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The perception of clinical risk among students of different health professions: a multicentre study

14 February 2019
Volume 28 · Issue 3



the need for health care to be safe is increasingly guiding the development of policies to improve clinical practice and education; risk management and patient safety are essential competencies for health professionals.


to examine how students working towards different degrees in Italy perceived their competence in clinical risk management and patient safety when learning in the classroom and the clinical setting.


the Italian version of the H-PEPSS questionnaire was given to 154 students; 78 were studying for a nursing degree and 76 were on the cardio-circulatory pathophysiology and cardiovascular perfusion techniques (CPCPT) degree course.


nearly half of the students (46.10%) did not feel confident about their competence in patient safety and risk management during clinical training.


significant differences in confidence between the two types of students were found in many areas, including in critical aspects of clinical risk management. However, both types of students had similar levels of confidence in some essential areas.

Patient safety has been defined as ‘avoidance of unintended or unexpected harm to the patient’ during healthcare provision, with a guarantee that methods and procedures will minimise the probability of errors and maximise the possibility that potential adverse events will be addressed promptly (Abbott et al, 2012). The international literature (Chenot et al, 2010; Butterworth et al, 2011) shows that one patient in 10 experiences harm from adverse events while receiving healthcare.

The need to guarantee patient safety is driving a continuing commitment to research with the aim of improving clinical practice and the education of all health care professionals (Day and Smith, 2007; World Health Organization (WHO), 2012). This commitment, which started at an international level with the creation of the World Alliance for Patient Safety in 2004 (Chenot et al, 2010), led to the development of centres and programmes promoting patient safety in several countries (Christiansen et al, 2010; Cooper, 2013). In Italy, the National System for Patient Safety has been operating since 2006 and regions have been drawing up plans and intervention strategies.

Knowledge and experience underpin patient safety. Therefore, academic research and refresher courses related to patient safety are essential (Mansour, 2012; Slater et al, 2012). Patient safety is fundamental to every course for both professions such as nursing (Butterworth et al, 2011; Vaismoradi et al, 2014) and for technical health workers. To improve patient safety, professional input is essential; every professional should play an active role in identifying problems within systems.

It is necessary to examine, both at an individual level and in the organisation as a whole, the dissemination of a culture of safety; this can be defined as ‘culture of responsibility, self-confidence and trust in the organisation to which you belong, where error is recognised and used for learning and for improving the system’ (Ministry of Health, 2001).

Even though commitment to patient safety is a concern and the responsibility of all health professionals, nurses play a key role (Butterworth et al, 2011; Vaismoradi et al, 2014) because of their direct, continuous involvement during convalescence and in patient care in general. Homecare nursing is increasing; nurses provide continuity of care that allows them to recognise when patients are exposed to risk at an early stage. Nurses' knowledge and experience influence patient safety to such an extent that continuing academic education is required (Abbott et al, 2012; Ginsburg et al, 2012; Cooper, 2013). The WHO proposed a European strategy on education programmes for nurses and midwives in 2001, which was subsequently reinforced (WHO, 2001; 2009; 2010).

The educational background of cardiocirculatory pathophysiology and cardiovascular perfusion technicians (CPCPTs) is considerably different from and more specialised than that of nurses. In Italy, the overriding majority of CPCPTs follow an educational path that begins and develops mainly in interventional cardiology and heart surgery. However, it also includes significant activities related to oncology such as hyperthermic intraperitoneal chemotherapy, general surgery treatments with organ perfusion systems, electrophysiology, non-invasive cardiovascular imaging and extracorporeal circulation (Ministry of Health, 1998; 2005).

The Health Professional Education in Patient Safety Survey (H-PEPSS) (Gjersing et al, 2010) is validated (Sidani et al, 2010). The Italian version, H-PEPSS_ita, is an efficient, reliable instrument for evaluating nursing students' perception of patient safety competence (Bressan et al, 2016). This tool can be useful to gain an understanding of the critical aspects of education that need to be strengthened and expanded, and when setting up safety-oriented programmes. There is a lack of research on which health professionals have a significant role in managing clinical risk and patient safety (Farokhzadian et al, 2015).

For health professionals, training plays a key role in risk perception, setting the foundations for the development of safe clinical practice (Agodi et al, 2014).

However, risk management education, which is included in many health profession programmes, is not always explicitly reported in terms of hours. Colleges tend to emphasise safety during each class, which limits analysis of the subject, and opt for a systematic approach to the topic less often and, in some cases, never (Leotsakos et al, 2014).

