Clinical Nurse Competence and Its Effect
Clinical Nurse Competence and Its Effect
Clinical Nurse Competence and Its Effect
Abstract
Background Unsafe health practices are one of the leading causes of disability and even death. Competent
nurses are crucial to ensure safe and high-quality healthcare services. The patient safety culture is concerned with
internalizing safety beliefs, values, and attitudes, translating them into healthcare practices, and committing to
maintaining an error-free health environment. A high level of competence ensures the achievement and compliance
with the safety culture goal. This systematic review aims to identify the relationship between the level of nursing
competence and the safety culture score and perception among nurses at their workplace.
Methods Four international online databases were searched to find relevant studies published between 2018 and
2022. Peer-reviewed articles using quantitative methods, targeting nursing staff, and written in English were included.
After reviewing 117 identified studies, 16 full-text studies were included. The PRISMA 2020 checklist for systematic
reviews was used.
Results Evaluation of the studies indicates safety culture, competency, and perception were assessed using various
instruments. Safety culture was generally perceived as positive. No unique and standard tool has been developed to
investigate the effect of safety competency on the perception of the safety culture in a standardized way.
Conclusions Existing research provides evidence of a positive correlation between nursing competence and patient
safety score. Future research is recommended to investigate ways to measure the effect of nursing competency level
on safety culture in healthcare institutions.
Keywords Patient safety, Nursing competence, Safety culture
Background
Unsafe health practices are highly regarded to cause dis-
ability and death. It is estimated that the chance that
unsafe practice can cause harm for the patient is 1 in 300
chance [1]. Nearly 400,000 deaths occur annually in the
United States due to several reversible adverse events,
*Correspondence:
Rasha Abu Zaitoun such as medication error, infection transmission, and fall
rasha.zaitoun@najah.edu events [2]. In addition, poor quality care can cause death
1
Head of the Continuing Nursing Education, nursing department, An and a global health burden [3]. Patient safety is a health
Najah National University Hospital, Nablus, Palestine
2
Department of Nursing and Midwifery, Faculty of Medicine and Health care discipline that evolved as a result of the increasing
Sciences, An Najah National University, Nablus, Palestine sophistication of health care systems and the increasing
3
Keigwin School of Nursing, Jacksonville University, Brooks Rehabilitation in adverse outcomes in health-care facilities. Its goal is to
College of Healthcare Sciences, 2800 University Boulevard North,
Jacksonville, FL 32211 904.256.8955, USA avoid and decrease risks, mistakes, and harm to patients
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Zaitoun et al. BMC Nursing (2023) 22:173 Page 2 of 10
while providing health care. Therefore, reliable, safe, This date period was chosen after agreement between the
equitable, effective, and highly standardized patient-cen- author to find the (five years) recent evidence regarding
tered care has become the ultimate goal of all health care the respected review topic. The current systematic review
institutions worldwide [4]. Besides that, patient safety was framed by SPIDER [13] with nurses as the Sample
culture focuses on organizational culture issues related (S); clinical competence as the Phenomenon of Interest
to patient safety, patient safety culture is concerned with (PI); Design (D) as quantitative or mixed-methods stud-
internalizing safety beliefs, values, and attitudes, translat- ies; Evaluation (E) as covering assessments of patient
ing them into health care practices and commitment to safety culture; and Research Type (R) as referring to all
maintaining an error-free health setting and emphasizing types of studies with the exception of case studies and
reporting culture [5]. review articles. The protocol was performed based on the
Competent nurses are key contributors to maintain- guidelines of the Preferred Reporting Items for System-
ing safe and effective health care services by integrating atic Review and Meta-Analyses Protocol (PRISMA-P)
knowledge, skills, and attitudes that enable them to adapt [14].
