified by cultural and contextual differences in patient safety education³⁶.

Regarding safety dimensions of APSQ, nursing students gave the highest means for “teaching patient safety issues followed by team functioning, patient involvement and perceived importance of patient safety”. This result could be strengthening by the result of the current qualitative part where the interviewed students reported that knowledge and awareness and teaching of patient safety are the most important factors influence their attitude positively towards patient safety. Additionally, nursing students reported that patient involvement, positive nurse-patient relationship as well as teamwork, collaboration and communication as facilitating factors. This result indicates students’ willingness to be positive in supporting each other and working together as a team, involve the patient in the care plan and teach him/her to improve patient safety. Similarly, Wami et al., (2016)³³ found the dimensions with the highest responses were; teamwork, collaboration, patient involvement, and learning which determined to be extensively related to enhanced patient safety. Also, Shah et al., (2015)³⁷ found that majority of students recognized the importance of patient safety teaching and education and very upheld its consideration in the medical curriculum. Moreover, Pazokian and Borhani (2017)³⁸ found that nursing respondents believed the collaboration of health professionals and respecting each other are important factors, while struggle amongst professionals and poor teamwork looked as obstacles adversely influence patient safety.

In the opposite, patient culture, customs and wrong ideas and over demands were identified by the interviewed students as barriers that affect their attitude and recommended that nurses should have enough patience and information about cultural and religious background to know how to deal with patients effectively. Similarly, Doherty and Stavropoulou (2012)³⁹ indicated that one facilitator arisen in their qualitative data, is that the patient and his relatives should be included and involved in the care, if acceptable to the patient. Therefore, there is a need for more research for better understanding of how patients can be involved in their own care.

In this context, the current qualitative findings highlighted that many interviewed students agreed on and recommended the provision of adequate lectures, workshops and training courses, campaigns, health events about patient safety and related issues in addition to clear safety regulations and policies and infection control guidelines in the work/ clinical environment to enhance their attitude and commitment towards patient safety. In the same line, Ridelberg et al., (2014)²⁹and Wami et al., (2016)³³ clinched that participating in hospital’s patient safety training programs increment the patient safety culture as the staff spend more times on safety reporting program, this situation favors them to deal more with patient safety issues.

On the other hand, "error management and error disclosure responsibility dimensions" were rated by nursing students as the lowest mean scores on APSQ. This result might be explained by what they verbalized in the qualitative finding that they still lack the experience and skills in the area of error disclosure and management in addition to the fear of reporting system and punishment as barriers toward patient safety attitude. Likewise, Safarpour et al., (2017) ⁴⁰ showed that students reported barriers such as fear of punishment and negative attitude and pressure by other staff after errors and lack of enough knowledge affect their attitude toward error reporting. In the same regard, the qualitative finding indicated that factors such as positive attitude toward reporting errors, blame-free environment and non-punishing attitude are considered by students as facilitators in the work environment can improve error disclosure and management. Nursing students require practicing in a safe environment that has a blame-free culture and clarified that error reporting could promote mindfulness and sensitivity to their own role and responsibility regarding patient safety.

This result is also supported by the qualitative finding of Wami et al., (2016)³³ in which respondents believed that error reporting has a positive impact on patient safety. Also, Samsiah et al., (2016)⁴¹ indicated that a positive culture for reporting and a non-punitive system will inspire reporting while blaming individuals instead of the system will be a barrier. Moreover, El-Jardali et al., (2011)⁴² pronounced the reality that event reporting systems produce valuable data to address shortcoming in work systems and processes, in turn, presents an opportunity to improve the patient safety. Furthermore, Langari et al., (2017)³⁶concluded that the prevention of incidents and acting after errors are important experiences for students to have during their education, as they can learn from events in which patient safety is jeopardized.

