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

This study focuses on the effect of nurse empowerment educational program on patient safety culture. It is a randomized controlled trial that measures and compares the study outcome both before and after the treatment. The study uses proportional stratified sampling technique and permuted block randomization. The main inclusion criteria used was 6 months of experience in adult ICU unit and with Bachelor degree in nursing. The study shows that training and education of nurse helps to improve patient’s safety on cultural grounds through empowering the nursing professionals in the domain of cultural safety.

Running head: ASSESSMENT 2
CASP: Quantitative Research
Name of the Student
Name of the University
Author Note

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ASSESSMENT 2
Answer 2
Can’t tell
Randomization was done by pre-test and post-test control groups (Amiri, Khademian
and Nikandish 2018). The pretest and posttest design in RCTs measures and compare the
study outcome both before and after the treatment and thus helping to increase the strength of
the research.
The selection of 60 nurses was done based on proportional stratified sampling. This
stratefied sampling technique provides greater precision in comparison to simple random
sampling of the same sample size and at the same time, it is cost-effective (Shuster, 2019). Of
them 30 nurses were randomly allocated to the control group. The inclusions of 20
supervisors were done with the help to permuted block randomization and of them 10
supervisors were recruited in the control groups (Amiri, Khademian and Nikandish 2018).
block randomization sampling method deals with division of the total sample into two sub-
groups known as block such that the variability within the blocks is kept less than variability
between the blocks this further help to refine the process of randomisation (Kim, and Shin
2014). The main inclusion criteria used was 6 months of experience in adult ICU unit and
with Bachelor degree in nursing. The nursing professionals who were unwilling to participate
or failed to conduct pre-test were excluded from the trial. The allocation detail was elaborated
in a tabular format with the help of the CONSORT diagram. This helps in parallel
representation of two phases of randomization (Vohra et al. 2016). However, it is not
mentioned in the study whether the participants were blinded about the scope of the trial or
aim of the trial (Amiri, Khademian and Nikandish 2018).

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ASSESSMENT 2
Answer 3
No.
Out of 30 nurses and 10 supervisors who were recruited in the experimental group,
only 200 nurses and 9 supervisors received intervention. During the follow-up session one
nurse failed to complete the pro-test and thus making the final sample after the completion of
the study is 21 nurses and 9 supervisors. In the control group the number was 27 nurses and 4
supervisors (Amiri, Khademian and Nikandish 2018). The decrease in the sample size due to
drop outs during the follow-up sessions hampers the strength of the RCTs (Singh and Masuku
2014). Thus all the people who were included in the group accounted for the study till its end.
However, the trial was not stopped early and the two groups were analysed separately
(experimental and control groups) in which they are randomised. Singh and Masuku 2014)
stated that analysis of both the control and the experimental groups separately helps to
compare the pre-test and post-test parameter during and thereby helping to clearly highlight
the significant outcome of the study in the RCTs.
Answer 5
Yes.
The patients were all adults in the ICU units. However, the adult patients who were
selected in order to review the level of cultural competency were not reviewed that if they are
from the same origin. Betancourt et al. (2016) are of the opinion that the adult patients who
are from the ethnic minority background are more likely to suffer from the cultural insecurity
or are cultural vulnerable. In that case, it is the duty of the nursing professional to handle such
ethnic minority patients more cautiously in comparison to other non-indigenous population.
Thus selection of the generalised version of the adult patient population might have led to a
biased recruitment of the population that is used for the assessment of the patients’ cultural

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ASSESSMENT 2
safety. The nursing professionals included in the trial have at least 6 months of experience in
handling the adults in ICU, while the minimum qualification for both the nurses and
supervisors are taken as bachelor in nursing (Amiri, Khademian and Nikandish 2018). The
use of the same inclusion criteria for both the supervisors group and the nursing groups
helped in maintaining uniformity. Moreover, only female nurses and supervisors were
selected for the study. Almutairi, McCarthy and Gardner (2015) stated that female nurses are
more competent than the make nurses towards procurement of the transcultural nursing.
Thus, selection of the female nurses helped to increase the probability of achieving primary
outcome. This can be considered as selection bias. The selection of the nurses after 6 months
of service tenure also can be regarded as more generalized selection of a vast sample. This is
because, nursing professional who are more than 5 years old in this profession are more likely
to be culturally competent in procurement of care in comparison to the other nurses who have
just complete their one year of service (Betancourt et al. 2016). Such that training giving of 5
years tenured nurse is more likely to fetch better culturally sensitive outcome in comparison
to the other nurses who are just only a year old in this profession.
Answer 6
No.
The experimental groups attended workshop for 2 days for 8 hours each. This is
followed by hanging posters or pamphlets about patient safety and cultural safety (Amiri,
Khademian and Nikandish 2018). However, the study failed to highlight whether the nurses
or the supervisors who are initially recruited in the study have previously undertaken any
training about cultural safety of the patients. Moreover during the follow-up session, the
researchers also failed to highlight whether the nurses and the supervisors are taking
additional workshops about cultural safety of the patients thus indicating the chances of

