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Ibrahim et al. BMC Health Services Research (2025) 25:1176 https://doi.org/10.1186/s12913-025-13384-3

BMC Health Services Research

*Correspondence: Mudasir Mohammed Ibrahim [email protected]

Full list of author information is available at the end of the article

Abstract Introduction Despite significant advancements in healthcare, patient safety remains a persistent global concern. Nurses’ competency in patient safety is essential for minimizing errors and improving key performance indicators (KPIs) related to patient outcomes.

Aim This study assessed the impact of nurses’ patient safety competency (PSC) on KPIs for patient safety outcomes at Tamale Teaching Hospital.

Methods A multi-method research design was employed, comprising quantitative data collected from 291 nurses using structured questionnaires and qualitative data from 10 in-depth interviews. Quantitative data were analyzed using SPSS Statistics and AMOS, while qualitative data were analyzed using QDA Miner Lite.

Results Majority of nurses (61.2%) demonstrated high PSC, with the highest scores recorded in professional characteristics (M = 3.04, SD = 0.74). PSC was significantly associated with age, educational level, work experience, rank, and prior exposure to quality and safety programs (p < 0.05). Among the KPIs, medication safety recorded the highest performance (M = 3.82, SD = 0.86). Structural equation modeling (SEM) revealed that nurses’ PSC significantly predicted KPIs for patient safety outcomes (β = 0.628, p < 0.001), with the leadership role in patient safety partially mediating this relationship (β = 0.218, p < 0.001). Qualitative findings identified key barriers to PSC development, including inadequate integration of patient safety into nursing education, lack of training and standardized protocols, limited career advancement opportunities, and limited scope of practice.

Assessing the impact of nurses’ patient safety competencies on key performance indicators (KPIs) for patient safety outcomes at Tamale Teaching Hospital: the mediating role of leadership and barriers to competency development Mudasir Mohammed Ibrahim1,2*, Fatima Abdul-Rahaman3, Mohammed Sherif Sayibu4, Dora Nyamekye Alhassan3, Ruhaima Tunteya Awudu2, Iddrisu Mohammed Sisala2, Abubakari Wuni5 and Abdul-Malik Abdulai2

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Introduction Patient safety (PS) is a critical component of healthcare quality and refers to the prevention of healthcare-related errors and adverse outcomes that affect patients. The Institute of Medicine (IOM) identifies medical errors as a leading cause of death and injury, underscoring the threat they pose to patient safety [1].

Many patients experience harm during hospitaliza- tion due to a variety of errors and adverse events [2], and the impact is even more severe in low-income countries, where unsafe medical practices tend to cause more dam- age compared to developed nations. One major contrib- uting factor is the insufficient integration of patient safety education into the curricula of health professional train- ing institutions [3].

Effective implementation of patient safety strategies requires a combination of skilled healthcare profession- als, strong leadership, clear policies, robust data systems to support safety improvement, and active patient partic- ipation in care [4]. As the largest group of healthcare pro- fessionals, nurses play a central role in ensuring patient safety due to their direct and continuous involvement in patient care. Their responsibility includes providing qual- ity care, detecting potential errors, and preventing harm [5, 6]. Because of the nature of their work, nurses are uniquely positioned to influence patient safety outcomes [7].

Although many nurses demonstrate a good under- standing and a positive attitude toward patient safety, studies have shown a need for continuous education and training to strengthen these attitudes and address exist- ing gaps [8]. Competent nurses contribute significantly to safe and effective healthcare delivery by combining rel- evant knowledge, skills, and attitudes that allow them to adapt to complex and evolving clinical settings [9].

Over the past decade, numerous strategies have been implemented to improve patient safety, with a strong emphasis on enhancing patient safety competency (PSC). PSC encompasses the essential attitudes, knowledge, and skills that enable healthcare professionals to minimize unnecessary risks and harms to patients. This compe- tency enables nurses to promptly report incidents, adopt preventive measures, and ultimately ensure patient well- being [10, 11]. It also facilitates the identification and res- olution of latent safety issues within healthcare systems [12]. However, research shows a variation in PSC levels among nurses. While some studies report low PSC [10, 13, 14], others find moderate levels [15– 17], and only a few report high levels [18].

Despite increasing attention to patient safety and the implementation of various improvement strategies over the past decade, evidence on the actual levels of patient safety competency (PSC) among Ghanaian nurses remains limited. Consequently, the Ghanaian health- care system continues to face persistent patient safety challenges. Reports have documented a high prevalence of patient safety incidents (PSIs) in Ghanaian hospitals, including medication errors, wound infections, infu- sion reactions, pressure ulcers, and patient falls, many of which occur at least monthly [19, 20]. These recur- ring incidents highlight the urgent need to evaluate and strengthen the PSCs of nurses, who serve as the pri- mary frontline providers in clinical care. There is also a critical need to demonstrate how nurses’ patient safety competencies translate into measurable improvements in patient safety outcomes. In response, this study was designed to assess the impact of nurses’ patient safety competencies on key performance indicators (KPIs) for patient safety outcomes at Tamale Teaching Hospital, while also exploring the roles of leadership and institu- tional barriers.

Literature review Nurses’ patient safety competencies and key performance indicators (KPI) for patient safety outcomes In healthcare institutions, key performance indicators (KPIs) for patient safety outcomes provide measurable standards for evaluating how well safety practices are implemented. Five common KPIs include medication safety, infection control, pressure ulcer prevention, fall prevention, and blood management [21–23]. These KPIs are not merely administrative tools but they directly reflect the quality and safety of nursing practice and are critical to achieving better clinical outcomes, enhancing patient trust, and reducing healthcare costs [21, 22].

Rooted in competency-based education and systems- thinking in healthcare, the development of patient safety competencies among nurses is essential to foster- ing high-reliability organizations [15, 22]. When nurses are empowered through training, they are more likely to engage in safety-enhancing behaviors that positively impact key performance indicators (KPIs) for patient safety outcomes [9]. For example, when nurses are well- trained in medication safety, they are more likely to fol- low the rights of medication administration thereby minimizing medication errors [24]. In infection con- trol, competent nurses consistently follow evidence- based practices such as hand hygiene, sterile technique,

Conclusion Strengthening nurses’ patient safety competencies and addressing barriers are essential strategies for improving patient safety outcomes, particularly in resource-constrained healthcare settings.

Keywords Nurses, Patient safety, Competency, Outcome, KPIs

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and isolation precautions, leading to reduced hospital- acquired infections [25]. Similarly, nurses proficient in pressure ulcer prevention routinely perform risk assess- ments using validated tools like the Braden Scale and implement timely repositioning, skin care, and nutri- tional interventions [26]. Effective fall prevention stems from nurses’ vigilance, routine risk screening, environ- mental checks, and patient or caregiver education [27]. In blood management, safety-oriented nurses ensure accurate crossmatching, monitor patients during transfu- sion, and adhere to institutional policies, which reduces adverse transfusion events [28].

