Skip to main content

Does problem-based learning education improve knowledge, attitude, and perception toward patient safety among nursing students? A randomized controlled trial

Abstract

Background

Patient safety is a top priority for any health care system. Most universities are looking for teaching methods through which they would be able to enhance students’ clinical decision-making capabilities and their self-centered learning to ensure safe and quality nursing care. Therefore, this study aimed to determine the effect of patient safety education through problem-based learning (PBL) on nursing students’ knowledge, attitude, and perceptions toward patient safety.

Methods

This randomized, controlled trial was conducted from September 2019 to January 2020. A total of 78 fourth-year nursing students participated in this study. The participants were randomly assigned to either the intervention group or the control group. In the intervention group, the educational materials were presented to the students using the PBL method during eight sessions of 45–60 min. In each control group, nursing students received eight education sessions through lectures and discussing the same educational content. Data were gathered 1 month after the intervention using demographic information and knowledge, attitudes, and perception questionnaires. Data were analyzed in SPSS ver. 22.0 using descriptive (mean and standard deviation) and inferential (chi-square test, independent t-test, paired t-test, and analysis of covariance (ANCOVA)) statistics.

Results

The results indicated that the difference in the mean scores of knowledge, attitudes, and perceptions of the nursing students about patient safety was statistically significant between the two groups after the PBL education (p = 0.001). The mean scores of students’ knowledge, attitude, and perceptions of patient safety increased significantly in the intervention group.

Conclusions

Implementing patient safety education through PBL positively affects knowledge, attitudes, and perceptions of patient safety among nursing students. Thus, the research team recommended the PBL method to be used by nursing professors to improve nursing students’ clinical skills and cognitive abilities to ensure safe patient care.

Trial registration

IRCT20190925044881N1; October 17, 2019.

Peer Review reports

Background

Patient safety is a priority issue for all health care systems worldwide [1, 2]. Providing safe and error-free care is the ultimate goal of all healthcare systems [3]. Nurses are leading healthcare team members [4], and they have a fundamental responsibility to ensure patient safety [5]. It is estimated that there are 421 million hospital admissions worldwide every year. Meanwhile, approximately 7.42 million cases of adverse events occur during these hospitalizations, making patient harm is the 14th leading cause of global deaths [6]. Furthermore, one in every ten patients is harmed while receiving hospital care as the world health organization (WHO) considers patient safety as an endemic and epidemic concern [7]. Annually, more than 400,000 premature deaths occur due to preventable adverse events, and the incidence of serious harm is 10 to 20 times higher than the mortality rate [8]. In clinical settings, nursing students sometimes participate directly in unsafe care, errors, adverse events, and poor patient care. For that reason, like other healthcare team members, they should use their knowledge, attitude, and perception of patient safety while caring for the patient [9]. Lack of patient safety knowledge is one of the nursing students’ educational problems that lead to unsafe practice [10]. Mansour and Francis (2013) stated that graduate nurses should have sufficient knowledge to identify potential safety risks, and they should have the confidence to protect patients against preventable harm or adverse events [11, 12].

On the other hand, an unsafe attitude is a precursor to adverse events because it shapes and influences the behavior, so any change in attitude has a significant effect on people’s safety behavior [13]. Nowadays, it is widely accepted that optimal patient safety development is not possible without a safe attitude in health care facilities [14]. Therefore, nurses’ attitude toward patient safety is very important to promote a safe environment for patients [15]. Nurses’ perceptions are the foundation of any behavior and lead to actions that affect patient safety and are vital for all hospitals and healthcare providers [16].

Hence, evaluating nursing and medical students’ knowledge, attitude, and perceptions toward patient safety is necessary because they are future healthcare professionals [17]. Most universities around the world are looking for teaching methods through which they would be able to enhance students’ clinical decision-making capabilities and self-centered learning [18]. In recent decades, the use of new and active student-centered learning methods has been trending strongly with educational systems [19]. The PBL is an innovative educational method that focuses on one problem, either assigned by the students or by the teacher [20], and it has been adopted in medical sciences such as nursing, midwifery, dentistry, and medicine in many universities around the world [21]. The PBL is a student-centered pedagogy in which students and professors are responsible partners in the learning-teaching process, and teaching is a way to facilitate learning [22]. The purpose of this method in medical education is to acquire basic clinical knowledge, make progress in personal learning skills, and evolve in dealing effectively with challenges at the patient’s bedside, and ultimately improve dynamism and motivation for learning [23].

