The Silent Struggle: Nursing Students' Experiences related to barriers to speaking up for Patient Safety: a qualitative study

doi:10.21203/rs.3.rs-4998623/v1

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Research Article

The Silent Struggle: Nursing Students' Experiences related to barriers to speaking up for Patient Safety: a qualitative study

https://doi.org/10.21203/rs.3.rs-4998623/v1

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Background

Patient safety is a significant concern in healthcare settings, and speaking up for patient safety is essential for promoting quality of care and preventing harm. However, nurses, including nursing students, may face barriers to speaking up, which can hinder their ability to report safety concerns.In this study, we explored the nursing students’ experiences related to the barriers to speaking up for patient safety.

Methods

The study was conducted using a qualitative research design. Data were collected by conducting semi-structured interviews with 19 final-year nursing students from April 2023 and June 2023 in Iran. Data were analyzed by conventional content analysis until data saturation was achieved.

Results

This study has revealed the formation of three distinct themes, namely negative organizational culture,inadequate preparation for speaking up for patients' safety and inconsistencies between learning through theories and learning through practice. These themes are comprised into eight subthemes. The main themes of the study showed the significant barriers to speaking up about patients’ safety. These barriers can lead to critical issues being overlooked, potentially harming patients. When healthcare staff feel unable to speak up, errors and unsafe practices may remain unreported.

Conclusion

Research findings revealed barriers to speaking up in organizational settings, including fear of retaliation, lack of confidence, and perceived futility. These barriers often prevent employees from voicing their concerns or suggestions. By understanding the underlying barriers to speaking up for patient safety, healthcare professionals can develop strategies to promote a culture of safety. They can also empower nursing students to become effective advocates for patient safety. This includes providing training on effective communication and assertiveness skills, encouraging a culture of open dialogue, and building trusting relationships between students and healthcare providers.

Patient safety is the absence of preventable harm to a patient during health care. This includes reducing the risk of unnecessary harm associated with health care to an acceptable minimum [1]. A growing body of evidence indicates that patient safety is a critical issue in contemporary health care [2]. Adverse events due to unsafe care are among the ten leading causes of death and disability worldwide [3]. There is a 1 in 300 chance that a patient will be harmed while receiving health care.

Maintaining patient safety and identifying possible risks are vital nursing tasks [4]. Human factors related to clinical errors and accidents have been identified as weak interpersonal relationships and ineffective communication within the care team [5]. Lee et al. (2023) reported that miscommunication between healthcare professionals is estimated to cause 80% of serious safety events [6]. A lack of communication between the care team and students can also risk patient safety [7].

However, nursing students must gain the necessary skills to express their opinions when observing unsafe practices in clinical environments [8]. Speaking up can be necessary in clinical situations when patient safety concerns are long-standing [9]. It can help to identify the underlying cause of a patient's condition and can also help to inform decisions about the most effective treatment plan. Furthermore, speaking up can help ensure that the patient receives the best care [10]. Failure to express a clear opinion is cited as the cause of 23% of hospital communication failure reports [11].

Speaking up refers to assertively communicating patient safety concerns through information, questions, or opinions when immediate action is needed to prevent patient harm [5]. In a safety culture that refers to shared beliefs and behaviors related to patient safety, speaking up is the most prominent element that promotes open communication of concerns [9].

In recent years, research has significantly increased the focus on understanding students' experiences during their clinical learning. This body of research has highlighted various concerns regarding unsafe and poor practices witnessed by students during clinical rotations [12-14]. Students can be particularly concerned about hazardous practices, as they raise concerns about patient safety and the quality of care delivered [8]. This can affect their professional development, future practice, and immediate learning experience. Students consider speaking up a professional and moral responsibility [7]. However, students indicate that they deliberate whether to speak up or remain silent [15]. Students are believed to fear negative consequences that may affect their learning experience [13].

A study by Fagan et al. (2021) demonstrated that final-year nursing students needed confidence and courage to uphold their professional responsibility and shield patients from harm [7]. Further research by Lindh et al. (2008) revealed that decision-making about errors is strongly related to students' ethical and professional attitudes [16]. Bickhoff et al. (2016) reported that students require moral courage when faced with poor clinical practice [17]. As moral courage impacts professional relationships, it also affects students' ability to speak up and report poor practices. Furthermore, they are concerned about being ostracized if they raise concerns [12]. Students usually disclose an incident or remain silent [18, 19]. Ion et al. (2015) emphasize the importance of clinical leadership in improving students' situations and their willingness to speak up [15].

