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Research in Critical Thinking

Each year it sponsors an annual International Conference on Critical Thinking and Educational Reform. It has worked with the College Board, the National Education Association, the U.S. Department of Education, as well as numerous colleges, universities, and school districts to facilitate the implementation of critical thinking instruction focused on intellectual standards.

The following three studies demonstrate:

• the fact that, as a rule, critical thinking is not presently being effectively taught at the high school, college and university level, and yet
• it is possible to do so.

To assess students' understanding of critical thinking, we recommend use of the International Critical Thinking Test as well as the Critical Thinking Interview Profile for College Students . To assess faculty understanding of critical thinking and its importance to instruction, we recommend the Critical Thinking Interview Profile For Teachers and Faculty . By registering as a member of the community, you will have access to streaming video, which includes a sample student interview with Dr. Richard Paul and Rush Cosgrove.

RESEARCH TITLES

View Abstract  -  View Full Dissertation (Adobe Acrobat PDF)

  A Critical Analysis of Richard Paul's Substantive Trans-disciplinary Conception of Critical Thinking

by Enoch Hale, Ph.D.

Union Institute & University - Cincinnati, Ohio - October 2008

View Abstract      Dissertation Table of Contents

Effect of a Model for Critical Thinking on Student Achievement in Primary Source Document Analysis and Interpretation, Argumentative Reasoning, Critical Thinking Dispositions and History Content in a Community College History Course Abstract of the Study, conducted by Jenny Reed, in partial fulfillment for her dissertation (October 26, 1998) View Abstract   -   View Full Dissertation (Adobe Acrobat PDF)

The Effect of Richard Paul's Universal Elements and Standards of Reasoning on Twelfth Grade Composition A Research Proposal Presented to the Faculty Of the School of Education Alliant International University In Partial Fulfillment of the Requirements for the Degree of Master of Arts in Education: Teaching Study conducted by J. Stephen Scanlan, San Diego (2006) View Abstract   -    View Full Dissertation (Adobe Acrobat PDF)

Study of 38 Public Universities and 28 Private Universities To Determine Faculty Emphasis on Critical Thinking In Instruction

Principal Researchers: Dr. Richard Paul, Dr. Linda Elder, and Dr. Ted Bartell

View Abstract    -    View the full study

Substantive Critical Thinking as Developed by the Foundation for Critical Thinking Proves Effective in Raising SAT and ACT Test Scores at West Side High School:  Staff Development Program Utilizes Critical Thinking Instruction to Improve Student Performance on ACT and SAT Tests, and in Critical Reading, Writing and Math Dr.   John Crook, West Side High School Principal View the Report

Teaching Critical Thinking Skills to Fourth Grade Students Identified as Gifted and Talented by Debra Connerly Graceland University - Cedar Rapids, Iowa - December 2006 View the Report

The Loss of the Space Shuttle Columbia: Portaging Leadership Lessons with a Critical Thinking Model

by Rob Niewoehner, Ph.D. U.S. Navy Graceland University - Cedar Rapids, Iowa - December 2006 View the Report

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Bibliometric Analysis of Studies on Empathy and Empathic Thinking Skills

Alsharif, A. H., Salleh, N. O. R. Z. M. D., & Baharun, R. (2020). Bibliometric analysis. Journal of Theoretical and Applied Information Technology, 98(15), 2948-2962. https://www.jatit.org/volumes/Vol98No15/6Vol98No15.pdf

Altavilla, G., Manna, A., & Lipoma, M. (2021). Relevance of empathy in educational relationships and learning processes. Journal of Physical Education and Sport, 21, 692-695. https://efsupit.ro/images/stories/februarie2021/Art%2084.pdf

Baron-Cohen, S. (2010). Empathizing, systemizing, and the extreme male brain theory of autism. Progress in Brain Research, 186, 167-175. https://doi.org/10.1016/B978-0-444-53630-3.00011-7

Bekiroğlu, D., & Güllühan, N. Ü. (2022). Trends of thinking skills in social studies and life studies courses: A meta-synthesis study. Thinking Skills and Creativity, 45, 101099. https://doi.org/10.1016/j.tsc.2022.101099

Betzler, M. (2020). The relational value of empathy. In The Value of Empathy (pp. 15-39). Routledge. https://www.taylorfrancis.com/chapters/edit/10.4324/9781003036685-2/relational-value-empathy-monika-betzler

Bischof-Köhler, D. (1991). The development of empathy in infants. Infant development: Perspectives from German-speaking Countries, 245-273. https://doi.org/10.1016/S1359-1789(98)00029-9

Björkqvist, K., Österman, K., & Kaukiainen, A. (2000). Social intelligence− empathy= aggression? Aggression and Violent Behavior, 5(2), 191-200. https://doi.org/10.1016/S1359-1789(98)00029-9

Coplan, A., & Goldie, P. (Eds.). (2011). Empathy: Philosophical and psychological perspectives. Oxford University Press. https://books.google.com.tr/books?id=gD5G4tBirIEC&printsec=front_cover&redir_esc=y

Coutinho, J. F., Silva, P. O., & Decety, J. (2014). Neurosciences, empathy, and healthy interpersonal relationships: recent findings and implications for counseling psychology. Journal of Counseling Psychology, 61(4), 541-548. https://psycnet.apa.org/doi/10.1037/cou0000021

Davis, M. H. (2006). Empathy. In Handbook of the sociology of emotions (pp. 443-466). MA: Springer US. https://link.springer.com/chapter/10.1007/978-0-387-30715-2_20

Decety, J. (2009). Empathy, sympathy and the perception of pain. Pain, 145(3), 365-366. https://doi.org/10.1016/j.pain.2009.08.006

Decety, J., & Fotopoulou, A. (2015). Why empathy has a beneficial impact on others in medicine: unifying theories. Frontiers in Behavioral Neuroscience, 8, 457-461. https://doi.org/10.3389/fnbeh.2014.00457

Decety, J., Norman, G. J., Berntson, G. G., & Cacioppo, J. T. (2012). A neurobehavioral evolutionary perspective on the mechanisms underlying empathy. Progress in Neurobiology, 98(1), 38-48. https://doi.org/10.1016/j.pneurobio.2012.05.001

Donthu, N., Kumar, S., Mukherjee, D., Pandey, N., & Lim, W. M. (2021). How to conduct a bibliometric analysis: An overview and guidelines. Journal of business research, 133, 285-296. https://doi.org/10.1016/j.jbusres.2021.04.070

Elliott, R., Bohart, A., Larson, D., Muntigl, P., & Smoliak, O. (2023). Empathic reflections by themselves are not effective: Meta-analysis and qualitative synthesis. Psychotherapy Research, 1-17. https://doi.org/10.1080/10503307.2023.2218981

Elliott, R., Bohart, A., Larson, D., Muntigl, P., & Smoliak, O. (2023). Empathic reflection. Psychotherapy skills and methods that work, 99-137. https://strathprints.strath.ac.uk/82469/

Ersoy, E., & Köşger, F. (2016). Empati: Tanimi ve Önemi/empathy: Definition and its importance. Osmangazi tıp dergisi, 38(2), 9-17. http://dx.doi.org/10.20515/otd.33993

Eskici, G. Y., & Özsevgeç, T. (2019). Yaşam becerileri ile ilgili çalışmaların tematik içerik analizi: bir meta-sentez çalışması. International e-Journal of Educational Studies, 3(5), 1-15. https://doi.org/10.31458/iejes.421255

Farrow, T. E., & Woodruff, P. E. (2007). Empathy in Mental Illness. Cambridge University Press. https://psycnet.apa.org/doi/10.1017/CBO9780511543753