Empirical studies have shown that nurses’ patient safety competencies positively contribute to improved perfor- mance on key performance indicators (KPIs) related to patient safety outcomes. For instance, Zhang et al. [29] found that the incidence of adverse events (AEs) corre- lates with nurses’ limited ability to apply clinical safety skills. Kakemam et al. [10] demonstrated that enhanced patient safety competence leads to a significant reduc- tion in AEs and improves nurses’ likelihood of report- ing errors, a critical step toward learning and system improvement. Similarly, Feliciano et al. [22] confirmed a positive association between nurses’ core competencies and key performance indicators (KPIs) for patient safety outcomes, including blood safety, fall and pressure ulcer prevention, infection control, and medication safety. Overall, the evidence highlights a strong and meaningful connection between nurses’ patient safety competencies and key performance indicators (KPIs) for patient safety outcomes.

Leadership role in patient safety: a critical mediator Leadership in healthcare settings is increasingly recog- nized as a fundamental driver of patient safety outcomes. In particular, nursing leadership exerts a powerful influ- ence on the translation of frontline nurses’ competen- cies into safe and effective clinical practice [30]. The World Health Organization, through its Global Patient Safety Action Plan 2021–2030, identifies leadership as a core strategic element essential for building a culture of safety, ensuring workforce competence, and embedding safety within healthcare systems and institutional poli- cies. Effective leadership provides the strategic direction, structural support, and motivational climate necessary for nurses to consistently apply patient safety competen- cies, especially in dynamic and high-risk clinical environ- ments [31–33].

Empirical studies consistently affirm the mediat- ing role of leadership in strengthening the relationship between nurses’ patient safety competencies and patient safety outcomes. Leadership is not merely an adjunct to clinical expertise but a critical enabler of its effective

implementation [34]. For instance, Etchegaray et al. [35] revealed that many nurses perceived leadership as a bar- rier when managers failed to act on safety concerns or created punitive environments, leading to disengage- ment and underreporting. Similarly, Hamdan et al. [36] demonstrated that transformational leadership is signifi- cantly associated with a positive patient safety culture and enhanced nursing patient safety practices, ultimately contributing to improved patient safety outcomes. Huang et al. [34] further established that leadership plays a criti- cal role in shaping frontline nurses’ attitudes and foster- ing institutional cultures that prioritize patient safety. By promoting open communication, accountability, and psy- chological safety, leadership creates an environment in which nurses are empowered to apply their patient safety competencies [37]. Conversely, poor leadership charac- terized by authoritarianism, inaccessibility, or disregard for safety concerns has been associated with nurse dis- engagement, which undermines the application of safety competencies and contributes to adverse patient safety outcomes [35, 38].

While the importance of patient safety competencies is well established, a critical gap remains in understanding how these competencies concretely translate into insti- tutional performance metrics, such as key performance indicators (KPIs). Much of the existing literature [10, 16–18, 39] has examined either individual nurses’ patient safety competencies or organizational outcomes in iso- lation, with limited integration of these domains into a unified evaluative framework. Moreover, although lead- ership is widely acknowledged as a key driver of patient safety culture, its mediating role in the relationship between nurses’ patient safety competency and KPIs for patient safety outcomes remains insufficiently explored particularly in low-resource settings such as Ghana. This study addresses a significant conceptual and empirical gap by investigating how nurses’ patient safety competen- cies influence KPI performance through the mediating effect of leadership. In doing so, it offers a more holistic understanding of the mechanisms through which safety competencies translate into measurable improvements in patient outcomes. The findings are expected to inform targeted interventions aimed at strengthening safety culture and institutional performance, offering practi- cal guidance for policymakers and hospital administra- tors seeking evidence-based strategies to improve patient safety in clinical environments.

Study objectives This study was conducted to achieve the following spe- cific objectives:

1. To assess the level of patient safety competency among nurses at Tamale Teaching Hospital.

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2. To investigate the relationship between patient safety competency and sociodemographic characteristics among nurses at Tamale Teaching Hospital.

3. To measure the key performance indicators (KPIs) for patient safety outcomes at Tamale Teaching Hospital.

4. To examine the relationship between specific dimensions of nurses’ patient safety competency and KPIs for patient safety outcomes at Tamale Teaching Hospital.

5. To explore the barriers to the development and application of patient safety competency among nurses at Tamale Teaching Hospital.

Research hypotheses The following hypotheses were formulated for this study:

• H₁: Nurses’ patient safety competency has a significant positive effect on key performance indicators (KPIs) for patient safety outcomes.

• H₂: Nurses’ patient safety competency has a significant positive effect on leadership role in patient safety.

• H₃: Leadership role in patient safety has a significant positive effect on key performance indicators (KPIs) for patient safety outcomes.

• H₄ (Mediation Hypothesis): Leadership role in patient safety mediates the relationship between nurses’ patient safety competency and KPIs for patient safety outcomes.

Methods Study design A multi-method research design was adopted for this study. In contrast to mixed methods, where integration occurs between quantitative and qualitative components, a multi-method design involves conducting two or more methods, each complete in itself, to address research questions and/or hypotheses, a topic, or a program [40]. The quantitative component assessed the levels of patient safety competencies, influencing factors, and perfor- mance outcomes, while the qualitative component inves- tigated the barriers to the development and application of patient safety competencies.

Study setting and population This study was conducted at Tamale Teaching Hospital (TTH), a major tertiary healthcare institution located in Tamale, the capital city of Ghana’s Northern Region. TTH provides a wide range of specialized medical ser- vices and functions as the primary referral center for the northern sector of the country. It also serves as a key training site for health professionals, including nurses, medical students, and allied health personnel. The target

population consisted of nurses working at TTH dur- ing the data collection period (N = 1,072). To ensure that the study captured relevant and reliable insights into patient safety competencies, only nurses who were fully employed, actively working during the study period, and willing to provide informed consent were included. Stu- dent nurses and graduate nurses undergoing national service were excluded, as the study focused specifically on the competencies and practices of qualified, experi- enced nursing personnel.

Sample size determination and sampling procedure Quantitative component The sample size for the quantitative phase was deter- mined using Yamane’s [41] sample size formula: n = N / [1 + N(e²)], where n represents the required sample size, N is the population size (1,072), and e is the margin of error (0.05). A margin of error of 0.05 was selected to achieve an optimal balance between statistical precision and practical feasibility, given the nursing population at the study site [42]. Based on this calculation, the required sample size was 291 participants. To ensure represen- tativeness, a proportionate stratified random sampling technique was employed. The total nursing population was stratified according to their respective wards or departments. Participants were then randomly selected from each stratum in proportion to the size of the ward to ensure fair representation across clinical areas. Each eligible nurse was assigned a unique identifier, and ran- dom selection was conducted using the SAS JMP Sta- tistical software randomization function. This sampling strategy enhanced the generalizability of findings by capturing the diversity of nursing roles and experiences within the hospital.

Qualitative component Ten (10) nurses were recruited through purposive sam- pling. The sample size was determined using the princi- ple of data saturation, which was reached when no new themes emerged following the 10th interview. Although the number of participants was relatively small, the data collected provided rich contextual insights into nurses’ understanding and experiences of patient safety compe- tency. Notably, only a few participants were able to clearly articulate the concept of patient safety competency and identify specific barriers to its development and appli- cation. To enhance the credibility and completeness of the findings, three (3) additional interviews were con- ducted to ensure both code and meaning saturation [43, 44]. Code saturation was achieved when no new codes or categories were identified, suggesting comprehensive coverage of the core concepts. Meaning saturation was confirmed when additional interviews failed to produce

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new insights, depth, or variations in participants’ inter- pretations of previously identified themes [45, 46].

