INTERDISCIPLINARY THEORIES AND NURSING PRACTICE ISSUES

OR I G I N A L R E S E A R CH

Clinical nurses' patient safety competency, systems thinking and missed nursing care: A cross-sectional survey

Hyoung Eun Chang PhD RN, Assistant Professor1 |

Milisa Manojlovich PhD RN, Professor2

1Research Institute of Nursing Science, College

of Nursing, Jeonbuk National University,

Jeonju-si, Republic of Korea

2University of Michigan School of Nursing,

Ann Arbor, Michigan, USA

Correspondence

Hyoung Eun Chang, PhD RN, Assistant

Professor, #712 College of Nursing, Jeonbuk

National University, 567 Baekje-daero,

Deokjin-gu, Jeonju-si, Jeollabuk-do, 54896,

Republic of Korea.

Email: [email protected]

Funding information

This research was supported by Basic Science

Research Program through the National

Research Foundation of Korea (NRF) funded

by the Ministry of Education

(2019R1G1A1100520).

Abstract

Aim: The aim of this study was to examine the relationships among patient safety

competency, systems thinking and missed nursing care.

Background: Patient safety competency and systems thinking are important nurse

attributes that promote patient safety. Missed nursing care is known to negatively

impact patient safety. However, how nurses' patient safety competency and systems

thinking relate to missed nursing care is unknown.

Methods: A cross-sectional survey design was used to collect data from nurses prac-

ticing in two general hospitals in South Korea. Data were collected between 3 March

and 17 April 2020. Questionnaires were distributed to nurses providing direct care in

general and specialty units. Patient safety competency, systems thinking and missed

nursing care were measured using reliable and valid instruments. A total of 432 com-

plete sets of data were used in final analysis.

Results: Higher patient safety competency of nurses was associated with lower

missed nursing care. Systems thinking partially mediated the relationship between

knowledge of patient safety competency and missed nursing care, and attitudes of

patient safety competency and missed nursing care.

Conclusions: The knowledge, skills and attitudes sub-scales of patient safety compe-

tency showed somewhat different effects in the relationship between missed nursing

care and systems thinking, suggesting that each attribute may tap into a separate

aspect of patient safety.

K E YWORD S

competency, missed nursing care, patient safety, quality of care, systems thinking

Summary statement

What is already known about this topic?

• Patient safety can be threatened when nurses are not competent to provide safe

care to patients.

• Systems thinking is an essential nurse attribute that enhances patient safety

competency.

• Greater missed nursing care has been associated with negative patient outcomes

including adverse events such as medication error, fall with injury and patient

mortality.

Received: 30 October 2021 Revised: 12 December 2022 Accepted: 23 December 2022

DOI: 10.1111/ijn.13130

Int J Nurs Pract. 2023;29:e13130. wileyonlinelibrary.com/journal/ijn © 2023 John Wiley & Sons Australia, Ltd. 1 of 9

https://doi.org/10.1111/ijn.13130

What this paper adds?

• Higher patient safety competency of nurses was associated with less missed nurs-

ing care.

• Nurses' systems thinking had a mediating effect on the relationship between the

patient safety knowledge and attitude competencies and missing nursing care.

• Nurses' systems thinking had the effect of reducing missed nursing care, but only

when nurses exhibited patient safety knowledge and attitude competencies.

The implications of this paper:

• By enhancing patient safety competency, missed nursing care can be reduced and

negative patient outcomes may decrease accordingly.

• Strategies to increase systems thinking should be applied as a way to reduce

missed care and increase patient safety.

1 | INTRODUCTION

Patient safety has been established as an important component of

providing nursing care to patients (Cronenwett et al., 2007). Patients

themselves have expectations and demands related to patient safety

performance of health-care institutions and professionals and these

have increased over time (Doyle et al., 2013). Accordingly, accredita-

tion agencies that manage the quality of medical services for health-

care institutions around the world have high expectations related to

quality, and now include performance indicators related to patient

safety (Despotou et al., 2020). Nurses are also actively participating in

these efforts to increase patient safety (Despotou et al., 2020).

As the importance of patient safety continues to rise, studies on

the patient safety competency of nursing personnel have recently

been conducted in South Korea (hereafter, Korea) (Jang & Lee, 2017;

Kim et al., 2019; Lee et al., 2014), and the suggestion that nursing stu-

dents should have patient safety competency programs in their under-

graduate curricula as a requirement has also been raised (Korean

Accreditation Board of Nursing Education, 2019). Such a stance dem-

onstrates the emphasis of patient safety competency for nurses,

rather than performance indicators for patient safety more generally.

