Design and practice of a novice nurse patient safety training curriculum: a quasi-experimental study

Abstract

Background

Novice nurses are particularly vulnerable to adverse events for various reasons, making it essential to enhance their patient safety competencies to ensure overall patient safety. Patient safety training is shifting from a knowledge-based to a competency-based model, thereby bridging the gap between theory and practice.

Aims

The aim of this study was to investigate the effectiveness of patient safety training based on the ADDIE model in bolstering the patient safety competency of novice nurses, a critical factor in ensuring patient safety.

Design

A quasi-experimental study conforming to the TREND guidelines was applied.

Methods

The study was conducted from August to December 2023 in a tertiary hospital in China. The ADDIE model was used as a framework to design and implement patient safety course training for 45 nurses. The effectiveness of the training was evaluated through pre- and post-training surveys of novice nurses’ patient safety competency, collection of fourth-quarter adverse events for novice nurses in 2022 and 2023, and semi-structured interviews.

Results

The training significantly improved novice nurses’ scores on the four dimensions of patient safety competency, providing reassurance about the effectiveness of the training: adverse event reporting and response(12.73 ± 1.60/14.18 ± 1.35; t=-6.153, P <0.05), adverse event communication(12.22 ± 1.70/13.73 ± 1.70; t=-5.231, P <0.05), safe nursing practice(38.53 ± 2.45/43.31 ± 3.23; t=-7.018, P <0.05), and attitude toward adverse event reporting(6.98 ± 2.96/9.02 ± 5.02; t=-3.139, P <0.05). The rate of adverse events decreased in the fourth quarter of 2023(5.6%) compared to 2022(17.1%), this difference was not statistically significant(χ²=1.365, P >0.05). The receptiveness of novice nurses to the ADDIE model-based training program is a promising finding that underscores the potential of this approach in patient safety training.

Implications

The study serves as a reference for nursing administrators, educators, and researchers to aid in the design of patient safety education programs. Healthcare organizations should implement systematic, comprehensive, and efficient training to enhance nurses’ ability to ensure patient safety.

Patient or public contribution

The study included nurses in the intervention.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-04104-7.

Introduction

Patient safety is a core principle of global health care and is now recognized as a vast and growing global public health challenge [1]. According to the OECD report related to 2022, approximately 1 in 10 patients are harmed in healthcare, and more than 3 million people lose their lives each year due to unsafe care [2]. Encouragingly, studies have shown that more than 50% of injuries can be avoided through preventive measures [3]. The World Health Organization (WHO) considers patient safety as reducing the risk of unnecessary harm associated with healthcare to the lowest acceptable level [4]. WHO established the World Patient Safety Alliance in 2004 to address this challenge and launched the Global Patient Safety Initiative [5]. In response to the WHO’s call, China has introduced a series of patient safety management policies and strengthened the importance of patient safety management [6, 7]. We are moving towards building a safer and more efficient healthcare system through these measures.

Strengthening patient safety education is a critical initiative to effectively ensure patient safety [8], which is of vital practical significance to nursing safety by fostering the safety awareness of nursing staff and enhancing their safety knowledge and skills, thereby improving the safety competence of nursing staff. By the end of 2022, the number of registered nurses in China exceeded 5.2 million. The number of nurses in the country has been increasing yearly at an average rate of 8%, with about 300,000 novice nurses joining the nursing workforce every year [9]. Novice nurses have become an indispensable force in the nursing community. However, studies have shown that nursing staff with less than two years of experience are at high risk for adverse events [10], with novice nurses with one year of experience having the highest rate of adverse events, making them the most at-risk group [11]. Nursing adverse events (NAE) are defined as incidents arising from medical care that lead to patient mortality, extended hospital stays, or discharge with varying degrees of disability, which may include occurrences such as patient falls or medication errors during hospitalization [12]. Novice nurses, after starting their jobs, are prone to adverse events during clinical care due to knowledge gaps, lack of practical experience, and insufficient critical thinking, which poses a potential threat to patient safety [13–15]. At this stage, most schools in China need a systematic curriculum for nursing safety education, which is affected by classroom time limitations and clinical disconnection, and its training effect cannot meet clinical needs [16]. The emergence of the COVID-19 pandemic in 2020–2023 affected the whole of China, and in part of the period, all schools in China shifted from offline to online education. The clinical practice of nursing students was forced to be terminated, which further contributed to the lack of patient safety awareness among novice nurses upon entry into the profession. Therefore, systematic and targeted patient safety education for novice nurses is particularly urgent and essential.