A nursing student, as a junior care team member, can play a significant role in patient safety. Compared with experienced nurses, students are subordinate and transient at work [20]. Despite understanding specific patient safety concerns, 56% of students fail to speak up in critical situations [21]. They feel powerless and unvalued in the clinical setting, so they do not report incidents [22]. According to a qualitative study, nursing students' self-expression skills and readiness to express frank opinions about patient safety can have significant psychosocial consequences for their self-confidence, empowerment, and success [23]. Therefore, a better understanding of "expressing a clear opinion" can help leaders and decision-makers improve healthcare quality and safety [24]. It is helpful to understand healthcare workers' "stand-up" behaviors and the perceived "voice-up" climate in healthcare organizations to identify areas for improvement [10]. Nurses are in a position of authority and can set an example for students by showing the importance of speaking up about patient safety issues [6].

Additionally, nurses can provide students with guidance and resources to help them understand the importance of speaking up [24]. However, students often face challenges such as fear of retaliation or criticism from more experienced staff [12]. They may also need more confidence in their knowledge and communication skills. Furthermore, the hierarchical nature of healthcare settings can make it intimidating for students to voice their concerns [25]. Because safety cultures and organizational conditions differ between countries and since our study population is students, it seems possible to collect data about their pure experiences by conducting a qualitative study. This study examines student nurses' experiences speaking up for patient safety in clinical practice settings.

Study design and setting

In this qualitative study, nursing students' experiences speaking up for patient safety were explored through content analysis. The researchers followed standards for reporting qualitative research (SRQR).

This qualitative study was conducted at the Tabriz Nursing and Midwifery Faculty. It is one of the oldest nursing faculties in Iran (1971) and aims to provide high-quality education and training for aspiring nurses and midwives. It offers a wide range of nursing and midwifery programs for students and professionals. Approximately 400 students enroll each year at different levels in the faculty, and more than 300 graduate each year.

Participants and Sampling

Nineteen final-year nursing students were recruited via purposive sampling. All participants in our study passed internship courses from various clinical settings, including emergency departments, psychiatric clinical settings, critical care units, intensive care units, general pediatric units, general adult units and operating rooms. This allowed us to capture a wide range of perspectives and experiences of the participants toward speaking up about patient safety challenges. The inclusion criteria were as follows: studied in their final year in a bachelor of nursing program, 2) had experience with patient safety, and 3) completed their courses without failure. In each educational center, a research team member (FR) identified potential participants and informed them about the study and its purpose. Once the participants expressed willingness to participate in the survey, the FR comprehensively explained the study's purpose and methodology. Finally, she obtained written consent from them.

The participants were all final-year nursing students (n = 19) with diverse backgrounds: the mean age of the participants was 21.6±5.3 years (age range: 21--25); 57.9% were female; 53.6% evaluated their financial status as fair; and the mean GPA of the participants was 17.5±3.7 (GPA range: 16--18) (Table 1).

Table 1 Demographic Characteristics of the Participants

No.	Age	Gender	GPA	Family income status
1	21	Female	16.2	Fair
2	22	Male	16.8	Good
3	23	Female	17.4	Good
4	23	Female	16	Fair
5	21	Female	17.9	Fair
6	22	Male	18.2	Poor
7	25	Male	17.3	Poor
8	22	Female	17.6	Fair
9	23	Male	16.1	Fair
10	23	Female	18.1	Good
11	24	Female	17.5	Poor
12	25	Male	17.7	Fair
13	22	Male	17.5	Fair
14	22	Female	18.1	Good
15	21	Female	16.3	Poor
16	21	Male	16.7	Fair
17	25	Female	17.2	Fair
18	24	Female	17.1	Poor
19	24	Male	16.3	Fair

The purposive sampling was aimed to select the maximum diversity in terms of nursing students' age and sex. The diversity of participants allowed us to ensure that our results were representative of the general population. Data saturation was not a consideration in the number of interviews gathered; instead, interviews were continued until enough rich, storied data were collected to inform robust data analysis and a comprehensive understanding of the phenomenon under study.