The current study revealed that Saudi nursing students' attitude towards patient safety not significantly affected by their academic levels and learning experiences either in classroom or clinical experience. The result may be related to their belief toward patient safety as an integral part of each academic level and related courses and they may be perceived that each learning experience has a special impact on their attitude. Classroom provides them with the knowledge while clinical experience teaches them how to practice safety measures. Also, this finding may be associated with the courses included in each level of nursing education. Most of the courses such as Adult Care Nursing, Maternal and Child Care, Mental Health Nursing, Emergency Nursing and Nursing Management have clinical learning experiences that constitute patient safety issues. However, conflicting findings bolster classroom teaching. Colet (2015)⁸found classroom learning gives more noteworthy impact than clinical exposure in developing patient safety competence among nursing students. Also, Sullivan et al., (2009)⁴³ reported that patient safety knowledge progressed efficaciously when taught in a classroom, whereas patient safety skills, such as those regarding hazards and near misses, improved most when taught in clinical environment. Moreover, Nabilou et al., (2015)³⁰ found significant relationships between students’ attitudes toward patient safety and years of study.

It can be drawn from these different findings that academic level and learning experience in the nursing program are factors that may influence students’ attitude toward patient safety. However, this is nevertheless an area need further study to better understand the connection between these two variables and fill the gap between the classroom and clinical settings. Bridging this gap ought to be accentuated so that the students’ attitude and skills in the classroom settings can be translated smoothly to practice for an optimal patient safety in the clinical area. In a related scene, Theory-practice gap was reported in qualitative data as a barrier that could influence patient safety. Since the clinical setting is perplexing and dynamic, this makes learning more complicated for the students ^43,44. This then creates a significant gap between theory and practice among the students since the application of patient safety learnings may not be translated to clinical practice, which may result to a low patient safety practices in the clinical area⁸.

This goes in the same line with Devakirubai et al., (2013)⁴⁴ who revealed theory-practice gap, inadequacies in the clinical environment, and lack of mentors affect students’ learning in clinical setting. From this perspective and to fill the gap between theory and practice, nurse educators must recommit themselves to ensure quality clinical learning for the future practice of professional nursing. Also, Vaismoradi et al., (2014)⁴⁵featured the significance of incorporating patient safety aspects in the students' curriculum and interdisciplinary education to guarantee compliance with patient safety rules and principles. Tella et al., (2014)⁵ recommended for embedding patient safety into nursing education through multiple teaching and learning strategies. Traditional teaching method can be very effective when used in conjunction with active learning and teaching strategies ⁴⁶. Traditional teaching and learning methods, reading, clinical practices, and demonstrations were still part of patient safety education ⁴⁷. Also, Integrated learning system, Web based learning, clinical safety reporting system, and incidents root cause analysis are learning methods could help to bridge academic- clinical practice gap^46,48.Moreover, Chandrachood et al., (2015)⁷valued the importance of Problem Based Learning (PBL) and Alkorashy and Abu Assi (2017)⁴⁹ recommended independent and self-directed learning as effective instructional strategies for imparting nursing motivation to learning, enhancing their problem solving, critical thinking, self-direction, and collaboration.

Related factors arise from the current qualitative findings clarified that nursing students believed that clinical exposure and training as well as learning from others’ experiences, errors and mistakes, clinical experience at the hospital as well as nurses’ skills, competency, and experience are interrelated factors that also play roles as facilitators or barriers to patient safety. This result could be defended by Tella et al., (2014)⁵who emphasized that learning from errors had an outstanding role in patient safety education for nursing students. Clinical exposure can help nursing students to learn from errors, comprehend why errors happen, distinguish, errors, analyze the type of errors that occurred, and learn from them. Subsequently, Nurse Educators ought to furnish students with more effective practice environment as well as educational strategies to prepare them with the skills needed to respond safely to errors and promote patient safety^5,36.