to dynamic health environments [6]. Nurses are often
the primary point of contact for patients and are respon- Search strategy and data sources
sible for ensuring that their needs are met. By providing Four online databases including MEDLINE (via
patient-centered care, nurses can help create a culture PubMed), CINHAL (via EBSCOhost), Scopus (via Else-
that prioritizes patient safety. In addition, they can act as vier), and Embase were searched for published stud-
advocates for patient safety, promoting a culture of safety ies that describing the relationship between nurse
within the organization and encouraging others to do the competencies and patient safety culture. Search terms
same. Nurses should be given the power to make deci- were developed based on experience and keywords
sions about patient care and safety, as well as to report from similar research. The search was structured using
any harmful conditions or concerns. They can indeed act Boolean operators (AND, OR) and consisted of MeSH
as role models for other healthcare professionals, empha- terms and free terms related to nursing, patient safety,
sizing the importance of patient safety and providing a competency, and safety culture. The term ‘OR’ was used
good example for others to follow. between keywords or comparable MeSH phrases; mean-
Patient safety competencies are a core competency in while, the Boolean operator ‘AND’ was used to connect
the continuum of professional development activities phrases or keywords with different meanings to refine
that protect patients from unnecessary risks and hazards the search (see Appendix A). Relevant studies were iden-
[7]. A high level of competence promotes the achieve- tified by two reviewers (R.A. and L.T.) independently, and
ment and compliance with the patient safety goal. search algorithm varied according to the specifications of
Several studies found that patient safety culture and each database. To identify the additional relevant studies
nurse safety competency are affected by many factors. being lost in the database search, we checked the refer-
For example, workplace regulations and climate, nursing ences of the selected publications.
fatigue, satisfaction, stress, demographics, type of health
institution type, teamwork and learning opportunity, spe- Inclusion and exclusion criteria
cialty, degree of bedside involvement, and job description In this review, studies were included if they are using the
are all factors that affect safety culture [5, 8–11]. quantitative approach mainly; targeting nursing staff;
Any improvement strategies to modulate these factors published in English language, and full text available. The
are unnegotiable. However, a better understanding of exclusion criteria were studies in the form of letters, edi-
nurse competence and patient safety culture is essential torials, essays, case studies, comments or narrative, sys-
to improve safe practice and professional development tematic reviews, and conference abstracts; studies focus
and minimize adverse events [12]. Therefore, this system- on nursing students only; and studies of pre-hospital and
atic review aimed to evaluate the literature concerning ambulatory care.
the relationship between self-reported competencies and
the perception of patient safety among nurses in their Study selection and quality assessment
workplace. In addition, to understand how related studies After preliminary selection of studies by the first reviewer
evaluated nurses’ core competencies and safety culture. (R.A) and their verification by the last reviewer (L.T.) the
duplicated studies were excluded. Two reviewers (R.A.
Methods and L.T.) independently screened the titles, abstracts and
Study design full text of the studies.
The present systematic review was designed and con- The Mixed Methods Appraisal Tool (MMAT) [15] was
ducted from April 1, 2022, and April 11, 2022, by the elec- used to evaluate the quality of the studies included in this
tronic search from January 1, 2018, through May 1, 2022. review. With the MMAT, two basic screening questions
Zaitoun et al. BMC Nursing (2023) 22:173 Page 3 of 10
must be asked first to determine whether or not the qual- pretest-posttest design [17], and one study used a mixed
ity appraisal for a specific study will be continued. The method approach [18]. Three out of the sixteen studies
first question is whether the related qualitative, quanti- were conducted in South Korea [19–21], Canada [19]
tative, or mixed-methods study has clear research ques- Three studies originated from Saudi Arabia [9, 22, 23].
tions or objectives. The second question is whether the Two studies from Iran [24, 25]. In addition, a study was
method of data collection addresses the research ques- conducted in each Australia [26], Belgium and Palestine
tions or objectives. When these initial screening ques- [27], Brazil [28], Jordan [29], Spain [18], England [17],
tions are answered positively, qualitative (QUAL) or and China [11]. The aforementioned research studies
quantitative (QUAN) studies can be rated as follows: ‘*’ were published from 2019 to 2022 in different journals.
(25%) for one met criterion, ‘**’ (50%) for two, ‘***’ (75%) Summary of the characteristics of included studies are
for three, or ‘****’ (100%) for the highest quality study. depicted in Table 1.
Studies with a rating of ** or higher were considered to
be of acceptable quality for this review and were included The sampling technique
for further analysis. Given the sampling technique, eight articles used the
convenience sampling technique [9, 11, 19, 22, 23, 25, 26,
Data extraction 30]. The highest sample size was 2,836 participants in the
Data extraction table included: author(s) and publica- study by Najjar et al. [27], while the least was 56 partici-
tion year, country, design of study, method of data collec- pants in [28] study.
