Enhancing generational change in patient safety attitudes through peer leadership

Abstract

Background

Despite peer-led teaching demonstrating benefits in patient safety education, few studies have evaluated these programmes from the perspective of peer leaders.

Objective

To evaluate the impact of peer leader participation in a patient safety education workshop in improving their patient safety attitudes.

Participants

34 final year pharmacy student peer leaders.

Methods

An interactive peer-led patient safety workshop was delivered to 249 first year pharmacy students. Peer leaders' attitudes were assessed 2 months prior to and immediately after peer leader training; and immediately after and 1 month following the workshop. Using a validated patient safety attitudinal survey, repeated measures analysis of variance and pairwise comparisons were used to evaluate changes in four key attitudes over time: being quality improvement focused; internalising errors; questioning more senior healthcare professionals' behaviours; and attitudes towards the open disclosure of errors.

Results

Compared to baseline, peer leaders' attitudes towards open disclosure significantly improved immediately following the workshop (p=0.010) and were sustained after 1 month (p=0.028). Attitudes towards being quality improvement focused also improved significantly 1 month after the workshop (p=0.003).

Conclusions

Participation in a peer-led patient safety education programme benefits both students and peer leaders, enabling further mastery of concepts and enhancing generational change in patient safety practices.

Education in patient safety has been widely regarded as a key strategy in creating generational change in patient safety attitudes and practices of graduating healthcare professionals.¹ In recognition of this, the WHO released a Patient Safety Curriculum Guide Multiprofessional Edition in 2011 to assist healthcare schools on a global level to implement patient safety education.² One of the key recommendations of the guide is to introduce patient safety principles during the early stages of healthcare professional degree training programmes. However, already full curricula and a lack of academic staff with knowledge and experience in patient safety can be barriers to implementation. First year students may also lack the contextual understanding that is required for the delivery of effective patient safety education. Additionally, many students may also have started to develop poor practices while on experiential placements or through casual employment in assistant roles within the healthcare setting, which may limit the effective delivery of patient safety education at latter stages of professional degree training programmes.^{3 4}

Peer-led education models have the potential to provide a solution to some of these issues. Previous studies have demonstrated that peer-led education results in improvements in student retention⁵ and academic performance⁶ and specifically can improve patient safety attitudes.^{7 8} However, the success of delivering this teaching model in the long term is reliant on identifying and employing good peer leaders who are able to instil generational change. Importantly, many peer leaders volunteer their time for the benefit of their junior peers, and hence it is necessary to determine whether participation in these programmes is mutually beneficial to both peer leaders and students. However, there is currently a lack of research examining the benefits of being a peer leader in health professional programmes.⁹ Therefore, using pharmacy students as an example, this study aimed to understand the impact of participation in a patient safety education workshop as a peer leader in terms of improving peer leaders' patient safety attitudes.

An introductory patient safety education module was introduced into one of the first year professional practice units of study as part of the 4-year Bachelor of Pharmacy programme at The University of Sydney. First year students were required to attend two 1-hour patient safety face-to-face lectures, delivered by an academic with expertise in patient safety, and one 2-hour workshop, where final year pharmacy student peer leaders would role-play a scenario and then use games and activities to demonstrate potential risks to safety. Peer leaders were required to undergo a 1 day training programme delivered by the research team which consisted of four 90 min sessions. The first session involved peer leaders completing leadership exercises and thinking about how they can be effective peer leaders. During the second session, peer leaders received the same lecture on patient safety principles that was to be delivered to the first year students. In the third session, peer leaders were taught the patient safety workshop that they would be delivering, and in the final session peer leaders were required to role-play a section of the workshop to demonstrate their understanding of the material to be delivered.

The patient safety attitudes of peer leaders were investigated at four time points: 2 months prior to peer leader training; immediately after peer leader training (2 months prior to workshop delivery); immediately after they delivered the educational workshop; and 1 month following the delivery of the workshop. Attitudes were assessed using a 23 item modified version of the Patient Safety/Medical Fallibility Curriculum Survey for pharmacy students, originally developed by Madigosky et al.^{10 11} A five-point Likert-type scale was used to measure student attitudes, with possible responses ranging from ‘strongly disagree’ to ‘strongly agree’. A previous validation study among pharmacy students¹¹ identified four attitudinal factors that could be measured by the survey: being quality improvement focused; internalising errors rather than taking action; the acceptability of questioning more senior healthcare professionals' behaviours; and attitudes towards the open disclosure of errors. In order to evaluate changes in attitudes, factor-based scores were first calculated at each time point using the confirmed factor model from the validation study¹¹ followed by repeated measures analysis of variance (ANOVA) with pairwise comparisons to evaluate when changes in peer leaders' patient safety attitudes occurred.

