Patients’ experiences of safety in a hospital learning department: A qualitative study

Abstract

Objectives

This study aimed to explore experiences of the safety of hospital-admitted patients in learning departments where students and nurses provide care together.

Methods

This general qualitative explorative study was conducted in a University Medical Center in the Netherlands. Patients admitted to a learning department were purposefully sampled. Semi-structured individual interviews were conducted. Data was collected between February and April 2021. Thematic analysis was used to analyse the data.

Results

Five main themes emerged after interviewing patients (n = 13): having accountable nurses, trust through autonomy and support, taking time to communicate, a safe learning environment with backup, and being unaware of being in a learning department. All patients indicated that they feel safe in a learning department.

Conclusion

Patients felt safe being admitted to a learning department and experienced no differences in feeling safe between nurses and students. Patients can feel safer in the department if they are informed in advance that they have been admitted to a learning department, so they are aware of the presence of students.

Highlights

• •Patients admitted in a learning department feel safe because there is always a supervising nurse present.
• •Patients did not mind that students are doing their internship in the department.
• •Nurses and students regularly visit the patients, which make patients feel protected and safe on learning departments.
• •Patients saw not a visible difference between a nurse and a student.

Introduction

Learning departments are increasingly being set up to train nursing students in realistic learning environments.¹ Since 2004, this innovative internship form has been used in Dutch hospitals to connect research, care, education, and innovation,^1,2 to preparing students for their future work.³ In a learning department, students learn from and with each other,^3,4 thereby creating a close learning relationship between students of vocational level and students of bachelor level.³ Furthermore, while under a nurse's supervision, students have responsibilities regarding the entire patient care.³ Results show that students trained in a hospital learning department can work independently at a quicker pace.³ Nurses who work in a learning department experience more time to guide students.³ While learning departments show promising results for students and nurses, it is unclear what influence a learning department has on patients. An especially relevant aspect is whether being admitted to a learning department influences patient safety.

Numerous health-related organisations provided definitions of patient safety. For instance, World Health Organization defined patient safety as: “the absence of preventable harm to a patient and reduction of risk of unnecessary damage associated with health care to an acceptable minimum”.⁵ The Institute of Medicine defined patient safety as: “avoiding harm to patients from the care intended to help them”.⁶ However, not much attention has been paid to patients' emotional responses. Healthcare workers' perceptions of safety might differ from patients' perceptions about safety.⁷ In this study, patient safety is seen as the feelings of safety from the patients' perspective.

Patients are not asked if they want to be admitted to a hospital learning department and if they feel safe in the department. A study on psychiatric patients describes that patients in departments compared to outpatients are expected to be more severely ill and, therefore, might experience student participation as more threatening.⁸ In addition, students in learning departments are responsible for the care, and patients do not know whether students have sufficient knowledge. However, a study of patient comfort in teaching clinics found that patients generally enjoyed their experience with medical students and believed that their involvement improved the quality of their care.⁹ These positive experiences with students can contribute to patients’ feelings of safety.

Patients' feelings of safety are not mentioned explicitly in studies of patients admitted to a hospital learning department. A study about patient attitudes towards medical students described 58.2% of patients expressing comfort with the presence of medical students.¹⁰ The most important reason for patients' comfort and satisfaction was the desire to get more attention. At the same time, the lack of students' experience was the main factor for discomfort with the presence of students.¹⁰ Patients can feel safer by getting more attention from students in a learning department. Carey et al. (2018) suggest that further research is needed that considers the patients' experiences when being cared for by students.¹¹ The concept of feeling safe has been studied mainly in intensive care units^12,13 and hemodialysis treatment.⁷ These studies show that proximity of the nurse and good communication were essential to give patients a safer feeling.^7,12,13 Research by Mollon (2014) about patients' feelings safe during an inpatient hospitalization identified four main categories of feeling safe: (a) trust in the nurse; (b) feeling cared for; (c) presence of the nurse and family; and (d) knowledge of the healthcare provider or the provider's provision of knowledge to the patient.¹⁴ It is unknown whether these factors also influence the feelings of safety of patients who are admitted to a hospital learning department. Therefore, this study focuses on patients' feelings of safety during admissions to a hospital learning department. Patients' safety experiences are important to help a learning department evaluate and adjust their nursing students' roles. Furthermore, patient experiences are essential for nursing students to become a qualified nurse.