A culture of patient safety begins during education so it is essential to map possible critical issues at this stage.

To the authors' knowledge, there are no reported studies investigating patient safety culture among CPCPT students and there are no tools to evaluate this specifically in these professionals.

The H-PEPPS_ita was first used in nursing education in 2013 (Bressan et al, 2016). It has proven to be efficient in evaluating nursing students' self-reporting of patient safety knowledge and competence and could be used for periodical evaluation and self-assessment reports on the acquisition of patient safety skills. It is arguable that this tool could be used among CPCPT students, but no study has investigated this.

Finally, although they carry out different jobs, both nurses and CPCPTs work in the same team; it would therefore be interesting to compare them regarding patient safety culture and identify areas for improvement.

The purpose of this study is to investigate patient safety culture in a sample of nursing and CPCPT students and to validate the H-PEPPS_ita for the latter group.

There is evidence that cognitive biases and incomplete or distorted perceptions of clinical risk can arise at different levels in the practice of students—future healthcare experts—and potential risks can occur in frequently performed professional activities (Miller and LaFramboise, 2009). In the authors' hospital, nurses and CPCPTs study for two different degrees and work closely in the operating theatre every day.

In this study, the authors sought to compare the perception of these two categories of healthcare students' knowledge and skills regarding patient safety.

Materials and methods

A cross-sectional, multicentre study was carried out on a non-randomised convenience sample of students attending nursing degree courses at the University of Milan (San Paolo School of Nursing) and CPCPT students enrolled at the universities of Milan, Genoa, Insubria, Pavia, Modena e Reggio Emilia and Sapienza University of Rome.

Data collection

After authorisation had been acquired from the deans of all participating universities, the questionnaire was sent electronically to all students enrolled on the two courses. The invitation included an information document about the project, its objectives and the data management procedures. All participants were explicitly required to give their consent to the use of data obtained.

Ethical issues

The study was conducted according to the Declaration of Helsinki and Italian law on data protection. Completed questionnaires were recorded and analysed anonymously. The authors complied with the rules of the local ethics committee, which does not require formal approval for administering questionnaires to students.

Survey description

The H-PEPPS_ita tool has three sections:

  • Section 1: learning about specific areas of patient safety. This section, with 26 items, reflects the six key areas of patient safety competence: clinical safety; working in teams with other health professionals; communicating effectively; managing safety risks; understanding human and environmental factors; and recognise, respond to and disclose adverse events and close calls. For each item, respondents self-assess their confidence in what they learned in theory classes and in the clinical setting using a Likert scale (‘strongly disagree’, ‘disagree’, ‘neutral’, ‘agree’, ‘strongly agree’ and ‘don't know’) Section 2: how broader patient safety issues are addressed in health professional education. The seven items in this section focus on how broader patient safety issues are addressed in healthcare education. It is completed using a Likert scale like that in section 1
  • Section 3: comfort when speaking up about patient safety. In the four items in this section, participants report on experiences during clinical practice. They are asked to give an initial yes/no answer about a potential adverse event, then are given space to comment further on what happened.
  • In the Italian version, the Cronbach's alpha survey reliability of the first Italian test outcomes showed a coefficient of 0.938 for ‘in the classroom’ and 0.942 for ‘in clinical settings’ answers.

    Statistical analysis

    In this study, data were described as mean and standard deviation, if normally distributed, or median and interquartile range if not; the Shapiro-Wilk test was used to assess normality. The frequency of the variables between the two categories was analysed using a Chi-square test. The Mann-Whitney U test was employed to verify differences between levels of perceived competence; this statistical test evaluates the probability that differences between two variables are significant, and is used when variables are not normally distributed.


    No changes were made to H-PEPSS_ita to preserve its validity and reliability (Gjersing et al, 2010; Sidani et al, 2010; Sousa and Rojjanasrirat, 2011).

    There were 154 survey respondents, 53 men and 101 women, with an average age of 22 (IQR [21; 23] (non-Gaussian distribution, Shapiro-Wilk test P<0.05). The sample consisted of 78 student nurses (response rate 67.83%) and 76 student CPCPTs (response rate 66.09%). There was no statistically significant difference in the distribution of men and women between the two courses (P=0.212). However, age distribution differed significantly (P=0.0037); student nurses were aged 19–27 years (median 23 years, IQR [21; 24] while CPCPT students were aged 19–27 years (median 21.5 years, IQR [21; 22]).