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ASSESSMENT 2
confounding bias. Jackson and Swanson (2015) reported that presence of cofounding bias
affects the association between the exposure and outcome. For example if the nursing
professional who are recruited in the study have previously undertaken any kind of training or
education during their undergraduate course about culturally safety care or about working as
a team towards procurement of the cultural safety, then such professionals are more likely to
show improve care plan execution towards improvement of the patients’ safety (Mareno and
Hart 2014). Thus giving rise to a biased judgement of the current workshop sessions in
improving the cultural safety training. In other words it can be said that confounding bias is
present in this study leading to the generation of the bias results as groups might not be
treated equally apart from the said intervention.
Answer 7
The main outcome that was highlighted in the research is improvement in the patient
safety culture among the nursing professionals in the adult unit of ICUs (Amiri, Khademian
and Nikandish 2018). However, the educational empowerment program covered patient
safety, patient safety culture and team strategies and tools to increase the team based
performance of patient safety. This team based strategy implemented through Team
Strategies and Tools to Enhance
Performance and Patient Safety (TeamSTEPPS) covers parameters like
communication, leaderships, situational monitoring skills and mutual support However, the
educational empowerment program covered patient safety, patient safety culture and team
strategies and tools to increase the team based performance of patient safety. This team based
strategy implemented through Performance and Patient Safety (TeamSTEPPS) covers
parameters like communication, leaderships, situational monitoring skills and mutual support.
However, study failed to show the separate measurements of primary and secondary

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ASSESSMENT 2
outcome. This decreased the different aspects of the main outcomes (Schneider and
Whitehead 2013). But each of the outcomes of the study that are studied in this research were
highlighted separately in the research article in a tabular format. The article that provided a
significant result as evident from the confidence interval was further highlighted in bold.
Proper interpretation of the data in the tabular format makes the overall research progress
easy to follow (Freeman 2017).
Answer 9
Yes.
The patients covered by the trials are similar enough to the patients in other settings.
This is because; the RCT was conducted over adult patients’ in ICU. Thus the outcome of the
study can be applied in other patient population in other units of the hospitals too in order to
study the improvements in the quotient in the patient's safety. In other words, the patient
population was generalised when the trained nurse executed their skills gained through the
workshop, improved outcome in the culturally safety was noticed. Thus selection of the
generalised patient population though is considered as one of the limitations of the study as
highlighted previously but in this section can be stated as one of the strength of the study.
Moreover, all the nursing professionals who have at least 6 months of experience in the adult
unit were entitled to be eligible for this study. This selection of nurse without any strict
specification helped to apply or to replicate results in other diverse group of population like
the nursing professionals handling the adult patients in the emergency units. However, same
approach might not be suitable for the paediatric population as the culturally safety of infants
or the children is also aligned to their patients and thus might require completely different
approach. Moreover, the nurses might require to approach with children friendly strategies

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for the ensuring of the cultural safety (Douglas et al. 2014). So the study results might not be
replicated in paediatric population.
Answer 11
Yes.
The benefits of the study are, it showed training and education of nurse helps to
improve patient’s safety on cultural grounds through empowering the nursing professionals in
the domain of cultural safety. Betancourt et al. (2016) reported that providing cultural
competent care helps to promote mental and physical wellbeing of the patient and at the same
time helps to increase the provision for patient-centred care. The study did not harm any one
as it did not include the patients directly in the study. Moreover, education of the nursing
professionals helps in improvement in the nursing skills irrespective of the domain in which
the nurses are trained and thus no harm is incurred in the grounds of professionalism.

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References
Almutairi, A. F., McCarthy, A., and Gardner, G. E. 2015. Understanding cultural competence
in a multicultural nursing workforce: Registered nurses’ experience in Saudi Arabia. Journal
of Transcultural Nursing, 26(1), 16-23.
Amiri, M., Khademian, Z., and Nikandish, R. 2018. The effect of nurse empowerment
educational program on patient safety culture: a randomized controlled trial. BMC medical
education, 18(1), 158.
Betancourt, J. R., Green, A. R., Carrillo, J. E., and Owusu Ananeh-Firempong, I. I. 2016.
Defining cultural competence: a practical framework for addressing racial/ethnic disparities
in health and health care. Public health reports.
Betancourt, J.R., Green, A.R., Carrillo, J.E. and Owusu Ananeh-Firempong, I.I., 2016.
Defining cultural competence: a practical framework for addressing racial/ethnic disparities
in health and health care. Public health reports.
Douglas, M.K., Rosenkoetter, M., Pacquiao, D.F., Callister, L.C., Hattar-Pollara, M.,
Lauderdale, J., Milstead, J., Nardi, D. and Purnell, L., 2014. Guidelines for implementing
culturally competent nursing care. Journal of Transcultural Nursing, 25(2), pp.109-121.
Freeman, L. C. (2017). Research methods in social network analysis. Routledge.
Jackson, J. W., and Swanson, S. A. 2015. Toward a clearer portrayal of confounding bias in
instrumental variable applications. Epidemiology (Cambridge, Mass.), 26(4), 498.
Kim, J., and Shin, W. 2014. How to do random allocation (randomization). Clinics in
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Mareno, N. and Hart, P.L., 2014. Cultural competency among nurses with undergraduate and
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Schneider, Z., and Whitehead, D. 2013. Nursing and midwifery research: methods and
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Commerce and Management, 2(11), 1-22.
Vohra, S., Shamseer, L., Sampson, M., Bukutu, C., Schmid, C. H., Tate, R., ... and Altman,
D. G. 2016. CONSORT extension for reporting N-of-1 trials (CENT) 2015
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