As members of the healthcare team, nurses play a vital role in improving patient safety, originating from their attitudes, knowledge, and skill in patient safety [15, 24]. Also, the WHO emphasizes teaching patient safety to medical and nursing students, and the ministries of health focus on patient safety programs [25]. Given the widespread adoption of PBL in medical and nursing schools worldwide and many nursing education, experts believe that PBL can bridge the gap between theory and practice [26, 27]. Thus, this study aimed to determine the effect of patient safety education through PBL on nursing students’ knowledge, attitude, and perceptions toward patient safety.

Methods

Research design and setting

This randomized, controlled trial was conducted in the Urmia School of Nursing and Midwifery from September 2019 to January 2020. This study was permitted by the Review Board of Urmia University of Medical Sciences (IR.UMSU.REC.1398.219) and obtained a registration code from the Iranian registry of clinical trials (IRCT20190925044881N1).

Study participants

In this study, all fourth-year nursing students who met the inclusion criteria constituted the study population. The inclusion criteria consisted of the following: (i) willing to participate in the study, (ii) being a fourth-year nursing student, and (iii) having no involvement in the same educational programs. The exclusion criteria included the following: (i) unwilling to stay in the research, and (ii) having more than two absences from the educational sessions. Based on the previous similar study (the mean and standard deviation of the problem-based learning score was 6 ± 2.14 and 7.76 ± 2.18 in the control and intervention groups, respectively) and considering the effect size (ES) = 0.814, α = 0.05, and power of 90%, the sample size was measured 32 for each group [28]. A total of 78 fourth-year nursing students were recruited into the study to consider a drop-out rate of 10%. Cohen (1992) suggested that an effect size of 0.80 is large enough to enable us to compare an experiment’s effect-size findings to a known benchmark [29].

$$ n=\frac{{\left({Z}_{1-\frac{\alpha }{2}}+{Z}_{1-\beta}\right)}^2\left({\delta}_1^2+{\delta}_2^2\right)}{{\left({\mu}_1-{\mu}_2\right)}^2} $$
$$ {\mathrm{n}}_1={\mathrm{n}}_2=\frac{{\left(1.96+1.28\right)}^2\left({2.18}^2+{2.14}^2\right)}{{\left(7.76-6\right)}^2}=31.63\cong 32 $$

Randomization

The department manager had divided the participants into nine groups based on the internship curriculum. The second researcher randomly allocated the participants into five intervention (n = 43) and four control (n = 35) groups. The simple randomization was used to allocate nursing students to either control or intervention groups. The random allocation was as follows: the first researcher assigned a name to each of the nine groups and placed the groups’ names inside opaque envelopes. The first five groups picked from the envelope were considered the intervention groups. The remaining four groups were recognized as the control groups.

Outcome measure

A two-part questionnaire was used to collect data: a demographic information questionnaire and a questionnaire on nursing students’ knowledge, attitude, and perceptions toward patient safety. It was adopted from Leung’s (2010) [30] and Madigoskay et al. (2006) [31] studies. This questionnaire comprises 26 questions, of which six questions assess students’ knowledge about patient safety (primary outcome), eight questions assess their attitude or tendency towards patient safety (secondary outcome), and 12 questions assess students’ perception of patient safety (secondary outcome). This questionnaire is scored on a 5-point Likert scale. In section 1 (attitude and perception items) of the questionnaire on patient safety, the 5-point Likert scale is scored as follows: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree, and in section 2 (knowledge items), this scale is scored as follows: 1 = very poor, 2 = poor, 3 = fair, 4 = good, 5 = very good. In a study by Nabilou et al. (2015), this questionnaire was first translated into Persian, and then it was re-translated into English (forward and backward translation method) and reviewed by two faculty members who were skillful at the English language. Ultimately, the necessary adaptations were made to the questionnaire. The research team and four patient safety experts reviewed the questionnaire and confirmed its validity. The reliability of the questionnaire was also confirmed using the internal consistency method with Cronbach’s alpha of 0.723 [25].