Chinese nursing administrators are paying increasing attention to patient safety education and have explored the curriculum content and teaching format [17, 18]. Still, the existing curriculum system needs more systematicity and standardization, and the content and format of the curriculum need to be improved [16]. Therefore, we still need to expand the content of patient safety education and explore teaching methods systematically to enhance nurses’ patient safety competency. The ADDIE (Analysis, Design, Development, Implementation, Evaluation) model is a learner-centered systematic instructional design framework that works through five consecutive and interrelated phases to build an efficient training system. Initially, the ADDIE model was utilized within the military context. In the 1970s, two professors from Florida State University designed a curriculum development model for the U.S. Army [19]. The introduction of this model greatly promoted the development of instructional design theory and is now widely used in fields such as medical education [20, 21], demonstrating its effectiveness and superiority. The ADDIE model is based on systems thinking, emphasizing systematic analysis and planning of instructional design, viewing teaching as a complex system composed of multiple interrelated elements. In this model, the analysis and design phases lay a solid foundation for the training program, and they ensure a close and precise match between the training content and the learners’ needs. Immediately after that, development and implementation form the core of the training program and directly impact the quality and effectiveness of the training. On the other hand, the evaluation phase provides a strong guarantee for the training results [22] and promotes continuous improvement and enhancement of training effectiveness through constant feedback and assessment. The model effectively avoids one-sidedness and blindness of training based on in-depth analysis of training needs, careful design and development of training programs, and timely evaluation and adjustment of each link in the implementation process. It ensures the relevance and effectiveness of training content and the quality and effectiveness of training [23]. This study aims to develop a safety training course for novice nurses based on the ADDIE model and to practice training for novice nurses to improve their competence and ensure patient safety.

The study

Aim

This study aimed to assess the effectiveness of a patient safety training program based on the ADDIE model on patient safety competency among novice nurses. We sought to answer the following questions:

1. Does the patient safety training course designed based on the ADDIE model improve the improve the patient safety competence of novice nurses?

2. Does the patient safety training course designed based on the ADDIE model reduce the incidence of adverse events among novice nurses?

3. What are the training experiences and feelings of novice nurses regarding the patient safety training course designed based on the ADDIE model?

Design

We conducted a quasi-experimental study consistent with the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) guidelines [24]. In addition, we used a convergent mixed-methods approach to evaluate the effectiveness of patient safety training programs on the patient safety competence of novice nurses. A standardized quantitative survey and semi-structured interviews were conducted.

Participants

In this study, newly recruited novice nurses participated in pre-service training in 2023 at a tertiary hospital in Zhenjiang City, China, were selected by convenience sampling. Forty-five eligible novice nurses were trained using the ADDIE model-based patient safety curriculum for novice nurses. These participants had a clear understanding of the research and voluntarily signed their informed consent to take part in the study. Nurses with existing work experience at entry and nurses who had previously participated in a series of patient safety training courses were excluded from the study; in addition, nurses who were absent from work for > 2 weeks during the training period, who left their jobs during the training period, or who were unable to continue participation during the training period due to force majeure factors were excluded.

Procedure

Establishment of patient safety training team for novice nurses

The training team consisted of 11 members, of which the team leader and deputy team leader were two directors and deputy directors of the nursing department in charge of training and quality, respectively (chief nurse practitioners with rich nursing management experience), who were responsible for the overall management of the patient safety education and training for novice nurses, including the training analysis, curriculum design, supervision of the training implementation process and the evaluation of the training effect. The other nine training team members were from the departments of Medicine, Surgery, and Emergency Medicine (associate chief nurse and above, and with rich nursing teaching experience), and they were mainly responsible for developing the curriculum content and implementing the specific training.

Design and practice of a patient safety training curriculum for novice nurses based on the ADDIE model

The course used the ADDIE model as a theoretical framework for developing a patient safety training curriculum for novice nurses, including training analysis, design and development, implementation, and evaluation of training effectiveness (Fig. 1).

Fig. 1.

Novice nurse patient safety training curriculum Design and implementation process