Materials and Methods

Aim

To explore experiences of the safety of hospital-admitted patients in learning departments where students and nurses provide care together.

Design

A general qualitative explorative research design was selected. This design was chosen to gain in-depth experiences directly from patients admitted to a hospital learning department.^15,16

Population and domain

Patients admitted to a learning department in the University Medical Center Groningen in the Netherlands were purposefully sampled. Patients were eligible to participate if they met all of the following criteria: were above 18 years of age, had been admitted to a hospital learning department for at least four days (to ensure the patient has enough time to experience students and nurses on the department), and understand, read and speak the Dutch language. Patients were excluded when they could not independently provide written informed consent.

Data collection

The researcher conducted individual, one-time, semi-structured interviews to gain an in-depth understanding of patients' safety experience in a hospital learning department. These interviews lasted between 20 and 53 min. Data were collected between February 2021 and April 2021. Patients were interviewed during hospital admission and in a private room at the department. A topic list based on previous literature^17,18 is shown in Table 1. Studies about patients' safety experiences in a general hospital department were used to compile the topic list because there were no studies about patients' safety experiences in a hospital learning department. The following key aspects of patients' experienced safety were included as topics for the interview guide: information, communication, trust, and empathy. The opening question was, ‘Can you tell me something about your safety experience in a learning department?’ This question was intended to let the patients talk about their experiences in the department and create an opening for follow-up with other topics. To determine whether patients experience a difference in feeling safe between nurses and students, additional questions about experienced differences were added to the interview guide. The interview guide was peer-reviewed by the research team (authors 2, 3, 4) to ensure the feasibility and completeness of chosen topics. The interviewer took one test interview to try out interview techniques and interview guide. This test interview was included in the data collection. Data collection stopped after saturation was researched, and the following three interviews also resulted in no new codes.^19,20 The interviews were audiotaped.

Table 1.

Topic list for the interviews.

•Patient experiences of safety in a learning department •Patient experiences of communication •Patient experiences to get information •Patient experiences in trust •Patient experiences in empathy

Procedures

The study was conducted in three learning departments in a University Medical Hospital in the Netherlands: cardiothoracic surgery, lung disease, and rehabilitation. At admission, patients should receive a folder about the learning department. The researcher sent information by e-mail to the contact person of these departments. This e-mail contained a flyer for patients with an explanation of the study. Students or nurses from the learning department gave this flyer to potential participants and asked about their willingness to participate in the study. Potential participants were based on the inclusion and exclusion criteria. The student or nurse informed the researcher if a patient wanted to participate, after which an interview was scheduled.

After signing informed consent, the patient was told to talk freely about their experiences and that they could not give wrong answers. Patients depend on the healthcare providers of the learning department; it might be difficult for them to talk freely about feeling safe. The interview was therefore conducted in a closed room, where healthcare providers could not influence what the patient said. After the interview, the individual results were not shared with students or nurses from the learning departments.

Data analysis

The data was analysed according to the six phases of thematic analysis by Braun and Clarke.²¹ The analysis of the data started after two interviews were conducted. In phase one, the interviews were transcribed verbatim and read and reread by the researcher (first author) to become familiar with the data. A content analysis was performed using Atlas.ti software (V.8).²² Two interviews were independently coded by the researcher and co-researcher (second author). These codes were compared and discussed until a consensus about codes, and their interpretation was reached. The researcher systematically coded the transcripts in phase two and assessed for similarities and differences by the co-researcher. In phase three, the initial codes were collated and discussed into potential subthemes. Potential themes were developed in phase four by a thorough analysis of the first five interviews. Each new interview was compared with existing codes and subthemes. New codes and subthemes were added, and main themes were modified if necessary. The researcher reviewed these themes in phase four for consistency with the codes and entire data. In phase five, the themes were refined and further developed, naming and defining each theme by the researcher. These themes were discussed with the co-researcher. The report was drawn up in phase six, and themes were supported with illustrative quotes. During the analysis, the researcher looked for differences and similarities between nurses and students in patients experience of feeling safe.

