Knowledge, attitudes, and self-reported practices toward patient safety among nurses in selected health centers in Banadir, Puntland, and Somaliland: a multi-regional cross-sectional study

Abstract

Background

Patient safety is a fundamental component of healthcare quality, yet it remains a major challenge in low- and middle-income and fragile settings. Nurses play a pivotal role in preventing harm through their continuous patient contact, but evidence of their preparedness for patient safety in Somalia is limited. This study aimed to assess nurses’ knowledge, attitudes, and self-reported practices toward patient safety in selected primary and comprehensive health centers in Banadir, Puntland, and Somaliland.

Methods

A facility-based cross-sectional study was conducted between May and September 2025 among nurses working in primary and comprehensive health centers in Banadir, Puntland, and Somaliland. Data were collected using a structured questionnaire adapted from previously published patient safety knowledge, attitude, and practice studies, particularly Wake et al., and informed by broader World Health Organization patient safety concepts. Descriptive statistics summarized participants’ knowledge, attitudes, and practices, while Pearson’s correlation and multiple linear regression analyses examined associations and predictors of attitude and practice scores.

Results

A total of 344 nurses participated. Overall, 60.5% demonstrated good knowledge, 63.7% reported positive attitudes, and 62.2% reported good patient safety practices. Knowledge was positively correlated with attitudes (r = 0.22, p < 0.01) and practices (r = 0.30, p < 0.01), while attitudes showed the strongest correlation with practices (r = 0.63, p < 0.01). Continuing patient safety education was significantly associated with higher attitude scores (B = 3.62, β = 0.21, p = 0.014) and better practice scores (B = 0.74, β = 0.20, p = 0.016). However, the regression models explained modest variance in attitudes and practices (R² = 0.071 and R² = 0.052, respectively). Only 25.0% of participants perceived a non-punitive response to errors.

Conclusion

Nurses working in participating Somali health centers demonstrated generally favorable knowledge, attitudes, and self-reported practices toward patient safety. However, important gaps remain, especially in relation to blame-oriented perceptions and weak non-punitive responses to errors. Continuing patient safety education was associated with more positive attitudes and better reported practices, although the regression models explained only modest variance. These findings suggest that patient safety improvement in Somali health centers requires more than individual knowledge improvement; it also requires supportive supervision, non-punitive reporting systems, and stronger facility-level safety culture.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12912-026-05012-0.

Introduction

Patient safety is a core dimension of healthcare quality and an essential determinant of patient outcomes. The World Health Organization defines patient safety as the prevention of avoidable harm during healthcare delivery and the reduction of risk to an acceptable minimum through effective systems, clinical processes, and human performance [1, 2]. Despite increasing global attention, unsafe care remains a major public health concern. Approximately one in ten patients’ experiences harm during hospital care, and many of these events are preventable [3–6]. Medication errors, healthcare-associated infections, diagnostic delays, surgical complications, and communication failures continue to contribute to avoidable morbidity, mortality, and financial burden across health systems [7–9].

The burden of unsafe care is particularly pronounced in low- and middle-income countries (LMICs), where health systems often operate under conditions of limited funding, workforce shortages, weak infrastructure, and insufficient reporting and learning systems [3, 10–13]. In these contexts, patient safety is further challenged by inconsistent implementation of safety standards and limited institutional capacity for quality improvement. Although patient safety education is increasingly recognized as essential, its integration into routine training and clinical practice remains uneven in many LMICs because of financial, structural, and educational barriers [14–16]. These constraints may leave frontline healthcare workers aware of patient safety principles but unable to apply them consistently in under-resourced clinical environments.

Nurses are central to patient safety because they represent a major component of the healthcare workforce and maintain continuous contact with patients across all levels of care. Their knowledge, attitudes, and practices regarding patient safety are therefore important indicators of how safely care is delivered in routine clinical settings. In this study, the Knowledge–Attitude–Practice framework was used as a conceptual lens to examine these domains as related constructs. However, because of the cross-sectional design, the framework was applied to interpret associations rather than to suggest a causal or directional pathway. Evidence from LMICs indicates that nurses’ patient safety-related knowledge, attitudes, and practices are linked to safety culture, incident reporting, and adherence to safe clinical processes, although important gaps remain across settings [17, 18].