Goleman, D., McKee, A., & Waytz, A. (2017). Empathy (HBR emotional intelligence series). Harvard Business Press. https://books.google.com.tr/books?hl=tr&lr=&id=qG0fDgAAQBAJ&oi=fnd&pg=PT7&dq=Goleman,+D.,+McKee,+A.,+%26+Waytz,+A.+(2017).+Empathy+(HBR+emotional+intelligence+series).+Harvard+Business+Press.&ots=zEGVuniR19&sig=KD0hABLItCx3plwUdZDtXcGeqSs&redir_esc=y#v=onepage&q=Goleman%2C%20D.%2C%20McKee%2C%20A.%2C%20%26%20Waytz%2C%20A.%20(2017).%20Empathy%20(HBR%20emotional%20intelligence%20series).%20Harvard%20Business%20Press.&f=false

Holt, S., & Marques, J. (2012). Empathy in leadership: Appropriate or misplaced? An empirical study on a topic that is asking for attention. Journal of business ethics, 105, 95-105. https://doi.org/10.1007/s10551-011-0951-5

Huang YQ, Wang HP, Xiong SQ, et al. (2018). Bibliometric analysis of nurses' empathy ability in China [J]. Medical Data Mining 1(2): 38-45. https://doi.org/10.12032/mdm20180005

Huberman, M., & Miles, M. B. (2002). The qualitative researcher's companion. Sage.

Kelly, M., McDonald, S., & Wallis, K. (2022). Empathy across the ages: “I may be older but I’m still feeling it”. Neuropsychology, 36(2), 116-127. https://psycnet.apa.org/doi/10.1037/neu0000783

Konrath, S. H., O'Brien, E. H., & Hsing, C. (2011). Changes in dispositional empathy in American college students over time: A meta-analysis. Personality and Social Psychology Review, 15(2), 180-198. https://doi.org/10.1177/1088868310377395

Krishnan, H., Awang, S. R., Zakuan, N., & Nor, K. M. (2020). Bibliometric analysis on emotional intelligence research. International Journal of Recent Technology and Engineering, 8(6), 864-877. https://www.researchgate.net/profile/Heamalatha-Krishnan/publication/363892037_Bibliometric_Analysis_on_Emotional_Intelligence_Research/links/6583b9e83c472d2e8e774b45/Bibliometric-Analysis-on-Emotional-Intelligence-Research.pdf

Morgan, H. (2022). Conducting a Qualitative Document Analysis. The Qualitative Report, 27(1), 64-77. https://doi.org/10.46743/2160-3715/2022.5044

Nair, T. K., Waslin, S. M., Rodrigues, G. A., Datta, S., Moore, M. T., & Brumariu, L. E. (2023). A meta-analytic review of the relations between anxiety and empathy. Journal of anxiety disorders, 102795. https://doi.org/10.1016/j.janxdis.2023.102795

Nishida, T. (2013). Toward mutual dependency between empathy and technology. AI & society, 28, 277-287. https://doi.org/10.1007/s00146-012-0403-5

Özbey, Ö. F., & Sarıkaya, R. (2019). Examining the effectiveness of studies carried out with the drama method in Turkey: A trace study. Gazi Journal of Educational Sciences,5, 231-253. https://doi.org/10.1177/10.30855/gjes.2019.os.01.013

Pham, H. (2023). Empathy. Mit Press. https://books.google.com.tr/books?hl=tr&lr=&id=lMZXEAAAQBAJ&oi=fnd&pg=PT6&dq=pham++empathy&ots=qMmR2eWA5Q&sig=E0xzbnV0qLOYGIFb5Hy7KTvueXY&redir_esc=y#v=onepage&q=pham%20%20empathy&f=false

Pittelkow, M. M., Aan Het Rot, M., Seidel, L. J., Feyel, N., & Roest, A. M. (2021). Social anxiety and empathy: a systematic review and meta-analysis. Journal of Anxiety Disorders, 78, 102357. https://doi.org/10.1016/j.janxdis.2021.102357

Sanders, J. J., Dubey, M., Hall, J. A., Catzen, H. Z., Blanch‐Hartigan, D., & Schwartz, R. (2021). What is empathy? Oncology patient perspectives on empathic clinician behaviors. Cancer, 127(22), 4258-4265. https://doi.org/10.1002/cncr.33834

Seçer, İ.,Ay İ., Ceyhun., O., & Yılmaz, B. (2014). Research trends in the field of guidance and psychological counseling: A content analysis. Turkish Psychological Counseling and Guidance Journal, 5(41), 49-60. https://dergipark.org.tr/en/download/article-file/200255

Singer, T., & Lamm, C. (2009). The social neuroscience of empathy. Annals of the New York Academy of Sciences, 1156(1), 81-96. https://doi.org/10.1111/j.1749-6632.2009.04418.x

Zhi-Jiang, Y. A. N., & Pan-Cha, S. U. (2017). Evolution in research topics on Empathy: Evidence from Bibliometrics. Journal of Psychological Science, 40(3), 699-707. http://www.psysci.org/EN/Y2017/V40/I3/699

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The role of critical thinking skills and learning styles of university students in their academic performance

Zohre ghazivakili.

1 Emergency medical services department, Paramedical school, Alborz University of Medical Sciences, Karaj, Iran;

ROOHANGIZ NOROUZI NIA

2 Educational Development Center, Alborz University of Medical Sciences, Karaj, Iran;

FARIDE PANAHI

3 Nursing and midwifery school, Shahid Beheshti University of Medical Sciences, Tehran, Iran;

MEHRDAD KARIMI

4 Department of Epidemiology and Biostatistics, Public Health School, Tehran, Iran;

HAYEDE GHOLSORKHI

5 Medical school, Alborz University of Medical Sciences, Karaj, Iran;

ZARRIN AHMADI

6 Amirkabir University of Technology(Polytechnic), Tehran, Iran

Introduction: The Current world needs people who have a lot of different abilities such as cognition and application of different ways of thinking, research, problem solving, critical thinking skills and creativity. In addition to critical thinking, learning styles is another key factor which has an essential role in the process of problem solving. This study aimed to determine the relationship between learning styles and critical thinking of students and their academic performance in Alborz University of Medical Science.

Methods: This cross-correlation study was performed in 2012, on 216 students of Alborz University who were selected randomly by the stratified random sampling. The data was obtained via a three-part questionnaire included demographic data, Kolb standardized questionnaire of learning style and California critical thinking standardized questionnaire. The academic performance of the students was extracted by the school records. The validity of the instruments was determined in terms of content validity, and the reliability was gained through internal consistency methods. Cronbach's alpha coefficient was found to be 0.78 for the California critical thinking questionnaire. The Chi Square test, Independent t-test, one way ANOVA and Pearson correlation test were used to determine relationship between variables. The Package SPSS14 statistical software was used to analyze data with a significant level of p<0.05.

Results: Our findings indicated the significant difference of mean score in four learning style, suggesting university students with convergent learning style have better performance than other groups. Also learning style had a relationship with age, gender, field of study, semester and job. The results about the critical thinking of the students showed that the mean of deductive reasoning and evaluation skills were higher than that of other skills and analytical skills had the lowest mean and there was a positive significant relationship between the students’ performance with inferential skill and the total score of critical thinking skills (p<0.05). Furthermore, evaluation skills and deductive reasoning had significant relationship. On the other hand, the mean total score of critical thinking had significant difference between different learning styles.

Conclusion: The results of this study showed that the learning styles, critical thinking and academic performance are significantly associated with one another. Considering the growing importance of critical thinking in enhancing the professional competence of individuals, it's recommended to use teaching methods consistent with the learning style because it would be more effective in this context.

