What Clinical Learning Contracts Reveal about Nursing Education and Patient Safety

OCTOBER 2009 INVITED FEATURE

ABSTRACT
While it is widely accepted that adopting a systems perspective is important for understanding
and addressing patient safety issues, nurse educators typically address these issues from the
perspective of individual student performance. In this study, the authors explored unsafe patient
care events recorded in 60 randomly selected clinical learning contracts initiated for students in
years 2, 3, and 4 of the undergraduate nursing program at the University of Manitoba. The
contracts had been drawn up for students whose nursing care did not meet clinical learning
objectives and standards or whose performance was deemed unsafe.

Using qualitative content analysis, the authors categorized data pertaining to 154 unsafe patient
care events recorded in these contracts. Thirty-seven students precipitated these events. Most
events were related to medication administration (56%) and skill application (20%). A
breakdown of medication administration events showed that the highest number were errors
related to time (33%) and dosage (24%).

International students and male students were responsible for a higher number of events than
their numbers in the sample would lead one to expect. The findings support further study related
to patient safety and nursing education.

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What Clinical Learning Contracts Reveal about Nursing Education and Patient Safety
The need to address patient safety issues from a systems perspective is receiving increasing
attention and action in Canadas health-care system. In contrast, patient safety is a relatively
new concept within nursing education. Understanding the impact of nursing education systems
on patient safety entails looking within and reviewing how existing program structures and
processes (e.g., curriculum; sequencing of courses; formal and collective feedback from clinical
instructors; clinical practice models; and frequency of, and pass rates on, math calculation tests)
may be fostering or undermining patient safety. Further, it requires looking between the
education and practice sectors to understand their impact on patient safety. Achieving this
perspective necessitates that the sectors cooperate, engage in dialogue, and share data
(Gregory, Guse, Davidson Dick, Davis, & Russell, 2008).

In clinical nursing education, the tendency is to hold each student accountable for her/his
clinical mistakes. According to Milligan (2007) and Neudorf, Dyck, Scott and Davidson Dick
(2008), there needs to be increased attention on nursing education as a
system. Milligan observes that the process of making significant moves toward a patient safety
culture requires changes in health-care education. Singh et al. (2009) notes that emphasizing a
systems approach to patient safety in the medical curriculum promotes systems thinking and a
culture of safety among undergraduate medical students. A culture shift toward patient safety
can only occur when mistakes students make in the clinical setting are considered within the
wider contexts of education and practice systems. Although students are
expected
to make mistakes as they learn, there is an equal expectation that nursing programs and
curricula are ensuring that students meet established clinical performance objectives and are as
safe as they can be. The
Canadian Association of Schools of Nursing
(2006) endorses the adoption of a systems perspective and the integration of patient safety
concepts, structures and processes within the nursing education sector.

METHOD
The purpose of our study was to explore unsafe patient care events recorded in clinical learning
contracts initiated for baccalaureate students in the faculty of nursing, University of Manitoba.
Ethical approval was obtained from the University of Manitoba Education Nursing Research
Ethics Board. One of the conditions imposed by the board was that only contracts from the files
of students who had already graduated could be accessed. Contracts had been drawn up for
students whose nursing care did not meet clinical learning objectives and standards or whose
performance was deemed unsafe. The contract outlined areas of concern the clinical instructor
(CI) had with the students performance, the rehabilitative and remedial activities the student
would undertake, the supervision and supports that would be provided, and the outcomes that
would indicate success. CIs, the majority of whom were not full-time faculty, taught in years Two
and Three and in the first half of Year Four of the program. In the latter part of Year Four,
preceptors (RNs and staff nurses) supervised students while they completed their senior
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What Clinical Learning Contracts Reveal about Nursing Education and Patient Safety
practicum. Buddy RNs (unit staff) were often in the background, ensuring patients received
safe, competent care.

We employed a member of the facultys support staff to search archived individual student files
from the years 1999 to 2005. A random selection of files garnered 60 contracts: 11 from
students in Year Two, 36 in Year Three and 13 in Year Four (80 % of the contracts were
initiated between 2001 and 2005). The data were subjected to qualitative content analysis and,
as appropriate, descriptive statistical analysis. Thirty-seven of the 60 students had precipitated
concerns about unsafe patient care. Table 1 shows the demographics of this group. The clear
majority of students placed on contracts were successful; only eight of the 37 failed their clinical
courses: two students failed in Year 2, three in Year Three and three in Year Four. Given that
we do not know the total number of contracts, some caution is warranted in the interpretation of
failure rates.

The percentage of male nursing students (21.62%) placed on contracts was higher than might
be expected in such a sample; we estimate that 8 to 10 % of students in the program were men.
Although the number of male nursing students in Canada remains unknown, the number of
male RNs employed in nursing in Canada is reported as 5.6 % (Canadian Nurses Association,
2006). The number of international students on contracts also seems relatively high and
noteworthy.