tion, quality assessment. Measurement Tools for Safety
Culture and Nursing Competency and main findings Methodological quality of included studies
focusing on Patient Safety Competency and the Patient The assessment of the methodological quality of the
Safety Culture. In this stage two authors (R.Z. and L.T.) included studies is presented in Table 2. After quality
independently extracted data from the included studies. assessment, nine studies graded as ‘****’ (100%) and seven
In case of disagreement between two reviewers (R.Z. and studies as ‘***’ (75%) quality using MMAT. Research con-
L.T.), a third reviewer (N.S) was involved to make a final ducted or published during the COVID-19 outbreak
decision. period [9, 11, 18–26, 28, 29] received additional review
to ensure it met rationale for inclusion and standards for
Data synthesis quality, to ensure rigor in response to the substandard
An iterative narrative synthesis technique was used for work proliferating during this period [31].
data analysis [16] to identify key themes from every study
that would adequately and accurately reflect the findings Measurement tools for Safety Culture and nursing
about clinical nurse competence and patient safety cul- competency
ture. The narrative synthesis was divided into four stages: The construct concepts of patient safety culture, safety
(1) identifying a frame of how findings from related stud- climate, and patient safety competency were opera-
ies work, why and for whom; (2) synthesizing themes tionally measured using various tools or instruments
through an iterative process of comparing and examining throughout the sixteen studies. Nursing safety compe-
findings from the included studies; (3) trying to explore tency was measured using the Patient Safety Competency
themes’ relationships; and (4) evaluating the synthesis’s Self-Evaluation Tool, the Health Professional Education
robustness. in Patient Safety Survey (H-PEPSS) [21], and the Nurses’
Attitudes and Skills Safety scale, the latest version of
Results NASUS [23]. Furthermore, AS Alshehry [22] used the
Results of the search strategy Health Professional Education in Patient Safety Survey
Through the flow of PRISMA-P, the search process (H-PEPSS) to assess safety competency. Halabi et al. [9]
found 1341 potentially relevant studies; initial screening used the short version of Nurse Professional Competence
revealed that 6 records were duplicated. After exclud- (NPC).The self-reported Patient Safety Competency
ing the irrelevant studies by title and abstract review Nurse Evaluation Scale (PSCNES) was used by Yan et al.
(1217) and applying exclusion criteria (57), reports not [11].
retrieved related to access issues (n = 18). Full text screen- Three studies applied the Hospital Survey on Patient
ing showed that 27 were not relevant. Finally, 16 studies Safety Culture (HSOPSC) developed by the Agency for
remained and were included in the analysis (Fig. 1). Healthcare Research and Quality to measure safety cul-
ture [21, 27, 32]. The safety climate was measured using
The design of the reviewed studies the Safety Attitudes Questionnaire (SAQ) and the Safety
Of the 16 qualifying studies, 14 were cross-sectional Climate Survey (SCS); [26, 28, 29] (Table 2).
descriptive studies, one applied a quasi-experimental,
Zaitoun et al. BMC Nursing (2023) 22:173 Page 4 of 10
The patient safety culture nurses for example, LM Lousada, FC da Silva Dutra, BV
Patient safety culture was mentioned in the title of six da Silva, NLL de Oliveira, IB Bastos, PF de Vasconcelos
studies [21, 23, 27, 28, 32, 33]. There was considerable and R de Carvalho [28] in his study found that profes-
variation of how this concept was perceived among sionals working in home care services perceived higher
Zaitoun et al. BMC Nursing (2023) 22:173 Page 5 of 10
scores related to safety culture compared with those of Chinese nurses with associate degree and they scored
working in primary care services. The accredited primary moderate level. A Habibi Soola, M Ajri-Khameslou, A
center in Jordan had an average positive response rate in Mirzaei and Z Bahari [25] found a positive correlation
some safety cultures ranging from 58.54 to 75.63% [33], A between safety competence and the dimension of team
total of 32 Iranian teaching hospitals out of 150 reported work, psychological safety, leadership, communication,
poor patient safety culture [32]. On the other hand, and mutual support, situation monitoring, and team struc-
with regard to the safety climate, the study by CJ Con- ture. JH Han and YS Roh [20] found that the night shift
nell, S Cooper and R Endacott [26] revealed that novice- among emergency nurses in Korean hospitals negatively
competent nurses in Australian emergency departments affected safety competence and was significantly and pos-
rated the safety climate higher than expert nurses in all itively correlated with the number of years of experience
domains except stress recognition. in the emergency department and number of reported
adverse events by others.