In Sub-Saharan Africa, previous studies have reported persistent challenges related to workforce training, patient safety culture, event reporting systems, and institutional oversight [19, 20]. Evidence from Ethiopia, Kenya, Nigeria, and other settings shows variation in nurses’ patient safety competencies, continuing professional development opportunities, and organizational support for safety improvement [17, 21–23]. These findings highlight the need for context-specific evidence, particularly from fragile and under-researched health systems where patient safety structures are still developing.

In Somalia, empirical evidence on patient safety remains limited. The health system continues to be shaped by prolonged conflict, decentralization, resource constraints, and ongoing institutional rebuilding [24, 25]. Health centers are an important point of access to care for many communities, particularly underserved populations, and nurses working in these facilities often manage high workloads with limited staffing and restricted access to formal training opportunities [25–28]. Although patient safety concerns have been recognized in broader Somali health system discussions, little published evidence describes nurses’ preparedness, perceptions, and routine practices related to patient safety in health-center settings [24–28].

Addressing this evidence gap is important because improving patient safety in fragile settings requires understanding both individual competencies and the broader conditions in which care is delivered. Compared with high-income countries, where national patient safety strategies, incident reporting systems, and accreditation mechanisms are more established, many LMICs continue to face challenges in translating patient safety principles into routine practice [29–36]. Locally generated evidence is therefore essential to inform workforce development, service improvement, and future patient safety policy in Somalia.

This study aimed to assess nurses’ knowledge, attitudes, and self-reported practices toward patient safety in selected health centers in Banadir, Puntland, and Somaliland and to identify factors associated with attitudes and reported practices. By providing evidence from participating facilities in three Somali regions, the study contributes baseline data to support patient safety research, policy dialogue, and quality improvement in Somalia and comparable fragile healthcare settings.

Methods

Study design

A facility-based cross-sectional study was conducted between May and September 2025 to assess nurses’ knowledge, attitudes, and practices regarding patient safety in health centers across Somalia. The study was carried out in primary and comprehensive health centers located in the regions of Banadir, Puntland, and Somaliland, which represent major geographical and administrative areas of the country. The final sample comprised 344 nurses, including 138 from Banadir, 109 from Puntland, and 97 from Somaliland. These facilities provide essential frontline healthcare services and employ nurses with diverse professional roles and experience levels. The study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline, and the completed checklist is provided as Supplementary File 1.

Study population and eligibility criteria

The study population consisted of nursing professionals directly involved in patient care, including practical nurses, registered nurses, midwives, and head nurses. Nurses who had been working in their current facility for at least six months were considered eligible to participate, ensuring adequate exposure to routine patient safety practices. Nurses who were on leave during the data collection period or who declined to provide informed consent were excluded.

Sample size determination and sampling technique

The sample size was estimated using a single population proportion formula with an assumed prevalence of 50%, a 95% confidence level, and a 5% margin of error, yielding an initial sample size of 384. After adding 10% to account for possible non-participation, the target sample size was 422. During the study period, 344 eligible nurses completed the questionnaire and were included in the final analysis. Participating facilities were selected purposively, and eligible nurses were recruited using convenience sampling through both facility-based contact and online professional nursing groups. Although the target sample size was 422, a total of 344 eligible nurses completed the questionnaire and were included in the final analysis. The target sample was not fully achieved because some eligible nurses were unavailable during data collection, some could not be reached because of work schedules and service demands, and others declined or did not complete the questionnaire. The final sample therefore represents nurses who were accessible and agreed to participate during the study period. This recruitment shortfall was considered when interpreting the precision and generalizability of the findings.

Data collection tool, measurement, and validation

Descriptive statistics were used to summarize participant characteristics and KAP scores. Pearson’s correlation analysis was used to assess associations among knowledge, attitude, and practice scores. Multiple linear regression was performed to identify factors associated with attitude and practice scores after checking the assumptions of normality, linearity, homoscedasticity, and multicollinearity. A p-value of < 0.05 was considered statistically significant for regression analyses, while correlations were interpreted at p < 0.01.