Study interventions

The PBL-based education

Implementing the educational process was such that in each session, the first researcher presented a written scenario to the students about knowledge, attitude, and perception of patient safety in the intervention group. Students had a week to review the scenario. A problem-based learning method was implemented to investigate each scenario in the intervention group. The PBL method’s steps were as follows: In the first step, the instructor asked the students to read the problem scenario and encouraged them to clarify vague concepts. In the second step, the problem was defined by the instructor. In the third step, the students had the brainstorming and group discussion about the problem. In the fourth step, students listed the facts, generated hypotheses based on the scenario content, and answered the questions based on the nursing process to achieve educational goals. In the fifth step, they reached a consensus on learning objectives within the group, and the instructor assured them in achieving complete, comprehensive, and appropriate goals. In the sixth step, they conducted independent and group study to gather information by using the library and the internet from resources introduced. In the seventh step, the instructor presented and analyzed the solutions based on the hypotheses, goals, and questions, conducted the interdisciplinary discussion, summarized and evaluated the proposed solutions (Table 1).

Table 1 Steps of the PBL-based intervention

In each of the five intervention groups, eight education sessions of 45–60 min were conducted. Then, a total of 40 sessions was carried out using the PBL in this study. The instructor reviewed the scenario delivered to the students last week at the beginning of each session. At the end of the session, the instructor presented the following week’s scenario to the students.

Routine education

In the control groups, the researcher performed routine education to teach the same educational content regarding patient safety. The hospital’s routine method was to lecture and discuss educational content. The students had eight routine sessions in each control group. A total of 32 sessions took place in the control groups (See supplementary file).

Data collection procedure

The second researcher held the introductory session at Urmia School of Nursing and Midwifery. He introduced himself to the participants and presented the study process and objectives for them. Participants completed questionnaires after they signed a written informed consent form. The study intervention lasted for 4 months. Then, all the participants filled in the questionnaire on patient safety 1 month after the intervention. The second researcher held the PBL educational sessions for nursing students in the control group after the intervention finished.

Data analysis

Collected data were entered into SPSS software version 22.0 (IBM Corp., Armonk, NY. USA) and analyzed using descriptive (mean and standard deviation) and inferential (chi-square test, independent t-test, paired t-test, and analysis of covariance (ANCOVA) statistics. The CONSORT flow diagram of the study is presented in Fig. 1. The CONSORT 2010 checklist was utilized to ensure quality reporting in the present study [32].

Fig. 1
figure1

CONSORT flow diagram of the study

Results

Seventy-eight nursing students entered the analysis, with no attrition in this study. The results indicated no statistically significant difference between the two groups in terms of age, gender, semester, marital status, residency, interest in the nursing major, clinical work experience, and grade point average (GPA), indicating that the two groups were homogeneous (Table 2).

Table 2 Demographics of the participants in the intervention and control groups

The results of the paired t-test indicated that the mean score of patient safety knowledge in the control group did not differ significantly before and after the intervention (p = 0.279). However, the mean score of patient safety knowledge in the intervention group increased significantly after the intervention (p = 0.001) (primary outcome). Moreover, based on the paired t-test result, the mean score of students’ attitudes toward patient safety was not significantly different in the control group after the PBL education (p = 0.529). However, the difference was statistically significant in the intervention group after the PBL education as the mean score of students’ attitudes about patient safety increased significantly after the intervention (p = 0.016) (secondary outcome). The paired t-test also showed no significant difference in the mean score of the students’ perception of patient safety in the control group before and after PBL education (p = 0.122). Nevertheless, the mean score of students’ perception of patient safety increased significantly in the intervention group after PBL education (p = 0.037) (secondary outcome) (Table 3).

Table 3 Comparison of the mean scores of patient safety knowledge, Patient safety attitude, and the perception of Patient safety between and within the intervention and the control group before and after the intervention

A significant difference was found in the mean score of patient safety knowledge between the control and the intervention group before and after the intervention (p = 0.001). No statistically significant difference was revealed in the mean score of students’ attitudes toward patient safety between the two groups before the intervention (p = 0.152). However, the difference was statistically significant between the two groups after the PBL education (p = 0.006). Consequently, the PBL positively affected students’ attitudes about patient safety in the intervention group. The independent t-test demonstrated that the difference in the mean score of the students’ perception of patient safety was not statistically significant between the two groups before the intervention (p = 0.264). Moreover, after the intervention, the mean score of students’ perception toward patient safety increased significantly in the intervention group compared to the control group (p = 0.001). Accordingly, the PBL had a positive effect on the mean score of students’ perceptions of patient safety in the intervention group.

Because there was a significant difference in the mean score of patient safety knowledge between the two groups before the intervention (Table 3), we used ANCOVA analysis to ensure that the significant difference in the mean score of patient safety knowledge after the intervention is due to the PBL educational approach, not the effect of the pre-interventional knowledge in the intervention group. After checking Levene’s test to confirm the homogeneity of variance between the two groups, we used ANCOVA analysis and confirmed the effect of PBL on the mean score of knowledge differences between the two groups after intervention (f = 40.90, p < 0.05) (Table 4).