    Ninety-three students were enrolled at the University of Milan, 21 at the University of Pavia, 26 at the University of Modena e Reggio Emilia, nine at the University of Genoa, two at the University of Insubria and three at Sapienza University of Rome. Fifty-five students were in the first year of study, 45 were in the second and 54 were in the third.

    Learning about risk management and patient safety

    Out of the total, 83 (53.90%) students had been trained specifically in clinical risk and patient safety, 68 (44.16%) had not, two (1.30%) did not remember, and one did not answer. The difference between the two courses was statistically significant (P<0.001) and in favour of technician education; 72.39% (n=55) of them received dedicated training, compared with 26.92% (n=21) of nurses.

    Adverse events and incident reporting

    More than one in three (37.67%, n=58) students had seen at least one adverse event while training, 29 (18.83%) did not know or remember and 67 (43.51%) had never seen one. There was a statistically significant difference between the two groups, with 43.42% (n=33) of CPCPT students against 32.05% (n=25) of students nurses (P=0.028) having seen an adverse event.

    Twenty-four students (15.58%) had witnessed an incident report being compiled, 118 (76.62%) had never seen this done and 11 (7.14%) did not know. The difference between the two courses was not statistically significant (P=0.201). Just one student, who was enrolled on a CPCPT degree course, compiled a report personally.

    Regarding confidence about competence around patient safety and risk management during clinical training, 46.10% of participants (n=71) did not feel confident (39 nursing and 32 CPCPT students), with no statistically significant differences between the two (P=0.539).

    Analysis of survey results

    Table 1 shows data obtained from the survey scores about perception in the classroom. As can be seen, the only area where no significant differences between the two courses was found is ‘working in team with other health professionals’.

    Section Minimum and maximum possible scores* Student nurses Student technicians P value
    Total score 26–130 72 (68; 78) 89 (83; 99) <0.001
    Clinical safety 4–20 16 (15; 17) 13 (11; 16) <0.001
    Working in team with other health professionals 5–25 15 (14; 16) 15 (13; 19) 0.847
    Communicating effectively 3–15 12 (12; 13) 9 (7; 12) <0.001
    Managing safety risks 3–15 6 (5; 8.5) 12 (10; 12) <0.001
    Understanding human and environmental factors 3–15 6 (5; 7) 12 (10; 13) <0.001
    Recognise, respond to and disclose adverse events and close calls 4–20 8 (7; 11) 15 (14; 16) <0.001
    Culture of safety 4–20 9 (8; 10) 15 (13; 16) <0.001
    * Scores on a 1–5 scale (‘don't know’ answers were excluded)

    The data obtained about ‘clinical safety’ and ‘communicating effectively’ is meaningful as it shows nursing students are more likely to perceive the development of their knowledge/skills as important than CPCPT students. In contrast, for ‘managing safety risks’, ‘understanding human and environmental factors’, ‘recognise, respond to and disclose adverse events and near misses’, CPCPT showed more interest in the classroom then nursing students.

    Table 2 shows H-PEPSS_ita data about students' perception in clinical settings. The significant differences between the two degree courses were ‘total score’, ‘communicating effectively’, ‘managing safety risks’, ‘understanding human and environmental factors’, ‘recognise, respond to and disclose adverse events and close calls’ and ‘culture of safety’.

    Data Minimum and maximum possible scores* Student nurses Students technicians P value
    Total score 26–130 71 (65; 79) 88 (82; 103) 0.009
    Clinical safety 4–20 15 (14; 16) 13 (11; 16) 0.081
    Working in team with other health professionals 5–25 15 (13; 15) 15 (12; 19) 0.3187
    Communicating effectively 3–15 10 (9; 10) 8.5 (7; 12) <0.001
    Managing safety risks 3–15 6 (6; 8) 12 (10; 13) <0.001
    Understanding human and environmental factors 3–15 6 (6; 8) 12 (10; 12) <0.001
    Recognise, respond to and disclose adverse events and close calls 4–20 11 (8; 14) 16 (14; 17) 0.02
    Culture of safety 4–20 9 (8; 10) 15 (13; 16) <0.001
    * Scores on a 1–5 scale (‘don't know’ answers were excluded)

    Again, student nurses proved to be more interested in ‘communicating effectively’ than CPCPT students. However, CPCPT students seem to be more interested than nursing students in the areas of ‘managing safety risks’, ‘understanding human and environmental factors’, ‘recognise, respond to and disclose adverse events and close calls’ and ‘culture of safety’.

