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Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 353-358

Knowledge, attitudes, and perception on patient safety among intern nurses at hemodialysis unit

Medical-Surgical Nursing Department, College of Nursing, University of Hail, Hail, Kingdom of Saudi Arabia

Date of Submission10-Jul-2020
Date of Decision24-Jul-2020
Date of Acceptance08-Aug-2020
Date of Web Publication15-Oct-2020

Correspondence Address:
Eddieson A Pasay-an
7395 Building 9, Almahatta, Alhmatta Street, Hail
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijhas.IJHAS_145_20

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BACKGROUND: The students must engage early in safety principles within their academic programs. This study aims to determine the differences in knowledge, attitude, and perception from interns' demographic information and correlates between knowledge, attitudes, and perception on patient safety.
MATERIALS AND METHODS: A quantitative comparative-correlational study was conducted at the hospital hemodialysis units in the Hail Region, Kingdom of Saudi Arabia. There were 118 nurse interns who participated in the study resulting from simple random sampling. The survey questionnaire was used for data collection from May to July 2019.
RESULTS: Nurse interns have a good knowledge (x̄= 2.94), attitudes (x̄= 3.51), and perception (x̄= 3.26). The t-test found significant differences between type of program to knowledge (P < 0.01) and attitudes (P < 0.02). However, no significant differences found between knowledge to sex (P > 0.18.) and patient safety (P > 0.73); perception to sex (P > 0.60), type of program (P > 0.45), and patient safety training (P > 0.68); and attitudes to sex (P > 0.14) and patient safety training (P > 0.51). There is a significant moderate positive correlation between the knowledge, attitude, and perception, and attitude to perception.
CONCLUSION: The good results of knowledge, attitudes, and perception of the nurse interns suggest a continuous improvement of the nursing intern program for patient safety. Further, the knowledge translation to attitude and perception is a good indication that nurse interns can acclimatize the patient safety in their future actual practice. Study findings contribute to the improvement of the outcomes of the educational process for the nursing internship program.

Keywords: Attitudes, hemodialysis unit, intern nurses, knowledge, patient safety, perception

How to cite this article:
Alshammari FF, Ahamed ST, Sallam SA, Pasay-an EA. Knowledge, attitudes, and perception on patient safety among intern nurses at hemodialysis unit. Int J Health Allied Sci 2020;9:353-8

How to cite this URL:
Alshammari FF, Ahamed ST, Sallam SA, Pasay-an EA. Knowledge, attitudes, and perception on patient safety among intern nurses at hemodialysis unit. Int J Health Allied Sci [serial online] 2020 [cited 2022 Sep 26];9:353-8. Available from: https://www.ijhas.in/text.asp?2020/9/4/353/298111

  Introduction Top

The inclusion of patient safety models in the nursing education curriculum builds nursing students to become safe practitioners.[1] As a result, there is a need for nurse educators to develop the competencies of nursing students toward patient safety and quality care. For this reason, students' errors in hospital practice could be significantly reduced and could improve the safety and quality care through quality education.[2] It is in this aspect that advancing teaching delivery is essential in how these students are being taught in their course of learning relative to patient safety. Miller and LaFramboise thought that the classroom and related learning activities could impact the knowledge, skills, and attitudes of nursing students regarding patient safety.[3] As such, the need to continuously expose students to patient safety was recommended and must be early enough in their undergraduate level. Thus, the need for advanced education must be guaranteed on patient safety as well as the skills to deliver safe patient care in the clinical setting.[4] The Bachelor of Science in Nursing (BSN) in Saudi Arabia is designed for a 5-year curriculum – a 4-year theoretical focus and 1-year internship. This program caters to regular/traditional nursing students (students who finished their preparatory year) and bridging program (with diploma in nursing but intends to upgrade to BSN).[5]

Recently, several studies have emerged concerning the patient safety on the professional nurses,[6],[7],[8] but the little emphasis was made for students.[9],[10] According to Olaf et al., the transition from student to skilled nurse is a stressful experience due to the increase in their responsibility and accountability.[11] Thus, there is a need to integrate knowledge and theory learned from the classroom to practical application and skills development in a professional setting. Indeed, patient safety insights of the nursing students can offer a valuable understanding as to how nursing education enables them to deliver safe care as early in their foundational years.[12] The literature on patient safety showed that most of the nursing students thought that they were knowledgeable and had acquired skill on patient safety, however, during their related learning activities, issues on patient safety arose.[4],[13] In a self-reported study by Colet et al.,[9] it shows a gap in the level of competence within the six dimensions of patient safety. As such, it could be implied that the lack of faculty with safety and quality improvement competence contributed to the prevailing problems.[14] While patient safety is increasingly recognized as a key dimension of quality care,[15] this could be achieved by developing a mechanism on patient safety education. As such, this enhances nursing students' readiness to practice safe patient care through the utilization of evidence-based learning activities in the classroom.[13] At the same time, it was shown that the students have an advantage in enhancing their knowledge with optimal clinical advising.[16]

This study is of paramount importance as it contributes to the improvement of the outcomes of the educational process of the nurse interns and the internship program as a whole. To the best of the researchers' knowledge, this is the first study conducted in Saudi Arabia regarding the nurse interns at the hemodialysis, which is one of the most complex units in the hospital settings. Therefore, nurses entering the workforce must acquire the knowledge, skills, and attitudes required to deliver safe patient care. This study aims at determining differences in knowledge, perception, and attitude from interns' demographic information. Furthermore, it determines the correlations between knowledge, attitudes, and perception.