Trustworthiness

Different techniques were used to enhance the trustworthiness of this study.²³ The credibility of the data was enhanced by researcher triangulation during data analysis and peer review by the research team throughout the study phases. The member check was done by giving a summary at the end of the interview. The co-researcher reviewed the researcher's interview techniques to enhance the quality of data collection. The transferability of the study was guaranteed by describing the diversity of the sample, the duration of the interviews, and the details for imitability. The researcher enhanced confirmability by writing memos to record methodological issues and ideas about the development of central themes. It is essential to address that the researcher also worked as a nurse but not in a hospital setting. The researcher had experience with talking to patients to build trust. The co-researcher and the other researchers from the research team were employed in the participating hospital. The 15-point checklist of Braun and Clarke was used to confirm the correct application of the six phases of thematic analysis.²¹ The ‘Consolidated criteria for reporting qualitative studies (COREQ)’ was used to facilitate reporting of the results.²⁴

Ethical issues

This study was conducted according to the principles of the Declaration of Helsinki (latest version WMA General Assembly 2013) and following the Medical Research Involving Human Subject Act (WMO).²⁵ A non-WMO statement was provided by the Medical Ethics Research Committee of the University Medical Center Groningen (File number: 202000768). All information was confidential according to General Data Protection Regulation.²⁶ To ensure the privacy and anonymity of the patients, a data management plan was developed according to the protocols of the University Medical Center.

Results

Of the 16 approached patients, 13 patients agreed to participate. The reasons for not participating in the study included having no interest (n = 2) and insufficient time (n = 1). Two patients were women, and the patients ranged in age from 56 to 76 years. Ten patients were admitted to the rehabilitation department. Two patients have previously been admitted to a learning department but did not notice any difference with this admission. Characteristics of the 13 patients are presented in Table 2.

Table 2.

Baseline characteristics of patients.

N	13
Male, n	11
Age in years, mean (range)	65 (56–76)
Education level1, n
Low	3
Medium	6
High	4
Length of Stay in days, mean (range)	22 (4–57)
Nursing department, n
Cardiothoracic surgery	2
Lung disease	1
Rehabilitation	10
Previously been admitted to a hospital learning department, n	2

¹Educational level: low = did not complete secondary school-completed low-level secondary school; medium = completed medium-level secondary school; high = completed upper-level secondary school and/or university degree.

Patients experience safety by interacting with nurses and students in learning departments. The following five main themes contributed to patients feeling safe: having accountable nurses, trust through autonomy and support, taking time to communicate, a safe learning environment with backup, and being unaware of being in a learning department. A summary of the themes, subthemes, and codes is provided in Table 3 and Figure 1.

Table 3.

Overview of main themes, subthemes, and code.

	Main themes	Subthemes	Codes
Feeling safe	Having accountable nurses	•Responsible	•Consultation •Instruction •Advice
	Trust through autonomy and support	•Act •Care provision •Involvement •Control by nurse and student	•Own value •Committed •Approach1 •Professional1 •Alertness •Protected •Check by patients themselves •Take a look1
	Taking time to communicate	•Time •Asking questions •Verbal communication •Receiving information •Empathy	•Consultation1 •Approach1 •Full answer •Direct answer2 •Students speak more freely2 •Students ask more questions2 •First contact
			•Patient centred •Active listening •Helpful1 •Professional1 •Experience2 •Atmosphere department
	Safe learning environment with backup	•Time •Care provision •Backup	•Experience2 •Familiarity2 •Direct answer2 •Nurse present to help
	Not being aware of being in a learning department	•Information •No visible distinction	•Informed •Assumed •Treat the same

¹Similarities between nurses and students regarding feeling safe experienced by patients.

²Differences between nurses and students regarding feeling safe experienced by patients.

Figure 1.

Thematic map, showing main themes, subthemes, and codes.

Having accountable nurses

Most of the time, students came to patients with their supervising nurse and received directions or advice from the nurse. This made patients feel safe because there was always a supervising nurse for each student who bore the final responsibility. In addition, a patient liked that nurses communicated with both the patient and the student, which made the patient feel involved in the care.

“The nurse gives directions … they [nurses (first author)] allow the student to have the action performed” (P11)

“ … if necessary, an experienced nurse will come along. … You can see from everything that it functions very well, giving a safe feeling.” (P8)

Trust through autonomy and support

Patients experience trust through autonomy. Allowing patients to have control and make decisions (self-empowerment) was mentioned by all patients as part of having confidence in nurses and students in the learning departments. A few patients monitored whether nurses and students had done their work correctly. This gave these patients a feeling of safety.

“I have noticed several times that I no longer received or suddenly received medication. … That was not communicated to me, but it was true [the medication was correct and confirmed trust (first author)]. I always stay alert.” (P13)

On the other hand, patients experience trust because they can receive support when needed. Nurses' and students' approach, appearance, attention, and professionalism ensure that patients feel safe and trusted. Nurses and students regularly visited the patients, and they responded quickly when a patient pressed the button, causing patients to experience a sense of protection.