Introduction

The current world needs people with a lot of capabilities such as understanding and using different ways of thinking, research, problem solving, critical thinking and creativity. Critical thinking is one of the aspects of thinking that has been accepted as a way to overcome the difficulties and to facilitate the access to information in life ( 1 ).

To Watson and Glizer, critical thinking is a combination of knowledge, attitude, and performance of every individual. They also believe that there are some skills of critical thinking such as perception, assumption recognition deduction, interpretation and evaluation of logical reasoning. They argue that the ability of critical thinking, processing and evaluation of previous information with new information result from inductive and deductive reasoning of solving problems. Watson and Glizer definition of critical thinking has been the basis of critical thinking tests that are widely used to measure the critical thinking today ( 2 ).

World Federation for Medical Education has considered critical thinking one of the medical training standards so that in accredited colleges this subject is one of the key points. In fact, one of the criteria for the accreditation of a learning institute is the measurement of critical thinking in its students ( 3 ).

In addition to critical thinking, learning style, i.e. the information processing method, of the learners, is an important key factor that has a major role in problem solving. According to David Kolb’s theory, learning is a four-step process that includes concrete experience, reflective observation, abstract conceptualization and active experimentation. This position represents two dimensions: concrete experience versus abstract thinking, and reflective observation to active experimentation. These dimensions include four learning styles: divergent, convergent, assimilate, and accommodate. According to Kolb and Ferry, the learner needs four different abilities to function efficiently: Learning styles involve several variables such as academic performance of learner, higher education improvement; critical thinking and problem solving ( 4 ).

Due to the importance of learning styles and critical thinking in students' academic performance, a large volume of educational research has been devoted to these issues in different countries. Demirhan, Besoluk and Onder (2011) in their study on critical thinking and students’ academic performance from the first semester to two years later have found that contrary to expectations the students’ critical thinking level reduced but the total mean of students’ scores increased. This is due to the fact that the students are likely to increase adaptive behavior with environment and university and reduce the stress during their education ( 1 ).

In another study over 330 students in Turkey, the students who had divergent learning style, had lower scores in critical thinking in contrast with students who have accommodator learning style ( 5 ).

Also Mahmoud examined the relationship between critical thinking and learning styles of the Bachelor students with their academic performance in 2012. In this study all the nursing students of the university in the semesters four, six and eight were studied. The results did not show any significant relationship between critical thinking and learning styles of nursing students with their academic performance ( 6 ).

Another research by Nasrabadi in 2012 showed a positive relationship between critical thinking attitudes and student's academic achievement. The results showed that there was a significant difference between the levels of critical thinking of assimilating and converge styles. Also converging, diverging, assimilating and accommodating styles had the highest level of critical thinking, respectively ( 4 ). Among other studies we can refer to Sharma’s study in 2011 whose results suggested a relationship between the academic performance and learning styles ( 7 ).

Today university students should not only think but also should think differently and should not only remember the knowledge in their mind but also should research the best learning style among different learning styles. Therefore, the study on the topic of how the students think and how they learn has received great emphasis in recent years. In this regard, with the importance of the subject, researchers attempted to doa research in this area to determine the relationship between critical thinking and learning styles with academic performance of the students at Alborz University of Medical Sciences.

This study is a descriptive-analytic, cross sectional study and investigates the relationship between critical thinking and learning styles with students’ academic performance of Alborz University of Medical Science in 2012. After approval and permission from university’s authorities and in coordination with official faculties, the critical thinking and learning styles questionnaire was given to the undergraduate students in associate degree, bachelor, medicine (second semester and after that). The total number of participants in the study was 216 students with different majors such as medical, nursing and midwifery, and health and medical emergency students. The tool to collect the data was a two-part questionnaire of Kolb's learning styles and California's critical thinking skills test (form B). The Kolb's questionnaire has two parts. The first part asks for demographic information and the second part includes 12 multiple choice questions. The participants respond to the questions with regard to how they learn, and the scores of respondents are ranked from 1 to 4 in which 4 is most consistent with the participants’ learning style 3 to some extent, 2 poorly consistent and 1 not consistent To find the participants’ learning styles, the first choice of all 12 questions were added together and this was repeated for other choices. Thus, four total scores for the four learning styles were obtained, the first for concrete experience learning style, the second for reflective observation of learning style, the third for abstract conceptualization learning style and the forth for active experimentation learning style. The highest score determined the learning style of the participant. The California critical thinking skills test (form B) includes 34 multiple choice questions with one correct answer in five different areas of critical thinking skills, including evaluation, inference, analysis, inductive reasoning and deductive reasoning. The answering time was 45 minutes and the final score is 34 and the achieved score in each section of the test varies from 0 to 16. In the evaluation section, the maximum point is 14, in analysis section 9, in inference section 11, in inductive reasoning 16 and in deductive reasoning the maximum point was 14. So there were 6 scores for each participant, which included a critical thinking total score and 5 score for critical thinking skills. Dehghani, Jafari Sani, Pakmehr and Malekzadeh found that the reliability of the questionnaire was 78% in a research. In the study of Khalili et al., the confidence coefficient was 62% and construct validity of all subscales with positive and high correlation were reported between 60%-65%. So this test was reliable for the research. Collecting the information was conducted in two stages. In the first stage, the questionnaires were given to the students and the objectives and importance of the research were mentioned. In the next stage, the students' academic performance was reviewed. After data collection, the data were coded and analyzed, using the SPSS 14 ( SPSS Inc, Chicago, IL, USA) software. To describe the data, descriptive statistics were used such as mean and standard deviation for continues variables and frequency for qualitative variables. Chi Square test, Independent t-test, one way ANOVA and Pearson correlation test were used to determine the relationship between variables at a significant level of p<0.05.

Research hypothesis

• There is a relationship between Alborz University of Medical Sciences students’ learning styles and their demographic information. 
• There is a relationship between Alborz University of Medical Sciences students’ critical thinking and their demographic information. 
• There is a relationship between Alborz University of Medical Sciences students’ academic performance and their demographic information. 
• There is a relationship between Alborz University of Medical Sciences students’ learning styles and their academic performance. 
• There is a relationship between Alborz University of Medical Sciences students’ learning styles and their critical thinking. 

225 questionnaires were distributed of which 216 were completely responded (96%). The age range of the participants was from 16 to 45 with the mean age of (22.44±3.7). 52.8% of participants (n=114) were female, 83.3% (n=180) were single, 30.1% of participants’ (n=65) major was pediatric anesthesiology of OR, 35.2% of participants (n=76) were in fourth semester, 74.5% (n=161) were unemployed and 48.6 % (n=105) had Persian ethnicity.

The range of participants’ average grade points, which were considered as their academic performance, were from 12.51 to 19.07 with a mean of (16.75±1.3). According to Kolbs' pattern, 42.7% (n=85) had the convergent learning style (the maximum percentage) followed by 33.2 % (n= 66) with the assimilating style and only 9.5%, (n= 19) with the accommodating style (the minimum percentage).

Among the 5 critical thinking skills, the maximum mean score belonged to deductive reasoning skill (3.38±1.58) and the minimum mean score belonged to analysis skill (1.67±1.08).

Table 1 shows the frequency distribution and demographic variables and the academic performance of the students. According to the Chi-square (Χ 2 ) p-value, there was a significant relationship between gender and learning style (p=0.032), so that nearly 50 percent of males had the assimilating learning style and nearly 52 percent of the females had the convergent learning style.

The relationship between demographic variable and student’s academic performance with learning styles

The relationship between employment, major and semester of studying with the learning style was significant at a p-value of 0.049, 0.006, 0.009 and 0.001, respectively. The mean and standard deviation of age and students' academic performance in the four learning styles are reported in Table 1 .