Data collection tools Quantitative component A close-ended structured questionnaire served as the pri- mary tool for collecting the quantitative data. The ques- tionnaire was divided into four sections: A, B, C, and D. Section A focused on gathering sociodemographic infor- mation through five multiple-choice questions on par- ticipants’ age, gender, educational qualifications, years of experience in bedside nursing, rank, and prior expo- sure to a quality and safety program. Section B incorpo- rated the 58-item Thai-Patient Safety Competency Scale (PSCS), developed by Yaprom et al. [47], which assessed seven domains of patient safety competency: ethical and legal aspects of patient safety; nursing practices to prevent or minimize harm from healthcare errors; pro- fessional characteristics regarding patient safety; risk management and quality improvement; academic and research skills regarding patient safety; effective com- munication in the healthcare team; and technology and informatics for patient safety. Responses for this section were recorded on a 5-point Likert scale ranging from 0 (“Absence or Inability to Practice the Claimed Feature”) to 4 (“Strong Belief in One’s Ability to Practice or Pos- sess the Indicated Characteristic”). Section C comprised a 23-item self-developed questionnaire adapted from the 2015 Australian Council of Healthcare Standards (ACHS) Key Performance Indicators for Patient Safety Outcomes (KPIs PSO) [22], assessing five key indicators from the nurses’ perspective: medication safety, infection control, pressure ulcer prevention, fall prevention, and blood management. Responses in this section were recorded on a 5-point Likert scale ranging from 1 (“Strongly Dis- agree”) to 5 (“Strongly Agree”). Lastly, Section D evalu- ated the leadership role in patient safety from the nurses’ perspective using a 7-item self-developed questionnaire, with participants rating their agreement with each state- ment on a 5-point Likert scale from 1 (“Strongly Dis- agree”) to 5 (“Strongly Agree”).

To establish the validity and reliability of the question- naire, confirmatory factor analysis (CFA) was conducted. This analysis was used to assess the construct validity of the measurement scales by evaluating factor loadings and confirming unidimensionality. Items that demon- strated cross-loadings on multiple factors were excluded to improve model fit and ensure conceptual clarity. The final CFA model indicated a good fit across all scales, consistent with established psychometric standards [48]. All item factor loadings ranged from 0.63 to 0.97, which are within the acceptable range for scale validation [49]. Additionally, composite reliability (CR) values for each scale exceeded the recommended threshold of 0.70,

confirming adequate internal consistency. The average variance extracted (AVE) values also surpassed the 0.50 benchmark, indicating good convergent validity [50] (Supplementary file 1).

Qualitative component A semi-structured interview guide was developed by the researchers using clear and simple English, comprising open-ended questions designed to explore barriers to the development and application of patient safety compe- tencies among nurses. To enhance the clarity, relevance, and appropriateness of the questions, a pretest was con- ducted with ten (10) nurses from a different healthcare facility. Based on the feedback, ambiguous items were revised and irrelevant questions were removed. This pre- testing process ensured that the final interview guide was well-structured, contextually appropriate, and capable of eliciting rich, meaningful responses from participants (Supplementary file 2).

Data collection procedure Prior to data collection, a copy of the study proposal was submitted to the hospital administration to obtain insti- tutional approval to conduct the research at the facil- ity. Upon receiving approval, participants were selected based on predefined eligibility criteria. Eligible nurses were approached individually and provided with detailed information about the study’s purpose, procedures, and ethical considerations. Written informed consent was obtained from all participants prior to their involve- ment. For the quantitative component, each participant was given a self-administered questionnaire to complete independently. To ensure effective tracking and control, a questionnaire register was maintained, documenting the distribution and return of all questionnaires.

In parallel, but independently, the qualitative compo- nent was conducted to explore aspects of the research not adequately captured by the quantitative data. This phase focused specifically on identifying perceived barri- ers to the development and application of patient safety competencies among nurses. Ten (10) individual inter- views were carried out using a semi-structured inter- view guide. Participants for this phase were purposively selected based on their clinical experience and their capacity to provide rich, in-depth perspectives. The interviews were conducted in private settings within the hospital to ensure confidentiality and were guided by open-ended questions aimed at eliciting context-specific insights. The entire data collection process spanned a two-month period.

Data management and analysis Quantitative data were analyzed using SPSS Statistics version 27 and AMOS version 24. Descriptive statistics

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were computed to summarize sociodemographic char- acteristics and mean scores across variables. Inferential analyses included one-way analysis of variance (ANOVA) and independent two-sample t-tests to explore associa- tions between nurses’ patient safety competency (PSC) and sociodemographic characteristics. Pearson correla- tion analysis was conducted to examine the relationships between specific domains of PSC and key performance indicators (KPIs) for patient safety outcomes. Moreover, a simple mediation analysis was performed using 5,000 bootstrapped samples to test the mediating effect of lead- ership role regarding patient safety on the relationship between patient safety competency and key performance indicators (KPIs) for patient safety outcomes [50, 51]. Statistical significance was determined at p < 0.05.

Qualitative data were analyzed using QDA Miner Lite (version 6), following Braun and Clarke’s [52] six-phase thematic analysis framework. All interview record- ings were transcribed verbatim and read repeatedly to enhance familiarity with the data. An inductive coding approach was used to generate initial codes that captured significant features of the data, particularly regarding barriers to the development and application of patient safety competencies. Codes were then organized into potential themes based on patterns across transcripts. Themes were refined iteratively to ensure internal coher- ence and external distinction. Representative quotations

were selected to substantiate each theme, and findings were interpreted in light of existing literature to enhance contextual relevance and credibility.

Ethical consideration Ethical approval for the study was obtained from the Tamale Teaching Hospital Department of Research and Development (Approval number: TTH/R&D/SR/24/016; Date: February 13, 2024). Prior to participation, all par- ticipants were fully informed about the study’s objec- tives, procedures, and their rights, including the right to decline or withdraw at any stage without any conse- quences. Written informed consent was obtained from each participant. Confidentiality and privacy were strictly maintained throughout the research process. All data were anonymized, and personal identifiers were removed to protect participant identity. The study adhered to established ethical standards for research involving human subjects, ensuring that participants were treated with respect, dignity, and transparency. Ethical principles of voluntary participation, informed consent, confiden- tiality, and data protection were upheld throughout all stages of the study.

Results Sociodemographic characteristics Out of 291 administered questionnaires, all were success- fully completed (response rate: 100%). Most participants were aged 20–29 years (59.5%) and female (55.3%). The majority held a Diploma in Nursing (71.5%) and had less than five years of bedside experience (75.3%). About one- third were Staff Nurses (34.4%), and 44.7% had received prior training in quality and safety (Table 1).

Objective 1: level of patient safety competency The mean patient safety competency score was 2.95 (SD = 0.64), with 61.2% of nurses demonstrating a high competency level. The highest scores were in profes- sional characteristics regarding patient safety (M = 3.04, SD = 0.74), ethical and legal aspects of patient safety (M = 3.01, SD = 0.76), and nursing practices to prevent or minimize harm from healthcare errors (M = 2.98, SD = 0.73). Lower scores were noted in academic and research skills regarding patient safety (M = 2.83, SD = 0.77), technology and informatics for patient safety (M = 2.87, SD = 0.84), and risk management and quality improvement (M = 2.88, SD = 0.76) (Table 2).