When nurses provide patient care, competency to perform safe

nursing care is very important. This is because nurses are the profes-

sionals who have the closest contact with patients, who administer

medications, provide important information and monitor the patient's

condition. Studies have shown that when nurses fail to provide safe

care to patients (Cho, Han, et al., 2020) or when the work environ-

ment is not configured in a way that allows nurses to provide safe

care, patient safety is threatened (Choi et al., 2019; Hessels

et al., 2019). Therefore, having the competency to provide safe nurs-

ing care is an essential ability for nurses, and is known as patient

safety competency, which is defined as knowledge, skills and attitudes

concerning patient safety, that are required for the provision of safe

health care (Cronenwett et al., 2007; Lee et al., 2014).

The association of patient safety competency with other con-

cepts that affect nursing practice has been investigated. In a previous

study (Hwang, 2015), patient safety competency of nurses was signifi-

cantly higher in nurses with master's or higher degrees and clinical

experience of longer duration suggesting that nurses' patient safety

competency could improve with experience and education. Another

study reported that nursing educators who were working as clinical

instructors in nursing programs or as hospital preceptors still had edu-

cational needs related to patient safety (Jang & Lee, 2017), which sug-

gests that nurse educators may lack sufficient knowledge of patient

safety competency to impart to nursing students. In addition, one

study found that especially newly licensed nurses showed a low level

of patient safety knowledge (Murray et al., 2018), which is one of the

components of patient safety competency. As such, although nurses'

patient safety competency can be enhanced through experience and

education, they may lack adequate patient safety competency, espe-

cially early in their careers. Since low patient safety competency of

nurses was reported to be correlated with adverse outcomes such as

low quality of care and patient satisfaction (Son et al., 2019), there is

an urgent need to improve nurses' patient safety competency. Despite

its importance, there is still a lot that we do not know about patient

safety competency. For example, the literature is silent on which of

the three aspects of patient safety competency: knowledge, skills or

attitudes may be of the greatest value for promoting patient safety

during the provision of nursing care.

Systems thinking has recently emerged as an important ability

related to patient safety and has been defined as a process where

solutions to complex problems are accomplished through collabora-

tive effort (Stalter et al., 2017). Previous studies have been conducted

to measure and develop strategies to enhance systems thinking ability

of nursing students (Bacon et al., 2018; Fura & Wisser, 2017) and

nurses (Phillips et al., 2016). A common theme across these studies is

the need for education in systems thinking because it is an essential

factor in enhancing the patient safety competency of nurses and nurs-

ing students. However, there has been little research on how systems

thinking affects patient outcomes or nurse performance.

One plausible outcome of systems thinking is that a patient

receives appropriate care. Providing appropriate nursing care means

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no omission of required nursing care, which was named as ‘missed

nursing care’ (Kalisch & Williams, 2009). Factors affecting missed

nursing care have been reported to be structural factors of the institu-

tions such as nurse work environment (Kim et al., 2018; Lake

et al., 2020; Park et al., 2018), including unit type, hospital type

(Bragad�ottir et al., 2017) and nurse staffing (Cho, Lee, et al., 2020) and

process factors such as teamwork (Kalisch & Lee, 2010) and patient

safety culture (Hessels et al., 2019; Kim et al., 2018). All of these fac-

tors are related to patient safety, so it may be that a contributing fac-

tor of missed nursing care may be a lack of systems thinking.

Missed nursing care has been investigated as both a predictor

and an outcome. When conceptualized as a predictor, the conse-

quences of missed nursing care were found to be related to negative

outcomes of patient safety (Cho, Lee, et al., 2020; Min et al., 2020),

including increased adverse events and patient mortality (Ball

et al., 2018), decreased quality of care (Cho, Lee, et al., 2020),

decreased patient satisfaction (Lake et al., 2016) and increased nurse

turnover intention (Smith et al., 2020). These previous studies have

shown that patient safety is actually threatened and the quality of

nursing is degraded by nurses' omission (Ball et al., 2018; Cho, Lee,

et al., 2020; Min et al., 2020). The ability to provide safe nursing care

for the patient and the ability to think about the impact of one's

actions on a patient's outcome (a component of systems thinking)

may be related to the act of missing care.