Using the one way analysis of variance (One way ANOVA) and comparing the mean age of four groups, we found a significant relation between age and academic performance with learning style (p=0.049).

The students with convergent learning style had a better academic performance than those with other learning styles and in the performance of those with the assimilating learning style the weakest.

Table 2 shows the relationship between the total score of critical thinking skills and each of the demographic variables and academic performance. The results of the t-test and one way ANOVA variance analysis are reported to investigate the relationship between each variable with skills below the mean standard deviation.

Relationships between CCT Skills and demographic variables Using t-test and ANOVA. Pearson Correlation coefficient between age and Student's performance with CCT Skills was reported

* Significant in surface 0.05 

** Significant in surface 0.01

Based on the t-test and ANOVA, p-value of t and F, the mean of total score of critical thinking skills had only significant relationship with students’ major (p=0.020). Also a significant relationship was found between the major of students and gender with inference skill; semester of study with deductive reasoning skill, and ethnicity with 2 skills of inference and deductive reasoning (p<0.05).

Also regarding the relationship between age and the student academic performance with each of the critical thinking skills, the Pearson correlation coefficient results indicated a significant positive relationship but a negative relationship between age and analysis skill, i.e. with the increase of age, the score of analysis skill was reduced (p<0.05). Academic performance of the students had a direct significant relationship with critical thinking total score and inference skill; the more the score, the better the academic performance of students (p<0.05).

Table 3 shows the mean and standard deviation of learning styles score in the 4 groups of learning style. Using ANOVA one way ANOVA, the relationship between learning style and critical thinking skills and the comparison of the mean score for each skill in four styles are reported in the last column of the Table 3 .

The Relationship between critical thinking styles with learning styles

Based on the p-value of ANOVA, the mean of evaluation skill and inductive reasoning skill had a significant difference and the relationship between these two skills with learning style was significant (p<0.05). Also the mean of critical thinking’s total score was significantly different in the four groups and the relationship between total score with learning style was significant, too (p<0.05).

The mean and confidence interval of university students’ performance in four learning  styles

The mean and confidene interval of critical thinking skills

The study findings showed that the popular learning style among the students was the convergent style followed by the assimilating style which is consistent with Kolb's theory stating that medical science students usually have this learning style ( 8 ). This result was consistent with the results of other studies ( 9 , 10 ). In Yenice's study in which the student of training teacher were the target of the project, the most frequent learning styles were divergent and assimilating styles and these differences originate from the different target group of study in 2012 ( 11 ).

This study showed a significant relationship between learning style and gender, age, semester and employment. Meyari et al. did not find any significant relationship between learning style, age and gender of the freshman but for the fifth semester students, a significant relationship with age and gender was found ( 10 ). Also in Yenice's study, no relationship with learning style, gender, semester and age was found.

Furthermore, in the first semester divergent style, in the second semester assimilating style and in the third and fourth semester divergent style were accounted for the highest percentage. Also in the group age of 17-20 years the assimilating style and the age of 21-24 years the divergent style were dominant styles ( 11 ).

In the present study, it was found a significant positive relationship between convergent learning style and academic performance. Also in the study of Pooladi et al. the majority of the students had convergent style and they also found a significant relationship between learning style, total mean score and the mean of practical courses ( 12 ). Nasrabadi et al. found that students with the highest achievement were those with convergent style with a significant difference with those with divergent style ( 4 ). But the results are inconsistent to Meyari et al.’s ( 10 ).

In this study, the obtained mean score from the critical thinking questionnaire was (7.15±2.41) that was compared with that in the study of Khalili and Hoseinzadeh which was to validate and make reliable the critical thinking skills questionnaire of California (form B) in the Iranian nursing students; the mean of total score was about the 11th percentile of this study ( 13 ).

In other words, the computed score for critical thinking of the students participating was lower than 11 score that is in the 50th percentile and of course is lower than normal range.

Hariri and Bagherinezhad had shown that the computed score for Bachelor and Master students of Health faculty was also lower than the norm in Iran ( 14 ). Also Mayer and Dayer came to a similar conclusion in critical thinking skill in the Agricultural university of Florida’s students in 2006 ( 15 ).

But in Gharib et al.’s study, the total score of critical thinking test among the freshman and senior of Health-care management was in normal range ( 16 ). Wangensteen et al., found that the critical thinking skills of the newest graduate nursing students were relatively high in Sweden in 2010 ( 17 ).

In this study, students of all levels (Associate, Bachelor and PhD) with various fields of study participated but other studies have been limited to certain graduate courses that may explain the differences in levels of special critical thinking skills score in this study. In this study we found a significant relationship between total score of critical thinking and major of the students. This result is consistent with Serin et al. ( 18 ).

It was found a significant relationship between major of participants, gender and inference skill, semester and deductive reasoning skill, ethnicity and both inference and deductive reasoning skills.

In the Yenice's study significant relationship between critical thinking, group of age, gender and semester was seen ( 11 ). In Wangensteen et al.’s ( 17 ) study in the older age group, the level of critical thinking score increased. In Serin et al.’s ( 18 ) study the level of communication skills in girls was better than that in boys. And also a significant relationship was found between critical thinking and academic semester, but in Mayer and Dayer’s study no significant relationship between critical thinking levels and gender was found ( 4 , 15 ).

The results also showed that the total score of critical thinking and analytical skills of students and their performance had a significant relationship. Nasrabady et al.’s study also showed that there was a positive relationship between critical thinking reflection attitude and academic achievement ( 4 ). This is contradictory with what Demirhan, Bosluk and Ander found ( 6 , 15 ).

The results of the relationship between learning style and critical thinking indicated that the relationship between evaluation and inductive reasoning was significant to learning style (p<0.05). The relationship of critical thinking total score with learning style was also significant (p<0.05). Thus the total score for those with the conforming style of critical skills was more than that with other styles. But in the subgroup of inference skills, those with the convergent style had a higher mean than those with other styles.

Yenice found a negative relationship between critical thinking score and divergent learning style and a positive relation between critical thinking score and accommodating style ( 11 ).

Siriopoulos and Pomonis in their study compared the learning style and critical thinking skills of students in two phases: at the beginning and end of education and came to this conclusion that the learning style of students changed in the second phase.

For example, the divergent, convergent and accommodating styles languished and the assimilating style (combination of abstract thinking and reflective observation) was noticeably strengthened. However, those with converging learning style had higher levels of critical thinking.

The level of students’ critical thinking was lower in all international standards styles. Perhaps it was because of widely used teacher-centered teaching methods (lectures) in that university ( 19 ).

The results in the study of Nasrabady et al. showed that there was a significant difference between the level of learners’ critical thinking and divergent and assimilating styles ( 4 ).

Those with converging, diverging, assimilating and accommodating styles had the highest level of critical thinking, respectively.

Also there was a positive significant relationship between the reflective observation method and critical thinking and also a negative significant relationship between the abstract conceptualization method and critical thinking ( 4 ). But in another study that Mahmud has done in 2012, he did not find any significant relationship between learning style, critical thinking and students’ performance ( 6 ).

The results of this study showed that the students’ critical thinking skills of this university aren't acceptable. Also learning styles, critical thinking and academic performance have significant relationship with each other. Due to the important role of critical thinking in enhancing professional competence, it is recommend using teaching methods which are consistent with the learning styles.

Acknowledgment

This study is based on a research project that was approved in Research Deputy of Alborz University of Medical sciences. We sincerely appreciate all in Research Deputy of Alborz University of Medical sciences who supported us financially and morally and all students and colleagues who participated in this study.