Data collection

Data were collected via semi-structured, in-depth individual interviews. An interview guide was used to ensure that key research questions were addressed by participants while also providing flexibility to explore emerging topics. Table 2 presents key interview questions.

Table 2. The key interview questions

1- Please tell me about your experiences speaking up about patient safety.

2- "Please explain any patient safety situations you have witnessed or encountered that raised your concerns.

2- How do you handle situations where patient safety is compromised?

3- Have you ever experienced any negative consequences for speaking up about patient safety? Please explain it.

4- What factors influence whether or not you speak up about patient safety concerns?

5- What strategies would help prompt a culture of speaking up about patient safety among nursing students?

Face‒to-face semi-structured individual interviews were conducted with 19 students recruited from final-year students. All interviews were conducted in Persian by the last author (FR) between April 2023 and June 2023. The interviews lasted between 45 and 90 min and were carried out at the participants' choice of location. This was on campus or in an office in a clinic location. All interviews were audio-recorded and transcribed verbatim with the participants' permission. Data collection and analysis were conducted concurrently, with developing themes further explored and examined through later interviews. Recruitment of participants continued until data saturation was reached.

Data analysis

For qualitative content analysis, Graneheim and Lundman's (2004) method was used [26]. Each interview was analyzed after it was conducted. The interviews were transcribed verbatim and then read and reread several times to better understand their content. The meaning units in the interviews were words, sentences, or paragraphs. Coding and abstracting meaning units (346 codes) were performed. Considering the similarities and differences between the original codes, the codes were condensed, interpreted, and compared. Through this continuous process, themes and subthemes were identified. Four researchers agreed on the final themes and subthemes in two meetings.

Rigor

The rigor of the study was established according to Lincoln and Guba's (1985) criteria for credibility, transferability, dependability, and confirmability. Credibility was ensured by recording and summarizing the interviews and verifying them during each interview with participants (member checking). After each interview was coded, it was shared with participants to confirm the correct codes and interpretations. Corrections were made when there was a mismatch between the research interpretation and the participants' point of view. Additionally, probing questions were asked during the interviews to confirm that the inferences drawn from the participants' views were accurate. Transferability was ensured by selecting samples with various sociodemographic characteristics. Dependability was achieved through the involvement of four researchers in the data analysis process. In addition to explaining the study's procedures, we cited the participants' statements appropriately to interpret the analysis results. Confirmability was enhanced by documenting the data collection, analysis, and interpretation details.

Ethical considerations

This study was approved by the ethical committee of Tabriz University of Medical Sciences (Number: TBZMED. REC.1401.987). Nursing students who met the study eligibility criteria were informed about the purpose and nature of the study and were asked to participate voluntarily. Consent was obtained from the participants. Participants' confidentiality was maintained via the use of unique identifier numbers.

Thematic analysis

The analysis of the interviews through conventional content analysis resulted in meaning units that were sorted and abstracted into eight subthemes and, through interpretation, further summarized into three main themes: negative organizational culture, inadequate preparation for speaking up for patients' safety, and inconsistencies between learning through theories and learning through practice (Table 3).

Table 3. Themes and subthemes extracted from qualitative content analysis

Themes	Subthemes
Negative organizational culture	Exclusion from the patient care team
Negative organizational culture	Fear of Reporting Incidents
Inadequate preparation for speaking up for patients' safety	Lack of Confidence and assertiveness skills
	Lack of mentorship and support
	Lack of awareness of professional ethics and the duty to warn
Inconsistencies between learning through theories and learning through practice	Clinical practice and theoretical knowledge are far apart
	The gap between the reality of clinical practice and students' expectations of their roles as future nurses
	Students' challenges with putting theory into practice

Theme one: Negative organizational culture

Unfortunately, many nursing students experience insecurity when expressing their concerns, fearing judgment or negative consequences. This insecurity hampers their ability to speak up and report errors, ultimately jeopardizing patient safety. Nurse students also experience a culture of fear and silence due to healthcare organizations' hierarchical nature. Nursing students may fear retaliation or adverse consequences if they voice their concerns, leading to the fear of rocking the boat. The fear of being perceived as incompetent or questioning authority can also contribute to their insecurity.

