Assessment and analysis of patient safety competency of Chinese nurses with associate degrees: A cross‐sectional study

Abstract Aim To analyse the patient safety competency (PSC) of Chinese nurses with associate degrees (ADNs) and explore factors. Design A cross‐sectional study. Methods A convenience sample of 451 ADNs working in 18 hospitals located in Chongqing city of China was investigated using the Patient Safety Competency Nurse Evaluation Scale (PSCNES). Descriptive and inferential statistics were used to analyse the data. Results ADNs had a moderate level of PSC. In terms of the six dimensions of PSC, ADNs performed well in clinical practice and safety risk management, while they performed poorly in patient‐centred care and patient safety culture. Statistically significant differences were reported in two items. Firstly, ADNs who have participated in patient safety training had a higher level in all dimensions of PSC than those who have not participated in related training. Secondly, ADNs without professional titles had a higher level of patient safety culture than those with professional titles.

assessed ADNs' PSC and identified which weaknesses should be strengthened through future patient safety education. More knowledge about this will help policymakers and educators to shape correlative programmes and policies.

| Background
Patient safety is a health issue of global interest, and nurses should be competent in their ability to provide care services based on relevant nursing standards. Nursing competency consists of core abilities required for performing one's role as a nurse (Fukada, 2018), and PSC refers to the knowledge, attitudes and skills that nurses should possess to prevent patients from the injuries of medical errors (Jang & Lee, 2017). Besides, proper tests can be conducive to assessing nurses' PSC, as diagnostic tools for identifying strengths and weaknesses, to guide competency improvements and for benchmarking. However, a pervading challenge in developing instruments specifically to assess nurses' PSC is the lack of clarity about applicable patient safety structures (Levett-Jones et al., 2020). To address this issue, Levett-Jones designed and validated the Patient Safety Competency Framework (PSCF) by a modified Delphi technique (Levett-Jones et al., 2017). The PSCF includes skill and knowledge statements categorized into nine domains (nine core competencies): therapeutic communication, person-centred care, teamwork and collaborative practice, preventing, minimizing and responding to adverse events, cultural competency, infection prevention and control, medication safety, evidence-based practice and clinical reasoning.
The framework was structured with reference to Miller's pyramid of competency. In the PSCF, firstly, knowledge is conceptualized as the foundation for competency. Next, nurses must know how to apply knowledge using cognitive skills such as critical thinking. Finally, nurses do with their knowledge and skills in clinical practice.
Based on PSCF, Jones designed a quiz to measure final year nursing students' knowledge about pivotal patient safety concepts. Moreover, we find most existing studies focused on nursing students' PSC (Han et al., 2020). Lee used the Patient Safety Competency Self-Evaluation (PSCSE) tool designed by his team to measure Korean nursing students' PSC, including knowledge, attitudes and skills .

Alquwez used the Health Professional Education in Patient Safety
Survey (H-PEPSS) to collect data on the perceived PSC of Saudi baccalaureate nursing students. The H-PEPSS has six areas: communicating effectively, working in teams with other health professionals, understanding human, recognizing and responding to adverse events, managing safety risks and environmental factors that influence patient safety and culture of safety (Alquwez et al., 2019). However, few studies described the PSC of ADNs and exactly what they should learn. In China, the Associate degree in Nursing programme is a threeyear programme (with a 2-year classroom and 1-year clinical courses).
Compared with baccalaureate nurses (a 4-year programme), ADNs are a high-risk group for the occurrence of nursing defects due to the lack of solid professional knowledge, the weakness of safe consciousness and inadequate understanding of medical errors . Therefore, it is vital to evaluate ADNs' PSC and this research gap is addressed by the current study.
A few studies have examined the factors bound up with nursing students' PSC: gender and years of study (Alquwez et al., 2019), clinical learning environments (Bianchi et al., 2016), clinical career (Jin & Yi, 2019), educational background (Anbari et al., 2019;Lee et al., 2016) and patient safety courses . These results make a contribution to providing productive insights and reference for strengthening participants' PSC. Accordingly, this study examined factors affecting ADNs' PSC to provide valuable insights for medical managers and nurse educators to implement patient safety education reform and enhance ADNs' PSC.
The aim of this paper was to describe the PSC of Chinese ADNs and explore factors. The research questions were as follows:

| Study design
The study adhered to the STROBE guideline for cross-sectional studies. This was a descriptive, cross-sectional study to evaluate the PSC of ADNs who were participating in an ADN-to-BSN curriculum of a university in Chongqing, China, and to identify related influence factors.
This ADN-to-BSN curriculum was held on weekends, which offered ADNs the opportunity to complete their BSN degrees after work.