Table 4 Results of ANCOVA test for mean scores of knowledge in control and intervention groups

Discussion

The results showed that the students’ knowledge about patient safety increased significantly after PBL educational approach. The results of the following studies are consistent with our study results. Meo (2013) showed that the students who were educated through the PBL method acquired significantly higher knowledge and skill compared to the students who were educated through lecture-based learning [33]. A study conducted by Yew and Goh (2016) showed that PBL is an effective teaching and learning approach, especially when evaluated for long-term knowledge retention and applications [34]. PBL is a preferential method for both the long-term retention of course content and the use of clinical skills [35]. It plays an important role in improving the knowledge horizons and learning skills and enriching the teamwork experience. Moreover, the tutor’s role as facilitators and motivators for appropriate activities is one of the main reasons for improving knowledge in PBL sessions [36]. PBL can improve nurses’ education by teaching them how to apply theory to clinical practice and develop their problem-solving skills [37]. It encourages students to be self-centered and promotes their critical thinking, leadership, and teamwork skills [38]. Dring (2019) revealed that PBL prepares students to work together and effectively communicate to provide more patient-focused care [39]. Contrary to our findings, Arpanantikul and Luecha (2010) reported that engaging in collaborative learning is considered a challenge, and the PBL method has failed to improve learning processes and knowledge acquisition. They concluded that nursing students in the PBL method discuss non-specific issues, fail to create group ideas, and obtain incomplete and superficial knowledge [40].

Our result revealed that nursing students’ attitudes toward patient safety increased significantly after the intervention. In line with our findings, Terashita et al. (2016) concluded that plain radiography practical training through PBL promoted students’ attitudes toward self-efficacy and increased their self-efficacy through self-centered learning [41]. Furthermore, Park and Choi’s (2015) study showed that PBL plays a considerable role in improving learning attitude, critical thinking disposition, and problem-solving skills in nursing students [42]. PBL improves learning by constructing an understanding of the interrelationship between basic science concepts and medical knowledge [43]. Limited studies have investigated the effect of PBL on nursing students’ knowledge and attitude toward patient safety. Liu et al. (2009) reported that the PBL approach is an effective way for nursing students to improve patient safety knowledge and enhance the integrative capacity [44]. Sahota (2020) stated that PBL promotes learners’ knowledge and skills in non-technical subjects, including patient safety, and enhances their ability to cope with the challenges they encounter in clinical environments [45].

Our findings also showed that the perception of patient safety increased significantly in nursing students after PBL education. High nursing students’ perceptions of patient safety were reported in a similar study [25]. This increased students’ perceptions of patient safety through implementing the PBL method can be explained by its significant effect on students’ learning, motivation, and experience [46]. Penjvini and Shahsawari (2013) found that students in the PBL group acquired more knowledge and had a higher level of motivation towards learning, and provided better care for patients than students in the lecture group [47]. Kim and Han (2016) showed that education programs that are implemented to strengthen critical thinking, self-efficacy, and problem-solving promote patient safety competence among clinical nurses [48]. Despite the many benefits of the PBL method, it can stress students by creating frustration, anxiety, uncertainty, and fear [49, 50]. PBL is also known as a time-consuming educational method [40, 49].

In general, Liu et al. (2019) concluded that problem-based learning is superior to the conventional teaching methods in areas such as interest in learning, teamwork spirit, problem-solving ability, analysis, knowledge attainment and application, and communicational skills [51]. Another study reported that problem-based learning enhances active learning and students’ innate motivation, which improves deep learning among students [52]. Khatiban et al. (2019) conducted a study to compare the effect of two methods of lecture-based and problem-based learning in ethics education among nursing students. They recommended problem-based learning to be used in other nursing areas since it is an effective tool for developing moral reasoning [53]. In a recent systematic review, authors have shown the effectiveness of problem-based learning in nursing education and student empowerment, so that they called for a widespread acceptance and use of this method for education in nursing schools [54].

Study limitations

One of our study’s limitations was the participants’ mental and emotional state while completing the questionnaires and answering the questions by which the study results could be influenced. This limitation was beyond the control of the researcher. The short follow-up period was another limitation of our study. Therefore, the authors suggest other studies with a more extended follow-up period to be conducted through which the effect of the PBL educational approach on the persistence of learning over time is determined. Another limitation of the study was that nursing students were from the same nursing faculty in the control and intervention groups. We suggest students be recruited from different nursing schools in future studies. Nursing students’ pre-interventional patient safety knowledge was another weakness of this study. The authors tried to control it with a statistics test of ANCOVA.