EVENTS
We categorized the unsafe patient care events noted on the contracts as errors, near misses, p
otential
adverse
events
and
adverse
events
(
see box
). These terms were based on definitions provided in the
Canadian Patient Safety Dictionary
(2003) that we modified to reflect nursing practice. By aggregating this data, we were able to
interpret these individual events more broadly and from a systems perspective. This is not to
imply that the students should not have been held accountable for their actions. The data
suggest, though, that education and practice contexts may be undermining patient safety.

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What Clinical Learning Contracts Reveal about Nursing Education and Patient Safety
A total of 154 unsafe patient care events were documented in the contracts. Errors (E)
accounted for 12.34% (19) of the total number of events; near misses (NMs) accounted for
30.52% (47); and potential adverse events (PAEs) constituted more than one-half of the events
(54.55%; 84). Adverse events (AEs) made up 2.60% (4) of the events (see Figure 1 ).

Although 30.52% (47) of the events were NMs, that is, they were intercepted by a CI or a buddy
RN, 57.14% (88) placed patients directly at risk for harm. And it is likely that many more NMs
were either not recorded in the contracts or precipitated by students who were not placed on
contracts. That observation made, it is of concern that so many events went sight unseen.
Further investigation is warranted to explain why.

Male nursing students precipitated 37.66% of all events. This group was also responsible for
46.43% (39) of all the PAEs. Male international students contributed to 25.64% (10/39) of the
male student PAEs. Female international students were implicated in 36.36% of all female
student errors, 40.45% of all female student NMs; and 33.33% of all female student PAEs.
These findings draw our attention to male students and international students and the need to
better understand why they were prominent in the data set.

As shown in Figure 2 , improper medication administration was the most frequently occurring
unsafe patient care event (56.49%; 87).
Inadequate
skill application
occurred with the following: use of intravenous devices (peripheral lines, central lines),
patient-controlled analgesia pumps and other kinds of pumps; patient transfers; nasogastric
tube insertion; oxygen tube placement; ventilation/suctioning; asepsis (dressing changes,
wound care); use of a Jackson-Pratt drain.
Other
refers to students failure to collect data, inability to prioritize nursing care and lack of
follow-through.

When data from Figure 1 are compared to medication administration data, a similar pattern of
events that went sight unseen is noted. That is, CIs or buddy RNs intercepted 35.64% (31) of
the 87 medication administration events. However, more PAEs and AEs were missed, i.e.,
56.32% (49) (see Figure 3 ).

Figure 4 shows that the majority of the medication administration events were in the wrong
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What Clinical Learning Contracts Reveal about Nursing Education and Patient Safety
time
category (33.3%; 29). Four NMs and 22 PAEs were observed with respect to
wrong time
. NMs were most often recorded in the category of
wrong dose
; CIs, preceptors, buddy RNs or other unit staff caught or prevented 61.90% (13/21) of these
events. Of concern, however, is that more than one-third (38.10%; 8/21) of wrong dose events
were not intercepted, placing patients at direct risk for harm.

An overall failed interception rate of 56.32% was identified for these combined events. In other
words, more than one-half were neither prevented nor stopped. Page and McKinney (2007)
observe that understanding the why of collective medication events among undergraduate
students requires examination of individual and systems-based factors. According to Wolf,
Hicks and Serembus (2006), a lack of learning time in the clinical setting and the poor quality of
math education may be contributing factors.

The power of aggregated data becomes clear when we look across the three categories of
events and see a pattern that is of concern. In each of the categories in Table 2 , the number of
NMs is consistently lower compared to the number of PAEs and AEs. Therefore, more patients
were placed at risk for harm than were protected by good catches.

CONCLUSION
The aggregated data reveal patterns of occurrences that implicate education and practice
system effects on patient safety that are common to nursing programs across Canada. Some
caution is warranted when interpreting the findings because they are informed by a data set
collected over a six-year period that focused on a small sample of students who struggled within
the context of clinical practice.

Wakefield et al. (2005) emphasize the value of nursing and medical curricula that stress the
importance of learning from mistakes rather than focusing exclusively on the mistake itself. A
student can learn from a mistake by being placed on a clinical learning contract. However, once
tucked away in a file, a contract loses any potential benefit it might have to anyone other than
the individual student (and possibly her/his clinical group). For example, by reviewing NMs
recorded on contracts, nurse educators, clinical instructors and administrators would gain
valuable information that could assist them in identifying patterns that warrant intervention. By
aggregating data and by fostering cooperation through data exchange between the practice and
education sectors, it becomes possible to understand the impact of these sectors on patient
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What Clinical Learning Contracts Reveal about Nursing Education and Patient Safety
safety.

Should the model of clinical instruction (i.e., one instructor for six or more students) that has
been in place for decades continue to be considered a best practice model? The model
warrants scrutiny, given clinical environments that have become increasing complex. Anderson
(2009) points out that CIs may lack experience as educators and find transitioning into this role
challenging, necessitating ongoing education, support and development (Scanlan, 2001). The
combined effect of the casualization of the nursing workforce (which contributes to staffing
instability), the increased acuity of patients on the unit and the presence of complex medication
treatment regimes are such that real pressures are exerted on the CI and, by default, the model.