Step 1: Analysis

To assess the learning needs of novice nurses, this study adopts a multidimensional analysis method to comprehensively understand the learning characteristics and current training status of novice nurses and to determine the training content based on the above analysis, which is carried out in the following three aspects in this stage: (a) The evaluation standards for tertiary hospitals in China clearly require a system for actively reporting nursing safety (adverse) events and hazard information [25]. Therefore, the data on adverse events in this study comes from the reports submitted by various departments in the hospital’s electronic system over the past three years. The training team organized and analyzed the detailed data on reported nursing adverse events from the previous system, and the results showed that novice nurses within their first year of employment are a high-risk group for adverse events. Special attention was paid to events such as identity verification errors, medication errors, and unplanned estuation, which were particularly common among novice nurses. (b) We organized two semi-structured focus group interviews, each consisting of 5–6 novice nurses with different educational backgrounds from 2022, with an average duration of 45–60 min. The interviews used a semi-structured outline to gain an in-depth understanding of their training needs regarding patient safety courses. The questions in the outline included: ① What do you think is the most important or useful content in the patient safety course? Why? ② What format do you hope the patient safety training course will take? The interviews revealed that most novice nurses had yet to be educated in a systematic patient safety course before joining the profession. Due to the impact of the COVID-19 pandemic, most of their courses and assessments during their schooling and internship were conducted online, resulting in insufficient mastery of practical teaching content. In addition, the novice nurses generally realized that their knowledge of patient safety needed to be improved, their ability to communicate with patients required improvement, and they were eager to obtain relevant guidance and training. At the same time, we hope to increase the diversity of training formats. We determine when to end the interview based on information saturation, meaning that when no novice viewpoints and information appear during the interview, we consider that the information has reached saturation. (c) By organizing a seminar with 11 head nurses from different departments, we solicited their opinions on previous pre-job training and the performance of novice nurses. The content of the speeches was recorded in writing on the spot, and after the meeting, it was summarized and analyzed using thematic analysis. The nurse leaders thought that in the last pre-service training, the allocation of patient safety education hours was insufficient, and the training content was not rich enough; the training form was a single theoretical lecture, which lacked novelty; they pointed out that most of the novice nurses appeared to be weak in the mastery of patient safety knowledge and were not good at combining theoretical knowledge with practical skills. Therefore, the nurse leaders hoped that the patient safety training curriculum could be optimized to enhance nurses’ self-reflection and practical skills in patient safety.

Step 2: Design

According to the existing problems and needs analysis, our training team followed the 5W1H principle and proposed the design of the patient safety training course for novice nurses from six aspects: training target (Who), training time (When), training place (Where), training goal (What for), training content (What), and training method (How) (Table 1). The training course was based on the theme of patient safety. In terms of course content, we focus on the most common and most frequent adverse events in clinical practice for novice nurses to systematize the design, but also give full consideration to the training needs of novice nurses and target the addition of relevant course modules. In teaching, we abandoned the traditional single and boring theoretical lectures and adopted the novel and exciting case workshops and the “Scary Ward” game. This fun approach creates a relaxed and pleasant learning atmosphere and enhances the training effect to a certain extent.

Table 1.

Patient safety training curriculum for novice nurses based on the ADDIE model

Who	What	What for	How	When	Where
Novice nurses novice to the profession in 2023	Patient identification, medication safety, occurrence and reporting of adverse events, nurse-patient communication.	Guaranteeing patient safety	Theoretical lectures, case workshops, breakout games	10 sessions on Friday afternoons	Conference room, clinical nursing skills centre

Step 3: Development

Based on the results of the above stages, our training team developed a patient safety training course, including training programs, training content, training format, class time, and training location. The list of training course content is shown in Table 2. The training included the following three formats: (a) Theory course: the trainer helped novice nurses to carry out the comprehension and mastery of knowledge related to patient safety in the form of knowledge review, and each part of the training content was taught for about All the training contents were made into PPT courseware and videos to support teaching. (b) Case Workshop: After each theoretical course, case analysis includes: ① Case distribution. Cases were presented in micro-video, PPT, or paper format. Before the start of the training, we carefully select real cases from the clinic and make these cases into video or courseware form. (e.g., errors in drug use from different manufacturers and specifications but with the same name, and reverse teaching cases such as nurse-patient communication in particular situations). ② Case analysis and discussion. Novice nurses are accessible to the group to analyze the reasons for adverse events, response methods, improvement measures, feelings and thoughts, etc.; the discussion time is about 20 min. ③ Scenario simulation. The trainer selected real cases in the clinic (e.g., communicating with patients who insisted on getting out of bed to urinate and defecate after percutaneous coronary intervention and were agitated). In small groups, the novice nurses demonstrated their learning through role-playing for about 20 min. (c) Horror Ward Breakout Game: To consolidate the effect of the previous training, the training team set up a three-station simulation of terror wards in the last three hours of the training program. ① Ward 1: “Pass Code”, four hidden safety hazards are in the room; team members find three, and you can enter the next level. ② Ward 2: “Avoid Traps”, each group has two opportunities to operate; each time the operation of two people with the completion of an operation, a failure to change two people again for the second operation. Failure to change two people again for the second operation (change that is, change the question), complete the operation to enter the next level, if both failed, the end of the barrier; ③ Ward 3: “Escape From The Room”, the third level of full participation in the group, in the prescribed 20 min to complete the case involved in the nursing operation, that is, the game-winning group. See Fig. 2 for the Horror Ward Breakout Game.

Table 2.