Conclusion

Patient safety is of great significance in various nursing education areas, including nursing education and practice. Like other healthcare team members, nursing students have the opportunity to improve the quality of patient safety. Meanwhile, nursing instructors play a vital role in improving the students’ required knowledge, attitude, and perception of patient safety. They can ensure that nursing graduates are well prepared to provide a safe environment and care for patients. Based on this study’s findings, PBL significantly impacted students’ knowledge, attitude, and perception toward patient safety compared to conventional teaching methods. Considering the PBL positive outcomes, including learning improvement, continuous and self-centered learning, concentration on understanding concepts, and innovation, it is recommended that nursing professors apply this teaching method in some courses to promote students’ clinical and cognitive capabilities to ensure safe patient care.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding authors on request.

Abbreviations

PBL:

Problem-based learning

WHO:

World Health Organization

SPSS:

Statistical Package for the Social Sciences

ANCOVA:

Analysis of covariance

CONSORT:

Consolidated Standards of Reporting Trials

GPA:

Grade Point Average

References

  1. 1.

    Brickell TA, McLean C. Emerging issues and challenges for improving patient safety in mental health: a qualitative analysis of expert perspectives. J Patient Safety. 2011;7(1):39–44. https://doi.org/10.1097/PTS.0b013e31820cd78e.

    Article  Google Scholar 

  2. 2.

    Kanerva A, Lammintakanen J, Kivinen T. Patient safety in psychiatric inpatient care: a literature review. J Psychiatr Ment Health Nurs. 2013;20(6):541–8. https://doi.org/10.1111/j.1365-2850.2012.01949.x.

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Bassuni EM, Bayoumi MM. Improvement critical care patient safety: using nursing staff development strategies, at Saudi Arabia. Global J Health Sci. 2015;7(2):335–43. https://doi.org/10.5539/gjhs.v7n2p335.

    Article  Google Scholar 

  4. 4.

    Minet C, Potton L, Bonadona A, Hamidfar-Roy R, Somohano CA, Lugosi M, et al. Venous thromboembolism in the ICU: main characteristics, diagnosis and thromboprophylaxis. Crit Care. 2015;19(1):287. https://doi.org/10.1186/s13054-015-1003-9.

  5. 5.

    Johnstone M-J, Kanitsaki O. The ethics and practical importance of defining, distinguishing and disclosing nursing errors: a discussion paper. Int J Nurs Stud. 2006;43(3):367–76. https://doi.org/10.1016/j.ijnurstu.2005.04.010.

    Article  PubMed  Google Scholar 

  6. 6.

    World health organization. Patient Safety Fact File. 2019. Available at: https://www.who.int/features/factfiles/patient_safety/patient-safety-fact-file.pdf. Accessed 11 Sept 2018.

  7. 7.

    Abdelhai R, Abdelaziz SB, Ghanem NS. Assessing patient safety culture and factors affecting it among health care providers at Cairo University hospitals. J Am Sci. 2012;8(7):277–85.

    Google Scholar 

  8. 8.

    James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Safety. 2013;9(3):122–8. https://doi.org/10.1097/PTS.0b013e3182948a69.

    Article  Google Scholar 

  9. 9.

    Hughes R. Patient safety and quality: An evidence-based handbook for nurses, vol. 3. Rockville: Agency for Healthcare Research and Quality; 2008.

    Google Scholar 

  10. 10.

    Usher K, Woods C, Parmenter G, Hutchinson M, Mannix J, Power T, et al. Self-reported confidence in patient safety knowledge among Australian undergraduate nursing students: a multi-site cross-sectional survey study. Int J Nurs Stud. 2017;71:89–96. https://doi.org/10.1016/j.ijnurstu.2017.03.006.

  11. 11.

    Mansour M. Examining patient safety education in pre-registration nursing curriculum: qualitative study. J Nurs Educ Pract. 2013;3(12):157–67. https://doi.org/10.5430/jnep.v3n12p157.

    Article  Google Scholar 

  12. 12.

    Francis R. Report of the mid Staffordshire NHS Foundation trust public inquiry: executive summary, vol. 947. London: The Stationery Office; 2013.

    Google Scholar 

  13. 13.