Objective 2: relationship between patient safety competency and sociodemographic characteristics Patient safety competency (PSC) was significantly asso- ciated with age, education, work experience, professional rank, and prior exposure to quality and safety pro- grams (p < 0.05). Nurses aged 30–39 scored higher PSC

Table 1 Sociodemographic characteristics of nurses Variable Frequency Percentage Age in years ≤ 19 11 3.8 20–29 173 59.5 30–39 98 33.7 ≥ 40 9 3.1 Gender Male 130 44.7 Female 161 55.3 Education Diploma 208 71.5 Bachelor’s degree 83 28.5 Years of experience in bedside nursing < 5 219 75.3 5–10 61 21.0 > 10 11 3.8 Rank Staff nurse 100 34.4 Senior staff nurse 68 23.4 Nursing officer 76 26.1 Senior nursing officer 33 11.3 Principal nursing officer 14 4.8 Prior exposure to a quality and safety program Yes 130 44.7 No 161 55.3

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(M = 3.15, SD = 0.51) than those aged 20–29 (M = 2.80, SD = 0.68, p < 0.001). Bachelor’s degree holders scored higher (M = 3.12, SD = 0.53) than diploma holders (M = 2.88, SD = 0.67, p = 0.003). Higher PSC scores were also observed among nurses with 5–10 years (M = 3.13, SD = 0.54) and over 10 years (M = 3.35, SD = 0.48) of expe- rience compared to those with under 5 years (M = 2.88, SD = 0.66, p < 0.001). Principal nursing officers reported higher PSC scores (M = 3.40, SD = 0.38) than staff nurses (M = 2.81, SD = 0.71, p = 0.011). Nurses with prior expo- sure to quality and safety programs had significantly higher PSC (M = 3.11, SD = 0.62) than those without such

exposure (M = 2.82, SD = 0.63, p < 0.001). No significant difference was found by gender (Table 3).

Objective 3: key performance indicators (KPIs) for patient safety outcomes Performance varied across patient safety KPIs. Medica- tion safety scored highest (M = 3.82, SD = 0.86), followed by blood management (M = 3.65, SD = 0.84), pressure ulcer prevention (M = 3.58, SD = 0.81), and infection con- trol (M = 3.57, SD = 0.82). Fall prevention recorded the lowest mean score (M = 3.55, SD = 0.82) (Table 4).

Objective 4: relationship between specific dimensions of nurses’ patient safety competency and KPIs for patient safety outcomes Pearson correlation analysis showed significant positive relationships between all seven patient safety compe- tency domains and the five KPIs (p < 0.001). The strongest association was between nursing practices to prevent or minimize harm from healthcare errors and medication safety (r = 0.675), followed closely by professional charac- teristics regarding patient safety (r = 0.668) and effective communication in healthcare team (r = 0.667). Effective communication in healthcare team also showed the high- est correlation with blood management (r = 0.605) and infection control (r = 0.587). Academic and research skills regarding patient safety were most strongly linked with fall prevention (r = 0.572) and pressure ulcer prevention (r = 0.557). Technology and informatics, though the low- est-scoring competency, was still moderately correlated with all KPIs, particularly medication safety (r = 0.601) and fall prevention (r = 0.525) (Table 5).

Objective 5: barriers to the development and application of patient safety competency In the qualitative phase, semi-structured interviews were conducted with 10 purposively selected nurses (mean age = 28 years, SD = 5.85), including seven males and three females – all bachelor’s degree holders with over five years of clinical experience, mostly serving as nursing officers. Thematic analysis revealed five key barriers:

1. Inadequate integration in nursing education

Table 2 Patient safety competency of nurses Variable Mean Standard

Deviation Ethical and legal aspects of patient safety 3.01 0.76 Nursing practices to prevent or minimize harm from healthcare errors

2.98 0.73

Professional characteristics regarding patient safety

3.04 0.74

Risk management and quality improvement 2.88 0.76 Academic and research skills regarding patient safety

2.83 0.77

Effective communication in healthcare team 2.97 0.74 Technology and informatics for patient safety 2.87 0.84

Table 3 Relationship between patient safety competency and sociodemographic characteristics among nurses Variable Total Mean ± SD P value Age in years < 0.001* ≤ 19 11 3.16 ± 0.52 20–29 173 2.80 ± 0.68 30–39 98 3.15 ± 0.51 ≥ 40 9 3.34 ± 0.53 Gender 0.734 Male 130 2.93 ± 0.62 Female 161 2.96 ± 0.66 Level of education 0.003* Diploma in nursing 208 2.88 ± 0.67 Bachelor of Science 83 3.12 ± 0.53 Years of experience in bedside nursing 0.002* < 5 219 2.88 ± 0.66 5–10 11 3.13 ± 0.54 > 10 61 3.35 ± 0.48 Rank 0.007* Staff nurse 100 2.81 ± 0.71 Senior staff nurse 68 2.91 ± 0.61 Nursing officer 76 3.02 ± 0.53 Senior nursing officer 33 3.07 ± 0.72 Principal nursing officer 14 3.40 ± 0.38 Prior exposure to a quality and safety program

< 0.001*

Yes 130 3.11 ± 0.62 No 161 2.82 ± 0.63 * Statistically significant at p < 0.05

Table 4 Key performance indicators (KPIs) for patient safety outcomes Variable Mean Standard

Deviation Medication safety 3.82 0.86 Infection control 3.57 0.82 Pressure ulcer prevention 3.58 0.81 Fall prevention 3.55 0.82 Blood management 3.65 0.84

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According to all nurses, patient safety is not explicitly integrated into the nursing curriculum. Rather than being taught as a standalone subject, safety-related content is minimally and inconsistently embedded within broader nursing courses. This lack of structured education results in limited exposure to essential safety principles and con- tributes to low competency levels in clinical practice.

“…I can’t really pinpoint a course that is specifically focused on patient safety. You might encounter one or two topics in other courses, but there isn’t a dedicated course that is deliberately based on patient safety” (Male, Partici- pant 3).

2. Lack of patient safety training

Many nurses expressed concern about the absence of continuous in-service training focused on patient safety. Training sessions often prioritized medical conditions and nursing management, with little to no attention given to patient safety. Furthermore, frontline staff, those most

engaged in direct patient care were frequently excluded from available workshops.

“I am yet to see a topic being discussed or taught on patient safety… it’s more about medical conditions and nursing management” (Male, Participant 4).

“When workshops are organized… they choose other people to go; people who are not providing direct care to the patients” (Female, Participant 8).

3. Lack of standardized patient safety protocols

Nurses reported that the absence of clear, written patient safety protocols pose a major challenge. In the absence of standardized procedures, nurses often rely on informal practices or personal judgment, which undermine con- sistent and effective responses to safety incidents.

“…If something like that [a patient safety protocol] is there, you will be able to follow… but something like that is not there.” (Female, Participant 9).

4. Limited opportunity for career advancement

Several nurses highlighted institutional barriers that restricted access to further education and professional development opportunities, such as study leave for advanced training. These limitations hinder their ability to continuously build clinical knowledge and improve competencies essential to patient safety.

“…When you come to the facility, the protocol says that you have to work for some number of years before you can go to school. You have worked over six to seven years, and you still don’t have study leave” (Male, Participant 3).