List of novice nurse patient safety training curriculum content

Training curriculum	Training contents	Forms of training	Lesson time(h)	Sites
The way you get along with me -- Patient identification system	How to get along - clinical situation The Complete List of Identification Tools Where is the identification system, process? How is identification done? Case discussion: everybody’s got a problem	Theory lecture + Case workshop	3	Conference room
Pit! Pit! Pit!-- Teaching you how to avoid the pit of medication safety	Current status, definitions and types of medication safety The dangers of medication errors What is the cause of medication errors? How can I avoid medication errors? Case study: The pits we climbed over those years	Theory lecture + Case workshop	3	Conference room
Is a small wound a big problem?! -- Risk assessment and protection of pressure ulcers	Current status of pressure injuries Staging of pressure injuries Evaluation of pressure injuries Prevention and monitoring of pressure injuries Case discussion: staging pressure ulcers stupidly	Theory lecture + Case workshop	3	Conference room
Safe Road, prevent “fall” start -- Fall risk assessment and protection	An overview of falls Factors associated with falls Risk assessment and prevention of falls What to do after a fall? Case discussion: Know the risk, prevent falling	Theory lecture + Case workshop	3	Conference room
How to play a good conduit defense battle? -- Risk assessment and prevention of unplanned extubation	How to play a good conduit defense battle? -- Risk assessment and prevention of unplanned extubation Risk factors for unplanned extubation Precautionary measures against unplanned extractions Code for catheter related care Case Study: Are you ready for the battle of Catheter protection?	Theory lecture + Case workshop	3	Conference room
How to avoid the “blood lesson”? -- Transfusion nursing and transfusion error prevention	Basics of blood transfusion Standard of blood matching and transfusion operation Common transfusion reactions How to avoid the risk of blood transfusion? Case discussion: blood for use, safe blood transfusion	Theory lecture + Case workshop	3	Conference room
Just about the shift?! -- Shift handover and patient safety	The significance of the shift handover Problems in the clinic Adverse events and analysis of causes Best evidence of nursing handover Case discussion: how to implement a good bedside handover?	Theory lecture + Case workshop	3	Conference room
Unlocking the truth behind the problem -- RCA analysis of nursing adverse events	Overview of RCA analysis Examples of applications of RCA analysis Case discussion: using the case as a lesson for change	Theory lecture + Case workshop	3	Conference room
Have you learned to communicate? -- Improvement of nurse patient communication and nursing safety management ability	Sedation safety building Patient safety building Ward safety construction Self-protection for nurses Case discussion: a case of nurse-patient communication	Theory lecture + Case workshop	3	Conference room
Horrors Ward	Teamwork, communication skills, emergency response, nursing skills	Breakout games	3	Clinical nursing skills centre

Fig. 2.

Example of horror ward breakout game

After completing the course development, training team members will discuss and modify the training content through symposiums to ensure its relevance, applicability, and effectiveness. After the design of the Horror Ward Breakout Game was completed, two nurses who had been working for one year were invited to experience the game. The problems were improved to ensure the rationalization and implementation of the Horror Ward Breakout Game.

Step 4: Implementation

The training was conducted from August 25 to October 27, 2023, according to the pre-planning, and 45 novice nurses participated in the training sessions. Before the start of the training, the novice nurses were uniformly informed about the purpose and process of the training, which took place every Friday afternoon, with a total of 10 sessions over 10 weeks. The first nine sessions were in the form of a theory course combined with a case workshop; novice nurses were free to mix in groups, 6–7 persons/group; each group drew cases for analysis and discussion, and after the discussion, each group sent one member to report the results of the discussion. The 10th course was the Horror Ward Breakout Game, where each group arrived at the Horror Ward within a specific time according to the order of the draw and played the game in turn. Before the game kicked off, the training team members introduced the rules of the game, and when the game was over, the training team members gave feedback and guidance on the problems that existed during the breakthrough game.

Step 5: Evaluation

This phase consists of both quantitative and qualitative evaluations. By using a questionnaire survey method, we compared the patient safety competency scores of novice nurses before and after training. According to previous hospital statistics, the first quarter (October to December each year) after novice nurses start their jobs is the period with the highest incidence of adverse events among novice nurses. Therefore, we compared the incidence of nursing adverse events in the fourth quarter (October to December) of 2022 for novice nurses and in 2023 for novice nurses who underwent systematic patient safety training. Based on the quantitative evaluation, semi-structured interviews were used to understand novice nurses’ experiences participating in the patient safety training curriculum. The evaluation indicators are listed below.

1. Evaluation of patient safety competence: the Patient Safety Competency Self-rating Scale developed by Li et al. (2022) was used [26], including 40 entries divided into 7 dimensions: safety nursing cognition, adverse event reporting and coping, communication of adverse events, information and evidence-based nursing practice, safe nursing practice, safe nursing duties, and attitude towards adverse event reporting. A Likert 5-point scale was used, assigning a score of 1 to 5 from very non-compliant ~ to very compliant, with one being very non-compliant and five being very compliant. The total score was calculated, with higher scores indicating better patient safety competence among nursing students. The content validity index for each entry was 0.8 to 1.0, and the content validity index for the scale was 0.98, with a Cronbach’s alpha coefficient of 0.948.

2. Incidence of adverse events for novice nurses: compare the incidence of adverse events for novice nurses in the fourth quarter (October-December) of 2022 and 2023.