“ … the fact that you press a button already helps because you know someone is coming, making me calmer. Then it gets better.” (P6)

Taking time to communicate

All patients felt that nurses and students communicated well with them and with other healthcare providers. All healthcare providers around the patient were kept informed about the patient. Nurses were not always the first contact for the patient; this depended on who had time and was nearby to visit the patient. In addition, nurses and students were consistently friendly in their approach to the patient. They provided direct and complete answers and took the time to answer the patient's questions.

“They [nurse or student (first author)] just sat at the table and took their time. They pressed the button to let their colleagues know they were busy.” (P2)

Patients noticed a difference in the amount of communication between nurses and students. The further students got in their internships, the more they communicated with patients. Students asked patients more questions than nurses did and inquired for advice from a nurse if a student could not answer a question from a patient. This often allowed patients to recognize whether the person was a nurse or a student. One patient also noticed that students speak more freely than nurses at times.

“ … an experienced nurse who comes in and says, Mr. [name], I am here to take blood samples. And a student who comes in and says Mr. [name] I am here to tease you, I am here to get some precious liquid.” (P8)

Patients felt that they had received sufficient information from nurses and students. In addition, nurses and students took time to convey the information. This is presented in the following quote:

“ … if you have anything to do with your medications or whatever. They [nurse and student (first author)] prefer to explain it three times until you fully understand it. … I am very insecure, but they take time.” (P1)

Moreover, patients noticed that nurses and students could listen actively, making patients feel understood and important. The feeling of being important was shared amongst patients, as the following quote illustrates:

“Nurses and students were all good listeners because of my illness; I had to be able to tell my story. They made me feel comfortable and safe.” (P11)

Safe learning environment with backup

Several patients noted that students sometimes take longer to perform the procedure because they do not yet have the experience and knowledge of a qualified nurse. Some patients had more confidence in nurses than in students because students do not yet have enough experience performing procedures and some patients were familiar with nurses from a previous admission. Several patients indicated that if students do not immediately know the answer to the patient's question, they will investigate it. On the other hand, nurses have that knowledge and can directly answer the patient. Patients did not mind it because they understood that students also must learn. A supervising nurse is always present for each student, making patients feel safe. Whether students carry out specific care depends on their knowledge. The following quote to illustrate:

“I know that people who will do my wound are not generally students. I know a few [students (first author)] who do it, but they have been working on me for two weeks.” (P5)

Not being aware of being in a learning department

All patients indicated they felt safe in a learning department but did not notice that they had been admitted to a learning department and could not recall being informed by a folder. On the other hand, patients did not mind that students were doing their internship in the department and were not informed about being admitted to a learning department. They assumed that students were doing an internship in the hospital because this is a place to learn in a realistic learning environment. None of the patients saw a visible difference between nurses and students because they wore the same uniform. Patients indicated that not all students present themselves as students; some patients asked if the person was a student or a qualified nurse. The patients treated students equally to nurses. This is shown in the following two quotes:

“I have not been informed that I am in a learning department. … But you know, you go to a University Medical Center. Then you know that students are doing an internship.” (P13)

“Sometimes I can not see the difference between a nurse or a student. If I do not know that person, I ask if that person is doing an internship. I would like to know who I am talking to.” (P4)

Discussion

This study explored the experiences of hospital-admitted patients regarding feeling safe in a learning department. Five main themes emerged: having accountable nurses, trust through autonomy and support, taking time to communicate, a safe learning environment with backup, and being unaware of being in a learning department. All patients indicated that they felt safe in a learning department. Patients felt safe because a nurse or student regularly visited them, a qualified nurse has final accountability for the care, and the nurses and students have professional and good communicative skills.

Patients indicated that they feel safe because there is always a supervising nurse for each student, and students would do nothing without consulting the nurse. Sayed-Hassan et al. (2012) stated that the feeling of safety and comfort is related to the supervisor's presence and indicated that privacy was the main reason for patients to feel uncomfortable with student involvement.¹⁰ The results of this study did not indicate that patients feel more uncomfortable with student involvement because they understand that students have to learn. Öster et al. (2015) showed that female patients felt less comfortable than male and young students.⁸ The two female patients did not report feeling less comfortable in this study.