Another related factor emphasized by the students in the qualitative findings is the provision of adequate clinical supervision and guidance from teaching staff. Conversely, inadequate teaching assistants (TAs) clinical supervision for students verbalized by the students as a barrier to enhance their attitude toward patient safety. Likewise, Reid-Searl et al., (2010)⁵⁰ indicated that a supportive learning environment had a crucial role in the teaching of patient safety as the potential for making mistakes or errors reduced when nursing students were adequately supervised by their educators and the danger of errors expanded when nursing students lacked the enough supervision. Additionally, Bianchi et al., (2016)⁵¹ revealed that nurse mentors should enable the students to figure out how to report, analyze and prevent hazardous events without punishing mistakes or cultivating a fear of failure. On the opposite, Stevanin et al., (2015)²⁴ found that the dearth of caring mentors to students, a blame attitude of teachers, and an unsafe practice environment all negatively impact the skills students gain during nursing education.

Additional factors derived from the qualitative findings highlighted by the interviewed nursing students as barriers hinder patient safety and make the hospital/work environment unsafe were; noncompliance of staff with infection control measures and standard precautions particularly physicians, shortage of nurses, workload on nurses and lack of adequate supplies and equipment. The association between nurses’ poor working conditions and poor patient outcomes is evidenced as the findings suggest that suboptimal staffing and equipment engender patient safety. This is congruent with findings of Wami et al., (2016)³³ and Pazokian, et al., (2014)⁵² which revealed that that high workloads, time pressure, insufficient nurse staffing, and a lack of properly hospital facilities and working equipment can endanger patient safety and contribute toward an environment in which errors can occur and cause harm to patients. Likewise, Ramya (2017)⁵³ highlighted, heavy workload, long working hours, night shift and sleep deprivation, fatigue from handling the patients, and stress on managing the very sick patients are significant factors that can have adverse effect on mental skill and reaction time, vigilance, and interpersonal relationship among the nurses which can have a negative influence on patient safety.

In this respect, certain recommendation shout be considered. As for compliance of staff with infection control measures and standard precautions, Al- Momani and Al Momania (2013)⁵⁴emphasizedthat compliance with standard precautions minimizes the risk of hospital infection, and a collaborative effort including the academics and hospital administrators to implement a multidisciplinary hospital-based programs coupled with periodic practice audits and performance feedback is needed to increase compliance with standard precautions and reduce the hospital infection rate, in turn improve patient safety. In addition, Ridelberg et al., (2014)²⁹, Shah et al., (2015)³⁷, Ramya (2017)⁵³ and Hassan and Mansour (2018)⁵⁵ pointed to several work factors are needed to promote working conditions and ensure safe practices such as supportive organizational structure, leadership, teamwork, feedback and communications, evidence-based management protocols, ongoing teaching and training programs, and a proper system of incident reporting, adverse event disclosure, and regular audit. Moreover, Pazokian and Borhani (2017)³⁸ recommended that improving facilities and equipment as well as providing sufficient and efficient personnel are necessary to achieve a high level of effectiveness in clinical services.

CONCLUSION AND RECOMMENDATIONS:

Investigating students’ attitude toward patient safety is an important part of improving patient safety education since it highlights parts of nursing curriculum that students feel need development. The present study concluded that Saudi Nursing students manifested high and positive attitude towards patient safety and indicated that their attitude not affected by their academic level or learning experience. “Teaching patient safety issues, team functioning, patient involvement and perceived importance of patient safety” scored as the highest dimensions of students’ attitude compared to "error disclosure and management dimensions" which rated lower. This result supported and congruent with the findings of the qualitative part where a broad range of factors are identified that influence students’ attitude toward patient safety. The interviewed students identified facilitators and barriers to improve attitude toward patient safety at multiple levels, including patient, staff, and work environment levels that should be considered from the educational and hospital administrators as well as nursing educators.

To sum up, regarding the theme of patient factors, students stressed on patient involvement and teaching patient and relatives on safety issues, while customs and wrong ideas and over-demanding patient can affect students negatively. Staff theme pointed to several factors that significantly associated with enhanced attitude toward patient safety including; knowledge and awareness of patient safety, nurses’ skills, competency, and experience, teamwork, communication and collaboration, clinical exposure and learning from other, adequate clinical supervision and positive nurse-patient relationship. While noncompliance of nurses and physicians toward patient safety measures and theory-practice gap are barriers related to this theme. Regarding work environment theme, workshops and training courses about patient safety, safety regulations and policies, constructive attitude toward reporting errors are supportive factors in the work /clinical setting while, fear of punishment for error reporting, shortage of nurses and workload on them as well as shortage of supplies and equipment are barriers to patient safety and influence students’ attitude. See figure 2 for the integrated findings of the study.