Conflict of Interest: None declared.

References:

• Open access
• Published: 25 April 2024

Exploring medical and nursing students’ perceptions about a patient safety course: a qualitative study

• Farwa Ayub 1 ,
• Noreen Afzal 2 ,
• Wajid Ali 2 ,
• Fozia Asif 1 ,
• Syed Sabih ul Hassan 1 ,
• Ghazal Haque 1 ,
• Fasih Ali Ahmed 1 , 3 ,
• Khairulnissa Ajani 4 ,
• Zahra Tharani 4 ,
• Mehtab Jaffer 4 ,
• Adil H Haider 5 ,
• Hanan J Aboumatar 6 &
• Asad Latif 1 , 6 , 7  

BMC Medical Education volume  24 , Article number:  452 ( 2024 ) Cite this article

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Educating health professionals on patient safety can potentially reduce healthcare-associated harm. Patient safety courses have been incorporated into medical and nursing curricula in many high-income countries and their impact has been demonstrated in the literature through objective assessments. This study aimed to explore student perceptions about a patient safety course to assess its influence on aspiring health professionals at a personal level as well as to explore differences in areas of focus between medical and nursing students.

A dedicated patient safety course was introduced for year III medical and year II and IV nursing students at the Aga Khan University (2021–2022). As part of a post-course assessment, 577 participating students (184 medical and 393 nursing) wrote reflections on the course, detailing its influence on them. These free-text responses were thematically analyzed using NVivo.

The findings revealed five major themes: acquired skills (clinical, interpersonal), understanding of medical errors (increased awareness, prevention and reduction, responding to errors), personal experiences with patient safety issues, impact of course (changed perceptions, professional integrity, need for similar sessions, importance of the topic) and course feedback (format, preparation for clinical years, suggestions). Students reported a lack of baseline awareness regarding the frequency and consequences of medical errors. After the course, medical students reported a perceptional shift in favor of systems thinking regarding error causality, and nursing students focused on human factors and error prevention. The interactive course format involving scenario-based learning was deemed beneficial in terms of increasing awareness, imparting relevant clinical and interpersonal skills, and changing perspectives on patient safety.

Conclusions

Student perspectives illustrate the benefits of an early introduction of dedicated courses in imparting patient safety education to aspiring health professionals. Students reported a lack of baseline awareness of essential patient safety concepts, highlighting gaps in the existing curricula. This study can help provide an impetus for incorporating patient safety as a core component in medical and nursing curricula nationally and across the region. Additionally, patient safety courses can be tailored to emphasize areas identified as gaps among each professional group, and interprofessional education can be employed for shared learning. The authors further recommend conducting longitudinal studies to assess the long-term impact of such courses.

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Introduction

Unsafe patient care is one of the leading causes of death and disability worldwide. The percentage of patients subject to adverse events while receiving healthcare services is 10% in high income countries (HICs) and may reach up to 25% in low- or middle-income countries (LMICs) [ 1 ]. The United States’ (US) National Academy of Medicine’s (previously called the Institute of Medicine) reports ‘To Err is Human’ and ‘Crossing the Quality Chasm’ brought international attention to the patient safety problem, and the World Health Organization (WHO) has since developed a curriculum to support healthcare professionals’ education in this area [ 2 , 3 , 4 ]. Deficits in patient safety education in medical and nursing curricula have been highlighted previously [ 5 , 6 ], and the introduction of such training for medical students in the US has demonstrated improvements in knowledge and attitudes about patient safety [ 7 ]. Furthermore, such curricula have been seen to result in sustained improvement among students in skills such as error root cause analysis, accurate entry of safety reports and error disclosure to patients [ 8 ].

While in the developed world, regulatory bodies have been formed and healthcare providers are urged towards continuous improvement [ 9 ], patient safety in developing countries is affected by a lack of accountability, material context, staffing issues and inter-professional working relationships [ 10 ]. One of the most important gaps identified in these settings is poor safety culture [ 11 ]. An imbalance of power and existing hierarchies hinder effective teamwork and safe practices [ 10 ]. However, these gaps are amenable to interventions such as training [ 12 ].

Although online courses have been employed to deliver patient safety education worldwide [ 13 ], the incorporation of formal, in-person patient safety training in medical and nursing curricula is new to LMICs such as Pakistan. In a recent national study, the academic leadership of 88 medical schools across the country agreed on incorporation of patient safety in undergraduate teaching as one of the top three proposed reforms to the national curriculum [ 14 ]. Recently, a patient safety course was introduced at one of the largest academic medical centers (AMCs) in Pakistan, demonstrating gains in medical and nursing student knowledge and systems thinking skills [ 15 , 16 ]. While the safety culture of a healthcare setting is highly dependent on physicians and nurses and both groups should ideally have a similar understanding of safety concepts, nurses tend to have more knowledge of patient safety than physicians [ 17 ]. Nursing students likewise have a more positive attitude towards patient safety education than medical students [ 18 ]. We hope that having similar structured education can address these differences at an early stage of training. Hence, we aimed to conduct a qualitative assessment of the reflections of medical and nursing students on this novel course to assess what depth the course added to students’ understanding of patient safety concepts and gauge course influence on aspiring health professionals at a personal level. Our secondary aim was to explore possible differences in the receptivity of the course as well as the uptake of course content between medical and nursing students. Since there is limited data available from the region, we employed a descriptive exploratory design.

Study design, setting, and duration

This study employed a descriptive exploratory qualitative design and was conducted at the Aga Khan University (AKU) in Karachi, Pakistan. The Bachelor of Medicine and Bachelor of Surgery (MBBS) program for physicians at AKU encompasses two years of basic sciences preceding three years of clinical clerkships [ 19 , 20 ], while the Bachelor of Science in Nursing (BScN) program comprises two preclinical and two clinical clerkship years [ 21 , 22 ].

The same 4.5 day course on Quality and Patient Safety was conducted between March 2021 and April 2022 separately for five student groups– two groups of Year III MBBS, two groups of Year II BScN and one group of Year IV BScN students. The course was modeled after a patient safety course taught at the Johns Hopkins University School of Medicine [ 7 ] and adapted for the local context. It included lectures, group activities, interactive case study discussions, and hands-on skill development workshops on quality improvement and patient safety (Table  1 ). The speakers used locally relevant examples during the lectures and activities. The case studies used were obtained from public sources such as the Agency for Healthcare Research and Quality’s (AHRQ) website and newspaper articles, and included the case of Josie King’s death at the Johns Hopkins Hospital [ 23 , 24 ]. Details on the course curriculum have been published previously [ 15 ].

Data collection

Pre and postcourse assessments were conducted on the university Virtual Learning Environment (VLE) as part of the course. The posttest comprised various components, one of them being personal reflections. All students were given time to complete the assessment online on the last day of the course, and responses were saved automatically. This voluntary assessment provided a platform for students to share their views on the course in writing. Through consecutive sampling, all participants were asked to note their thoughts and brainstorm learning, and to explore how the course influenced them. They were informed about the open-ended nature of the assignment and that the reflection was only to receive a completion grade and encouraged to express themselves without hesitancy. To elicit focused information from the participants, probes developed by subject matter experts (Table  2 ) were also provided for consideration while writing. These were designed based on course objectives to assess impact through exploration of aspects such as opinions, feelings, thought processes and experiences which were not otherwise covered in the objective assessment.