Exclusion from the patient care team

Nursing students reported needing more effective communication between them and other healthcare professionals. They reported instances where critical information was not shared, communication channels were ineffective, and teamwork was not fostered. One participant said,

“Many of us feel excluded from the patient care team. If something happens to the patient, it has nothing to do with us since we are only observers. Nurses and doctors do not communicate with us about the patient's situation. We cannot participate in patient care decisions. We did not participate in the patient's treatment plan. We cannot share our knowledge or opinions.” (Participant No. 5)

Students cannot connect with the patient care team due to a lack of collaboration and communication. As a result, they missed opportunities to contribute their knowledge and insight to patient safety: Another participant stated this:

"It is not our responsibility to be part of the patient care team. We must be recognized as people who can comment on the patient's care plan. In other words, they do not give us this right. In other words, we do not give ourselves this right. We cannot speak up when patient safety is compromised." (Participant No. 1)

Fear of Reporting Incidents

The negative safety culture resulted in a culture of fear, where students were reluctant to speak up about incidents or safety concerns. The students expressed reluctance to report patient safety incidents due to concerns about retaliation. They also needed more trust in the system or believed that their concerns would not be taken seriously. Fear of reporting incidents hindered corrective actions and prevented learning from incidents. One participant expressed,

“The fear of being labeled troublemakers discouraged me as a nursing student from raising safety issues. The consequences of reporting them scared me. I was also afraid my voice would not be heard and ignored." (Participant No. 12)

Fear of speaking up due to negative consequences also results in a culture of silence, where issues and problems remain unresolved. This perpetuates an unsafe and unhealthy environment for students. Another participant stated:

I'm tired of being silenced. I want to express my opinions without fear of retribution. I want to be heard. Fear of facing consequences or backlash for speaking up is a constant deterrent, leaving me frustrated and stifled." (Participant No. 17)

Nursing students also reported a culture of blame, fear, or lack of transparency, which can impact their perception of patient safety. This included bullying, harassment, or a lack of support from other healthcare professionals. In this respect, participant no. 6 stated,

“In our clinical setting, there is always the fear that if we report safety errors, the nurse or supervisor will not treat us well from now on. We will lose learning opportunities. The nurse may be rude to us, or the department conditions may become more difficult." (Participant No. 6)

Theme two: Inadequate preparation for speaking up for patient safety

Students also reported needing more preparation to speak up about patient safety in their experiences. This theme highlights the lack of guidance and support provided to nursing students to address safety concerns effectively. Inadequate preparation for nursing students often results in incomplete guidance in identifying and addressing potential safety issues. In addition, they were given no support when they reported problems. This lack of guidance and support made it difficult for them to advocate for their patients.

Lack of confidence and assertiveness skills

Nursing students reported that they felt unprepared or unsure about their ability to speak up about patient safety concerns. They felt inadequate or need more confidence and knowledge to express their concerns appropriately. One participant said,

“I was not sure I knew enough about patient safety issues. A nurse hurriedly performed the angiocath change and did not follow some basic procedures. Owing to a lack of confidence in myself, I could not speak. I should have spoken up and helped ensure patient safety. I regret not acting.” (Participant No. 10)

Nursing students reported not receiving adequate assertiveness training, which is essential for communicating safety concerns effectively. Students found it difficult to express their concerns confidently and assertively without these skills. Another participant stated:

“During clinical courses, we are rarely taught how to express our opinions about patient safety to other healthcare professionals. We are expected to follow the rules and protocols outlined by healthcare facilities. However, it is important to voice concerns about patient safety when necessary. We should also be encouraged to do so.” (Participant No. 16)

Lack of mentorship and support

Nursing students reported that they often faced barriers to speaking up related to patient safety due to the lack of support and training in their educational programs. Furthermore, they revealed that they could not address patient safety issues without adequate support and mentorship. Consequently, they hesitated to discuss patient safety issues because they would not receive adequate training or support. In this regard, one of the participants stated,

“Nobody supported us when we spoke out about patient safety. Our clinical professor said that we should not interfere with routine clinical work. She probably worried that raising concerns about patient safety would disrupt clinical authority. Possibly, she feared that if we spoke up, existing processes and protocols would be undermined.” (Participant No. 18)

Lack of awareness of professional ethics and the duty to warn

Nursing students must understand their professional responsibility to disclose safety concerns, resulting in hesitation or uncertainty. They indicated that patient safety issues were not considered serious. Safety issues should be addressed in patients' care programs. More education is needed regarding reporting safety concerns. One participant expressed,