Data were collected using a structured questionnaire adapted from previously published patient safety knowledge, attitude, and practice (KAP) studies, particularly Wake et al., [17, 37, 39] and informed by broader World Health Organization patient safety concepts [17, 37, 39]. The questionnaire consisted of four main sections: sociodemographic characteristics, knowledge of patient safety, attitudes toward patient safety, and patient safety practices. Sociodemographic variables included age, gender, educational level, work experience, job title, and type of health facility. The knowledge domain included 11 items, the attitude domain included 9 items, and the practice domain included items related to teamwork, communication, reporting, handover, supervision, management support, non-punitive response to errors, and continuous learning.

Knowledge items were assessed using “Yes,” “No,” and “Not sure” response options. Correct responses were scored as 1, while incorrect or “Not sure” responses were scored as 0, and item scores were summed to generate a total knowledge score. Attitude items were measured using a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5), and responses were summed to produce a total attitude score, with higher scores indicating more positive attitudes toward patient safety. The practice domain assessed self-reported patient-safety-related workplace practices and behaviors using binary Yes/No items. These items reflected safety-supportive processes and behaviors, including teamwork within and across units, supervisor support, communication and feedback about errors, non-punitive response to errors, management support, safe handover and transfer, and continuous learning.

For descriptive presentation, participants scoring equal to or above the mean score for each domain were classified as having good knowledge, positive attitudes, or good self-reported practices, while those scoring below the mean were classified as having poor knowledge, negative attitudes, or poor self-reported practices. No universally validated cut-off points were available for classifying patient safety KAP levels among nurses in Somali health-center settings; therefore, mean-based cut-offs were used only for descriptive comparison and were interpreted cautiously as sample-dependent classifications rather than definitive measures of competence.

The questionnaire was reviewed for contextual relevance by three senior nursing experts and three public health/patient safety experts. The experts assessed the items for clarity, cultural appropriateness, and relevance to Somali health-center practice. Minor wording modifications were made to improve comprehension while preserving the original meaning of the items. The revised questionnaire was pretested among 20 nurses who were not included in the final analysis, and feedback from the pretest was used to refine item wording. Internal consistency was assessed using Cronbach’s alpha for the knowledge and attitude domains, which demonstrated acceptable reliability in the present sample, with Cronbach’s alpha values of 0.76 and 0.74, respectively [38]. The practice domain consisted of heterogeneous binary items reflecting different facility-level safety processes; therefore, reliability was interpreted cautiously and the practice findings were presented as self-reported workplace practices rather than directly observed behavior.

Data collection procedure

Data were collected using both online and facility-based approaches. For the online component, the questionnaire link was distributed through professional WhatsApp groups used by nurses. The first page of the form contained an eligibility statement and study information, and only eligible nurses who consented were allowed to proceed. For the facility-based component, trained data collectors approached eligible nurses in participating health centers, explained the study objectives and procedures, obtained written informed consent, and administered the questionnaire in a quiet setting. Data collectors received prior orientation to ensure consistency in participant approach, consent procedures, and questionnaire administration. Institutional and administrative permissions were obtained from participating facilities in addition to ethical approval from the SIMAD University Institutional Review Board. To reduce the risk of duplicate responses, participants were instructed to complete the questionnaire only once, and submitted responses were screened before analysis for repeated or highly similar entries. Eligibility screening was included at the beginning of the online form, and only nurses who met the inclusion criteria and provided consent were allowed to proceed. The use of both online and facility-based recruitment was intended to improve access to nurses across participating regions; however, the possibility of selection bias from online recruitment and convenience sampling was acknowledged when interpreting the findings.

Data analysis

Data were analyzed using SPSS version 26. Descriptive statistics were used to summarize participants’ sociodemographic characteristics and patient safety knowledge, attitude, and self-reported practice scores. Continuous variables were presented as mean and standard deviation, while categorical variables were summarized using frequencies and percentages. Pearson’s correlation analysis was used to assess associations among knowledge, attitude, and practice scores. Multiple linear regression analyses were performed to identify factors associated with attitude and self-reported practice scores. Before regression modeling, assumptions of normality, linearity, homoscedasticity, and multicollinearity were assessed and found to be acceptable. Regression results were reported using unstandardized coefficients, standardized beta coefficients, p-values, and R² values. A p-value of less than 0.05 was considered statistically significant for regression analyses, while correlations were interpreted at p < 0.01.

