This study described senior undergraduate nursing students’ emic understanding of unsafe clinical practices and learning contexts. Across both sites in this study, the resultant six viewpoints and two consensus perspectives support the premise that by virtue of their humanness, senior students are aware of their fallibility. As such, students are not immune to involvement in practices that threaten patient safety. The senior students’ perspectives of when it is most unsafe in the clinical setting reveal concerns that warrant consideration for strengthening nursing curricula to render safety praxis overt. Educators mindful of multiple students’ perspectives about clinical safety have the potential to promote professional integrity through shared consciousness and supportive educative learning partnerships [1, 11, 26, 41].
Unique to Site A is a single discrete viewpoint that emphasizes the student’s accountability for safety. This perspective, Overt Patterns of Unsatisfactory Performance, identifies that students are most unsafe if they are unprepared, lack knowledge and engage in a pattern of errors. The focus of clinical safety for these students, regardless of the quality and quantity of systemic supports, is individual competence. This viewpoint supports the need for concurrent integration of safety knowledge, skills and attitudes with clinical learning to ensure individual competence [5, 30, 32]. Without such development, it is most unsafe in the clinical setting. This perspective is similar to a blame-oriented understanding of error causation by individual practitioners . Sole responsibility for clinical safety is problematic however, given that central role of educators in the development and evaluation of student competence. Skilled educators balance the student’s right to learn in the clinical setting with the patient’s right to competent care. In the presence of Overt Patterns of Unsatisfactory Clinical Performance the patient’s right to competence care must supersede the student’s right to learn in the clinical setting. In such circumstances, immediate student removal from the clinical setting is imperative. To foster the student’s potential as a safe novice practitioner and uphold the patient’s right to safety, professional development initiatives for educators regarding their roles and responsibilities is fundamental to supporting a contemporary curriculum aligned with the safety mandate.
System accountability for patient safety is most evident across the remaining discrete viewpoints for Site A and Site B participants. These viewpoints suggest that students’ predominantly understood safety as a shared rather than individual responsibility [20, 42]. More specifically, the responsibility to uphold a culture of safety is not only the purview of students, but also educators and the nursing program as a whole. These findings support the importance of creating clinical learning environments constituted by structures, processes and practices that align with safety. It is important to note that a culture of safety does not negate an individual’s accountability for safeguarding patients [12, 19, 33]. Rather, it emphasizes the importance of partnerships focused on continuous quality improvement . As partners in the learning process, educators are responsible for guiding and evaluating students’ development of entry level competencies to uphold safety standards. Students, also members of the learning partnership, are responsible for their individual development according to professional and program standards.
All those involved in the teaching and learning of nursing must be vigilant for error prevention, detection, reporting, analysis, and if warranted, individual remediation and system reconfiguration. The findings at both program sites support the premise that vigilance is not limited to attentiveness for clinical errors, but is the impetus for the creation of a culture of safety . The results also expand this notion to shared vigilance as the simultaneous, conscious and sustained expenditure of effort to knowledgeably attend to program standards, procedures, regulatory guidelines, practice boundaries in variable care contexts by both educators and students.
A competency that is foundational to the adherence of standards, procedures, guidelines, and boundaries is critical thinking in practice [14, 30]. From a student perspective, effective teaching and learning approaches aimed at promoting clinical judgment include conceptual mapping, case studies and collaborative decision making for patient care . Each of these strategies is strengthened with regular authentic dialogue between students and educators for the purpose of articulating “what they know, how they know it, and who they are in nursing” (p. 135) . Collectively, the discrete student perspectives in this study acknowledge the merit of student educator interactions for safe experiential learning.
The importance of open dialogue about patient safety and clinical errors is not unique to nursing. Within medical education, Halbach and Sullivan’s  work supports the success of brief, forthright discussions between faculty and intermediate medical students about patient safety issues. Although these authors acknowledge a dearth of evidence for incorporating specifics about safe practice into the education of health professions, they advocate for the use of active experiential learning strategies. These include, but are not limited to genuine one-to-one discussions between students and educators, role-play, simulations, and small group peer discussions. Similarly, in nursing, the use of strategic interactions between students and educators offer an opportunity to increase knowledge about patient safety and in turn, prevent clinical errors [25, 26, 30, 41].
The two consensus perspectives, Contravening Practices (Site A) and Eroding Conventions (Site B) implore both educators and students to demonstrate nursing ontological, epistemological and praxis fundamentals to minimize safety risks. Two statements that were similarly ranked as positive indicators of unsafe clinical practice at both Site A and B were dishonesty and rushing through care. These two points of agreement suggest that professional morality and patient-centered care are areas that warrant emphasis in safety curricula. Further, positively ranked statements suggest that safety is threatened when established expectations for sound clinical judgement and action are violated by students. Based on these findings, it is imperative that nursing curricula explicitly detail the cognitive, moral, and practice parameters of safe practice to engender safety among students in the clinical setting. Unique to the consensus perspective at Site B is the importance assigned to clinical educators’ role in preserving safety through student evaluations. The rigor of clinical evaluations are influenced by educator role confidence and competence, and clarity of program expectations and policies [17, 41]. These findings support the need for ongoing development of educators as competent safety ambassadors [30, 32, 45]. Overall, senior nursing students agree that the absence of a moral consciousness, patient-centeredness, and professional competency renders clinical safety violations inevitable.
A limitation of this study was time intensive nature of the Q-sorting process by students. Some students requested additional time to thoughtfully sort the 43 Q-sample statements. The findings of this study are not generalizable, nor is this an aim of Q-methodology. The results however, offer a conceptual representation of potential areas for thoughtful consideration by educators in the mitigation of unsafe clinical practices in their respective curricula.