As nurses, we still need to be perceived as the ones to take care of our patients. We are not involved in the patient's care program at all. However, can we speak up for our patients' safety? (Participant No. 2)

Furthermore, the legal and ethical implications of not speaking up were not understood. They needed to recognize the importance of voicing their concerns and understanding available resources. Another participant stated,

"If we do not talk, what will happen?" We should defend patients' rights ethically. It has happened many times that we did not say anything, and the patient was fine the next day! Maybe he was apparently healthy (laughs). (Participant No. 7)

Or another participant said,

We often failed to speak up, and no extraordinary events occurred. I do not know if we realized it happened, but maybe it did! (Participant No. 4)

Theme three: Inconsistencies between learning through theories and learning through practice

Students were concerned and needed clarification on the differences between what they had learned in theory and what they observed in practice. They felt that their theoretical knowledge was required to apply to real-world scenarios. As a result, they could not speak about patient safety risks.

Clinical practice and theoretical knowledge are far apart

In clinical practice, nursing students observed that nurses and other treatment team members did not pay attention to patient safety issues. Care was provided routinely. Furthermore, the nursing students noted that safety protocols were not strictly followed, resulting in preventable errors. One participant said,

“What we learned in theory lessons seemed useful only in classes. What we learned in theory lessons was for class only. Our learnings were completely different from those observed in hospitals.” (Participant No. 19)

The gap between the reality of clinical practice and students' expectations of their roles as future nurses

The participants reported a mismatch between their expectations regarding their roles and responsibilities as future nurses and their experiences during clinical rotations. Many students hold idealized notions of being nurses, envisioning themselves as advocates for patient safety and bearers of good news. However, they often encounter barriers such as hierarchical structures, fear of repercussions, or concerns about patient confidentiality that prevent them from fully embracing their role as advocates. This subtheme explores the tension between students' aspirations and their practice constraints. In this regard, one of the participants stated,

There was a considerable difference between what we learned in theory and what we saw in practice's routine work. We observed that nurses must adhere to rules and standards to complete tasks and provide care promptly. What should we do? We need clarification. (Participant No. 15)

Without strong role models and leaders who prioritize patient safety and empower students to voice their concerns, students may struggle to advocate effectively for their patients. Another participant stated this:

Our future as nurses will be like theirs. What are the benefits of becoming more Catholic than pope? If there were a problem with their work, it would have happened by now. I think following caring rules only exists in textbooks (laughs). (Participant No. 10)

Students' challenges with putting theory into practice

One key challenge explored in nursing studies has been putting theory into practice. Nursing students reported encountering situations where the theoretical knowledge acquired through coursework and textbooks failed to adequately prepare them for clinical practice complexities. This subtheme provides insight into students' difficulties when their theoretical understanding is applied to patient care situations. One participant expressed,

"The most challenging aspect for me as a student is putting theory into practice when speaking up for patient safety. Understanding the concepts and principles we learn in the classroom is easy, but applying them in real-life situations can be intimidating." (Participant No. 11).

Another participant stated this:

"The theory we learn in the classroom provides a solid foundation for advocating for patient safety, but translating this knowledge into practice can be challenging. It requires us to develop strong communication skills and the confidence to voice our concerns when it matters most." (Participant No. 1)

In this study, the participants provided insights into their challenges as nursing students when speaking up for patient safety. These challenges stem from many factors, including a negative safety culture, inadequate preparation for speaking up for patients' safety, and disparities and inconsistencies between learning through theory and learning through practice. Despite these challenges, all participants remained committed to maintaining patient safety. Their unwavering commitment to patient safety indicates their strong dedication and resilience in the face of adversity. Fagan et al. revealed that similar challenges were faced by nursing students in their study, particularly with respect to the impact of a negative safety culture and insufficient training [7].

Nursing students also recognize that their involvement in the treatment plan and therapeutic decision-making can improve patient safety. They want to communicate and coordinate with nurses to ensure patient safety effectively. This includes actively planning and implementing the treatment plan and providing feedback on the treatment outcomes. Additionally, nursing students believe that they should proactively recognize and respond to potential patient safety risks.