    Sheeran P, Maki A, Montanaro E, Avishai-Yitshak A, Bryan A, Klein WM, et al. The impact of changing attitudes, norms, and self-efficacy on health-related intentions and behavior: a meta-analysis. Health Psychol. 2016;35(11):1178–88. https://doi.org/10.1037/hea0000387.

  14. 14.

    Alfaqawi M, Böttcher B, Abuowda Y, Alaloul E, Elnajjar I, Elhout S, et al. Treating patients in a safe environment: a cross-sectional study of patient safety attitudes among doctors in the Gaza strip, Palestine. BMC Health Serv Res. 2020;20(1):1–9. https://doi.org/10.1186/s12913-020-05230-5.

  15. 15.

    Brasaite I, Kaunonen M, Suominen T. Healthcare professionals’ knowledge, attitudes and skills regarding patient safety: a systematic literature review. Scand J Caring Sci. 2015;29(1):30–50. https://doi.org/10.1111/scs.12136.

    Article  PubMed  Google Scholar 

  16. 16.

    Mwachofi A, Walston SL, Al-Omar BA. Factors affecting nurses’ perceptions of patient safety. Int J Health Care Q Assurance. 2011;24(4):274–83. https://doi.org/10.1108/09526861111125589.

    Article  Google Scholar 

  17. 17.

    Yoshikawa JM, Sousa BEC, Peterlini MAS, Kusahara DM, Pedreira MLG, Avelar AFM. Comprehension of undergraduate students in nursing and medicine on patient safety. Acta Paul Enferm. 2013;26(1):21–9. https://doi.org/10.1590/S0103-21002013000100005.

    Article  Google Scholar 

  18. 18.

    Rana S, Ardichvili A, Polesello D. Promoting self-directed learning in a learning organization: tools and practices. Eur J Training Dev. 2016;40(7):470–89. https://doi.org/10.1108/EJTD-10-2015-0076.

    Article  Google Scholar 

  19. 19.

    Lupien A, George-Gay B. Fuszard’s innovative teaching strategies in nursing; 2010.

    Google Scholar 

  20. 20.

    Noordegraaf-Eelens L, Kloeg J, Noordzij G. PBL and sustainable education: addressing the problem of isolation. Adv Health Sci Educ. 2019;24(5):971–9. https://doi.org/10.1007/s10459-019-09927-z.

    Article  Google Scholar 

  21. 21.

    Azer SA. Introducing a problem-based learning program: 12 tips for success. Med Teach. 2011;33(10):808–13. https://doi.org/10.3109/0142159X.2011.558137.

    Article  PubMed  Google Scholar 

  22. 22.

    Martens SE, Wolfhagen IH, Whittingham JR, Dolmans DHM. Mind the gap: teachers’ conceptions of student-staff partnership and its potential to enhance educational quality. Med Teach. 2020;42(5):529–35. https://doi.org/10.1080/0142159X.2019.1708874.

    Article  PubMed  Google Scholar 

  23. 23.

    Mansoori S, Abedini-baltork M, Lashkari H, Bagheri S. Effectiveness of problem-based learning on student’s academic performance: A quasi-experimental study. Res Med Educ. 2017;9(1):8–1. https://doi.org/10.18869/acadpub.rme.9.1.8.

    Article  Google Scholar 

  24. 24.

    Sermeus W, Cullum N, Balzer K, et al. European Academy of Nursing Science 2016 Summer Conference. BMC Nurs. 2016;15:67. https://doi.org/10.1186/s12912-016-0186-y.

  25. 25.

    Nabilou B, Feizi A, Seyedin H. Patient safety in medical education: students’ perceptions, knowledge and attitudes. PLoS One. 2015;10(8):e0135610. https://doi.org/10.1371/journal.pone.0135610.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Mahmud A. The integration of theory and practice of paramedic curriculum. Int J Sci Res Publ. 2013;3(7):1–4.

    Google Scholar 

  27. 27.

    Ajani K, Moez S. Gap between knowledge and practice in nursing. Procedia Soc Behav Sci. 2011;15:3927–31. https://doi.org/10.1016/j.sbspro.2011.04.396.

    Article  Google Scholar 

  28. 28.

    Hemmati Maslak Pak M, Orujlu S, Khalkhali H. The effect of problem-based learning training on nursing students’ critical thinking skills. J Med Educ Dev. 2014;9(1):24–33 http://jmed.ssu.ac.ir/article-1-211-en.html.

    Google Scholar 

  29. 29.