3. Novice nurse training experiences: semi-structured interviews were used to understand novice nurses’ experiences participating in patient safety training. The interview guide is shown in Table 3.

Table 3.

Semi-structured interview guide

Number	Content
1	How do you feel about this patient safety training?
2	Do you think the patient safety training has helped you improve your safety awareness? How exactly did it help?
3	What aspects of this training were most appealing or made for a poor experience?
4	Do you have any suggestions or comments for improving our curriculum?

Data collection

The Nursing Department distributed an online e-questionnaire to survey novice nurses’ patient safety competence before and after the novice nurse-patient safety course training. The e-questionnaire had uniform instructions for completing the questionnaire, explaining the purpose, significance, method of completing the survey, and the anonymity, confidentiality, and voluntariness of the survey. The study participants agreed to fill in the questionnaire independently and submitted it online after completion. In this study, 45 questionnaires were returned before, and 45 were returned after the training with a 100% return rate.

The researcher conducted semi-structured interviews at the end of the training with 15 novice nurses who had participated throughout the training. The nurses were asked to speak about their feelings about their experiences during the training, the strengths of the training program, and possible weaknesses. After seeking permission from the interviewees, we recorded all the interviews using a tape recorder.

Data analysis

Quantitative data analysis

Data were analyzed using SPSS 26.0, and the measurement data satisfying normal distribution were described by mean standard deviation (). The t-test was used to compare the differences between groups; the count data were statistically described by frequency and percentage. The chi-square test or rank-sum test was used to compare the differences between groups according to needs, and α = 0.05 was the test level.

Qualitative data analysis

Interviews were conducted by a researcher trained in qualitative research techniques. Two researchers with experience in qualitative research used NVivo 12.0 software to organize the data and analyzed the interview content using Braun and Clarke’s thematic analysis method [27]. First, the two researchers repeatedly read the transcripts to familiarize themselves with the overall interview data. Next, they independently conducted open coding to develop initial codes from the data. After that, they re-read all the codes and cross-checked them, resolving any discrepancies with the help of a third researcher. Once coding was completed, the researchers organized and categorized the codes they identified, forming themes with logical connections. During this phase, the researchers continuously reflected on their own perspectives, assumptions, and biases in the coding and theme extraction process to ensure the objectivity of the research process and the rationality of theme extraction, avoiding subjective factors from interfering with the research results.

Ethical considerations

This study was conducted in a normal educational and training environment and did not involve patients, thus there were no ethical violations or privacy protection issues for the novice nurses involved in the training. The Ethics Committee of the Affiliated Hospital of Jiangsu University confirmed on August 11, 2023, that no ethical approval was required for this study. The Ethics Committee has issued an ethical exemption form for us as set out in Additional file 1. The decision was made in accordance with the policy issued by the China National Health Commission, Ministry of Education, Ministry of Science and Technology, and National Administration of Traditional Chinese Medicine (National Health Commission, Science and Education Development [2023] No. 4) in February 2023. The study complies with the Helsinki Declaration.

Furthermore, participation in the study was voluntary, and participants could withdraw at any stage of the research. All participants were provided with a detailed explanation of the study, signed an informed consent form, and received a copy of the consent document.

Results

Demographic characteristics

A total of 45 individuals were included in this study, including 9 males and 36 females; ages ranged from 21 ~ 27 (23.02 ± 1.44) years. Education: 1 postgraduate student, 34 undergraduates, 10 tertiary students; working departments: 17 in the medical ward, 10 in the surgical ward, 2 in the obstetrics, 14 in the emergency and rescue room and EICU, and 2 in the operating theatre.

Quantitative findings

Patient safety competency scores for novice nurses before and after training

Differences in patient safety competency scores before and after training in the patient safety course for 45 novice nurses were statistically significant (P < 0.05) in the four dimensions of response to adverse event reporting, communication about adverse events, safe nursing practice, and attitude towards adverse event reporting, and not statistically significant (P > 0.05) in the three dimensions of perception of safe nursing care, information and evidence-based nursing practice, and responsibility for safe nursing care(Table 4).

Table 4.

Comparison of novice nurse patient safety competency scores before and after training (n = 45)

Item	Pre-training M ± SD	Post-training M ± SD	t	p
Perception of safe care	27.09 ± 3.34	26.96 ± 2.96	0.191	0.850
Adverse event reporting and response	12.73 ± 1.60	14.18 ± 1.35	-6.153	0.000
Adverse event communication	12.22 ± 1.70	13.73 ± 1.70	-5.231	0.000
Information and evidence-based nursing practice	23.42 ± 2.53	23.33 ± 2.26	0.173	0.863
Safe nursing practice	38.53 ± 2.46	43.31 ± 3.23	-7.018	0.000
Safety care responsibility	46.60 ± 4.75	46.64 ± 4.00	-0.047	0.963
Adverse event reporting attitude	6.98 ± 2.96	9.02 ± 5.02	-3.139	0.003
Total score of patient safety competency	167.58 ± 11.43	177.18 ± 14.49	-3.446	0.001

Incidence of adverse events among novice nurses

A comparison of novice nurses in 2022 and 2023 in terms of age, gender, and education showed no statistically significant difference (p > 0.05) (Table 5).