  Materials and Methods Top


This research employed a quantitative-comparative-correlational study.


This study was conducted at the hemodialysis unit of King Khalid Hospital, Hail city, and the only hospital caters to all hemodialysis patients in the region.

Samples and sampling

The samples of the study were the nurse interns who were deployed in the hemodialysis unit. Although considered as part of the health-care team, these nurse interns had limited roles supervised by a licensed nurse. The researchers employed RAOSOFT sample calculator (https://www. calculator.net) with a 95% confidence level. From the 169 interns as the samples, the researchers used simple random sampling yielded to 118 participants. In simple random sampling, the researchers apportioned a number to each of the candidates and used the random number generator to choose the participants.

Data collection

The self-administered questionnaire was used to collect the required data which was commenced after the approval from the institutional review board. Before the actual data collection, the researchers conducted an orientation for the respondents with the aim of explaining the purpose of the study, their extent of participation, and their rights as participants. The researchers directly handed the questionnaire to the participants during their break time. Data collection was conducted from May 2019 to July 2019 with a 100% return rate.


The tool was researchers' made which was based on the literature and similar studies. The first part was the demographic information such as sex, type of program, and attendance to training courses. Concerning knowledge, it contains 16 multiple-choice questions that were categorized into three subitems such as definitions, types of errors in hemodialysis, and causes of errors. The correct answer scored 1, whereas the incorrect answers scored 0. The knowledge of the nurse interns was described as: no knowledge (0–1.80), poor (1.81–2.61), average (2.62–3.41), good (3.42–4.20), and very good (4.21–5.00).

The second part was a 15-question item to assess the perception of the intern nurses affecting the patient safety and the patient safety improvement. Some examples of the questions are “improvement on the organizational culture encourages reporting and avoids blaming”and “improvement of instruction/training concerning hemodialysis can enhance patient safety.”This was measured with a five-point Likert scale, with five responses ranging from strongly disagree to strongly agree (1–5). The language of the tool is in English.

The third part of the questionnaire measures the attitude to patient safety with seven items. It was a five-point Likert scale ranging from strongly disagree to strongly agree (1–5). Some examples of the questions include: “as a nurse intern, I am able to discuss my errors I made”and acknowledging and dealing with my errors will be an important part of my job.”

The tool was subjected to validity and reliability. The researchers invited four panels of experts to check and review the items in the questionnaire. Two of them were research consultant in one of the universities in Saudi Arabia, and the other two were patient safety officers and quality directors in the hospitals in the Hail Region. The face validity yielded a valid result which was viewed as covering the concept it seeks to measure. Thereafter, the tool was subjected to the content validity index (CVI). The questionnaire obtained an overall CVI score of 0.91 for relevance and a CVI score of 0.90 for clarity, indicating a high level of content validity.

The tool was piloted among 20 nurse interns to check for the reliability of the questionnaire. The questionnaire yielded a reliability coefficient of 0.71.

Ethical consideration

This research has obtained an ethical clearance from the Institutional Review Board of the University of Hail. The researchers ensured the privacy, anonymity, confidentiality, and the right to withdraw at any time. Furthermore, written informed consent was provided for the participant to read and affixed their signature, should they decide to participate.

Data analysis

The data collected were statistically analyzed using the Statistical Package for Social Sciences version 22 (SPSS v. 22, IBM Software Group, Chicago, IL, USA). Frequency and percentage were used to describe the demographic information of the respondents. The t- test was used to record any differences in sex, type of program, and patient safety training. Meanwhile, Pearson's r was used to record the correlations of knowledge, attitude, and perception of the nurse interns on patient safety at the hemodialysis unit.

  Results Top

Of the 118 nurse interns who participated in this study, the majority of them were females (78.70%). There were more regular students (78.80%) and only 25 belonged to the bridging (21.20%). Regarding patient safety training, there were more intern nurses (54.20%), who had training compared to those who had no training (45.80%) [Table 1].
Table 1: Demographic information of the respondents (n=118)

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The intern nurses have good knowledge (2.94), attitudes (3.51), and perception (3.26) regarding the patient safety [Table 2].
Table 2: Level of knowledge, perception, and attitude on patient safety=118

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On knowledge to patient safety, there was no significant difference in sex (P < 0.18). However, there is found a significant difference in the type of program (P < 0.01) but no significant difference between patient safety training (P > 0.73) [Table 3].
Table 3: Differences between the level of knowledge, perception, and attitude regarding patient safety of the respondents across their profile n=118

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Regarding perception, there were no significant differences in sex (P > 0.60), type of program (P > 0.45), and patient safety training (P > 0.68).