Study Strengths and Limitation:

Nevertheless, this study contributed a unique dimension to the existing body of knowledge in Saudi Arabia through conducting a triangulation study to merge the quantitative data regarding students’ attitude towards patient safety in addition to qualitative data that identified the factors that influencing their attitude towards patient safety and related practice which is a good point for future researches. It is based on the belief that the interviews would lead to a more in-depth understanding of those factors which are important to nursing students, and nurse educators. Also, the response rate of the study is high, which serves as another strength of the study.

However, this current study has some limitations that must be considered when interpreting the results. The external validity of this study is limited by using non-probability convenience sampling technique and the surveyed nursing students were from one educational institution limits the generalizability of the quantitative data. Also, the quantitative part is based on students’ self-reports of their attitude which may include bias. This warrants the replication of the studies in other nursing colleges for future research studies. In addition, the sample size for qualitative data was relatively small (14 nursing students) although the data analysis confirmed that data saturation was reached before cessation of the interviews. Although this study focused on nursing students’ perceptions, nurses and other professional groups may echo some of the facilitators and barriers to improved patient safety. The identified factors associated with patient safety are not intended as a complete list of all possible facilitators and barriers to patient safety as perceived by nursing students; however other studies may yield different factors or give different priorities to various factors.

RECOMMENDATIONS:

Administrators of nursing colleges and nurse managers should work together to ensure that nursing students provided with adequate professional education, training courses, workshops, campaigns, and health events about the safe practice. Professional education and training may offer the chance for the students to learn with other members of the healthcare team, thus, enhancing their safety attitude, knowledge and practice and fostering good working relationship, build teamwork and generate positive attitudes toward inter-professional collaboration in the training.

Error reporting and blame-free culture should be a norm on health care/clinical environment. Therefore, students must participate in the process of error reporting, analysis and management with the provision of adequate clinical supervision.

Monitoring of Teaching Assistants (TAs) from nurse educators is expected to ensure that students adequately supported and guided in the clinical setting.

To maintain high levels of quality and safety in healthcare, all schools of nursing and faculties have to revise their curricula with more emphasis on theoretical and practical aspects of patient safety.

Several and various teaching-learning strategies including traditional teaching method, Integrated learning system and Problem Based Learning (PBL) should be utilized as instructional strategies for imparting students’ motivation to learn, enhances their problem solving and critical thinking and improves communication. This can help the students to acquire adequate knowledge and bridge the theory-practice gap.

RECOMMENDATION FOR FUTURE RESEARCH:

Replication of the studies in other nursing colleges is recommended for generalization.

Involving the teaching staff in a similar study is recommended to identify the factors influencing nursing students' attitude toward patient safety from their point of view as well as to identify patient safety content and needs in nursing curricula which could be helpful to gain a comprehensive perspective, in turn, improvement in nursing education and learning experience can occur.

ACKNOWLEDGMENT:

Our deepest thanks to Dr Jennifer De Beer, Assistant Professor, College of Nursing, King Saud bin Abdul-Aziz University for Health Sciences, Saudi Arabia for her valuable assistance and guidance in the current qualitative data analysis. Also, we would like to thank all nursing students who agreed to participate in this research study.

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

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Received on 25.12.2018 Modified on 01.01.2019

Int. J. Nur. Edu. and Research. 2019; 7(3):435-452.