All patients could not recall whether they had been informed about a learning department. In addition, patients could not see a visible difference between nurses and students because they both wear the same uniforms. Sadollahi et al. (2017) stated a significant difference between patients who were informed about the presence of students and those who were not informed.²⁷ Patient satisfaction is increased by being aware of the presence of students.²⁷ Patients want to see themselves as part of the essential support for students.²⁸ They commit themselves to students' care and allow them to develop their healthcare expertise.²⁸ The positive atmosphere between patients and students can contribute to the students' learning process and patient satisfaction.²⁸ Moreover, nurses and students can combine their knowledge, which creates a feeling of safety for patients.²⁸ The patients in this study did not indicate that being informed about a learning department would increase their feeling more satisfied and safer. Patients assumed that students do an internship in the hospital.

Patients indicated that they have no problem with students in the department. This is consistent with the study of Sayed-Hassan et al. (2012) and Ali et al. (2019).^10,29 Sayed-Hassan et al. (2012) described the acceptance rate of medical students as high because patients want to contribute to medical education, they do not mind students spending extra time with them, and the opportunity to learn more about their medical problems.¹⁰ Results of this study showed that receiving the attention of nurses and students may make patients feel safer in the department. The study of Shetty et al. (2021) found that patients believed that bedside required medical students to learn and become proficient,³⁰ which is consistent with this study.

The themes from this study shared similarities with the four main categories in the study of Mollon (2014): trust, cared for, nurse and family present, and knowledge.¹⁴ A difference between these results is that this study did not investigate whether the presence of family members provided a feeling of safety but whether the presence of students created a feeling of safety. Patients were interviewed during admission to the department, and in both studies, Lasiter (2011) and Russel (1999), patients who were no longer admitted to the department were interviewed.^12,13 The difference in time when patients were interviewed can influence results. How longer patients are discharged from the department, the more difficult it is to remember conversations and situations with healthcare providers.

Patients recruited for this study had to understand, read and speak Dutch. They were similar in cultural background. People from other ethnic groups and cultures may experience a different feeling of safety in the hospital. Research showed that immigrant patients feel misunderstood by healthcare professionals and express dissatisfaction with the treatment and care in their new country.³¹

A strength of this study was that all interviews with patients took place face to face during the department's admission so patients could recall recent events. Moreover, results were strengthened by researcher triangulation during data analysis. This increases the validity and reliability of the results. A limitation is that nurses and students had the possibility of only asking patients who were positive about the learning departments to participate. Therefore, it is possible that patients experiencing feeling unsafe were asked less to participate. Another limitation of this study is that patients who participated in this study have no difference in cultural background.

The results of this study have implications for learning departments. Supervising nurses should stand in the background when a student is caring for the patient. This gives the patient a feeling of safety. Furthermore, nurses and students need to visit patients regularly and take their time talking to them, making them feel protected and safe in learning departments. The results are in line with other studies. It is important that patients are informed that they have been admitted to a learning department because patients can feel safer if they are aware of the presence of students.

Further research is needed to determine whether these results are similar to learning departments where more acute care is offered, with a broader cultural background or differences between multiple learning departments with different specialties.

Conclusion

Patients felt safe being admitted to a learning department and experienced no differences in feeling safe between nurses and students. There was always a supervising nurse above the student who bore the responsibility, and nurses and students took their time to listen and communicate with the patient. Furthermore, nurses and students are always friendly in their approach, and they visit the patients regularly, which gives patients a safe feeling. This research shows that patient experiences are essential for patient safety in a department and also important for nursing students to become a well-qualified nurse.

Source of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest

The authors have no conflict of interest to declare.

Ethical approval

Ethical approval was obtained from the research ethics committee of the medical faculty where the study was conducted (File number: 202000768). The research objectives and methods were explained to the respondents and they signed an informed consent form to participate in this study. Participants were made aware of the fact that they could withdraw from the study at any time and a researcher guaranteed the privacy and confidentiality of their data.

Authors contributions

Jantine van der Schaaf: Conceptualization, Methodology, Writing-Original Draft. Fenna Wolthuis: Conceptualization, Methodology, Writing-Original Draft, Supervision. Pepijn Roelofs: Conceptualization, Methodology, Writing-Original Draft, Supervision. Annita van Wijlen: Resources, Writing-Review & Editing. Jojanneke van Schie: Resources, Writing-Review & Editing. Evelyn Finnema: Writing-Review & Editing. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.