Ethical approval and participant consent

Ethical approval for this study was granted by the Institutional Review Board (IRB) of SIMAD University, Mogadishu, Somalia (Approval date: April 16, 2025; Reference No: 2025/SU-IRB/FMHS/P069). All research procedures were conducted in strict adherence to internationally accepted ethical guidelines, including the principles of the Declaration of Helsinki. Prior to enrollment, each participant received a comprehensive explanation of the study’s purpose and procedures, after which written informed consent was obtained. Participants were assured that their responses would remain confidential and were clearly informed that participation was voluntary, with the right to withdraw at any stage without any consequences.

Results

Table 1 summarizes the socio-demographic characteristics of the participating nurses. Most respondents were female and worked in primary health centers. Participants were drawn from Banadir, Puntland, and Somaliland, reflecting the study’s multi-regional scope. The sample also included nurses with varied educational backgrounds, professional roles, and years of experience.

Table 1.

Socio‑demographic characteristics of the study participants

Variable	Category	n (%) / Mean ± SD
Age (years)	Mean ± SD	36.8 ± 7.1
Work experience (years)	Mean ± SD	13.6 ± 6.9
Weekly working hours	Mean ± SD	38.2 ± 5.6
Gender	Male	96 (27.9)
	Female	248 (72.1)
Region	Banadir	138 (40.1)
	Puntland	109 (31.7)
	Somaliland	97 (28.2)
Marital status	Single	64 (18.6)
	Married	263 (76.5)
	Divorced/Widowed	17 (4.9)
Educational level	Diploma	179 (52.0)
	Bachelor’s degree	146 (42.4)
	Postgraduate	19 (5.6)
Type of health facility	Primary health center	214 (62.2)
	Comprehensive health center	130 (37.8)
Job title	Practical nurse	121 (35.2)
	Registered nurse	162 (47.1)
	Midwife	44 (12.8)
	Head nurse	17 (4.9)

Table 2 shows that participants demonstrated generally favorable knowledge, attitudes, and practices regarding patient safety. The mean knowledge score was 9.41 ± 1.07, while the mean attitude and practice scores were 34.63 ± 2.69 and 5.68 ± 1.15, respectively. Approximately 60% of the nurses had good knowledge, nearly two-thirds reported positive attitudes, and just over three-fifths demonstrated good patient safety practices.

Table 2.

Levels of knowledge, attitudes, and practices toward patient safety

Domain	Possible score range	Mean ± SD	Mean percentage	Category	n (%)
Knowledge	0–11	9.41 ± 1.07	85.5%	Good knowledge	208 (60.5)
				Poor knowledge	136 (39.5)
Attitudes	9–45	34.63 ± 2.69	76.9%	Positive attitudes	219 (63.7)
				Negative attitudes	125 (36.3)
Practices	0–8	5.68 ± 1.15	71.0%	Good self-reported practice	214 (62.2)
				Poor self-reported practice	130 (37.8)

Note: Classification was based on the sample mean score for each domain. Participants scoring ≥ mean were categorized as good/positive, while those scoring below the mean were categorized as poor/negative. These categories should be interpreted as relative descriptive classifications rather than externally validated thresholds

Table 3 highlights nurses’ understanding of key patient safety principles. Knowledge levels were high for most items, particularly those related to system-based causes of errors. Nearly all participants recognized that clinical errors can arise from multiple contributing factors and that adverse events have the potential to cause patient harm. A strong majority also agreed that patient safety reflects the overall reliability of healthcare systems and that errors require follow-up and corrective actions.

Table 3.