Table 5.

Comparison of general information on novice nurses in 2022 and 2023

Groups	N	Age (years) M ± SD	Genders (n, %)		Academic qualifications (n, %)
			Female	Male	Three-year college	bachelor degree	Master’s degree
2022	43	23.26 ± 1.38	41(95.3)	2(4.7)	17(39.5)	25(58.1)	1(2.3)
2023	45	23.02 ± 1.44	37(82.2)	8(17.8)	10(22.2)	34(75.6)	1(2.2)
Statistical value		t=-0.78	χ²=2.57		Z=-1.66
P-value		0.44	0.11		0.11

A comparison of the incidence of nursing adverse events for novice nurses in the fourth quarter (October-December) of 2022 and 2023 showed no statistically significant difference (P > 0.05) (Table 6).

Table 6.

Comparison of adverse nursing event rates for novice nurses in the fourth quarter of 2022 and 2023

	Total	Adverse events for novice nurses (n, %)	Non-novice nurse adverse events (n, %)	chi-square test
				χ²	P
Fourth quarter of 2022	35	6(17.1)	29(82.9)	1.365	0.243
Fourth quarter of 2023	36	2(5.6)	34(94.4)

Qualitative findings

A total of 15 novice nurses, aged 22 ~ 24 (22.75 ± 0.75) years, 3 males and 12 females, were interviewed in this study. After reading, analyzing, and integrating the interview data from the 15 novice nurses, the training experience of the novice nurses was distilled into three themes (informative and beneficial; diversified and interesting; checking for gaps and continuous improvement).

Theme 1: Informative and beneficial

Novice nurses perceived their knowledge of patient safety as weak, did not take relevant courses during school, and even lacked opportunities for practice due to the COVID-19 pandemic. They felt that this systematic training had honed their critical and logical thinking and increased their awareness of patient safety. N7: " There is no training that is so targeted in undergraduate; this kind of training is essential. We have just graduated, we are still novice to everything, and advanced training gives us a wake-up call so that we can pay more attention to actual work.” N13: “People will have different understandings of the same issue. Case discussion is the collision of ideas, and it has also taught me to think and analyze issues from different perspectives.” N4: “Our department has little contact with blood transfusion operations, and we usually did not notice that there would be such a big hidden danger in the blood transfusion process.” N12: “This training has increased my awareness and understanding of adverse events, and in the future, if I encounter any, I will definitely report them actively.”

Theme 2: Diversified and interesting

Workshops and horror ward breakout games were used to increase the motivation of nurses to participate in the training. During the interviews, we learned that the novice nurses found the training to be rich in format and increased in fun. N6: “The training had a variety of patterns; the teacher let us discuss freely, and there were role-play and breakout games at the back, which sounded fascinating.” N10: “Every hospital has pre-service training, but I’ve never heard of a breakout game. After participating in this course, I feel like I can’t get enough of it and look forward to this training every week.”

Theme 3: Checking for gaps and continuous improvement

The novice nurses were satisfied with the patient safety training. However, they felt there were still areas of improvement in the training, such as the relatively short preparation time for the game scenarios and the failure to correct deficiencies in the set-up details promptly. In the future, in the training of novice nurses, we are committed to improving the existing problems, constantly improving the training curriculum, paying more attention to the quality of the case design and the accuracy of the simulation of real-life scenarios, and starting from the details to further provide a better teaching experience. N3: “We did it from the memory of the book, but there was a discrepancy with the actual implementation, and with the nervousness, many key points were missed, while there were ambiguous matters in some of the case settings.” N9: “The lecturer has tried his best to show us the measures to take when we encounter special cases, but the actual situation in each department is very different, and it is confusing when we encounter content that we have not encountered before, so I hope that future cases will cover all departments as much as possible.”