According to previous studies, nurses' low patient safety compe-

tency and high missed nursing care were found to increase negative

patient outcomes (Son et al., 2019), including adverse events such as

medication error and fall injury (Min et al., 2020). However, the asso-

ciation between nurses' patient safety competency and missed nurs-

ing care has not been investigated. Additionally, the influence of

systems thinking, which is an important concept in patient safety

competency needs to be examined. By revealing direct and indirect

relationships among knowledge, skills, and attitude attributes of

patient safety competency, missing nursing care and systems thinking,

we may be able to develop strategies to reduce missed nursing care

and consequently increase nurses' ability to provide safe nursing care.

2 | METHODS

2.1 | Aim of the study

The aims of this study were (a) to examine the direct relationships

among nurses' patient safety competency, systems thinking and

missed nursing care and (b) to determine the mediating effects of sys-

tems thinking on the relationship between patient safety competency

and missed nursing care.

2.2 | Conceptual framework

The Missed Nursing Care Model (Kalisch & Williams, 2009) guided

the conceptual framework of this study, which was developed

based on Donabedian's Structure-Process-Outcomes Model

(Donabedian, 1980). In this study, we hypothesized that there

would be a direct relationship between patient safety competency

and missed nursing care because patient safety competency could

determine whether nurses had sufficient competency to do nursing

activities without omission. Since systems thinking is concerned

with the key interrelationships, structures and processes that

control and monitor behaviour (Silverman, 2000), we hypothesized

that systems thinking would act as a mediator in the relationship

between patient safety competency and missed nursing care.

2.3 | Study design

This study used a cross-sectional survey study design to determine

the relationships among patient safety competency, systems thinking

and missed nursing care of clinical nurses in Korea.

2.4 | Settings and participants

One general hospital located in Daejeon city and one tertiary hospital

located in Seoul, Korea were selected as study settings. Two Univer-

sity hospitals with a history of more than 20 years in the community,

which were accessible by the researcher were selected. The general

hospital in Daejeon has 900 beds and provides a full range of in-

patient services to the citizens of Daejeon (population about 1.5 mil-

lion) and surrounding area. Daejeon city is located in the central

region of Korea and about 95 miles away from Seoul, which is the

capital city of Korea, and has 10 general hospitals. The hospital that

was selected from Seoul has 1045 beds. In order to prevent the differ-

ence between hospitals from appearing as a potential source of bias,

role in the community, size of the hospital and whether it was a uni-

versity hospital were considered when selecting two hospitals.

The sample size was estimated using G-power programme

3.1.9.2. Performing multiple regression analysis based on the effect

size 0.15 (median effect), the power level of 95%, and the signifi-

cance level α = 0.05, the appropriate number of participants was

estimated to be 199. However, we over-sampled to account for a

potential 20% drop out rate, so that the total number of partici-

pants in each hospital was 240. Therefore, data were collected

from a total of 480 nurses.

To recruit research subjects, after receiving approval from the

head of the hospital, 240 clinical nurses from each hospital were

invited to participate in the study. To be eligible to participate in

this study, a ‘clinical nurse’ was defined as a nurse who has been

working for at least 3 months or more in a general hospital at the

time of investigation. In addition, we included nurses working in

general wards and specialty units (intensive care unit, emergency

room, operating room, anesthesiology department, haemodialysis

room etc.) but excluded nurses working in outpatient or administra-

tive departments because they were not involved in direct

nursing care.

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2.5 | Data collection

After receiving approval from the nursing department of each hospi-

tal, a recruitment announcement was posted in the hospital online

bulletin board. A total of 480 questionnaires were distributed by a

researcher to each of the nursing units that indicated their intention

to participate. The researcher was not affiliated with the hospitals.

Questionnaires were placed in survey packets that consisted of a

study introduction letter, consent form, the questionnaire, and an

envelope to facilitate return. After completing surveys, nurses sealed

them in envelopes individually and submitted them to the collection

box. The researcher collected questionnaires at intervals of once a

week for a total of 2 weeks for each ward, so that data were collected

between 3 March and 17 April 2020 for a total of 52 nursing units in

two hospitals.

2.6 | Measures

2.6.1 | Patient safety competency

Patient safety competency of the nurses was measured using the

Patient Safety Competency Self-Evaluation (PSCSE) tool (Lee

et al., 2014). The scale consists of a total 41 items with three sub-

scales: knowledge (6 items), skills (21 items) and attitudes (14 items).

The PSCSE was designed to measure patient safety competency of

nursing students with items arranged on a 5-point Likert-type scale.