Knowledge of patient safety among nurses in Somalia

Item	Yes n (%)	No n (%)
The clinical environment can contribute to errors	303 (88.1)	41 (11.9)
Medical errors indicate professional incompetence	168 (48.8)	176 (51.2)
Patient safety is guided by national health policies	289 (84.0)	55 (16.0)
Patients play a role in preventing errors	281 (81.7)	63 (18.3)
Human error is inevitable in healthcare	254 (73.8)	90 (26.2)
Adverse events may harm patients	330 (95.9)	14 (4.1)
Patient safety reflects healthcare reliability	337 (98.0)	7 (2.0)
Safety culture is a key dimension of patient safety	319 (92.7)	25 (7.3)
Errors include failure to carry out planned actions	287 (83.4)	57 (16.6)
Multiple factors contribute to clinical errors	333 (96.8)	11 (3.2)
Errors require follow‑up and corrective action	336 (97.7)	8 (2.3)

Most nurses acknowledged that the clinical environment can influence the occurrence of errors and that patients themselves play an important role in preventing harm. In addition, a large proportion accepted that human error is unavoidable in healthcare. Responses to the item “medical errors indicate professional incompetence” were mixed, suggesting variation in participants’ understanding of system-based versus individual-blame explanations of error. Because this item may partly reflect blame-oriented safety culture rather than factual knowledge alone, it was interpreted cautiously and discussed separately from the other knowledge items.

Attitudes toward patient safety, as presented in Table 4, were generally positive across most items. Nurses reported feeling that management places strong importance on patient safety and that they would feel safe receiving care in their own facilities. Perceptions of teamwork, mutual respect, and staff support were also favorable.

Table 4.

Attitudes toward patient safety among nurses

Statement	Mean ± SD
Staff input is respected in my workplace	3.91 ± 0.88
It is easy to speak up about patient safety concerns	3.84 ± 0.86
Conflicts are resolved appropriately	3.62 ± 0.97
Staff support each other to ensure patient safety	3.87 ± 0.90
I feel safe receiving care in my facility	3.94 ± 0.85
Errors are handled fairly and constructively	3.78 ± 0.91
I am comfortable discussing mistakes	3.59 ± 0.93
Management prioritizes patient safety	3.98 ± 0.82
Fatigue affects performance during emergencies	4.10 ± 0.94

Note: Attitude items were measured using a 5-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Higher mean scores indicate more positive attitudes toward patient safety

Fatigue was widely recognized as a factor that can negatively affect performance during emergencies, receiving the highest agreement score. In contrast, lower scores were observed for comfort in discussing mistakes and for effective conflict resolution, suggesting that open communication and psychological safety remain areas needing improvement.

Patient safety practices reported by nurses are summarized in Table 5. Most participants indicated strong teamwork within their units and safe practices during patient handovers and transfers. Supervisory involvement and management support for patient safety were also commonly reported.

Table 5.

Self-reported patient-safety-related workplace practices among nurses

Practice item	Yes n (%)	No n (%)
Teamwork within the unit	291 (84.6)	53 (15.4)
Teamwork across units	216 (62.8)	128 (37.2)
Supervisors promote patient safety	278 (80.8)	66 (19.2)
Feedback and communication about errors	241 (70.1)	103 (29.9)
Non‑punitive response to errors	86 (25.0)	258 (75.0)
Management supports patient safety	312 (90.7)	32 (9.3)
Safe handover and patient transfer practices	302 (87.8)	42 (12.2)
Continuous learning and improvement	229 (66.6)	115 (33.4)

Note: Practice items were assessed using binary Yes/No responses. Each “Yes” response was scored as 1 and each “No” response as 0, giving a total possible practice score ranging from 0 to 8. These items reflect self-reported patient-safety-related workplace practices and should not be interpreted as directly observed clinical behavior

While feedback and communication about errors were present in many settings, a major concern was the low proportion of nurses who perceived a non-punitive response to errors. Only one-quarter of participants felt that mistakes were handled without blame, highlighting an important barrier to transparent reporting and continuous improvement.

The regression analysis shown in Table 6 identified several factors associated with nurses’ attitudes toward patient safety. Increasing age was significantly linked to more positive attitudes, suggesting that maturity and experience may shape safety perceptions. Participation in continuing patient safety education was also a strong positive predictor of attitude scores.

Table 6.