Mixed results

Compare and merge the quantitative and qualitative results from various aspects such as the overall effectiveness of the training, the training experience, shortcomings, and optimization suggestions. Regarding the overall effectiveness of the training, novice nurses mentioned in qualitative interviews that the training content was highly practical and improved their practical skills, which corresponds with the quantitative results showing an enhancement in novice nurses’ patient safety competencies. In the interviews, novice nurses stated that through the training, their understanding of patient safety deepened, and their ability to handle adverse events improved, which aligns with the significant improvements in dimensions such as adverse event reporting and response, safe nursing practices, communication about adverse events, and attitudes towards reporting adverse events found in the quantitative results. The quantitative research indicates that the safety nursing practice abilities of novice nurses improved after the training. The qualitative interview results suggest that this improvement is mainly attributed to the case workshops and the “scary ward” simulation game included in the training. In this study, they practiced and consolidated safe nursing operation skills by simulating actual work scenarios, which enabled them to conduct nursing operations more standardly in real clinical practice settings and thus reduce the occurrence of adverse events. In terms of shortcomings and optimization suggestions, the quantitative results show that the improvements in safety nursing cognition, information and evidence-based nursing practice, and safety nursing responsibilities were not significant after the training. novice nurses also pointed out in qualitative interviews that there is room for improvement in the authenticity of case design and simulated scenarios. They suggested that future training should focus more on the diversity and complexity of cases to better simulate real work situations. Additionally, novice nurses hope that the training can provide more personalized guidance and support to meet the learning needs of different nurses.

Discussion

It is critical to base the design of an educational curriculum on a well-established theoretical model. This study followed the five stages of the ADDIE instructional model to develop a patient safety education program. The model emphasizes that the design of educational programs should be based on the learning needs of learners, and appropriate educational strategies should be selected to motivate course designers to establish a more systematic and practical educational system, which in turn mobilizes learners’ motivation and initiative [23]. The orderly promotion of the five links ensures the integrity of the training process, which is currently applied in many fields [28–30]. Patient safety training programs for novice nurses need to be developed based on the specific circumstances of the hospital as well as the individual needs and backgrounds of the novice nurses, thus ensuring the program’s relevance. In contrast, previous studies that developed patient safety education curricula lacked in-depth analysis of learners’ training needs [31, 32], which may appear that the training curricula do not match the actual needs, affecting the effectiveness of the training. In this study, we analyzed the main types of previous nursing adverse events among the novice nurse population in our hospital to understand the situational characteristics of their occurrence. Focus group interviews were used to understand the training needs of novice nurses for patient safety training courses. A symposium was used to understand the perceptions of nurse managers on previous pre-service training and the work of novice nurses. The comprehensive analysis of the above data from different sources will be used to develop targeted training content and methods and lay the foundation for high-quality training.

Adopting appropriate training methods for novice nurses can enhance their training motivation and improve the training effect [33]. A diverse range of training strategies can help novice nurses acquire patient safety knowledge and skills more effectively. The traditional training methods are often indoctrination, with a single form of training, boring content, and a disconnect between theory and practice [34]. This study used various teaching methods such as " Workshop” and “Horror Ward Breakout Game” to stimulate novice nurses’ enthusiasm and desire to explore. Through the experiential and participatory teaching method of “Workshop” [35], novice nurses can find and solve problems in clinical case simulation to continuously strengthen their communication and clinical thinking skills. Simulation training for novice nurses through the “Horror Ward Breakout Game” develops their ability to use known theoretical knowledge to analyze and solve potentially unknown problems in practical work in near-realistic simulation scenarios.

Through evaluation, we can gain a more comprehensive understanding of the effectiveness, practicality, and satisfaction of the course design. We combined quantitative surveys with qualitative interviews, selecting patient safety competence, the incidence of adverse events, and novice nurses’ genuine views on the patient safety education course as the main indicators for analysis and discussion. The quantitative data provides us with objective, quantifiable evidence of the changes in novice nurses’ patient safety competence before and after training, as well as changes in the incidence of adverse events. Meanwhile, the qualitative data reveals in-depth insights into novice nurses’ subjective experiences and feelings during the training process, as well as the impact of the training on their actual work.

As an essential part of the clinical frontline force, the patient safety competencies of novice nurses are critical to ensuring patient safety. The results of this study showed that novice nurses’ total patient safety competency scores and their scores in the four dimensions were significantly higher after ADDIE model-based patient safety training for novice nurses compared with their scores before the training (all P < 0.05), indicating that ADDIE model-based patient safety training for novice nurses is conducive to the improvement of novice nurses’ patient safety competency. Qualitative data also indicates that novice nurses generally report that the training content is rich and practical, significantly enhancing their awareness of patient safety. For example, many novice nurses mentioned that the case analyses and discussions during the training provided them with a deeper understanding of the processes for handling adverse events, while simulation games significantly improved their emergency response skills and team collaboration efficiency. Our findings are consistent with those of previous studies from several countries that have assessed the impact of different training strategies (case studies, blended online and offline teaching, flipped classrooms, etc.) on the patient safety competence of nursing staff, including nursing students, using patient safety competence as an assessment of the outcome indicator [36–38].