    Cohen J. Statistical power analysis. Curr Dir Psychol Sci. 1992;1(3):98–101. https://doi.org/10.1111/1467-8721.ep10768783.

    Article  Google Scholar 

  30. 30.

    Leung GK, Patil NG. Patient safety in the undergraduate curriculum: medical students’ perception. Hong Kong Med J. 2010;16(2):101–5.

    CAS  PubMed  Google Scholar 

  31. 31.

    Madigosky WS, Headrick LA, Nelson K, Cox KR, Anderson T. Changing and sustaining medical students’ knowledge, skills, and attitudes about patient safety and medical fallibility. Acad Med. 2006;81(1):94–101. https://doi.org/10.1097/00001888-200601000-00022.

    Article  PubMed  Google Scholar 

  32. 32.

    Schulz KF, Altman DG, Moher D, Group C. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMC Med. 2010;8(1):18. https://doi.org/10.1186/1741-7015-8-18.

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Meo SA. Evaluating learning among undergraduate medical students in schools with traditional and problem-based curricula. Adv Physiol Educ. 2013;37(3):249–53. https://doi.org/10.1152/advan.00031.2013.

    Article  PubMed  Google Scholar 

  34. 34.

    Yew EH, Goh K. Problem-based learning: an overview of its process and impact on learning. Health Prof Educ. 2016;2(2):75–9. https://doi.org/10.1016/j.hpe.2016.01.004.

    Article  Google Scholar 

  35. 35.

    Prosser M, Sze D. Problem-based learning: student learning experiences and outcomes. Clin Linguist Phon. 2014;28(1–2):131–42. https://doi.org/10.3109/02699206.2013.820351.

    Article  PubMed  Google Scholar 

  36. 36.

    Yadav RL, Piryani RM, Deo GP, Shah DK, Yadav LK, Islam MN. Attitude and perception of undergraduate medical students toward the problem-based learning in Chitwan medical college, Nepal. Adv Med Educ Pract. 2018;9:317–22. https://doi.org/10.2147/AMEP.S160814.

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Shin I-S, Kim J-H. The effect of problem-based learning in nursing education: a meta-analysis. Adv Health Sci Educ. 2013;18(5):1103–20. https://doi.org/10.1007/s10459-012-9436-2.

    Article  Google Scholar 

  38. 38.

    Kong L-N, Qin B, Zhou YQ, Mou SY, Gao H-M. The effectiveness of problem-based learning on development of nursing students’ critical thinking: a systematic review and meta-analysis. Int J Nurs Stud. 2014;51(3):458–69. https://doi.org/10.1016/j.ijnurstu.2013.06.009.

    Article  PubMed  Google Scholar 

  39. 39.

    Dring JC. Problem-based learning–experiencing and understanding the prominence during medical school: perspective. Ann Med Surg. 2019;47:27–8. https://doi.org/10.1016/j.amsu.2019.09.004.

    Article  Google Scholar 

  40. 40.

    Arpanantikul M, Luecha Y. Problem-based learning: undergraduate Thai nursing students’ perceptions. Pacific Rim Int J Nurs Res. 2010;14(3):262–76.

    Google Scholar 

  41. 41.

    Terashita T, Tamura N, Kisa K, Kawabata H, Ogasawara K. Problem-based learning for radiological technologists: a comparison of student attitudes toward plain radiography. BMC Med Educ. 2016;16(1):236. https://doi.org/10.1186/s12909-016-0753-7.

    Article  PubMed  PubMed Central  Google Scholar 

  42. 42.

    Park S, Choi SH. Effects of problem-based learning on the learning attitudes, critical thinking disposition and problem solving skills of nursing students: Infant Care, doctoral dissertation, Chonnam National University, Gwanju; 2015. https://doi.org/10.14257/astl.2015.103.41.

    Book  Google Scholar 

  43. 43.

    Chakravarthi S, Haleagrahara N. Implementation of PBL curriculum involving multiple disciplines in undergraduate medical education programme. Int Educ Stud. 2010;3(1):165–9.

    Article  Google Scholar 

  44. 44.

    Y-l L, L-l C, M-z R, Liu F, Jl Y, Gao CH, et al. The application of problem-based learning approach in patient safety education among nursing students [J]. Chin J Nurs. 2009;10.

  45. 45.

    Sahota S. Using problem-based learning to improve patient safety in the emergency department. Emergency Nurse. 2020;28(2):3–42. https://doi.org/10.7748/en.2020.e1958.

    Article  Google Scholar 

  46. 46.