Data analysis

All responses comprising text were included in the analysis, and blank responses excluded. Following deidentification of the dataset, Braun and Clark’s six-step method for thematic analysis was followed for data analysis [ 25 ]. Free-text responses to the online form for each student group were imported as transcripts and transferred to NVivo to facilitate sub-group analysis and obtain accurate code counts for comparison between groups. These were read multiple times by two researchers (NA and FA) for familiarization with the data. Through a combined inductive and deductive approach, the investigators independently coded the data, followed by a discussion to decide the final list of codes. This list was used to generate a codebook that was employed to code all transcripts. Themes and subthemes were derived by grouping similar codes, which were then named and paired with their representative quotations. Responses were further grouped by respondent type and code counts were tabulated to determine intergroup commonalities and differences.

Methodological rigor

Credibility of the findings was ensured through investigator triangulation whereby two research team members independently analyzed the data to eventually reach a consensus on code assignment and derivation of themes and subthemes, and data triangulation where perceptions of two groups of respondents (medical and nursing students) were obtained about the same course [ 26 ].

To reduce investigator bias, the two researchers held regular team meetings for a reflexive dialogue about how their individual perspectives and exposure impacted their understanding and interpretation of the data [ 27 ]. FA is a medical doctor and was familiar with the content taught to participants since she was directly involved in course administration, whereas NA is from a nonclinical background with expertise in qualitative research. The basis for interpretation of study findings was established during these meetings and discrepancies were resolved in an inclusive manner by mutual consensus. The study findings were reported in accordance with the Standards for Reporting Qualitative Research (SRQR) [ 28 ].

Ethical considerations

This study received an exemption from ethics approval by the Ethics Review Committee at the Aga Khan University (2021-5976-16957). Student participation in the survey was voluntary and subject to informed consent. All data were deidentified prior to analysis.

Out of a total of 641 enrolled students, 577 wrote free-text responses which were then used for analysis. Table  3 illustrates the demographic characteristics of the study participants.

A similar percentage of medical and nursing students (11.4% and 10.9% respectively) did not participate in this section of the survey. Among the 64 non-respondents, 44 (68.8%) were females and 20 (31.3%) were males. The ages of these students ranged from 19 to 27 years. 38 (59.4%) were residents of Sindh, 4 (6.3%) originated from Punjab, 14 (21.9%) from Khyber Pakhtunkhwa, 3 (4.7%) from Gilgit-Baltistan and 1 (1.6%) from outside Pakistan.

Table  4 shows the five major themes, further divided into subthemes and the codes used to derive themes. Representative quotations are listed in Table S1 .

Theme 1: skills acquired from the course

Clinical skills.

Participants mentioned the range of skills they learned during the course that were relevant to clinical practice, including infection prevention practices such as correctly donning and doffing Personal Protective Equipment (PPE), particularly due to the COVID-19 pandemic. This was highlighted by a higher proportion of nursing students as compared to medical students (Table  3 ). Learning the importance of medical documentation and its appropriate implementation was also mentioned.

“Donning and doffing of PPE is something every health care professional should know, and we learned that in this module which will be very helpful for the future.” (Year V, MBBS) . “We learned about the different forms of documentation and how to write nursing notes.” (Year IV, BScN) .

Interpersonal skills

Participants reported that they learned about tools for effective communication, teamwork and conflict management. They commented on understanding the importance of these areas in reducing the occurrence of medical errors and ensuring patient safety.

“I learned different tools like SBAR [Situation, Background, Assessment, Recommendation] and ALEEN [Anticipate, Listen, Empathize, Explain, Negotiate] which help in strengthening communication between nurses and prescribers.” (Year II, BScN) . “As the course progressed, I was able to analyze the importance of inter-professional collaboration to reduce medical errors.” (Year IV, BScN) . “…the sessions made me aware of the possible conflicts that could occur in the hospital area and gave me a guideline to solve such conflicts.” (Year II, BScN) .

Theme 2: understanding of medical errors

Increased awareness.

A key subtheme that emerged was the lack of awareness among students regarding medical errors. Most participants mentioned hearing about such errors for the first time during the course and were unaware of the incidence and potential consequences of such errors in clinical practice.

“Perhaps the most important thing that I personally found enlightening in this module was knowledge about the frequency of human medical errors. I was surprised to find out how often they occur, how easily they occur and how a lot of us have a careless attitude towards it.” (Year III, MBBS) . “In some examples I was totally shocked because I never thought a single small mistake can be so dangerous for a patient’s life.” (Year II, BScN) .

Prevention and reduction

Students also highlighted the need for preventing errors and how they learned ways to do so. They further suggested that employing error prevention strategies such as staff training, improving communication, conducting double checks and remaining vigilant could be helpful in this regard. This subtheme came up in a higher proportion of nursing student reflections (Table  3 ).

“As healthcare workers who literally have patients’ lives in our hands, it is essential that we try to commit zero errors and make a system that also decreases the probability of errors.” (Year III, MBBS) . “One of the best chunks was strategies to minimize medical errors along with our role to combat them.” (Year II, BScN) .

Responding to errors

Participants mentioned that the course taught them how to respond appropriately to situations involving medical errors. It made them realize the importance of reporting medical errors to authorities and of the disclosure of such events to patients and their families. They further reported that the course helped them become familiar with the official reporting system of the hospital and taught them ways to report errors, both to the management and patients.

“I also learned the different techniques to avoid having such errors and if God forbids it happens then how to confront the situation accordingly.” (Year II, BScN) . “I learned of the significance of reporting medical errors even when it seems unnecessary.” (Year III, MBBS) . “I learned a lot of ways how to monitor and report any medical error and how to disclose a medical error to the patient.” (Year IV, BScN) .

Theme 3: personal experiences with patient safety issues

During the course, participants were able to reflect on their personal experiences with patient safety issues and shared accounts of being impacted by medical errors. They mentioned how the course helped them to view these experiences in a different light, especially regarding their causes. Some students also managed to capture a system lens toward the causes of adverse events.

“I personally had experience with a medical error when my aunt was admitted for an eye infection and the doctor prescribed the wrong medication, which we found out was to be given to the next patient. As a result of that, my aunt reacted to it leading her to be admitted to the ICU. The doctor did not disclose this information to us for a long time and my aunt continued to develop complications which eventually led her to forming a brain hematoma. Had the doctor disclosed this information on time, the complications could have been avoided or reduced to the very least.” (Year III, MBBS) . “I lost one of my family members because of multiple errors that took place at different intervals of healthcare provision and I learned how the Swiss cheese model represented that.” (Year III, MBBS) .

Theme 4: impact of the course

New information and changed perceptions.

Participants reported how the course increased their knowledge and changed their perceptions about patient safety and the causes of medical errors. They realized that instead of pinning the blame on one person, a series of events within the system were responsible for causing errors, which should be identified to create a blame-free culture. This was highlighted by a higher proportion of medical students (Table  3 ).

“When I used to hear about medical errors, I would always assume it was due to staff incompetency or lack of care. The understanding now that most medical errors do not occur due to malicious behaviour but rather are a result of system defects is eye-opening.” (Year III, MBBS) .

Professional integrity: responsibility, vigilance, and increased confidence

Students mentioned how the case studies detailing medical errors and their consequences had evoked their empathy for patients. They felt a greater sense of responsibility and the need to be vigilant during patient care to avoid medical errors. They further reported how they were able to develop confidence in themselves through the course, to speak up and act to protect their patients’ safety. These perceptions were highlighted by a greater fraction of nursing students (Table  3 ).

“This week of learning has also provoked a feeling of empathy, as the courage and confidence to accept and report mistakes can arise only when we can understand the pain of the patient and care for them.” (Year III, MBBS) . “…we should deal with patients very cautiously because one minor mistake can have detrimental effects on people’s lives.” (Year IV, BScN) . “After this course, I am more confident that I can also play a role and put forward my suggestions for reducing medical errors in the future.” (Year II, BScN) .