| Participants
Four hundred and fifty one ADNs from 18 hospitals located in Chongqing, China, participated in this study. All ADNs were licensed Registered Nurses (RNs) Certification in China and got associate degrees. The inclusion criteria for this study were as follows: (a) ADNs; (b) RNs; (c) with Chinese nationality; and (d) voluntary participation.

| Instrument
We used a questionnaire in this study. The first part of the ques-  In the second part, we used the Patient Safety Competency Nurse Evaluation Scale (PSCNES) developed by Wang (2018). The PSCNES is comprised of 35 items divided into dimensions of patient-centred care (4 items), safety risk management (10 items), evidence-based nursing practice (5 items), patient safety culture (4 items), clinical practice (5 items) and continuous quality improvement (7 items).
Participants evaluate whether their abilities are consistent with the item statements and use a 5-point Likert scale to score (1 = strongly inconsistent-5 = strongly consistent). The scores for each dimension are calculated to obtain an overall score, and the overall score ranges from 0-175. A high score signifies the better level of PSC. PSCNES's Cronbach's alpha ranged from 0.76-0.91 for the six dimensions, which showed good internal consistency reliability (Wang, 2018). And the computed KMO value was 0.970, Bartlett χ 2 = 12,112.30 (p < .01), which showed acceptable construct validity. The scale was used in this study after obtaining permission from the copyright holder via email.

| Data analysis
All statistical analyses were performed with SPSS version 22.0.
Descriptive statistics (i.e. percentage, frequency count) were calculated for the demographic profiles of participants. Means and standard deviations were calculated for ADNs' PSC. The t test and one-way analyses of variance were computed to examine the association between PSC and demographics. In addition, a multiple stepwise regression analysis was used to determine the factors affecting the ADNs' PSC. The level of significance was set at .05.

| Demographics and scores of PSCNES
There were 451 ADNs enrolling in this study. and the mean of a single item was 3.92 (SD 0.48). In terms of six dimensions of PSCNES, the dimension "clinical practice" received the highest mean (4.05 SD 0.53), followed by "safety risk management" (4.02 SD 0.48), "evidence-based nursing practice" (3.92 SD 0.55), "continuous quality improvement" (3.91 SD 0.56) and "patient-centred care" (3.80 SD 0.56). The dimension "patient safety culture" received the lowest mean (3.65 SD 0.70).

| Factors affecting the scores of PSCNES
The researchers conducted a multiple stepwise regression analysis to examine the factors affecting the scores of PSCNES (Table 3). titles were related to the dimension "patient safety culture" (p = .009).

| D ISCUSS I ON
Nurses' PSC plays a pivotal role in ensuring patient safety. To the best of our knowledge, this is the first study to examine ADNs' PSC, and six domains of PSC-clinical practice, safety risk management, evidence-based nursing practice, continuous quality improvement, patient-centred care and patient safety culture. This study also revealed the factors affecting nurses' PSC with demographics of respondents.
In our ADNs sample, the level of overall PSC was found to be moderate. This finding is consistent with previous research conducted among Korean nurses (Cho & Choi, 2018). When examining six fields of PSC separately, the dimensions "clinical practice" (4.05 SD 0.53) and "safety risk management" (4.02 SD 0.48) scored higher than the other four domains. These two dimensions can be attributed to safety practice skills. However, in a Korean study examining safety attitudes, knowledge and skills, the results showed that nurses were less skilful in the safety practice (Cho & Choi, 2018 (Horntvedt et al., 2018). And the continuous quality improvement is the adoption of reliable data and improvement methods (such as SBAR handoff) to learn which interventions, in which context, can comprehensively optimize care processes in healthcare systems (Gallen et al., 2019). Nurses are expected to generate evidence from clinical practice to establish guidelines for the continuous quality improvement. Furthermore, IOM also required all healthcare professionals to possess core competencies in quality and safe care. Two of the core competencies were evidence-based practice and quality improvement (Balakas & Smith, 2016). Accordingly, it is crucial for nurses to master these two competencies to ensure patient safety. Our present results showed that the domains "patient safety culture" (3.65 SD 0.70) and "patient-centred care" (3.80 SD 0.56) scored lower than the mean of a single item of PSC (3.92 SD 0.48), which may indicate that ADNs had a weakness in these two competencies comparing with the other four competencies of PSC.