The pool of nursing students today includes many for whom English is a second language,
greater numbers of immigrant Canadians and international students, and higher numbers of
men. Admission standards may be set too low in some nursing programs, leading to
acceptance of students who will struggle academically and clinically. Many will necessarily draw
heavily on a CIs time and energy, at the expense of other students.

In our study, male students and international students appeared overrepresented. Perhaps the
male students were socialized to be more autonomous, to take independent action and,
consequently, to take more risks. On the other hand, they may have hesitated to ask for
assistance, especially from female instructors. The clinical instructors (almost exclusively
female) may have made assumptions about these students, i.e., that they were more
independent and competent, and required less supervision than their female counterparts. It is
also possible that the male students were more closely supervised. However, this hypothesis is
not readily supported by the PAE data; CIs, buddy RNs and other unit staff discovered PAEs
precipitated by male students after the fact. Socio-cultural and language comprehension
differences may explain the greater presence of international students in the data set. Clearly,
additional research is required in these areas.

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What Clinical Learning Contracts Reveal about Nursing Education and Patient Safety
Given the possible limitations associated with the clinical instructor model, the realities of the practice context and recent changes in the student applicant pool, we suggest that nursing programs ought to be moving in new directions. And in fact, some have hired full-time clinical instructors as a first step. Our hope is that the findings from this study will be reviewed and debated, so that patient safety will get its due in nursing education. Furthermore, we suggest that research on the relationship between education (and clinical education, in particular) and patient safety in all the health-care professions is long overdue. Acknowledgment: The research team thank Manitoba Institute for Patient Safety; the Faculty Endowment Fund, Faculty of Nursing, University of Manitoba; and the Health Quality Council of Alberta for generously funding this research. Their findings do not, in any way, however, implicate or hold the agencies accountable for the conclusions reached. HQCA also provided a research studentship to support one of the research assistants. The following individuals contributed to the study: David Hultin, project manager, Manitoba Nursing Research Institute; Colleen Chan, faculty of arts and science, University of Lethbridge; Katherine Egan, faculty of health sciences, University of Lethbridge; and TerriJo Oler, faculty of health sciences, University of Lethbridge and Karen Dempsey, student services, University of Manitoba. DAVID GREGORY, RN, PhD, IS A PROFESSOR, FACULTY OF HEALTH SCIENCES, UNIVERSITY OF LETHBRIDGE, LETHBRIDGE, ALBERTA. LORNA GUSE, RN, PhD, IS AN ASSOCIATE PROFESSOR, FACULTY OF NURSING, UNIVERSITY OF MANITOBA, WINNIPEG, MANITOBA. DIANA DAVIDSON DICK, BScN, MEd, IS A PROFESSIONAL AFFILIATE AND FORMER DEAN OF NURSING, SASKATCHEWAN INSTITUTE OF APPLIED SCIENCES AND TECHNOLOGY (SIAST). PENNY DAVIS, RN, MEd, IS AN INSTRUCTOR, FACULTY OF NURSING, UNIVERSITY OF MANITOBA. CYNTHIA K. RUSSELL, RN, PhD, IS A PROFESSOR, COLLEGE OF NURSING, UNIVERSITY OF TENNESSEE HEALTH SCIENCE CENTER, MEMPHIS, TENNESSEE. REFERENCES Anderson, J.K. (2009). The work-role transition of expert clinician to novice academic educator. Journal of Nursing Education , 48(4), 203-208. Canadian Association of Schools of Nursing. (2006). Patient safety and nursing education [Position statement]. Author: Ottawa, ON. Canadian Nurses Association. (2006). 2005 workforce profile of registered nurses in Canada . Author: Ottawa, ON. Gregory, D., Guse, L., Davidson Dick, D., & Russell, C. (2008). The question of safety: An exploration of errors among undergraduate nursing students placed on clinical learning contracts . Milligan, F.J. (2007). Establishing a culture of patient safety the role of education . Nurse Education Today, 27(2), 95-102. Neudorf, K., Dyck, N., Scott, D., & Davidson Dick, D. (2008). Nursing education: A catalyst for the patient safety movement . Healthcare Quarterly, 11(3 Spec No.), 35-39. Page, K., & McKinney, A.A. (2007). Addressing medication errors the role of undergraduate nurse education . Nurse Education Today, 27(3), 219-224. Scanlan, J.M. (2001). Learning clinical teaching: Is it magic? Nursing and Health Care Perspectives , 22(5), 240-246. Singh, R., Singh, A., Fish, R., McLean, D., Anderson, D., & Singh, G. (2009). A patient safety objective structured clinical examination . Journal of Patient Safety, 5(2), 55-60. Wakefield, A., Attree, M., Braidman, I., Carlisle, C., Johnson, M., & Cooke, H. (2005). Patient safety: Do nursing and medical curricula address this theme? Nurse Education Today, 25(4), 333-340.
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