Predictors of attitude scores toward patient safety among nurses in Somalia

Predictor	B	β	p‑value
Age	0.31	0.23	0.008
Gender	1.94	0.07	0.214
Patient safety education (initial)	0.28	0.02	0.861
Patient safety education (continuing)	3.62	0.21	0.014
Years of experience	−1.21	−0.10	0.227

R² = 0.071

Other variables, including gender, initial patient safety education, and years of experience, were not significantly associated with attitudes. Overall, the model explained a modest proportion of the variation in attitude scores.

As presented in Table 7, continuing patient safety education was significantly associated with higher self-reported practice scores. Nurses who had received continuing patient safety education reported better patient-safety-related practices than those who had not received such training. Age, qualification level, and work experience were not significantly associated with practice scores. However, the model explained only a modest proportion of the variance in practice scores, indicating that other unmeasured organizational and contextual factors may also shape patient safety practices.

Table 7.

Predictors of practice scores toward patient safety among nurses in Somalia

Predictor	B	β	p‑value
Age	0.02	0.09	0.281
Continuing patient safety education	0.74	0.20	0.016
Qualification level	−0.24	−0.08	0.209
Work experience	−0.01	−0.01	0.941

R² = 0.052

Correlation analysis in Table 8 showed significant positive associations among knowledge, attitudes, and practices. The strongest association was observed between attitudes and practices, suggesting that more favorable safety-related perceptions were linked to better reported safety practices.

Table 8.

Correlation between knowledge, attitude, and practice scores

Variable	Knowledge	Attitude	Practice
Knowledge	1	0.22**	0.30**
Attitude	0.22**	1	0.63**
Practice	0.30**	0.63**	1

Correlation is significant at p < 0.01

Discussion

This study provides important multi-regional evidence on nurses’ knowledge, attitudes, and practices regarding patient safety in Somali health centers, a setting where empirical evidence remains limited. Overall, nurses demonstrated generally favourable knowledge, attitudes, and reported practices. However, the findings also reveal important weaknesses, particularly in relation to blame-oriented perceptions, limited comfort in discussing mistakes, and low perceptions of non-punitive responses to errors. These results suggest that patient safety improvement in Somali health centers requires more than individual awareness. It also requires supportive workplace cultures, fair reporting systems, leadership engagement, and continuous learning environments that allow nurses to speak openly about safety concerns without fear of blame.

The relatively favourable knowledge scores indicate that many nurses were aware of core patient safety principles, including the system-based causes of errors, the harmful effects of adverse events, and the need for corrective action after mistakes occur. This finding is consistent with international patient safety frameworks, which emphasize that errors often arise from system weaknesses rather than individual incompetence alone [1, 2, 29]. Similar findings have been reported in Ethiopia and other low- and middle-income settings, where nurses may have basic awareness of patient safety concepts despite working in resource-constrained environments [17, 19, 39]. The findings are also relevant to the recent Somali tertiary-hospital study by Hilowle et al., [26] which suggests that patient safety knowledge and attitudes may vary across different levels of healthcare delivery in Somalia. However, the mixed responses to the item “medical errors indicate professional incompetence” require cautious interpretation. This item may partly reflect a knowledge misconception, but it may also reflect blame-oriented beliefs. Such perceptions are important because they can discourage error disclosure, reduce learning from mistakes, and weaken the development of a just safety culture [13, 27, 40].

Attitudes toward patient safety were also generally positive, particularly regarding management commitment, teamwork, and mutual support. This suggests that many nurses recognize the importance of patient safety and perceive some level of institutional support within their facilities. These findings are broadly consistent with studies from Sub-Saharan Africa showing that nurses often maintain a strong professional commitment to safe care, even in settings affected by limited resources, staffing pressures, and weak infrastructure [20, 24, 41, 42]. However, lower scores for comfort in discussing mistakes and conflict resolution suggest that psychological safety remains limited in some clinical environments. This is an important finding because patient safety depends not only on whether nurses know what safe care means, but also on whether they feel able to raise concerns, report mistakes, and participate in learning without fear of punishment or negative judgment [15, 31, 34, 43–45].