TA B L E 2
Patient safety culture refers to the perceptions, attitudes, beliefs and values of patient safety shared among members of the healthcare organization (Zhong et al., 2019). Establishing a positive patient safety culture among clinical and administrative staff is essential for the improvement of safety quality. Our study showed that ADNs without professional titles had a higher level of patient safety culture than those with professional titles, and this result is inconsistent with many Chinese research (Wu et al., 2017). In China, nurses must have a certain number of working years and scientific research results and pass many examinations to obtain different levels of professional titles. To some extent, the professional title is a sign that reflects nurses' technical level and working ability. Compared with ADNs without professional titles, ADNs with professional titles are likely to have a strong awareness of perceiving the risk of adverse events and a great patient safety culture. However, our result seems to be debatable. Given the measurement tool we used in this study is not an independent tool for measuring patient safety culture, which may lead to detection bias. Therefore, we suggest that future research can use specialized tools for patient safety culture, such as the Hospital Survey on Patient Safety Culture (Giai et al., 2017), to measure ADNs' patient safety culture, in order to obtain more reliable data.  al., 2017). Successful patient-centred care is both the patient and the nurse mutually agree to healthcare needs, treatments and experiences. Our results indicated that ADNs had a weakness in patient-centred care competency, which is in accordance with Hwang's study (2019). According to Hwang, the degree of patient participation in patient safety was positively correlated with nurses' patient-centred care competency. However, the degree of patient engagement in clinical practice was not high and most patients preferred a passive involvement in safe care encountered and were accustomed to complying with medical instructions and responding to medical staff's questions (Hwang et al., 2019). Also, ADNs may lack the awareness of involving patients as care partners owing to busy work situations. In 2019, the China Hospital Association released the annual 10 patient safety goals. One of the 10 safety goals was that patient engagement in patient safety.
Patient involvement in safe care is also suggested as a core element of patient-centred care (Kitson et al., 2013 (Nie et al., 2011). Since then, many countries have spent substantial resources and funds to implement patient safety education programmes and guarantee the quality of patient care (Alquwez et al., 2019). But different educational systems in different countries provide varying academic knowledge, professional experience, teaching styles, health equipment resources and financial supports (Alquwez et al., 2019). These factors may affect the performance of nurses' PSC. Therefore, we suggest that hospitals, based on popularizing patient safety education as much as possible, restructure the patient safety education framework considering varied safe levels and pedagogical needs of nurses.
In addition, to maximize the effect of patient safety education, healthcare policymakers should consider the differences in the medical systems and cultural backgrounds of different countries, fully draw on the experience of other countries and explore an optimal patient safety education programme suitable for their domestic conditions.

| Limitations
Some limitations of our study should be acknowledged and considered. Firstly, the potential selection and response bias might arise from using a convenience sample and a self-reported questionnaire.
Additionally, generalization of results requires caution because the respondents (ADNs) were not representative of all nurses in China.
Consequently, further work may be needed to definitely examine that the PSC of nurses with different academic degrees. And related clinical safety outcome index should be taken into consideration when appraising nurses' PSC, such as incidence of complications, length of stay and patient satisfaction.

| CON CLUS IONS
This study determined the PSC of Chinese ADNs from Chongqing city of 18 hospitals, analysed the scores of six dimensions of PSC and explored factors associated with PSC. Chinese ADNs are at a moderate level of PSC. In terms of the six domains of PSC, they perform better in clinical practice and safety risk management, while they have a weakness in patient-centred care and patient safety culture.
In addition, ADNs who have participated in patient safety training have a higher level in all areas of PSC and ADNs without professional titles perform well in patient safety culture. These findings provide valuable references aimed at improving the quality of safety care.
For instance, nurse managers should adopt reliable instruments to regularly assess nurses' PSC, which can guide the creation of safety policies and pedagogical interventions. Secondly, there is a need to develop a specialized curriculum to strengthen ADNs' evidencebased nursing practice and continuous quality improvement competencies. And nurses should learn to encourage patients to participate in patient safety. Moreover, it is necessary for hospital executives to popularize patient safety education as much as possible and form an individualized patient safety curriculum based on the actual needs of health care to ensure the continuous advancement of front-line nurses' PSC.

ACK N OWLED G EM ENT
The authors thank all respondents who participated in the study.