The Effect of Nurse Empowerment Educational Program on Patient Safety Culture: A Randomized Controlled Trial

R E S E A R C H A R T I C L E Open Access
The effect of nurse empowerment
educational program on patient safety
culture: a randomized controlled trial
Maryam Amiri1 , Zahra Khademian 1* and Reza Nikandish 2
Abstract
Background: The complexity of patients’ condition and treatment processes in intensive care units (ICUs) predisposes
patients to more hazardous events. Effective patient safety culture is related to lowering the rate of patients’
complications and fewer adverse events. The present study aimed to determine the effect of empowering nurses
and supervisors through an educational program on patient safety culture in adult ICUs.
Methods: A randomized controlled trial was conducted during April–September 2015 in 6 adult ICUs at Namazi
Hospital, Shiraz, Iran. A total of 60 nurses and 20 supervisors were selected through proportional stratified sampling and
census, respectively, and randomly assigned to the experimental and control groups. The intervention consisted of a
two-day workshop, hanging posters, and distributing pamphlets that covered topics such as patient safety, patient
safety culture, speak up about safety issues, and the skills of Team Strategies and Tools to Enhance Performance and
Patient Safety. Data were collected through a hospital survey on patient safety culture. Eventually, 61 participants
completed the study. Data were analyzed using descriptive statistics, independent-samples t-test, paired-samples t-test,
and Chi-square test. P < 0.05 was considered statistically significant.
Results: In the experimental group, the total post-test mean scores of the patient safety culture (3.46 ± 0.26) was
significantly higher than that of the control group (2.84 ± 0.37, P < 0.001). It was also higher than that of the pre-
test (2.91 ± 0.4, P < 0.001). Additionally, significant improvements were observed in 5 out of 12 dimensions in the
experimental group. However, dimensions such as non-punitive response to errors and the events reported did
not improve significantly.
Conclusion: Empowering nurses and supervisors could improve the overall patient safety culture. Nonetheless,
additional actions are required to improve areas such as reporting the events and non-punitive response to errors.
Trial registration: IRCT2015053122494N1. Date registered: March 2, 2016.
Keywords: Culture, Intensive care units, Nursing, Supervisory, Nurses, Patient safety, Patient safety culture, Safety
Background
Patient safety is an important element in offering
high-quality health care services. However, it is esti-
mated that approximately 400,000 annual deaths are re-
lated to preventable harms [1]. The complexity of
patients’ condition and treatment processes in Intensive
Care Unit (ICU) predisposes patients to more hazardous
events [2]. In a prospective study, during 2013–2014, the
rate of adverse events per 1000 patient-days in an ICU
was 80.5 in which 45% were preventable [3]. The epi-
demiology of medical errors in Iran is ambiguous. Zar-
garzadeh has estimated that 24,500 annual deaths are
related to medical errors [4]. In addition, in an ICU,
among 307 medication doses, 214 (69.7%) errors were
identified during administration (n = 132, 42.99%), pre-
scription (n = 74, 24.1%), and transcription (n = 8, 2.61%)
of medications [5]. Moreover, 48 medication errors per
100 orders were observed in a pediatric ICU [6].
* Correspondence: [e-mail]; [e-mail];
[e-mail]
1
Department of Nursing, School of Nursing and Midwifery, Shiraz University
of Medical Sciences, Shiraz, Iran
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. 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.
Amiri et al. BMC Medical Education (2018) 18:158
https://doi.org/10.1186/s12909-018-1255-6