The practice findings further support this interpretation. Although many nurses reported positive teamwork, supervisory support, management support, and safe handover practices, only a small proportion perceived that errors were handled in a non-punitive manner. This gap is critical. A punitive or blame-oriented response to mistakes can reduce incident reporting, prevent open discussion, and limit opportunities for organizational learning. Similar barriers have been reported in Somalia and neighboring settings, where fear of punishment, criticism, or reputational harm may discourage healthcare workers from reporting errors and near misses [27, 46, 47]. International patient safety literature also emphasizes that sustainable improvement depends on leadership, reporting systems, feedback mechanisms, and a just culture that focuses on learning rather than blame [30, 31]. Therefore, the low perception of non-punitive response in this study should be viewed as a key area for patient safety intervention in Somali health centers.

The KAP framework provided a useful structure for examining how nurses’ knowledge, attitudes, and reported practices relate to patient safety. However, the findings also show the limitations of interpreting patient safety only through an individual-level KAP lens. Knowledge was positively associated with both attitudes and practices, but the strongest association was observed between attitudes and practices. This suggests that patient safety behavior may depend not only on awareness of safety concepts, but also on the workplace climate in which nurses apply this knowledge. In settings where staff do not feel safe discussing mistakes or where errors are handled punitively, knowledge alone may be insufficient to improve practice. Therefore, the KAP framework should be interpreted alongside systems-based patient safety models that emphasize leadership, reporting culture, feedback, staffing, and institutional learning [1, 7, 21, 38].

Continuing patient safety education was significantly associated with more positive attitudes and better reported practices. This finding suggests that repeated exposure to patient safety training may help nurses develop greater confidence, awareness, and readiness to apply safety principles in routine care. Similar patterns have been reported in other low- and middle-income settings, where continuing education and in-service training have been linked to stronger patient safety culture and improved clinical performance [15, 17, 39, 43]. However, education alone is unlikely to be sufficient if workplace systems do not support safe practice. Training should therefore be combined with supportive supervision, clear reporting pathways, constructive feedback, and leadership practices that encourage learning from errors.

The modest explanatory power of the regression models is also important. Although continuing education was associated with attitudes and practices, the models explained only a small proportion of the variation in these outcomes. This suggests that other unmeasured factors may play a larger role in shaping patient safety behavior. These may include workload, staffing levels, availability of supplies, leadership style, reporting systems, team communication, supervision quality, and broader organizational culture. The non-significant associations for qualification level and years of experience also suggest that academic credentials or length of service alone may not be enough to ensure safer practice. In fragile and resource-limited settings, even experienced nurses may face the same structural barriers, including limited staffing, weak reporting mechanisms, and inadequate institutional support. This interpretation is consistent with broader patient safety literature showing that safe care is shaped strongly by system design and organizational culture, not only by individual competence [20, 30, 34].

These findings have several implications for patient safety policy and practice in Somalia. First, patient safety interventions should move beyond knowledge improvement alone and focus on the conditions that allow nurses to practice safely. Second, continuing education should be institutionalized in primary and comprehensive health centers, especially in areas where access to structured professional development is limited. Third, health facilities should prioritize non-punitive reporting systems, supportive supervision, and regular feedback mechanisms so that errors and near misses can be used as learning opportunities. Fourth, leadership development is needed to strengthen open communication, teamwork, and psychological safety within clinical units. Finally, because this study included nurses from Banadir, Puntland, and Somaliland, future research should examine whether patient safety competencies and workplace cultures differ across regions, facility types, and governance contexts.

The public health implications of these findings are important for Somalia’s developing health system. Patient safety improvement should not depend only on individual nurses’ knowledge, but should be supported through institutional and system-level interventions. Regular continuing education, supportive supervision, non-punitive incident reporting, and structured feedback mechanisms are needed to help nurses identify, report, and learn from safety events. Health centers should also strengthen teamwork, communication during handover and transfer, and leadership practices that promote psychological safety. At policy level, these findings support the need for regional and national patient safety strategies that include frontline nursing staff, routine safety monitoring, and quality improvement activities in primary and comprehensive health centers [31, 36, 43].