5. Limited scope of practice

Some nurses described how rigid task assignments restrict their ability to engage in broader patient care responsibilities. They are often assigned to a single task per shift, such as wound dressing, medication adminis- tration etc., with little opportunity to practice more com- prehensive clinical skills. This limited scope of practice impedes their development and application of patient safety competencies.

“When you come to the ward, for instance, you are assigned to do certain work and leave others. Sometimes you come for a shift, and you are supposed to just dress wounds and go home. Also, some are assigned to take care of the drug administration aspect…. So, if you are not allowed to practice on your own, how will you develop patient safety competency” (male, participant 1).

Hypotheses testing The results supported all four proposed hypotheses. Hypothesis 1 (H₁) was confirmed, indicating that nurses’

Table 5 Intercorrelation between specific dimensions of nurses’ patient safety competency and the key performance indicators (KPIs) for patient safety outcome Patient safety competency Dimensions

Medi- cation safety

Infec- tion control

Pressure ulcer prevention

Fall preven- tion

Blood man- age- ment

Ethical and legal aspects of patient safety

0.604*** 0.493*** 0.483*** 0.511*** 0.510***

Nursing practic- es to prevent or minimize harm from healthcare errors

0.675*** 0.522*** 0.501*** 0.538*** 0.564***

Professional characteristics regarding patient safety

0.668*** 0.535*** 0.517*** 0.521*** 0.550***

Risk man- agement and quality Improvement

0.600*** 0.452*** 0.524*** 0.565*** 0.514***

Academic and research skills regarding patient safety

0.590*** 0.526*** 0.557*** 0.572*** 0.512***

Effective com- munication in healthcare team

0.667*** 0.587*** 0.536*** 0.570*** 0.605***

Technology and informat- ics for patient safety

0.601*** 0.476*** 0.502*** 0.525*** 0.509***

* p < 0.050, ** p < 0.010, *** p < 0.001 (Statistically significant)

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patient safety competency significantly predicted KPIs for patient safety outcomes (β = 0.846, p < 0.001). Hypoth- esis 2 (H₂) was also supported, with patient safety compe- tency having a significant positive effect on the leadership role in patient safety (β = 0.540, p < 0.001). Hypothesis 3 (H₃) was validated, as the leadership role significantly influenced KPI outcomes (β = 0.401, p < 0.001). Hypoth- esis 4 (H₄) proposed that the leadership role mediates the relationship between nurses’ patient safety compe- tency and KPIs; this was confirmed by mediation analy- sis showing a significant direct effect (β = 0.628, p < 0.001) and a significant indirect effect through leadership (β = 0.218, p < 0.001), indicating partial mediation (Fig. 1).

Discussion This study examined the impact of nurses’ patient safety competency on key performance indicators (KPIs) for patient safety outcomes at Tamale Teaching Hospital. The results revealed that most participating nurses exhib- ited a high level of patient safety competency. This aligns with studies conducted in Indonesia and Iran, where high competency levels were also reported among nurses [53]. These similarities suggest that, given appropriate institu- tional support, nurses can achieve high safety standards across different health systems. However, the findings diverge from the study by Yan et al. [17], who reported only moderate competency levels. Such differences may stem from contextual factors such as nursing education quality, safety culture, and available healthcare resources.

In terms of specific KPIs, medication safety recorded the highest mean score, followed by blood management, indicating strong performance in these critical domains. This is consistent with findings by Feliciano et al. [22], who also identified these two domains as top-performing areas. The high performance reflects nurses’ proactive

roles in minimizing medication errors and ensuring proper handling of blood products – practices known to reduce adverse events, patient harm, and healthcare costs [54]. Conversely, the study revealed average perfor- mance in domains like infection control, pressure ulcer prevention, and fall prevention. These gaps may reflect inadequate training, insufficient resources, or limited prioritization. Addressing them requires targeted inter- ventions such as in-service training, the implementation of evidence-based protocols, and routine performance monitoring [21]. Improving these domains is essential to ensuring a holistic and equitable approach to patient safety.

The study supported all four proposed hypotheses, reinforcing the central role of both individual com- petence and institutional leadership in patient safety. Hypothesis 1 (H₁) confirmed that nurses’ patient safety competency significantly and positively predicts the KPIs for patient safety outcomes. This finding underscores the critical role of individual clinical competence in achiev- ing institutional safety goals. It suggests that nurses who possess strong safety competencies are more likely to contribute to improved patient outcomes. Similar con- clusions have been drawn in previous studies by Zaitoun et al. [9] and Kakemam et al. [10], reinforcing the idea that safety competency is foundational to safe, high-qual- ity care. Hypothesis 2 (H₂) established a positive relation- ship between nurses’ safety competencies and leadership role in safety. This result implies that enhancing nurses’ competencies not only improves their direct care deliv- ery but also empowers them to engage with and influence institutional leadership processes. Competent nurses are more likely to identify safety concerns, advocate for sys- temic improvements, and actively participate in foster- ing a culture of safety. Their increased engagement may,

Fig. 1 The mediating effect of leadership role in patient safety on the relationship between nurses’ patient safety competency and key performance indicators (KPIs) for patient safety outcomes

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in turn, reinforce and strengthen leadership responsive- ness and accountability structures [9]. Hypothesis 3 (H₃), which proposed that leadership has a significant positive impact on KPIs, was similarly supported. This finding aligns with extensive literature underscoring leadership as a key driver of patient safety outcomes [21, 55, 56]. Effective leadership influences team behavior, morale, and protocol adherence – factors that directly shape institutional safety outcomes. Hypothesis 4 (H₄) fur- ther confirmed that leadership mediates the relationship between nurses’ safety competencies and KPIs for patient safety outcomes. The partial mediation effect indicates that while individual competency directly influences out- comes, a significant portion of its impact is channeled through leadership. This highlights the synergistic rela- tionship between frontline competence and leadership, consistent with findings by Murray and Cope [57], who argued that strong leadership creates the environment necessary for competencies to be effectively applied.

In addition, the qualitative findings revealed several systemic and institutional barriers to the development and application of patient safety competencies. A key issue was the limited integration of patient safety into nursing curricula. Many nurses reported insufficient for- mal education on safety principles, consistent with lit- erature that describes patient safety as often being only implicitly included in nursing training [58, 59]. Conse- quently, new nurses may lack essential competencies when entering practice. Limited opportunities for profes- sional development further exacerbate this gap. Also, in this study, nurses described inequitable access to study leave or training programs, hindering ongoing skill acqui- sition. This echoes findings from Zaitoun et al. [9], who observed higher safety competency levels among nurses who had undergone safety training.

The absence of standardized safety protocols emerged as another major barrier. Without clear guidelines, nurses often rely on personal judgment or informal routines, increasing the risk of inconsistent practices. This sup- ports recommendations by the Institute of Medicine [60], which advocates for standardization to reduce variability and human error. Moreover, nurses reported a restricted scope of practice characterized by limited autonomy, rigid task assignments, and top-down decision-making. This stifles critical thinking and proactive risk manage- ment. Studies by Oshodi et al. [61] and Faridi et al. [62] also emphasize that empowering nurses through role clarity and shared decision-making improves both job satisfaction and safety outcomes.