Poor communication and collaboration [7], lack of
knowledge, and inadequate training were among the
main causes of nursing errors in ICUs [8]. Studies have
shown the lack of communication skills in nurses and
nursing students [9, 10]. Hence, a training program for
nurses on patient safety alongside with strategies to im-
prove professional communication is required to im-
prove patient safety.
High mortality and morbidity associated with medical
errors indicate the importance of promoting patient
safety in critical care units. Nurses play a key role in im-
proving patient safety due to their continuous presence
at patients’ bedsides and interaction with their families
and other healthcare professionals [11]. For instance,
critical care unit nurses have often reported that they
identified and corrected errors such as medication and
procedural errors related to nurses and other caregivers
[12]. Henneman et al. identified multiple strategies to
identify the patient, recognize other team members, and
the plan of care, which nurses used to detect, discon-
tinue, and correct errors in critical care settings [13].
Research findings indicated that a strong patient safety
culture is associated with a lower rate of patients’ com-
plications and fewer adverse events [14, 15]. It is defined
as a culture whereby nurses are aware of errors and are
encouraged to discuss them. This, in turn, improves
their ability to learn from past mistakes and take cor-
rective measures [16].
A meta-analysis, including 11 descriptive studies on
hospital staff, showed that only 8.3 and 32.3% of the re-
spondents of the reviewed articles have rated patient
safety culture in Iran as excellent and very good, respect-
ively [17]. The important role of patient safety culture
necessitates improvement of these strategies in clinical
settings. Nevertheless, interventions that may improve
patient safety culture are not adequately defined [18]. In
a study, the positive effects of some interventions, such
as executive walk rounds [19] and the role of nurse
managers in regular assessment and support of the
safety culture were reported [20]. Consequently, the par-
ticipation of nurse managers in the planning and imple-
mentation of strategies, to improve patient safety
culture, may reinforce these strategies [18].
Several studies have reported the effects of nurse em-
powerment interventions on patient safety culture. A
type of strategy is an educational program, such as on-
line module, addressing patient safety which increases
positive scores of nurses in two dimensions of patient
safety culture (i.e. “non-punitive response to errors” and
“frequency of event reporting”) [21]. Teaching teamwork
also improves staff perception of patient safety culture in
the emergency department [22]. Another empowerment
strategy is to encourage nurses to speak up. Sayre (2010)
reported that nurses behavior towards patient safety
protection increased when encouraged to speak up in a
situation of a threat to patient safety [23].
In order to improve the quality of care and patient
safety, the Institute of Medicine (2003) recommended a
reform in health profession education [24]. Accordingly,
the Quality and Safety Education for Nurses (QSEN) pro-
ject was introduced to train nurses on the required com-
petencies to improve the quality of care and patient safety
[25]. Considering the important role of nurses and leaders
in ensuring patient safety and in providing a strong patient
safety culture, we developed and studied the effects of an
innovative empowerment program on patient safety cul-
ture. This program is unique in a sense that it involves
nurses and supervisors with an integrated exclusive educa-
tional program which encourages them to speak up. The
present study aimed to determine the effect of empower-
ing nurses and supervisors through an educational pro-
gram on patient safety culture in adult ICUs.
Methods
This randomized controlled trial with a pre-test and
post-test control groups was conducted during
April–September 2015 in 6 adult ICUs at Namazi
Hospital, Shiraz, Iran. All the above-mentioned ICUs were
similar in terms of patient safety policies. The study popu-
lation included 160 nurses and 20 supervisors. The nurse:-
patient ratio in these wards was 1:2. The sample size
consisted of 60 nurses and 20 supervisors. The nurses
were selected based on proportional stratified sampling.
Therefore, the number of selected nurses from each ICU
was proportional to the total number of its nurses.
Supervisors were nurses with at least a Bachelor’s de-
gree and responsible for oversight nursing services in
the studied ICUs. Note that the supervisors did not
provide direct patient care. All supervisors at the hos-
pital participated in the study. To randomly allocate
nurses, a number was assigned to each ICU and catego-
rized into the control and experimental groups, based
on permuted block randomization. In total, 30 nurses
from ICUs number 1, 3, and 6 (surgical, neurosurgical,
and general ICU) were assigned to the experimental
group. In addition, 30 nurses from ICUs number 2, 4,
and 5 (medical, neurosurgical, and general ICU) were
assigned to the control group. Based on permuted
block randomization, all supervisors at the hospital
were assigned to the experimental (n = 10) and control
(n = 10) groups. The experimental group, including 30
nurses (ICUs number 1, 3, and 6) and 10 supervisors
received the educational empowerment program. The
control group included 30 nurses (ICUs number 2, 4,
and 5) and 10 supervisors that did not receive any
intervention. The inclusion criteria were having at least
6 months experience in an adult ICU and at least a
Bachelor’s degree in nursing. The exclusion criteria
Amiri et al. BMC Medical Education (2018) 18:158 Page 2 of 8

were the unwillingness to participate, failure to
complete the pre-test, and lack of participation in train-
ing sessions. A total of 61 out of 80 individuals (experi-
mental group: n = 30, control group: n = 31) completed
the post-test questionnaire (Fig. 1).
The educational empowerment program
The educational empowerment program was carried out
by one of the researchers. This program started with a
two-day workshop (8 h), followed by hanging posters
and handing out educational pamphlets to the nurses
and supervisors of the experimental group at their work-
place. The educational contents of the workshop, post-
ers, and pamphlets were matched. The workshop
included education on patient safety, patient safety cul-
ture, speak out in a situation of a threat to patient safety,
and the skills of Team Strategies and Tools to Enhance
Performance and Patient Safety (TeamSTEPPS). Team-
STEPPS was developed by the Agency for Healthcare
Research and Quality (AHRQ) to improve patient out-
comes. It included communication, leadership, mutual
support, and situational monitoring skills [26]. The
workshop consisted of a lecture, group discussion, and
presenting scenarios. In addition, some textual and
graphical posters (related to TeamSTEPPS skills, speak
up, and patient safety culture) were placed on the walls
of patient’s unit in the ICUs of the experimental group
for a period of 6 weeks. During the following 6 weeks,
every week one pamphlet was handed out to the nurses
in the experimental groups. Pamphlets contents included
communication, mutual support, situation monitoring,
leadership, speak up, and patient safety culture.
Data collection
Data were collected using the Persian version of Hospital
Survey on Patient Safety Culture (HSOPSC) developed
by the AHRQ. The validity of the HSOPSC in Iran was
verified by 15 experts and its reliability measured by
Cronbach’s alpha coefficient (0.84) [27]. This question-
naire has 42 items in 12 dimensions. These dimensions
include: teamwork within units, manager expectations
and actions promoting patient safety, organizational
learning and continuous improvement, management
support for patient safety; overall perception of patient
safety, feedback and communication on errors, commu-
nication openness, frequency of events reported; team-
work across hospital units, staffing, handoffs and
transitions, non-punitive response to errors. The items
Fig. 1 The CONSORT diagram
Amiri et al. BMC Medical Education (2018) 18:158 Page 3 of 8