Overall, this study contributes important context-specific evidence to the limited literature on patient safety in Somalia. The findings suggest that nurses in Somali health centers have a reasonable foundation of patient safety knowledge and generally supportive attitudes, but that weaknesses in reporting culture and institutional support remain major barriers to safer care. Improving patient safety in this context will require a combined approach that includes continuing education, supportive leadership, non-punitive reporting systems, and broader system-level reforms. Such efforts are essential to help health workers report, reflect on, and prevent errors in a culture focused on learning rather than blame.

Strengths and limitations

This study has several notable strengths. It represents one of the first multi-regional investigations of nurses’ knowledge, attitudes, and practices regarding patient safety in Somali health centers, a context where empirical evidence remains limited. The inclusion of participants from Banadir, Puntland, and Somaliland broadens the contextual relevance of the findings and provides useful baseline evidence from different Somali health settings. The use of a structured questionnaire adapted from previously published patient safety KAP studies and informed by broader World Health Organization patient safety concepts strengthened the measurement approach and allowed comparison with related studies. In addition, the assessment of internal consistency improved the transparency of the measurement process, while the use of correlation and regression analyses allowed exploration of factors associated with attitudes and practices beyond descriptive reporting.

Several limitations should be considered when interpreting these findings. First, the cross-sectional design prevents causal inference among knowledge, attitudes, continuing education, and patient safety practices; therefore, the observed associations should not be interpreted as directional relationships. Second, the use of purposive facility selection and convenience recruitment, including online distribution through professional nursing groups, may have introduced selection bias and may limit the generalizability of the findings to all nurses or health centers in Somalia. Third, although the target sample size was 422, the final analytic sample included 344 participants, which may have reduced the precision of some estimates. Fourth, the practice domain was based on self-reported yes/no items and may therefore be affected by recall bias and social desirability bias. These responses should be interpreted as perceived or reported workplace practices rather than directly observed patient safety behavior. Future studies should complement self-reported data with direct observation, clinical audit, incident reports, and facility-level safety indicators. Fifth, the regression models explained only a modest proportion of the variance in attitudes and practices, indicating that important organizational and contextual determinants, such as staffing levels, workload, leadership support, supervision quality, reporting systems, and workplace safety culture, were not fully captured. Finally, one knowledge item related to whether medical errors indicate professional incompetence may partly reflect blame-oriented perceptions rather than factual knowledge alone; therefore, this item should be interpreted cautiously.

Conclusion

This study provides baseline evidence on nurses’ knowledge, attitudes, and self-reported practices toward patient safety in selected health centers in Banadir, Puntland, and Somaliland. Although participants demonstrated generally favorable KAP levels, important gaps remain, particularly in relation to blame-oriented perceptions and weak non-punitive responses to errors. The positive associations among knowledge, attitudes, and reported practices support the usefulness of the KAP framework as an interpretive model; however, causal or directional relationships cannot be inferred because of the cross-sectional design. Continuing patient safety education was associated with more favorable attitudes and better reported practices, although the modest explanatory power of the regression models suggests that broader organizational and contextual factors also influence patient safety. Strengthening patient safety in Somali health centers will require sustained professional development alongside system-level reforms, including supportive leadership, non-punitive reporting mechanisms, open communication, and stronger institutional safety culture.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

AHE contributed to conceptualization, methodology, data curation, formal analysis, investigation, project administration, and writing the original draft. RKI contributed to methodology, supervision, and writing—review and editing. NAM contributed to investigation, data curation, and writing—review and editing. All authors read and approved the final manuscript and agreed to be accountable for all aspects of the work.

Funding

This Research Supported by SIMAD University.

Data availability

The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was granted by the Institutional Review Board of SIMAD University, Mogadishu, Somalia, on April 16, 2025, with reference number 2025/SU-IRB/FMHS/P069. All study procedures were conducted in accordance with relevant ethical guidelines and the principles of the Declaration of Helsinki. Informed consent was obtained from all participants before participation. For facility-based data collection, written informed consent was obtained, while for online data collection, participants provided electronic consent before accessing the questionnaire. Participation was voluntary, and participants were informed that they could withdraw at any stage without any consequences.

Consent for publication

Not applicable for this study.

Competing interests

The authors declare no competing interests.