Enhanced patient safety training is the first step in effectively ensuring patient safety. This study showed a decrease in the incidence of nursing adverse events among novice nurses in the fourth quarter of 2023 compared to the fourth quarter of 2022. However, the difference between the two comparisons was not statistically significant (p >0.05). Combining the nurses’ increased confidence in their work after training and their heightened awareness of patient safety from qualitative interviews, this positive change may be closely related to the implementation of the training. novice nurses reported that the training not only improved their professional skills but also enhanced their ability to identify and prevent potential risks in their actual work. The analysis may be limited as the study only examined data from one quarter in 2022 and 2023. Although this improvement in comprehensive abilities may not immediately lead to a significant reduction in the incidence of adverse events in the short term, it could have a profound positive impact on reducing nursing errors and enhancing patient safety in the long run. After Cai et al. (2020) trained junior nurses in a systematic approach to patient safety, their findings showed that the number of junior nurses who experienced all types of adverse events 1 year after training was significantly lower than 1 year before training [39]. The incidence of nursing adverse events can continue to be tracked over a more extended period to explore further the impact of this course on the incidence of nursing adverse events in novice nurses.

This study, by cross-validating quantitative and qualitative data, not only allows us to confirm the effectiveness of the training but also provides a deeper understanding of the reasons and mechanisms behind the success of the training. This offers more practically meaningful suggestions for nursing educators and managers. Future research can build on this foundation to further explore how to optimize training content and methods based on the individual differences and clinical needs of novice nurses, in order to achieve more precise and efficient patient safety education, thereby making a greater contribution to improving nursing quality and ensuring patient safety.

Limitations

This study also has the following shortcomings: firstly, this study used a class-experimental research method, which was limited by the source of the training subjects and the schedule of the training time, and only novice nurses from a tertiary general hospital, and was not compared with the traditional training methods or blank controls to judge their strengths and weaknesses. Secondly, only a self-assessment scale was used in the study to measure the change in novice nurse-patient safety competence, and the validation of the novice nurse-patient safety competence other assessments and the long-term effect has not yet been conducted, which needs to be further researched. Additionally, since the hospital collects adverse event data on a quarterly basis and only three months of data were collected at the time of writing the article, the comparison of the incidence of adverse events is limited to the fourth quarters of 2022 and 2023. This is one of the limitations of this study, and in the future, we will further track and understand the effectiveness of the course. Finally, the sample size of this study is small, and the sample source is singular, which makes the research results lack representativeness. Future research could conduct large-sample, multi-center training to further validate the effectiveness of this educational program.

Conclusion and implications

Based on the widely recognized ADDIE model, this study carefully designed and implemented an innovative patient safety training course. The course was constructed in a way that followed scientific, educational theories to ensure the systematic and practical nature of the training content; the process was efficient, optimizing resource allocation and time management through well-planned stage divisions; and the format was diversified, integrating a variety of teaching tools, such as case studies, role-playing, simulation training, etc., to accommodate nurses with different learning styles. The training program in this study improved novice nurses’ awareness of the importance of patient safety. It significantly enhanced their ability to prevent and respond to nursing adverse events in clinical practice. Through systematic training, the novice nurses could master the necessary knowledge and skills, effectively reducing the incidence of nursing errors and adverse events and providing safer, higher-quality patient care. Looking to the future, we believe such systematic and comprehensive patient safety education should be part of routine nursing education.

In addition, to further improve the effectiveness and attractiveness of the training, it is recommended that more innovative forms of teaching and learning be incorporated into the curriculum, such as virtual wards constructed with virtual reality (VR) technology. This technology, which simulates a natural medical environment, allows nurses to practice their operational skills without risk, improve their decision-making and problem-solving abilities, and thus become more confident and competent in real work scenarios.

Through ongoing education and skill enhancement, nurses will be better able to identify and manage patient safety risks, promote care team collaboration, and improve the overall quality of patient care. Ultimately, this will contribute to a safer, more efficient healthcare system with better patient health outcomes.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

All coauthors have given final approval of the submitted version. Songmei Cao and Liping Yang planned and designed the research. Fang Xu and Yiqing Liang were responsible for data collection. Teng Li and Yuan Qin performed the statistical analysis. Teng Li, Zhuoran Xia and Yuan Qin wrote the first draft. Songmei Cao and Jingjing Wang revised the draft.

Funding

There was no financial support for the study.

Data availability

The data of the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in a normal educational and training environment and did not involve patients, thus there were no ethical violations or privacy protection issues for the novice nurses involved in the training. The Ethics Committee of the Affiliated Hospital of Jiangsu University confirmed on August 11, 2023, that no ethical approval was required for this study. The Ethics Committee has issued an ethical exemption form for us as set out in Additional file 1. The decision was made in accordance with the policy issued by the China National Health Commission, Ministry of Education, Ministry of Science and Technology, and National Administration of Traditional Chinese Medicine (National Health Commission, Science and Education Development [2023] No. 4) in February 2023. The study complies with the Helsinki Declaration. Furthermore, participation in the study was voluntary, and participants could withdraw at any stage of the research. All participants were provided with a detailed explanation of the study, signed an informed consent form, and received a copy of the consent document.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.