Need for similar sessions

The students expressed that the existing component of patient safety in the undergraduate curriculum was inadequate. They opined that patient safety courses should be offered repeatedly to refresh their skills and knowledge. They further strongly recommended offering this course to all other healthcare professionals as well.

“Such courses and sessions should be held for all years, and we would really appreciate if we were to receive refresher sessions and mock drills in the near future.” (Year II, BScN) .

Importance of the topic

Students acknowledged the importance of quality and patient safety, not only to ensure the provision of high-quality healthcare to patients, but also to protect healthcare workers.

“It made me analyze the system and realize that patient safety is something that should be standardized and taught to all healthcare workers in order to reduce risk of injury and harm to both patients and healthcare workers.” (Year III, MBBS) . “ …over the course of the past week, I have learned about very important topics such as patient safety. It is crucial for doctors to have a know how about such topics before their professional career begins.” (Year III, MBBS) .

Theme 5: course feedback

Students reported positive feedback on the use of examples and case studies as a teaching strategy. They felt that it helped invoke critical thinking, analytical skills, and the application of relevant knowledge.

“The case-based exercises, with all the real scenarios mentioned opened my eyes about the multi-layered approach to problem solving.” (Year III, MBBS) .

Discussions on case studies from the US, including the one on Josie King’s death at Johns Hopkins Hospital, was a novel learning experience for the participants. It helped them realize that patient safety issues are not limited to the local context.

“The [learning from defects activity] case was surprising for me, as I didn’t expect such an error from Johns Hopkins. However, I learnt that errors in safety can occur anywhere and how important Learning from Defects is.” (Year III MBBS) .

Students also mentioned how group activities made the course more interactive and stimulated peer learning. In-person sessions were favored over the virtual format.

“The session was very interactive and engaging. Learning in groups and peers was very helpful, as it gave us an opportunity to share our thoughts.” (Year IV, BScN) .

Preparation for clinical years

Participants appreciated how the course prepared them to transition to clinical clerkships and adjust their expectations. They also commented that in the absence of such a course, they would have learned about medical errors only through trial and error.

“It is very ideal to place this module right before our clinical rotation. Now I know how to handle a patient and the dos and don’ts in a health care setting.” (Year III, MBBS) .

Suggestions

Students shared ideas on how to improve the course and suggested including more in-person sessions and hands-on training activities. They also mentioned that patient safety courses should be offered from the first year of their professional education.

“I think it would have been better to have more in-person and small group sessions as they help more in learning than lectures and large class formats.” (Year III, MBBS) . “Perhaps in the years to come this module can incorporate actual documentation practice as part of our observership with nurses…” (Year III, MBBS) . “As this course progressed, I realized that it should have been taught to us in the first year as basics.” (Year IV, BScN) .

Comparison of medical and nursing student reflections

Tabulating code counts by group helped identify differing and similar areas of focus between the cohorts. It was seen that twice the proportion of nursing compared to medical students commented on learning about infection prevention, communication skills and acquiring new information because of the course. A similarly higher proportion reported enjoying the activity-based sessions and suggested that more of such sessions should be held. Nursing students also reflected to a greater extent on the need to be careful and vigilant while providing care. A higher proportion of nursing students also reported that the course had resulted in them having increased confidence to voice safety concerns.

Double the percentage of medical as compared to nursing students remarked that the course had helped prepare them for their upcoming clinical rotations. About a six times higher proportion of medical students reported being surprised to learn about the high frequency of errors in medical practice. This group also reflected more on personal experiences with patient safety issues. Additionally, a more than three-fold higher proportion of medical students reported learning about systems thinking and adopting a blame free approach towards patient safety events.

A similar proportion of medical and nursing students reported a newfound awareness of the potentially drastic consequences of medical errors. Both groups commented on the importance of learning about patient safety to a similar extent. The effectiveness of use of examples in teaching was also similarly remarked upon by both medical and nursing students.

This study aimed to assess the perceptions of medical and nursing students about a patient safety course following its introduction at one of the largest AMCs in Pakistan. The course was received positively by both groups and the results demonstrated that the training gave students a better understanding of the various aspects of medical errors. A higher proportion of medical students reflected on systemic causes of errors, while nursing students appeared to focus on individual roles and error prevention strategies. Both groups expressed how impactful the course had been in helping them understand the importance of teamwork between all cadres of healthcare workers and improving their communication skills. Overall, students appreciated the interactive format and course content, and believed they helped them gain a deeper understanding of patient safety-related issues, taught them essential hard skills, and helped prepare them for clinical practice. These findings highlight the effectiveness and potential benefits of addressing the topic through such dedicated courses.

In concordance with previous literature, students reported having a lack of baseline knowledge and developing an increased understanding of medical errors after the course [ 29 , 30 ]. They appreciated learning what to do in case an error occurred, the importance of reporting and disclosure and local reporting procedures. In Pakistan, error reporting and disclosure have been low scoring domains on patient safety assessments among healthcare providers [ 31 ]. Possible causes of underreporting are lack of awareness and fear of consequences, and according to studies, increasing awareness of medical errors could lead to increased incident reporting among health professionals [ 32 ]. Therefore, it is anticipated that educating health professionals at an early stage in their education can address the issue of underreporting in the local context.

Although both groups were similarly surprised to learn about the possible consequences of medical errors, a higher proportion of medical students reflected on the high frequency of errors and multifactorial causality of adverse events in comparison to nursing students. As reported in previous studies, they demonstrated an understanding of latent errors and systemic causes of errors as a result of the course [ 33 ] which made them open toward adopting a blame-free approach. This was an important finding, as an assessment of baseline perceptions of patient safety in Hong Kong showed that medical students lack an understanding of nonphysician-based causes of errors [ 34 ]. On the other hand, a higher proportion of nursing students demonstrated an understanding of the concept of error preventability, with a large number discussing at length the possible error prevention strategies, along with infection prevention. They also emphasized the need to be cautious and vigilant during care delivery [ 35 ], as the course had made them aware that the stakes are high otherwise. This finding is similar to a previous study and an indication of focus on an individual level and not on the culture of safety or the system as a whole [ 36 ]. These differences in the distribution and types of subthemes elucidated in the reflections of the two groups after the same course could be explained by the current power dynamics in healthcare settings in LMICs. In such settings, leadership comprises mostly senior physicians, which could mean that other health professionals are more vulnerable to blame and punishment than physicians [ 37 ]. Additionally, they could be a result of different areas of focus in the core medical and nursing curricula. While the nursing curriculum places great emphasis on skill development, medical education has more of a biomedical focus [ 6 ]. These differences could be addressed by employing interprofessional education and team-based learning strategies so that both groups can learn from each other and develop a more balanced approach [ 38 , 39 ]. The course could also be tailored for each group to specifically address the gaps identified. It is worth noting, however, that gender differences were not accounted for in this study and further research might be warranted to assess any possible impact they might have on the uptake of patient safety concepts among course participants.

While highlighting the importance of teamwork and communication for ensuring patient safety, students appreciated learning the use of structured methods such as the ALEEN and SBAR tools to resolve conflicts and communicate effectively within the healthcare team. Such tools have been useful in reducing patient harm and improving interprofessional communication, a critical element in patient safety [ 40 , 41 , 42 ].

Historically, physicians tend not to recognize the importance of teamwork and collaboration as much as nurses [ 43 , 44 , 45 ], perhaps owing to the general perception of physician dominance and nurse subversion [ 46 ]. This is a barrier to forming a good nurse‒physician relationship, and this lack of interprofessional collaboration could result in a higher possibility of errors and omissions in patients’ care [ 47 ]. It was thus noteworthy that both medical and nursing students in this study demonstrated a similar understanding of the importance of teamwork after the course, which highlights the effectiveness of including this subtopic in patient safety training.