Higher scores mean higher knowledge (ranging from 1 = not knowl-

edgeable to 5 = very knowledgeable), skills (ranging from 1 = not

uncomfortable to 5 = very comfortable) and attitudes (ranging from

1 = strongly disagree to 5 = strongly agree), on patient safety compe-

tency. The scale was originally developed in Korean for nursing stu-

dents and the questionnaire items were presented and published in

English (Lee et al., 2014). The scale has also been applied to nursing

educators (Jang & Lee, 2017). A sample item for the knowledge sub-

scale is ‘I know how to describe factors that create a culture of

safety’. A sample item for the skills sub-scale is ‘I can report errors

using an organizational error reporting system’. A sample item of the

attitudes sub-scale is ‘Health care professionals should routinely

report when certain errors occur’. Cronbach's alpha for the scale has

been reported as 0.86 (knowledge), 0.91 (skills), 0.79 (attitudes) and

0.90 (overall) (Lee et al., 2014). In this study, the Cronbach's alpha was

0.89 (knowledge), 0.94 (skills), 0.78 (attitudes) and 0.94 (overall) for

clinical nurses.

2.6.2 | Systems thinking

Systems thinking was measured by the Systems Thinking Scale (STS)

(Dolansky et al., 2020). The scale consists of 20 items arranged on a

5-point Likert-type scale (0 = never, 1 = seldom, 2 = some of the time,

3 = often and 4 = most of the time). A sample item from this scale is

‘When I want to make an improvement, I keep in mind that proposed

changes can affect the whole system’. We used the Korean version of

the scale, which was translated and used for nursing students

(Jang, 2018). At the time of development, the test–retest reliability of

the tool was 0.74, the internal reliability was 0.89, and discriminant

validity was verified. The Cronbach's alpha of the scale in this study

was 0.92.

2.6.3 | Missed nursing care

Missed nursing care was measured using the MISSCARE survey devel-

oped by Kalisch and Williams (2009). The MISSCARE survey has been

translated into Korean and used to examine nurses' performance in

Korea (Cho et al., 2015). The MISSCARE survey is the most widely

validated tool to measure unfinished nursing care across countries

(Palese et al., 2021) including Korea.

The first part of the MISSCARE survey explores perceptions of

missed care and the second part includes the reasons for missed care.

In this study, only the first part of MISSCARE survey was used

because we focused on analysing the degree rather than the cause of

omission. Nurses were asked to answer on a 4-point Likert-type scale

how frequently they had missed each of 24 nursing care elements

(1 = rarely, 2 = occasionally, 3 = frequently and 4 = always). Higher

scores indicated a greater extent of missed care. The first part of the

MISSCARE survey ask nurses how frequently they miss items such as

‘turning patient every 2 hours’, ‘mouth care’ or ‘PRN medication

requests acted on within 15 minutes’ when they are providing nursing

care to patients. Cronbach's alpha for the 24 elements of missed care

in the Korean nurse study (Cho et al., 2015) was 0.89. In this study,

Cronbach's alpha for the overall 24 elements of missed care was 0.89.

2.7 | Data analysis

Descriptive statistics including means, standard deviations, frequen-

cies and percentages were used to describe the general characteristics

of participants and main variables. For patient safety competency, the

mean score for each sub-scale and for the overall scale was calculated.

Systems thinking, and missed nursing care were calculated as the

mean of the item responses. Higher scores of patient safety compe-

tency and systems thinking indicated higher levels of those variables.

Higher scores of missed nursing care indicated higher occurrence of

missing nurse activities.

Multiple linear regression was conducted to analyse the effects of

independent variables on missed nursing care. Finally, Hayes (2012)'s

Model 4 and bootstrapping were used to identify the mediating

effects of systems thinking on the relationship between patient safety

competency and missed nursing care. Models were run to demon-

strate the mediating effects of systems thinking on the relationship

between patient safety competency overall as well as each sub-scale

and missed nursing care.

One of the respondents was immediately excluded because she

or he was not a nurse providing direct nursing care, and the data of

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seven additional respondents whose questionnaires had a page miss-

ing were also excluded. In addition, 40 participants returned question-

naires with missing answers to questions about the main variables and

these questionnaires were excluded. Therefore, a total of 48 question-

naires were excluded and data from 432 participants were used for

the final analysis. Data analysis was performed using SPSS 24.0 statis-

tical package (IBM Corporation) and PROCESS (version 3.3) macro

for SPSS.