Moreover, sociodemographic factors were found to significantly influence patient safety competency. Age, in particular, showed a strong association. This is consistent with studies by Linda [63], Shin and Jang [64], and Bahr et al. [16], which found significant associations between

age and patient safety competency. Further, nurses aged 30–39 years exhibited significantly higher competency than those aged 20–29. This suggests that increasing age may enhance patient safety competency. However, this finding contrasts with that of Tasbihi et al. [18], who reported a negative association between age and patient safety competency (r = -0.095, p = 0.04). Such inconsis- tencies may reflect differences in training quality, institu- tional support, or work environments.

Educational level was also found to significantly influ- ence patient safety competency. Nurses with higher aca- demic qualifications demonstrated greater competency, reinforcing findings from Bahr et al. [16] and Shin and Jang [64]. This underscores the importance of promot- ing academic advancement and continuous professional learning as strategic approaches to strengthening safety competencies in clinical practice. Similarly, years of clinical experience was positively associated with patient safety competency. Nurses with 5–10 years and more than 10 years of bedside experience had higher com- petency levels than those with less than five years. This observation is consistent with prior studies by Shin and Jang [64], Bahr et al. [16], Kalsoom et al. [65], and Yan et al. [17] and suggests that cumulative clinical expo- sure contributes to skill refinement and safer practice. However, Tasbihi et al. [18] reported no significant rela- tionship between work experience and patient safety competency, which may be due to contextual factors such as limited access to mentorship or structured training in their study setting.

Furthermore, the study also demonstrated that profes- sional rank was significantly associated with patient safety competency. Nurses in higher ranks exhibited greater competency levels, corroborating findings from Shin and Jang [64] and Yan et al. [17]. This may be because higher- ranked nurses often assume greater clinical and super- visory responsibilities, have better access to leadership opportunities, and participate more frequently in profes- sional development activities, all of which enhance their competency in patient safety. Moreover, prior exposure to quality and safety programs was significantly related to higher patient safety competency. This is consistent with Yan et al. [17] suggesting that structured exposure to such programs can enhance nurses’ knowledge and confidence in implementing safety protocols. However, other studies did not find a significant association [16, 39], indicating that the effectiveness of these programs likely depends on their content, delivery method, and integration into rou- tine clinical practice.

Conclusion This study revealed that the majority of nurses at Tamale Teaching Hospital demonstrated high levels of patient safety competency. Among the seven competency

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domains, the highest scores were observed in profes- sional characteristics, ethical and legal aspects, and nursing practices to prevent or minimize harm from healthcare errors. Conversely, the lowest scores were recorded in academic and research skills, technology and informatics for patient safety, and risk management and quality improvement indicating critical areas in need of targeted capacity building. Patient safety competency was found to be significantly associated with age, edu- cational level, years of bedside experience, professional rank, and prior exposure to quality and safety programs. Moreover, all seven competency domains showed sig- nificant and positive correlations with the five key per- formance indicators (KPIs) for patient safety outcomes (namely medication safety, blood management, fall pre- vention, pressure ulcer prevention, and infection control) underscoring the essential role of individual competence in improving institutional safety performance. Qualita- tive findings further highlighted key barriers to the devel- opment and application of patient safety competencies, including the inadequate integration of patient safety into nursing education, lack of structured training, absence of standardized protocols, limited opportunities for profes- sional advancement, and a limited scope of nursing prac- tice. Crucially, the study confirmed that nurses’ patient safety competency significantly predicts patient safety outcomes, both directly and indirectly through the medi- ating role of leadership. This underscores the importance of cultivating not only clinical competency among nurses but also supportive leadership structures that amplify their impact on patient safety.

Recommendations Based on the findings, several recommendations are proposed for policymakers, healthcare administrators, and nurse educators to enhance patient safety compe- tency (PSC) among nurses. Given that the majority of nurses demonstrated high PSC particularly in profes- sional characteristics, ethical and legal aspects, and nursing practices to prevent or minimize harm, efforts should be made to sustain and expand these strengths. However, the lowest scores in academic and research skills, technology and informatics, and risk manage- ment and quality improvement highlight critical gaps that require targeted interventions. Nursing curricula should be revised to incorporate a dedicated course on patient safety, with structured modules addressing these weaker domains. For instance, academic and research competencies can be enhanced through evidence-based practice training, research appraisal workshops, and stu- dent-led safety audits. Technology and informatics skills can be improved using simulation-based training on electronic health records, clinical decision support sys- tems, and digital incident reporting tools. Likewise, risk

management and quality improvement can be strength- ened by involving nurses in hospital safety committees, root cause analyses, and continuous quality improve- ment (CQI) initiatives. Administrators should institu- tionalize regular, inclusive in-service training and ensure that frontline nurses are not excluded from workshops and capacity-building programs. Given that all PSC domains were positively associated with key perfor- mance indicators (KPIs) such as medication safety, blood management, and infection control, it is critical to link competency development efforts to measurable perfor- mance outcomes. Furthermore, as institutional leader- ship was shown to mediate the relationship between PSC and KPIs, healthcare leaders must be empowered, supported, and held accountable for embedding a cul- ture of safety across all organizational levels. Policymak- ers should also address systemic barriers such as the absence of standardized safety protocols, restrictive edu- cation policies, and limited autonomy in nursing prac- tice. Finally, further research is recommended to evaluate the long-term effects of targeted interventions on PSC, determine the most effective leadership styles for advanc- ing patient safety, and explore how contextual variables including resource constraints and organizational climate influence the development and application of patient safety competencies.

Limitations Although this study offers valuable insights into nurses’ patient safety competency and its influence on key per- formance indicators (KPIs) for patient safety outcomes, several limitations should be acknowledged. First, the sample size of 291 nurses, while adequate for analysis, may not fully represent the entire nursing population at the hospital, potentially limiting the generalizability of the findings. Additionally, the use of self-reported data introduces the risk of response bias, as participants may have either overestimated or underestimated their com- petencies due to social desirability or recall issues. The study’s cross-sectional design also limits the ability to infer causal relationships between patient safety com- petencies and KPIs, making it difficult to determine the directionality or temporal sequence of observed asso- ciations. Furthermore, the study focused on five primary KPIs, which, while important, may not capture the full spectrum of patient safety outcomes. Future research should consider using longitudinal designs, incorporat- ing objective measures of competency, and exploring a broader range of safety indicators to provide a more com- prehensive understanding of how patient safety compe- tencies translate into improved outcomes.

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Supplementary Information The online version contains supplementary material available at h t t p s : / / d o i . o r g / 1 0 . 1 1 8 6 / s 1 2 9 1 3 - 0 2 5 - 1 3 3 8 4 - 3.

Supplementary Material 1

Supplementary Material 2

Acknowledgements The authors express their gratitude to all the nurses who volunteered for this study.

Author contributions M.M.I., F.A., M.S.S., D.N.A., R.T.A., I.S.M., A.W., and A.A. contributed to the research design; supported the development of the proposed paper, including writing background, methodology, and editing/proofreading. M.M.I., F.A., M.S.S., D.N.A., R.T.A., and I.S.M. collected the data. M.M.I conducted formal analysis and visualization. A.A. and A.W. validated the results. All authors read and approved the final version of the manuscript.

Funding This study was fully-funded by the authors.

Data availability The data used and/or analyzed in this research are available from the corresponding author upon reasonable request, provided that participants’ confidentiality is maintained.