    Matthew-Maich N, Martin L, Hammond C, Palma A, Pavkovic M, Sheremet D, et al. Nursing students’ perceptions of effective problem-based learning tutors. Nurs Stand. 2016;31(12):48–59. https://doi.org/10.7748/ns.2016.e10318.

  47. 47.

    Penjvini S, Shahsawari SS. Comparing problem based learning with lecture based learning on medicine giving skill to newborn in nursing students. J Nurs Educ Pract. 2013;3(9):53–9. https://doi.org/10.5430/jnep.v3n9p53.

    Article  Google Scholar 

  48. 48.

    Kim H-S, Han S-J. The survey on the influence of clinical Nurse's critical thinking disposition, problem-solving skill and self-efficacy on patients safety competencies. J Korea Acad Industrial Coop Soc. 2016;17(6):598–608. https://doi.org/10.5762/KAIS.2016.17.6.598.

    Article  Google Scholar 

  49. 49.

    Biley F. Creating tension: undergraduate student nurses’ responses to a problem-based learning curriculum. Nurse Educ Today. 1999;19(7):586–91. https://doi.org/10.1054/nedt.1999.0371.

    CAS  Article  PubMed  Google Scholar 

  50. 50.

    Klunklin A, Subpaiboongid P, Keitlertnapha P, Viseskul N, Turale S. Thai nursing students’ adaption to problem-based learning: a qualitative study. Nurse Educ Pract. 2011;11(6):370–4. https://doi.org/10.1016/j.nepr.2011.03.011.

    Article  PubMed  Google Scholar 

  51. 51.

    Liu L, Du X, Zhang Z, Zhou J. Effect of problem-based learning in pharmacology education: a meta-analysis. Stud Educ Eval. 2019;60:43–58. https://doi.org/10.1016/j.stueduc.2018.11.004.

    Article  Google Scholar 

  52. 52.

    Dolmans DH, Loyens SM, Marcq H, Gijbels D. Deep and surface learning in problem-based learning: a review of the literature. Adv Health Sci Educ. 2016;21(5):1087–112. https://doi.org/10.1007/s10459-015-9645-6.

    Article  Google Scholar 

  53. 53.

    Khatiban M, Falahan SN, Amini R, Farahanchi A, Soltanian A. Lecture-based versus problem-based learning in ethics education among nursing students. Nurs Ethics. 2019;26(6):1753–64. https://doi.org/10.1177/0969733018767246.

    Article  PubMed  Google Scholar 

  54. 54.

    Hajibabaee F, Ashrafizadeh H. A Comprehensive Review of Problem-based Learning in the Iranian Nursing Education. Iran J Nurs. 2019;32(118):11–28. https://doi.org/10.29252/ijn.32.118.11.

    Article  Google Scholar 

Download references

Acknowledgments

This article is derived from a master thesis in nursing approved by the Research and Ethics Committee of the Urmia University of Medical Sciences. The researchers would like to express their sincere gratitude and appreciation to the Dean of nursing school, nursing students, and the honorable Research Vice President of Urmia University of Medical Sciences for making this research possible. They also wish to thank Rosemary Carter for reviewing the manuscript and writing assistance.

Funding

This research received a grant (No. 2476) from Urmia University of Medical Sciences to support the research in terms of study design, collection, analysis, interpretation of data, and the article’s preparation.

Author information

Affiliations

Authors

Contributions

Design of the study: MHM, HJ, NP; data collection: NP, HJ; analysis and interpretation of data: MHM, HJ, NP; manuscript preparation: NP, HJ, MHM; manuscript revision: NP, HJ. All authors checked and confirmed the final manuscript before submission. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Naser Parizad.

Ethics declarations

Ethics approval and consent to participate

The participants were explained about the purpose of the study, and they were assured of their privacy and confidentiality of their personal information. They were explained regarding the voluntary nature of the study, and they can leave the study at any time. They signed the consent form before participating in the study. Moreover, the study was approved by the Review Board of Urmia University of Medical Sciences.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Jamshidi, H., Hemmati Maslakpak, M. & Parizad, N. Does problem-based learning education improve knowledge, attitude, and perception toward patient safety among nursing students? A randomized controlled trial. BMC Nurs 20, 70 (2021). https://doi.org/10.1186/s12912-021-00588-1

Download citation

Keywords

  • Education
  • Problem-based learning
  • Patient safety
  • Knowledge
  • Attitude
  • Perception
  • Nurse
  • Student