Similar to previous studies, students considered the use of personal stories of medical errors as an effective and engaging means of learning [ 35 , 48 ]. While studies report the impact of personal stories narrated by involved personnel themselves [ 48 ], students in this cohort were deeply impacted by the medical error case scenario from the Johns Hopkins Hospital, as they were shocked to learn that medical errors could also happen in the best of settings. Students felt that this case discussion made them realize the importance of formal patient safety training for all health professionals. In addition, they were able to reflect on their own experiences of encountering or observing patient safety events. Furthermore, in line with findings from previous studies, medical students reported finding the use of real-life examples to be helpful [ 49 ].

There has been debate about the best way to impart core patient safety concepts, and different formats have been employed globally [ 35 , 50 , 51 , 52 , 53 ]. While online courses appear feasible and have been shown to increase knowledge [ 13 ], the literature shows that these courses alone do not show long-term effects on attitudes towards patient safety, an area that needs to be addressed in patient safety education [ 54 , 55 ]. Students in our study expressed greater engagement in the in-person sessions than in the virtual sessions. The effectiveness of interactive activities was reported in terms of solidifying concepts and learning practical implementation and has been highlighted in the literature as well [ 50 ]. Holding in-person training sessions might be more important for nonmandatory areas of study to improve student engagement and ensure long-term impact.

We believe that by providing an increased understanding of the perceptions of end users, this study can help with designing and incorporating patient safety courses into medical and nursing curricula globally. The findings indicate that the said course increased students’ awareness, imparted skills and changed their perceptions and outlook towards patient safety. This is in line with the literature [ 56 ], supports the use of the format adopted, and can potentially lead to improved attitudes, a better safety culture and safer practices while also being a step towards achieving a similar understanding of patient safety among physicians and nurses.

To address safety issues in LMICs, patient safety can be incorporated as a core component in the national medical and nursing curricula early on in training. We suggest modifying the course content to address local gaps and employing interprofessional education and simulation-based training exercises to allow medical and nursing students to learn about shared responsibility and practice identifying and managing potential risks, errors, and adverse events in a safe and controlled environment. Clinical rotations during training could allow them to further observe and address patient safety issues firsthand, reinforcing their understanding and skills. We further recommend incorporating patient safety into continuing education programs for healthcare professionals through workshops, seminars, or online courses that provide updates on emerging patient safety practices and encourage ongoing professional development. Future research can be designed to measure long-term impact and outcomes, and to continuously assess and improve educational approaches. By implementing these recommendations, educational institutions can ensure that patient safety becomes an integral part of healthcare education, equipping future healthcare professionals with the knowledge, skills, and mindset needed to prioritize patient safety throughout their careers.

This study has a few limitations. Self-reported student reflections could be subject to self-reporting and social desirability bias. However, the relevant section of the survey was not graded and had no potential repercussions for the students, allowing them to freely express their opinions. The study was conducted at a single AMC, and students from other institutes in the region may have different exposures and perceptions regarding patient safety. It is worth noting that unlike most medical colleges across the country, AKU has a diverse student body with varying backgrounds and ethnicities from all over the country, which offered broad insight into student perceptions. Additionally, the COVID-19 pandemic led to variability between online and in-person delivery of lectures between cohorts. Finally, nursing students significantly outnumbered medical students, which could lead to a biased comparison.

Dedicated patient safety courses can lead to an improved conceptual understanding of patient safety among medical and nursing students. The reported lack of awareness regarding essential patient safety concepts prior to this course highlights a gap in the existing curricula in LMICs, and the student perspective demonstrates the benefits of addressing this gap through introduction of dedicated interactive courses at early stages of professional education. Similar courses could be implemented at the national level and regionally across medical and nursing schools to address local deficits, and the differing areas of focus of medical and nursing students after a similar training could be addressed by designing future interventions accordingly. Further research could be conducted to continually assess and improve these courses and measure their long-term impact on patient outcomes.

Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

High-income countries

• Low- and middle-income countries

World Health Organization

United States

Academic medical center

Aga Khan University

Bachelor of Medicine and Bachelor of Surgery

Bachelor of Science in Nursing

Agency for Healthcare Research and Quality

Learning from Defects

Situation, Background, Assessment, Recommendation

Anticipate, Listen, Empathize, Explain, Negotiate

Virtual Learning Environment

Noreen Afzal

Standards for Reporting Qualitative Research

Personal Protective Equipment

Global Patient Safety Action. Plan 2021–2030 towards eliminating avoidable harm in Health Care. Geneva: World Health Organization; 2021.

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F.A. and N.A. wrote the main manuscript text and analyzed the data. F.A. was involved in data acquisition and handling, prepared tables for the manuscript and coordinated contributions from the coauthors. N.A. developed the study methodology and provided software-related expertise. A.L. and F.As. put together the curriculum and surveys, and conceptualized and supervised the study. F.A.A., S.S.H., F.As., K.A., Z.T. and M.J. were involved in data acquisition. A.H.H. conceived the idea for this study. W.A. contributed to writing the first draft of the manuscript and G.H. made contributions to editing. A.H.H and H.J.A. conducted a thorough critical review of the manuscript. A.L. was responsible for study validation, overseeing the analysis and critical review of the manuscript. All authors reviewed and approved the final manuscript.

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Ayub, F., Afzal, N., Ali, W. et al. Exploring medical and nursing students’ perceptions about a patient safety course: a qualitative study. BMC Med Educ 24 , 452 (2024). https://doi.org/10.1186/s12909-024-05348-8

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DOI : https://doi.org/10.1186/s12909-024-05348-8

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Advancing the entrepreneurship ecosystem of India: A qualitative study with Chevening Fellows

• Published: 26 December 2023

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• Kamal Gulati 1 ,
• Amrik Sohal 2 ,
• Tharaka de Vass 2 &
• Nrupal Das 3  

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Using social cognitive theory as a guide, this research seeks to explain the perceptions of current and aspiring Indian entrepreneurs. A multiple case study approach using 19 interviews with intellectuals provided qualitative data to conduct a cross-case analysis of the two groups with the qualitative analysis software NVivo. Rare insights from current and aspiring opportunity-motivated entrepreneurial Chevening Fellowships from a predominantly necessity-motivated context offer valuable insights into entrepreneurship in India. The findings reveal what entrepreneurship means to established entrepreneurs, their motivation for embarking on the entrepreneurial journey, the skills they require to be successful, the challenges they face and their strategies to sustain are mostly different to what aspiring entrepreneurs believe how it would be. Compiled recommendations may help strengthen the entrepreneurial ecosystem, particularly in developing economy contexts, to help improve the 10% startup success rate.

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Acknowledgements

Authors gratefully acknowledge the support of Chevening fellows who consented to participate in this study, Chevening Secretariat, Foreign Commonwealth & Development Office, Prof. Richard Briant, University of Oxford, Prof. John Hoffmaire, Chairman, Oxford Pharmaceuticals, Ms. Sarah Fallon, Regional Director, Science and Innovation, British High Commission New Delhi, Ms. Supriya Chawla, Head Chevening Scholarships India for their support.

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Gulati, K., Sohal, A., de Vass, T. et al. Advancing the entrepreneurship ecosystem of India: A qualitative study with Chevening Fellows. Asia Pac J Manag (2023). https://doi.org/10.1007/s10490-023-09940-2

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DOI : https://doi.org/10.1007/s10490-023-09940-2

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