Declarations

Ethics approval and consent to participate Ethical approval was granted by the Department of Research and Development of Tamale Teaching Hospital (TTH/R&D/SR/24/016). Informed consent was obtained from all research participants in this study. This study was conducted in compliance with the principles of the Helsinki Declaration.

Consent for publication Not applicable.

Competing interests The authors declare no competing interests.

Author details 1Department of Internal Medicine (M3), Tamale Teaching Hospital, Tamale, Ghana 2Department of Nursing, Nurses’ and Midwives’ Training College, Tamale, Ghana 3Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana 4Outpatient Department, Cheyohi CHPS, Kumbungu District, Ghana 5College of Nursing, University of Kentucky, Lexington, USA

Received: 4 March 2025 / Accepted: 14 August 2025

References 1. Ayyad A, Baker NA, Oweidat I, Al-Mugheed K, Alsenany SA, Abdelaliem SMF.

Knowledge, attitudes, and practices toward patient safety among nurses in health centers. BMC Nurs. 2024;23:171.

2. Biresaw H, Asfaw N, Zewdu F. Knowledge and attitude of nurses towards patient safety and its associated factors. Int J Afr Nurs Sci. 2020;13:100229.

3. Mohammed T, Woldearegay E, Kedir S, Ahmed K, Getnet M, Gudina EK. Patient safety knowledge, attitude and practice among undergradu- ate health science students in South West Ethiopia. Front Public Health. 2023;10:1064896.

4. Wake AD, Tuji TS, Gonfa BK, Waldekidan ET, Beshaw ED, Mohamed MA, et al. Knowledge, attitude, practice and associated factors towards patient safety

among nurses working at Asella referral and teaching hospital, ethiopia: a cross-sectional study. PLoS One. 2021;16:e0254122.

5. Akram S, Bibi F, Parveen N. Nurses’ knowledge and attitudes regarding patient safety and factors associated to it. Biol Clin Sci Res J. 2024;2024:952–952.

6. Rahmani P, Molaei Tavani F, Sheikhalipour Z, Behshid M, Khodayari MT, Zadi akhuleh O. The relationship between attitude of nurses toward the patient safety and missed nursing care: a predictive study. J Healthc Qual Res. 2022;37:138–46.

7. Han JH, Roh YS. Teamwork, psychological safety, and patient safety compe- tency among emergency nurses. Int Emerg Nurs. 2020;51:100892.

8. Yin L-P, Wang F, Li Q, Feng X-N, Li Y-L, Li L-L. A Cross-Sectional descriptive study on the attitudes towards patient safety and influencing factors of nurses in infectious diseases wards. J Multidiscip Healthc. 2023;16:731–40.

9. Zaitoun RA, Said NB, de Tantillo L. Clinical nurse competence and its effect on patient safety culture: a systematic review. BMC Nurs. 2023;22:173.

10. Kakemam E, Albelbeisi AH, Rouzbahani M, Gharakhani M, Zahedi H, Taheri R. Nurses’ perceptions of patient safety competency: a cross-sectional study of relationships with occurrence and reporting of adverse events. PLoS ONE. 2024;19:e0297185.

11. Mortensen M, Naustdal KI, Uibu E, Mägi L, Kangasniemi M, Põlluste K, et al. Instruments for measuring patient safety competencies in nursing: a scoping review. BMJ Open Qual. 2022;11(2):e001751.

12. Park J-H, Lee N-J, Lee H, Park G. Determinants of clinical nurses’ patient safety competence: a systematic review protocol. BMJ Open. 2024;14:e080038.

13. Torkaman M, Momennasab M, Yektatalab S, Eslami Shahrbabaki M. Nurses’ patient safety competency, a predictor for safe care in psychiatric wards? Perspect Psychiatr Care. 2022;58:2854–61.

14. Alidousti-Shahraki N, Farzi S, Tarrahi MJ. Patient safety competencies among senior students of health professions: an Iranian evaluation study. Open Nurs J. 2022;16:1–6.

15. Hwang J-I. What are hospital nurses’ strengths and weaknesses in patient safety competence? Findings from three Korean hospitals. Int J Qual Health Care J Int Soc Qual Health Care. 2015;27:232–8.

16. Bahr RRR, Atalla ADG, El Sayed AAI. Assessment of patient safety competen- cies among critical care nurses. Alex Sci Nurs J. 2025;27:233–44.

17. Yan L, Yao L, Li Y, Chen H. Assessment and analysis of patient safety compe- tency of Chinese nurses with associate degrees: a cross-sectional study. Nurs Open. 2021;8:395–403.

18. Tasbihi N, Moghri J, Ghavami V, Raesi R, Janghorban A, Tabatabaee SS. Patient safety competency and it associated with teamwork and psychological safety among emergency nurses in Iran. Sci Rep. 2025;15:16602.

19. Poku CA, Attafuah PYA, Anaba EA, Abor PA, Nketiah-Amponsah E, Abuosi AA. Response to patient safety incidents in healthcare settings in ghana: the role of teamwork, communication openness, and handoffs. BMC Health Serv Res. 2023;23:1072.

20. Botchwey CO-A, Boateng AA, Ahimah PO, Acquah F, Adoma PO, Kumah E, et al. Patient safety culture and satisfaction in ghana: a facility-based cross- sectional study. BMJ Open. 2024;14:e073190.

21. Bhati D, Deogade MS, Kanyal D. Improving patient outcomes through effective hospital administration: a comprehensive review. Cureus. 2023;15:e47731.

22. Feliciano AZ, Feliciano EE, Feliciano JRD, Fernandez ZS, Mejia PCG, Diamla MRL, et al. Philippine professional core competencies’ impact on nurses’ key performance indicators (KPIs) for patient safety outcomes. Int J Adv Appl Sci. 2020;7:1–5.

23. Health Information and Quality Authority. Guidance on Developing Key Per- formance Indicators and Minimum Data Sets to Monitor Healthcare Quality. 2017. h t t p s : / / w w w . h i q a . i e / s i t e s / d e f a u l t / fi l e s / 2 0 1 7 - 0 1 / K P I - G u i d a n c e - V e r s i o n 1 . 1 - 2 0 1 3 . p d f

24. Hanson A, Haddad LM. Nursing rights of medication administration. Stat- Pearls. Treasure Island. (FL): StatPearls Publishing; 2025.

25. Alshagrawi S, Alhodaithy N. Determinants of hand hygiene compliance among healthcare workers in intensive care units: a qualitative study. BMC Public Health. 2024;24:2333.

26. Li Z, Marshall AP, Lin F, Ding Y, Chaboyer W. Registered nurses’ approach to pressure injury prevention: a descriptive qualitative study. J Adv Nurs. 2022;78:2575–85.

27. Ojo EO, Thiamwong L. Effects of Nurse-Led fall prevention programs for older adults: a systematic review. Pac Rim Int J Nurs Res. 2022;26:417–31.

28. Bediako AA, Ofosu-Poku R, Druye AA. Safe blood transfusion practices among nurses in a major referral center in Ghana. Adv Hematol. 2021;2021:6739329.

Page 13 of 13Ibrahim et al. BMC Health Services Research (2025) 25:1176

29. Zhang X, Wang F, Wang Q, Liu H, Lee S-Y. The link between patient safety competence and adverse event among master of nursing students: a cross- sectional mixed-methods study. BMC Nurs. 2024;23:539.