Concerning attitude, there found no significant difference in sex (P > 0.14) but with a significant difference in the type of program (P < 0.02). Conversely, there is no significant difference found in patient safety training (P > 0.51).

The results of the Pearson's r yielded a significant moderate positive correlation between the knowledge and attitude and perception of the respondents. Moreover, there was a significant moderate positive correlation between the perception and attitude (0.72) of the respondents [Table 4].
Table 4: Relationships between the level of knowledge, perception, and attitude regarding patient safety of the respondents (n=118)

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  Discussion Top

This present study aimed at determining the knowledge, skills, and attitudes of the intern nurses at the hemodialysis unit and its relationship with their demographic information. In general, the knowledge, skills, and attitudes of the nurse interns as to the patient safety at the hemodialysis unit were good. The good knowledge, attitudes, and perception of patient safety could be due to the educational institutions that successfully trained the nurse interns regarding the standard hemodialysis caring practices by demonstrating hemodialysis procedures at the point of care. The present result supported the findings reported earlier by Almaramhy et al.[17] on good self-rating of specific knowledge and Nabilou et al.[18] on the nursing students' knowledge on patient safety. Other studies found that the competence of nursing students on patient safety was at varying levels[9] but with favorable confidence on patient safety competencies.[19] Furthermore, the good perception of the nurse interns in this study refers to Nabilou et al. findings, which showed that nursing students should have a deeper perception of patient safety.[18] Such perception of the students in patient safety is an important indicator of their willingness to engage and support the patient safety practices once they are in the work actual setting. It is essential that students must be engaged early in safety principles within their academic programs.[19]

The positive attitude of the nurse interns at the hemodialysis units, on the other hand, could be due to an essential prerequisite for any service provider. This improves the quality of services in health-care centers.[20] The present findings indicate that hemodialysis procedures should be provided to hemodialysis intern nurses, but also, the standardized evaluation of ample knowledge, skills, and competencies regarding safe practices is necessary. According to Keshk et al.,[21] ensuring intern nurses' competency regarding patient safety is crucial as they are considered the future professional nurses. The findings on good knowledge, attitudes, and perception could contribute to improving patient safety in the hemodialysis unit once they are independent practitioners, although the latter requires intensified educational efforts from the educational institution for continuous improvement.

The type of program (regular/bridging) was noted to have significant differences in knowledge and attitude. This suggests that nurse interns who belonged to the bridging program have a good knowledge and attitude on patient safety at the hemodialysis unit. The finding could be related to the introduction of learning approaches, through which the students develop greater self-awareness of their own learning. Indeed, study finding demonstrated that nurse interns from the bridging program have a higher level of adaptation in the practice than those from the regular program.[22] For the nurse interns, it is important to increase the clinical experiences by means of choosing the right clinical placement with a clear matching objective and give constructive feedback on nursing interns' performance, whether they belong to regular and bridging programs. Indeed, the expansion of knowledge could play a decisive role in shaping a positive attitude toward patient safety.[23] It is important that nurses entering the workforce needed to acquire the knowledge, skills, and attitudes required to deliver safe patient care.[24] This finding is useful for universities that cater to regular BSN programs and bridging programs, where students collaborate in small groups and work together to manage real-life problems. This reform would enable and promote nursing interns to develop knowledge and clinical competence regarding patient safety.

The observed significant moderate positive correlation between knowledge, attitude, and perception of the respondents indicates that the knowledge could be translated to attitude and good perception. This further implies that the expansion of knowledge and awareness is a prerequisite for effective nursing care, as it forms a positive attitude. Consequently, positive attitudes lead to improved health-care services in hemodialysis units as well as control and prevention of adverse effects of hospitalization. This finding is reinforced by the researches of Sarani et al.[25] and Nasrabadi and Mousavi[26] where the authors established that attitude score increased with improving knowledge of the patients on hemodialysis. Having basic knowledge does not always lead to good practice and that, attitudes be reworked in a rigorous and scientific manner to achieve proper practice.[27] Thus, it is important to include critical thinking components and critical thinking skills in education programs, in order to prepare graduate students to become successful in the workplace. According to Monfared et al.,[23] the factor that differentiates hemodialysis nurse interns from their peers in other units is that this group needs a great amount of knowledge on the nursing subjects, in both scientific and practical sense, to be able to appropriately meet the needs of their patients. It is in this context that to improve safety, there is a need to prioritize goals and develop outcome-based, data-driven action plans that will improve the nurse interns' knowledge and skills. Nurse interns should be encouraged to express their concerns in a blame-free environment, as the facility strives to create a culture of safety.

  Conclusion Top

The good results of knowledge, attitudes, and perception of the nurse interns suggest a continuous improvement of the nursing intern program for patient safety. Further, the knowledge translation to attitude and perception is a good indication that nurse interns can acclimatize the patient safety in their future actual practice. Study findings contribute to the improvement of the outcomes of the educational process for the nursing internship program.


The authors would like to acknowledge the Scientific Research Deanship of the University of Ha'il (project number 160547) for the financial support of this study.

Financial support and sponsorship

This study was funded by the Scientific Research Deanship at the University of Ha'il, Saudi Arabia, with project number 160547

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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