Patient safety competency In a medical city in Saudi Arabia, AS Alshehry [22]
Six studies examined patient safety competency and studied the correlation between the conflict between
several studies connected safety competencies with the nurses and the patient, and safety competencies. The
domains of safety culture. For example, L Yan, L Yao, Y Li study revealed that nurses were highly competent
and H Chen [11] assessed the safety competence scores in effective communication, but they had the lowest
Zaitoun et al. BMC Nursing (2023) 22:173 Page 6 of 10
competency in ‘working in teams with other health pro- similar to SM Cho and J Choi [36] in their study inves-
fessionals.’ Nurses perceived ‘mistrust of motivations’ tigated relationship between the three parts of safety
and “contradictory communication” got the poorer self- competency and domains of patient safety culture among
reported safety competency. 343 registered nurses in an educational hospital in, South
Korea and found that the safety competency was highly
Discussion correlated with teamwork within units. Teamwork within
The purpose of this study was to provide a systematic and across units, supervisor or manager expectations,
review of the literature investigating the relationship and each of the three patient safety competencies were
between nursing competencies and perception of patient strongly associated to attitudes, while teamwork within
safety among nurses in their workplace. In this systematic units and learning were significantly connected to skills.
review, and after a thorough analysis of the entire manu- Knowledge was only significantly correlated with organi-
script of the retrieved articles, we selected and discussed zational learning.
sixteen articles based on their conformity with the inclu- The concentration on assessing and improving Safety
sion criteria. competency for nurses instead of more general clini-
Nurse’ competence refers to the knowledge, skills, and cal nurse competence may due to that many health care
abilities that nurses possess to provide safe and effective institutions tend to adopt the principles of patients safety
care to patients in many fields such as clinical, safety, as their institutional goal and so try to improve nursing
communication, and leadership. This can include things skills, knowledge and attitude related to patient safety
like knowledge of clinical guidelines, critical thinking and it would be better to assess the level of nurses’ cul-
skills, and the ability to identify and respond to changes ture of safety and their safety competency level in order
in a patient’s condition, how to manage conflict and com- to improve area of weakness or poor practices and reduce
municate with patients and other health care team. A adverse events [37, 38].
positive patient safety culture is one in which all mem-
bers of the healthcare team are committed to provid- Measurement of patient safety culture
ing safe care and are empowered to identify and report Measuring patient safety culture involves assessing the
potential hazards. Research has shown that, specifically, attitudes, perceptions, and behaviors of healthcare staff
safety nurse competence is positively associated with a related to patient safety in a healthcare organization.
positive patient safety culture [34]. Nurses who are com- There are several tools and survey instruments available
petent in their practice are more likely to be engaged in to measure patient safety culture. In this review, two self-
the safety culture of their organization and more likely reported questionnaires were found to have been applied
to identify and report safety concerns [11]. Addition- to understand the dimensions and scores of patient safety
ally, nurses who possess the knowledge, skills and abili- culture in health institutions. The Safety Attitude Ques-
ties required to provide safe care are less likely to make tionnaire (SAQ) [28, 33] and the Hospital Survey on
errors which can lead to adverse patient outcomes [35]. Patient Safety Culture (HSOPSC) [21, 23, 27, 32] were
Overall, clinical nurse competence is a critical compo- two assessment tools that employed Likert scales. How-
nent of a positive patient safety culture, as it helps ensure ever, in their study, G Alsalem, P Bowie and J Morrison
that nurses are able to provide safe and effective care to [39] revealed that five instruments are used to assess the
patients and promotes engagement and active participa- patient safety culture and climate in health institutions.
tion in the safety culture of the organization. Furthermore, these tools vary in their psychometric
None of the reviewed articles explicitly explored the properties and scope.
relationship between clinical or professional nursing The aforementioned survey instruments assess various
competencies and the safety culture dimensions and how aspects of patient safety culture, such as communication,
they affect each other. Furthermore, studies identified teamwork, error reporting, and leadership. The results
no specific comprehensive tool with high reliability and of these surveys can be used to identify areas of strength
validity and mostly recommend assessing the relationship and areas for improvement in the patient safety culture of
between nursing safety competency and the dimensions an organization.
of safety culture. Rather, the included articles examined In general, patient safety culture measurement is a con-
patient safety culture, health care safety climate, and tinuous activity that should be conducted on a regular
other nursing competencies that influenced or affect basis to assess success and identify areas for improve-
safety climate independently. Most of the retrieved stud- ment. The information gathered through these surveys
ies investigated the very specific competencies for nurses and other ways may be utilized to design and execute
which were safety competency and the level of this com- plans to improve the patient safety culture.
petency varied among different clinical setting or nation- The most common study design among the studies was
ality and range between poor and moderate level and this a questionnaire-based descriptive quantitative approach.