DOI: 10.5958/2454-2660.2019.00100.5

	Dimensions of Attitude Towards Patient Safety						Overall Attitude
Variable	Importance of patient safety	Error Disclosure	Error Management	Team functioning	Patient role and involvement	Teaching patient safety issues	Overall Attitude
Variable	Mean ± SD.	Mean ± SD.	Mean ± SD.	Mean ± SD.	Mean ± SD.	Mean ± SD.	Mean ± SD.
Current Academic Level
- Fourth	75.75 ±11.11	72.17 ±11.75	70.08 ± 10.13	81.17 ± 13.01	77.63 ±14.90	86.06 ±12.37	75.18 ±7.37
- Fifth	71.12 ±14.83	72.11 ± 16.12	67.91 ± 11.36	75.51 ±14.67	76.28 ±18.96	84.82 ±18.22	72.86±10.24
- Six	75.94 ±10.50	71.27 ± 10.61	67.97± 8.55	78.47 ±12.73	75.26 ±19.38	86.07 ±13.54	73.91 ±6.57
- Seventh	76.31 ±14.23	75.10 ± 14.30	71.01 ± 11.75	78.37 ±13.41	75.60 ±17.45	79.32 ±17.49	74.86± 10.37
- Eighth	75.61 ±13.86	74.63 ±14.29	71.27 ± 11.56	79.68 ±15.43	75.88 ±21.89	84.65 ±16.79	75.60 ± 10.10
F(p)	1.435 (0.222)	0.833 (0.505)	1.166 (0.326)	1.469 (0.212)	0.194 (0.942)	1.596 (0.175)	0.857 (0.490)
Learning experience
- Classroom	75.2±13.1	75.2±11.8	72.6±10.8	77.8±15.9	78.6±19.3	79.4±21.8	75.4±10.6
- Clinical	74.6±13.1	72.5±13.6	69.0±10.8	78.9±13.7	75.9±18.3	85.1±15.0	74.2±8.8
-Both classroom and clinical experience	77.7±10.2	74.1±11.9	72.5±8.9	81.4±13.6	77.9±77.9	85.3±12.1	76.6±7.0
F(p)	0.975 (0.378)	0.651 (0.522)	2.804 (0.062)	0.685 (0.505)	0.400 (0.671)	1.507 (0.223)	1.381(0.253)

Category/Theme N=3	Description of category	Subcategory Facilitators (F) n=12	Subcategory Barriers (B) n=13	Both F & B
I-Patient factors	Patient factors relate to how patients and/or family, relatives can influence his/her safety according to the respondents thought.	Patient involvement in the care plan.	Non-patient involvement.	P
		Patient teaching about safety and nurse instructions to the patient or the visitors.	Patients and visitors lack knowledge about infection control and patient safety	P
			Patient culture, customs and wrong idea, over-demanding patient
II-Staff factors	Staff factors refer to various personal characteristics and behaviors of the nurses and other health care professionals the respondents perceived to influence patient safety.	Nurses/physician/HCPs knowledge and awareness about patient safety	Lack of knowledge about patient safety or inappropriate application of knowledge about patient safety	P
		Clinical exposure and training at hospital	No exposure to clinical experience and to others’ mistake	P
		Learning from others’ experiences, errors and mistakes
		Adequate clinical supervision for nurses, physician and students for safety practices	Inadequate TAs clinical supervision for students	P
		Nurses skills, competency and experience	Lack of skills and experience	P
		Teamwork, communication and collaboration	Poor communication and teamwork among health care providers regarding patient safety issues	P
			Noncompliance of staff and physicians toward patient safety, infection control measures and standard precautions
		Positive attitude toward the nurse-patient relationship
			Theory-practice gap
III-Work Environment factors	Work environment factors relate to workplace conditions, staffing, facilities and resources the respondents perceived to influence patient safety.	Workshops and training courses, health events about patient safety
			Shortage of nurses and workload on nurses
		Regulations and policies regarding to patient safety
			Unsafe hospital/work environment due to lack of supplies and equipment
		Positive attitude toward reporting errors, blame free environment and non-punishing attitude for error reporting	Fear of punishment and Reporting system	P

Ebtsam Aly Abou Hashish*1,2, Wa'ad Aljuaid3, Ohud Almuzaini3

Ebtsam Aly Abou Hashish*^1,2, Wa'ad Aljuaid³, Ohud Almuzaini³