Identifying and testing a conceptual model of the individual factors that influence patient safety learning for medical students
Introduction: The field of patient safety has increased in prominence over the last decade in response to information about the harm that occurs to patients in their journeys through healthcare. Healthcare education has also responded with the introduction of patient safety into many undergraduate and postgraduate curricula. Understanding how to influence healthcare worker behaviours is key to these responses. A vital area is the influence that individual factors have on patient safety behaviours. A model of the influences on patient safety has been proposed (Jackson 2008). There is little research in undergraduates that explores this area. This thesis presents a longitudinal series of studies following a cohort of students through a medical curriculum to answer the primary question: which individual factors influence learning about patient safety? Additionally to this how could these factors be tested in relation to patient safety for medical students? Methods: The series of studies used the Medical Research Council’s framework for the evaluation of complex interventions together with Kirkpatrick’s framework to test a conceptual model of individual factors relevant to medical students in patient safety. Measurable outcomes relevant to medical students needed to be identified for each level in Kirkpatrick’s hierarchy. Study 1 used focus group data, when the students were in year 1 of the curriculum, to identify the conceptual model of the influences on patient safety for medical students at level Kirkpatrick’s level 1. Study 2 tested the conceptual model at level 2a when the cohort of students was in year 3. The study used validated questionnaires to test associations between reflective ability, and knowledge and attitudes to patient safety (Kember 1999, Patey 2007). Study 3 occurred in year five. This study identified associations between reflective ability, safe behaviours and error behaviours, in a standardised simulated ward setting. This was used to establish an association between individual factors and behaviours at level 3. Results: Pilot/Study 1: The interpretation of data from seven focus groups involving sixty students identified reflection and intellectual development as individual factors which influenced learning about error. Study 2: Sixty-one students participated and the questionnaires showed acceptable levels of reliability; Cronbach alpha for the reflection questionnaire was 0.71 and the patient safety questionnaire 0.90. The following significant associations were demonstrated: • Reflection and knowledge of actions to take for patient safety, correlation coefficient 0.44 (p=0.0002). • Critical reflection and intentions regarding patient safety, correlation coefficient 0.40 (p=0.0007) Study 3: Forty-eight students participated and the self-administered questionnaires showed acceptable levels of internal consistency, Cronbach alpha for reflection was 0.70 and for critical reflection was 0.78. The generalisability coefficient for the judgments about safe behaviour was 0.84 and for the error behaviours was 0.52. The following significant association was demonstrated: • Reflection and knowledge based errors, correlation coefficient r -0.30 (p=0.03) There were no significant correlations between critical reflection and error, and reflection and safe behaviour. Discussion: The results of these studies in a single cohort identify reflection as an individual factor that influences error behaviours as shown below add greater depth to Jackson’s model (Jackson 2008). The link between reflective thinking and a reduced rate of knowledge-based errors appears to be associated with thoughtful action with reflection rather than critical reflection transforming meaning frameworks. This series of studies identify an association between reflection and error and give a new perspective on the use of reflection in patient safety education.
Patient safety, Medical education, Reflection, Human Factors
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