Of the 36 peer leaders who delivered the programme, 34 (94%) completed the survey at all time points. Although there were no significant changes in peer leaders' attitudes prior to the delivery of the education programme to first year students, two of the four measured attitudes (being quality improvement focused and open disclosure) improved after teaching as a peer leader in the programme (table 1). Improvements in these attitudes may be due to an increased level of mastery of the subject matter that is required as a teacher,⁵ which maps to Miller's pyramid of clinical competence. Specifically, peer leaders' competence in these areas increased from either ‘knowing’ or ‘knowing how’ to ‘showing how’.¹²

Table 1.

Attitudinal factor-based mean scores before and after the delivery of the workshop

	Factor-based score						Change in attitude from baseline
	T1 (Baseline)	T2	T3	T4			T2	T3	T4
Attitudinal factors*	Two months prior to training	Immediately after training and 2 months prior to workshop	Immediately after workshop	One month after workshop			Immediately after training and 2 months prior to workshop	Immediately after workshop	One month after workshop
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	F(df)	p Value†	p Value‡	p Value§	p Value¶
Being quality improvement focused	9.62 (0.67)	9.80 (0.90)	9.85 (0.90)	10.01 (0.77)	2.550 (3,96)	0.060	1.000	0.567	0.003
Internalising errors**	7.99 (1.04)	8.15 (0.88)	8.35 (1.07)	8.47 (0.90)	2.874 (3,102)	0.040	1.000	0.432	0.092
Acceptability of questioning more senior healthcare professionals' behaviours	6.27 (0.59)	6.53 (0.67)	6.61 (0.64)	6.53 (0.64)	3.185 (2.447,83.205)	0.037	0.281	0.109	0.121
Attitude towards open disclosure of errors	4.86 (0.90)	5.08 (0.88)	5.30 (0.72)	5.30 (0.86)	3.769 (3,102)	0.013	1.000	0.010	0.028

*Determined by confirmatory factor analysis.¹¹

†p Value from one way repeated measure ANOVA.

‡p Value from T1–T2 pairwise comparison.

§p Value from T1–T3 pairwise comparison.

¶p Value from T1–T4 pairwise comparison.

**Reverse scored, so that higher scores indicate a more positive attitude.

ANOVA, analysis of variance.

Attitudes towards the open disclosure of errors were found to have significantly increased immediately after the delivery of the patient safety workshop and these were also sustained after 1 month. This is particularly noteworthy considering that peer leaders were volunteers and are likely to have chosen to participate in the programme as they have an interest in patient safety and at the time of participation in the programme, peer leaders had already received all their formal patient safety training. Despite patient desire and healthcare authorities requiring healthcare professionals to openly disclose errors, it remains poorly practised in clinical settings.¹³ Notably, during the delivery of the workshop, peer leaders were required to demonstrate and role-play open disclosure scenarios with the first year students. In order to teach this concept to students, peer leaders were required to increase their familiarity and be comfortable with the open disclosure process and language used during disclosure. Consequently, when peer leaders enter the workforce as trained healthcare professionals, they may be more likely to implement open disclosure in their practice.¹⁴

Despite this positive result, two factors (internalising errors rather than taking action; and the acceptability of questioning more senior healthcare professionals' behaviours) did not show improvement as a result of participating in the programme. This was unexpected given that the workshop involved role-plays highlighting the importance of questioning the behaviours of other healthcare professionals. At the time of the workshop, peer leaders were all undertaking the final semester of their Bachelor of Pharmacy programme and, as such, spend most of their time on clinical placements. As the most junior member of the clinical team, power dynamics may have influenced peer leaders' attitudes and behaviours in these aspects, overriding any positive effects of the programme.¹⁵ However, peer leaders were also volunteer students and are likely to have been motivated to participate in the programme as they already have a strong interest in patient safety, potentially limiting any observable changes resulting from participation in the programme.

Overall, this study has shown that participation in a peer-led programme enables further mastery of patient safety concepts by peer educators, and therefore is mutually beneficial for both students and peer leaders. Importantly, it will also serve to enhance generational change in patient safety attitudes and potentially results in better outcomes for patient care. Further qualitative research would be beneficial to understand the motivation for senior students to participate as peer leaders and their perceptions of how being a peer leader affects their learning and mastery of patient safety concepts.