The lack of a positive safety culture significantly impacts students' silence when faced with safety problems. They fear reporting safety problems due to concerns about potential negative consequences, such as retribution or being labeled troublemakers. This fear of reprisal can further perpetuate a culture of silence and hinder a safer environment [9]. Previous studies have consistently shown that students feel powerless and that their concerns are not taken seriously when safety problems are reported [20, 27]. Without a positive safety culture, students feel that their voices will not be heard and that their concerns will not be addressed [28].

The findings demonstrate that nursing students feel excluded from patient care teams because of a lack of opportunities for involvement. They often need more participation in assessing, planning, and implementing patient care, which limits their ability to observe and identify potential safety hazards. This exclusion can lead to a need for increased awareness and understanding of patient safety issues, hindering their ability to speak up on behalf of patients. This finding supports earlier research regarding the empowerment of nursing students in clinical practice, which required them to feel valued as learners, team members, and individuals [22]. Another study showed that despite wanting to participate and comment on the patient's treatment process, nursing students were not given the opportunity to do so [29]. They felt that their opinions needed to be valued and recognized for their input. Like those identified by other studies, this has a detrimental impact on their ability to speak up for patient safety issues [30, 31].

In this study, the students expressed concerns about retaliation as the reason for their reluctance to speak about patient safety incidents. They worried that reporting incidents would have negative consequences, such as being ostracized or facing disciplinary action. Additionally, the nursing students were concerned that reporting incidents about patient safety would not be taken seriously or lead to no action being taken. According to Courtney‐Pratt et al. (2018), this fear can be rooted in the belief that if they speak up, they will be judged or ridiculed by clinical staff. As a result, they may choose to remain silent rather than express their opinions [12]. Previous studies have demonstrated that many nursing students feel discouraged from reporting due to fear of reprisal or doubt that their reports would result in meaningful change [7, 32]. This highlights the urgent need for better support systems and transparent follow-up procedures [17].

They also worried that reporting incidents would damage their reputation or lead them to be labeled troublemakers. Because of the consequences of conflict and risk, students believed that speaking up about patient safety may also negatively impact learning and clinical placement. Hoffman et al. argued that one of the most common barriers to speaking up was fear of negative or unpredictable reactions [29]. These factors can lead to students ignoring standards and precautions or employing inefficient strategies [33].

The lack of skills to speak up about patient safety prevented the students from speaking up. They also believed that their supervisors or other healthcare personnel were more experienced and qualified to identify unsafe practices. Other studies have reported that nursing students lack the skills to address issues that threaten patients' safety [8, 23]. According to Fagan et al. (2021), nursing students need more training or qualifications to recognize unsafe practices. They also feel that the issue is not their responsibility and would be better addressed by experienced healthcare professionals. [33]

A lack of mentoring and support was reported as another challenge to students speaking up. mentoring and support could encourage students to discuss their ideas and opinions openly. Like what was identified by Street et al. (2018), this lack of communication can lead to a lack of creativity and innovation in the clinical setting when dealing with patients' safety issues [34]. Nursing students also need more guidance from their teachers or mentors to develop the communication skills necessary to speak up. As a result, many nursing students feel unprepared to voice their opinions [12]. According to Mubuuke et al., mentors play a vital role in helping students improve their communication skills by providing constructive feedback [24]. They can create a supportive environment where students feel safe in expressing their thoughts and asking questions. Additionally, mentors can facilitate practice scenarios that help students gain confidence in speaking up [35].

Nursing students reported a lack of guidance or support to understand the legal and ethical implications of disclosing safety concerns. This indicates a critical gap in the nursing curriculum, which must be addressed by integrating comprehensive training on patient safety and the importance of speaking up [36]. Similarly, a study conducted by Dehkordi et al. revealed that a lack of awareness of the professional responsibility to disclose safety concerns can lead to a lack of reporting of safety concerns, leading to increased patient harm [37]. By including modules that emphasize the ethical and legal implications of addressing safety issues, nursing students can be better prepared to handle such situations effectively [38]. Additionally, fostering a culture of open communication and support within healthcare education can empower students to prioritize patient safety without hesitation [7]. Nursing students must understand their professional responsibility to disclose safety concerns and ensure that they are adequately supported [39].