30. Xue X, Tao J, Li Y, Zhang G, Wang S, Xu C, et al. Impact of clinical leadership on frontline nurses’ quality of care: work engagement as mediator role. BMC Health Serv Res. 2025;25:560.

31. World Health Organization. Global Patient Safety Action Plan. 2021. h t t p s : / / w w w . w h o . i n t / t e a m s / i n t e g r a t e d - h e a l t h - s e r v i c e s / p a t i e n t - s a f e t y / p o l i c y / g l o b a l - p a t i e n t - s a f e t y - a c t i o n - p l a n

32. Alsadaan N, Salameh B, Reshia FAAE, Alruwaili RF, Alruwaili M, Awad Ali SA, et al. Impact of nurse leaders behaviors on nursing staff performance: a systematic review of literature. Inq J Med Care Organ Provis Financ. 2023;60:00469580231178528.

33. Ystaas LMK, Nikitara M, Ghobrial S, Latzourakis E, Polychronis G, Constan- tinou CS. The impact of transformational leadership in the nursing work environment and patients’ outcomes: a systematic review. Nurs Rep. 2023;13:1271–90.

34. Huang C-H, Wu H-H, Lee Y-C, Li X. The critical role of leadership in patient safety culture: a mediation analysis of management influence on safety fac- tors. Risk Manag Healthc Policy. 2024;17:513–23.

35. Etchegaray JM, Ottosen MJ, Dancsak T, Thomas EJ. Barriers to speaking up about patient safety concerns. J Patient Saf. 2020;16:e230.

36. Hamdan M, Jaaffar AH, Khraisat O, Issa MR, Jarrar M. The association of trans- formational leadership on safety practices among nurses: the mediating role of patient safety culture. Risk Manag Healthc Policy. 2024;17:1687–700.

37. American Nurses Association. Safety Strategies Every Nurse Leader Needs to Know. 2023. h t t p s : / / w w w . n u r s i n g w o r l d . o r g / c o n t e n t - h u b / r e s o u r c e s / n u r s i n g - l e a d e r s h i p / s a f e t y - i n - n u r s i n g /

38. Ahmed AK, Atta MHR, El-Monshed AH, Mohamed AI. The effect of toxic lead- ership on workplace deviance: the mediating effect of emotional exhaustion, and the moderating effect of organizational cynicism. BMC Nurs. 2024;23:669.

39. Choi J, Kim K. A structural equation model for the patient safety competency of clinical nurses. PeerJ. 2024;12:e18462.

40. Martha D, Sousa VD, Mendes IAC. An overview of research designs relevant to nursing: part 3: mixed and multiple methods. Rev Lat Am Enfermagem. 2007;15:1046–9.

41. Yamane T, Statistics. An Introductory Analysis. 2nd edition. New York: Harper and Row; 1967.

42. Lohr SL, Sampling. Design and Analysis. 2nd edition. Chapman and Hall/CRC; 2019.

43. Guest G, Bunce A, Johnson L. How many interviews are enough?? An experi- ment with data saturation and variability. Field Methods. 2006;18:59–82.

44. Fusch P, Ness L. Are we there yet?? Data saturation in qualitative research. Qual Rep. 2015;20:1408–16.

45. Rahimi S, khatooni M. Saturation in qualitative research: an evolutionary concept analysis. Int J Nurs Stud Adv. 2024;6:100174.

46. Hennink MM, Kaiser BN, Marconi VC. Code saturation versus meaning satura- tion: how many interviews are enough?? Qual Health Res. 2017;27:591–608.

47. Yaprom C, Thungjaroenkul P, Abhichattibutra K, Nantsupawat A. Develop- ment and psychometric testing of the Thai-Patient safety competency scale for new graduate nurses. PRIJNR. 2023;28:181–20.

48. Kyndt E, Onghena P. The integration of work and learning: tackling the complexity with structural equation modelling. Discourses on professional learning: on the boundary between learning and working. New York, NY, US: Springer Science + Business Media; 2014. pp. 255–91.

49. Comrey AL, Lee HB. A first course in factor analysis. 2nd ed. Hillsdale, NJ, US: Lawrence Erlbaum Associates, Inc; 1992.

50. Hair JF, Sarstedt M, Hopkins L, Kuppelwieser VG. Partial least squares structural equation modeling (PLS-SEM): an emerging tool in business research. Eur Bus Rev. 2014;26:106–21.

51. Hair JF, Hult GTM, Ringle CM, Sarstedt M, Danks NP, Ray S. Evaluation of reflective measurement models. In: Hult H Jr, Ringle GTM, Sarstedt CM, Danks M, Ray NP S, editors. Partial least squares structural equation modeling (PLS- SEM) using R: a workbook. Cham: Springer International Publishing; 2021. pp. 75–90.

52. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.

53. Najafi Ghezeljeh T, Keyvanloo Shahrestanaki S, Mohammadbeigi T, Haghani S. Patient safety competency in emergency nurses in Educational-Medical cen- ters of Iran university of medical sciences, 2020. Iran J Nurs. 2022;34:60–73.

54. Kamath A, Acharya SD, Bharathi RP. Burden of death and disability due to adverse effects of medical treatment in india: an analysis using the global burden of disease 2019 study data. Heliyon. 2024;10:e24924.

55. Sfantou DF, Laliotis A, Patelarou AE, Sifaki- Pistolla D, Matalliotakis M, Patelarou E. Importance of leadership style towards quality of care measures in health- care settings: a systematic review. Healthcare. 2017;5:73.

56. Albright-Trainer B, Dayal R, Agarwala A, Pukenas E. Effective leadership and patient safety culture. Anesth Patient Saf Found. 2020;35(2):44–6.

57. Murray M, Cope V, Leadership. Patient safety depends on it! Collegian. 2021;28:604–9.

58. Alanazi WMR, Alanazi BAQ, Alanazi AI, Alanazi HHF, Alenezi NAK, Alruwaili DAM, et al. The impact of nurse education on patient safety and quality control. Saudi J Nurs Health Care. 2023;6:501–5.

59. Lee SE, Dahinten VS. Evaluating a patient safety course for undergraduate nursing students: a quasi-experimental study. Collegian. 2023;30:75–83.

60. Farokhzadian J, Dehghan Nayeri N, Borhani F. The long way ahead to achieve an effective patient safety culture: challenges perceived by nurses. BMC Health Serv Res. 2018;18:654.

61. Oshodi TO, Bruneau B, Crockett R, Kinchington F, Nayar S, West E. Registered nurses’ perceptions and experiences of autonomy: a descriptive phenom- enological study. BMC Nurs. 2019;18:51.

62. Faridi K, Mohamadi MA, Mehri S, Dadkhah B. Assessing the relationship between happiness and professional autonomy among clinical nurses: an analytical cross-sectional study. BMC Nurs. 2025;24:320.

63. Linda SE. Factors relating to patient safety competencies in D3 nursing students. J Keperawatan Komprehensif Compr Nurs J. 2024;10:63-71

64. Shin JY, Jang EH. Influence of Person-Centered perioperative nursing and patient safety competency on patient safety management activities among operating room nurses: A descriptive survey study. Korean J Adult Nurs. 2023;35:97–106.

65. Kalsoom Z, Victor G, Virtanen H, Sultana N. What really matters for patient safety: correlation of nurse competence with international patient safety goals. J Patient Saf Risk Manag. 2023;28:108–15.

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