    The classroom experience scores were compared with the clinical practice settings scores of the entire sample. Table 3 shows P values between scores in academic and clinical settings. There are significant differences in ‘communicating effectively’ and ‘recognise, respond to and disclose adverse events and close calls’ content areas.

    Data P value (classroom vs clinical setting) Classroom scores* Clinical setting scores*
    Total score 0.346 80 (78; 85) 79 (77; 85)
    Clinical safety 0.457 14 (13; 16) 15 (12; 16)
    Working in team with other health professionals 0.083 15 (14; 16) 15 (13; 16)
    Communicating effectively 0.02 11 (10; 12) 9 (7; 11)
    Managing safety risks 0.6325 9 (8; 10) 9 (7; 10)
    Understanding human and environmental factors 0.062 9 (7; 11) 9 (7; 10)
    Recognise, respond to and disclose adverse events and close calls 0.03 11 (10; 12) 14 (13; 16)
    Culture of safety 0.679 12 (12; 13) 13 (12; 14)
    * Median (interquartile range)

    Finally, differences in scores by year of the course were examined; those of third-year students were significantly higher (P<0.001).


    The questionnaire includes two domains, classroom and clinical practice settings, which cover risk perception at the theoretical level, knowledge acquired and its practical application. Similar results were found with student nurses and CPCPTs, probably because all students were attending classes and training in the same hospital at the time of data collection, which should reduce potential bias among first-year students, who responded to the survey at a crucial time of their education.

    The technicians reported that theoretical classes were as effective as practical training in creating a culture of clinical safety, while nurses favoured classroom learning. This might indicate the strong impact of learning about concepts of clinical practice in the classroom (Lawson et al, 2017). As regards teamworking, both groups of students considered classroom and clinical practice training equivalent.

    Nursing students had higher scores regarding effective communication in classroom education than CPCPT students. This may be because clinical practice settings are perceived as more informal, with lower levels of perceived judgment (Kahan et al, 2006). CPCPT students had lower scores regarding communication skills than nurses, which might be because they were underconfident (Bacha et al, 2017). Scores for ‘understanding human and environmental factors’ were the same in the classroom and clinical setting.

    In the ‘recognise, respond to and disclose adverse events and close calls’ area, nursing students said that theoretical education was better than practical training, although they were not confident in this domain. In contrast, they said ‘safety culture’ was unsatisfactory in their clinical practice; this finding was comparable to the technicians' group and is consistent with the literature (Lawson et al, 2017).

    A significant number of students did not feel confident about their competence around patient safety and risk management during their theoretical and practical education, although they perceived learning as important. A lack of knowledge is likely to affect their perception of risk, which could increase the likelihood of harm. This should be taken into consideration by hospital managers as well as educators, considering the practical implications of this finding for patient safety.

    The literature suggests that universities improve patient safety education for nurses (Vaismoradi et al, 2014) in both classes and training in clinical settings (Tella et al, 2014), and introducing learning assessment tools (Sullivan et al, 2009).

    Further studies should focus on introducing and evaluating programmes about patient safety in university education (Ginsburg et al, 2013), especially in the CPCPT degree course.

    The tool validated in this study could be used in future research to assess the evolution of patient safety skills in students; this possibility is presently being taken into consideration by the authors' research team.


    According to some authors (Tella et al, 2014) it is possible that, despite educational efforts to develop individual and teamwork skills, limitations in clinical settings still exist. For example, nursing students are not always involved in teamwork, mainly because they follow a single clinical tutor who is responsible for their education. Moreover, students are not always directly exposed to group dynamics, and sometimes their attention is rather focused on their learning targets. Students focused on their own learning objectives are likely to be missing important aspects of interaction within their working group, and teamwork is a fundamental skill in the operating theatre.

    The present study was conducted in Italy; notwithstanding the limited number of students, our results are comparable to those resulting from the first validation work of the instrument in Italian (Bressan et al, 2016) whose sample of 574 nursing students was larger.


  • All health professionals need to be competent in patient safety and risk management
  • Nurses' knowledge and experience influence patient safety to such an extent that continuing academic education on this is required
  • A significant percentage of students do not feel confident about their theoretical and practical training in patient safety; a lack of knowledge is likely to affect their perception of risk, which could increase the likelihood of harm
  • CPD reflective questions

  • Why is it important to evaluate nursing students' perceptions of patient safety?
  • Should perception of clinical risk and patient safety be included in a multidisciplinary plan to prevent errors and ensure safety in healthcare?
  • What is the role of health professionals in preventing errors and ensuring patient safety?