Nursing students reported that patient safety was not a priority in the clinical setting. They also reported a lack of safety protocols, which led to preventable errors. Nurses and other treatment team members are often overworked and overwhelmed. This can lead them to take shortcuts and fail to follow safety protocols thoroughly [39]. This lack of attention to patient safety issues was concerning, as it could lead to severe consequences [3]. As role models, nurses can help nursing students speak up for patient safety. By observing experienced nurses confidently advocate for patient safety, students learn the importance of speaking up and becoming more comfortable doing so themselves [6]. This behavior instills a culture of vigilance and responsibility in future nurses. Additionally, role modeling provides students with practical examples of effective communication and problem-solving skills in real-world situations [25].

In terms of nursing students' experiences, there was a significant difference between what students learned in theory and what they observed in practice with respect to patient safety. According to a similar study, disparities between theoretical knowledge and practical experience are becoming increasingly apparent in nursing education, particularly with respect to patient safety [40]. Theory typically provides a basic understanding of concepts, principles, and theories, but it needs to provide the details and nuances necessary for practical application [41]. This is why bridging the gap between theory and practice is essential by providing students with real-world examples and hands-on activities [42]. Hoffman et al. highlighted the disconnect between students' learning experiences and the skills required to speak up for patient safety [29]. These findings indicate that nursing education programs may need more comprehensive training or experiential learning opportunities to effectively prepare students to advocate for their patients [43]. The theory‒practice gap in research settings can be attributed mainly to the lack of supportive clinical environments that reduce student motivation to apply theoretical knowledge in practice [32].

In accordance with the participants' experiences, they needed to be more consistent with their expectations regarding their roles and responsibilities as future nurses. They also emphasized that this mismatch contrasted with the realities they encountered during their clinical rotations. Consistent with this finding, Afaneh et al. reported that students may have expected to speak up when they disagreed with something, but in reality, they were often discouraged from doing so [44]. This transition can be difficult, as students are expected to take initiative and speak up in clinical settings. However, instructors or peers may discourage them from doing so [31]. One way to navigate this challenge is to seek mentors who encourage open dialog and provide a safe space for discussion [24]. Building strong relationships with supportive nursing staff can help students confidently voice their concerns appropriately [35].

Limitations

The fact that the study was conducted in one nursing school may limit the ability to generalize the findings more broadly. Only one nursing school was examined within the limited study time frame. Furthermore, some students may have been reluctant to share their experiences. In this case, including an anonymous written account provided an extra avenue for participants to share their experiences.

Creating a culture of safety and trust in healthcare settings is essential to address students' reluctance to report patient safety incidents due to retaliation concerns. By fostering an environment where open communication is encouraged and where reporting is seen as a learning opportunity rather than punishment, students will feel more comfortable speaking up and contributing to patient safety improvement. Furthermore, the study revealed disparities and inconsistencies between learning through theory and practice. Therefore, introducing patient safety education into the undergraduate nursing curriculum is necessary and timely. Evidence from the literature emphasized the significant impact of early exposure of undergraduate students to basic concepts in patient safety and error-reduction strategies.

Acknowledgment

We would like to thank the Tabriz University of Medical Science for financial support and all of the nursing students who participated in this study. We are grateful for their cooperation, collaboration, and support.

Authors’ contributions

The study was designed by MV and ZA. FR participated as the main interviewer. The initial data analysis was done by FR and used as validation of the analysis carried out by MV and HNA. The final data analysis of the interviews was discussed and consented to by all authors. A first draft of the article was developed by FR. All authors then contributed to this, and finalized it together. FR was responsible for the final draft of the manuscript. All authors read and approved the final manuscript.

Funding

This research study was supported by the Tabriz University of Medical Sciences. The funding source was not involved in the design, data collection, data analysis, and manuscript development

Availability of data and materials

The datasets generated/analyzed during the current study are not publicly available due to ethical concerns but are available from the corresponding author upon reasonable request. All applications should be sent to [email protected].

Ethics approval and consent to participate

This study was approved by the ethical committee of Tabriz University of Medical Sciences (Number: TBZMED. REC.1401.987). The purpose and nature of the study were explained to nursing students who met the eligibility criteria and they were encouraged to participate voluntarily in the study. Informed consent was obtained from participants. A unique identifier number was used to protect participants' confidentiality.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Clinical trial number

Not applicable

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The Silent Struggle: Nursing Students' Experiences related to barriers to speaking up for Patient Safety: a qualitative study

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