Zaitoun et al. BMC Nursing (2023) 22:173 Page 8 of 10
Using different study designs, such as qualitative research the scope of keywords used to search online databases
and a variety of data collection methods, could help to focus on the core of this study. In addition, it is rec-
improve understanding of the safety culture and health ommended to investigate the effect of nursing compe-
care provider perceptions and would be required to tency on perceptions of dimensions of safety culture and
address the existing relationship between safety culture to make valid comparisons between demographics and
and nursing competency [40]. cultures.
More research would provide a better understanding
Measurement of safety nursing competency and may have a greater clinical impact and aid in improv-
Eight of the studies, or 50% of the literature, in this review ing and delivering highly effective, safe, and efficient care.
showed that nurses were more competent in communi- Furthermore, the findings would support synchronicity
cating effectively than working in teams with colleagues, between academic clinical programs and nursing staff
and their overall safety culture score was positive. Like- safety practices. For example, nursing students receive
wise, LM Zabin, RSA Zaitoun and AA Abdullah [41] competency-based training that allows them to live in a
found that both organizational learning and continu- safe environment and directly implement the dimension
ous improvement, as well as cooperation within units, of safety culture [44].
received the highest composite frequency of patient
safety perception. Limitations
In the current findings, the reviewed literature men- This systematic review study has several limitations. First,
tioned four self-reported measurement tools for safety we restricted the databases to four primary resources
competency. Despite that, there was no consensus on considered suitable for gathering eligible articles for the
the best tool for measuring safety competencies, and the study purpose. The second is that the delimiters of this
lack of a key self-reported tool for measuring safety cul- review included only articles in English, so some related
ture and linking it to nursing safety competency limited articles may not have been included. Another limita-
the ability to directly assess the effect of nursing compe- tion that should be highlighted is that we reviewed arti-
tency on safety culture [42]. As a result, more research is cles published between 2018 and 2022 to include the
needed to enrich the literature, improve the understand- most recent data, but this also restricted the number of
ing of the effect of safety competency on safety culture retrieved studies.
scores among nurses, and help in providing more appro- Another potential limitation was that the results of the
priate operational definition of safety culture and nursing reviewed studies could not be generalized. The articles
safety competency [43]. were only published in peer-reviewed journals to ensure
Although we used broad keywords to search different the high quality of evidence and the reported findings,
online databases, the retrieved articles did not specifi- which omitted many worthwhile studies such as grey
cally discuss the relationship between the dimensions of and unpublished studies. Additionally, the study designs
the safety culture, perception, and competency in nurs- of the majority of the retrieved papers were descriptive,
ing safety. Additionally, the lack of a standardized tool to which restricts the generalizability of their findings and
measure the concepts of safety culture and nursing safety prevents access to many relevant studies. Therefore, it is
competency made it difficult to find a robust number of recommended to conduct further systematic or integra-
targeted studies and limited our ability to find specific tive reviews that might include qualitative and descrip-
operational definitions to the concepts of safety culture tive studies as well as expand the inclusion criteria for
and nursing safety competency that was used consis- other types of literature.
tently across the literature.
Moreover, using self-reported surveys and relying on Conclusions
convenient sampling eased data collection and provide This systematic review draws several conclusions from
more objective data for many of the studies in this review. the sixteen reviewed articles. First, the study showed no
However, there were drawbacks that limited the gener- specific tool to measure the safety culture and nursing
alizability and might not cover all aspects of the stud- safety competency dimensions. Additionally, no study
ies’ content. Therefore, future use of mixed designs with explicitly discussed the effect of nursing safety com-
the use of qualitative methods is highly recommended petency on safety culture scores among nursing staff.
to deepen the study issue and explore the unique rela- However, most of the studies employed a questionnaire-
tionship between the dimensions of the safety culture based descriptive approach. Conducting more research
and nursing competency that can play a pivotal role in with different study designs such as the experimental,
improving safety practices. qualitative, and longitudinal approaches may enhance
This review study recognizes the importance of con- the understanding and assist in constructing a valid and
ducting additional searches and reviews and broadening more reliable tool to measure the effect of nursing safety
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