2.8 | Ethical considerations

The study received institutional review board (IRB) approval (IRB

No. 2020–015-01) from the university of the first author. This study

was conducted in accordance with the principles of the Declaration of

Helsinki and the guidelines provided by the IRB. Nurses completed a

written consent form prior to participating in the survey voluntarily.

They were informed that they could stop the survey whenever they

wanted without any harmful consequences for their career. Partici-

pants' personal information was managed in a separate master file

from the dataset used for analysis.

3 | RESULTS

General characteristics of the participants are presented in Table 1.

The majority of the nurses were female (95.4%) and most of the par-

ticipants had bachelor's degrees (86.6%). The average age of the

nurses was 28.7 years. More than half of the nurses worked in general

care (i.e., medical and/or surgical) wards (60.6%) and had more than

3 years of unit experience (67.8%), with an average of 5.9 years.

Table 2 presents the means and standard deviations of patient

safety competency, systems thinking and missed nursing care scales.

The average mean score of patient safety competence was 3.81

± 0.39. Among the subscales, attitudes (4.01 ± 0.46) was the highest,

followed by skills (3.84 ± 0.47) and knowledge (3.44 ± 0.66). The

mean score of systems thinking was 2.73 ± 0.46 and missed nursing

care was 1.39 ± 0.32.

Relationships among patient safety competency, systems thinking

and missed nursing care are presented in Table 3. In examining direct

relationships, patient safety competency overall showed an inverse

relationship with missed nursing care. However, when examining sub-

scales, only the skills sub-scale of patient safety competency had a

significant inverse effect on missed nursing care (β = �0.126,

p = 0.014). Systems thinking did not show a significant, direct rela-

tionship with missed nursing care.

The mediating effects of systems thinking on the relationship

between patient safety competency and missed nursing care are pre-

sented in Figure 1. Patient safety competency knowledge

(β = �0.073, p = 0.002), skills (β = �0.160, p < 0.001), attitudes

(β = �0.113, p < 0.001) and overall (β = �0.198, p < 0.001) showed

direct inverse effects on missed nursing care. Adding systems thinking

to the model as a mediator showed different results depending on

which sub-scale of patient safety competency was being tested. Sys-

tems thinking had a significant mediating effect on the relationship

between both knowledge (β = �0.120, p = 0.002) and attitudes

(β = �0.114, p = 0.004) of patient safety competency and missed

nursing care (Figure 1a,c). The indirect effect of systems thinking was

significant for patient safety knowledge (β = �0.045; Boot-

CI = �0.074 to �0.019) and attitudes (β = �0.060; BootCI = �0.102

to �0.019), which indicated systems thinking as a partial mediator of

the relationship between patient safety knowledge and attitude

TABLE 1 General characteristics of participants (N = 432)

Characteristics Category

N (%) or M

± SD

Gender Female 412(95.4)

Male 20(4.6)

Age (years)a 22–24 70(16.2)

25–27 159(36.8)

≥28 202(46.8)

28.7 ± 4.88

Education levelb Associate degree 40(9.3)

Bachelor's degree 374(86.6)

Master's or higher 16(3.7)

Hospital type (location) General (non-

metropolitan)

217(50.2)

Tertiary

(metropolitan)

215(49.8)

Type of nursing unit Medical ward 128(29.6)

Surgical ward 134(31.0)

Intensive care unit 94(21.8)

Emergency room 15(3.5)

Others 61(14.1)

Duration of unit experience

(years)c <1 79(18.3)

1–2 59(13.7)

≥3 293(67.8)

5.94 ± 4.97

aOne missing value in category of age. bTwo missing values in category of education level. cOne missing value in category of duration of unit experience.

TABLE 2 Scores of patient safety competency, systems thinking and missed nursing care of participants (N = 432)

Characteristics M ± SD Range Min–Max

Patient safety competency 3.81 ± 0.39 1–5 2.90–5.00

Knowledge 3.44 ± 0.66 1–5 1.67–5.00

Skills 3.84 ± 0.47 1–5 2.62–5.00

Attitudes 4.01 ± 0.46 1–5 2.71–5.00

Systems thinking 2.73 ± 0.46 0–4 1.55–4.00

Missed nursing care 1.39 ± 0.32 1–4 1.00–3.67

Note: M = mean; SD = standard deviation; Min = minimum;

Max = maximum.

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competency and missed nursing care. However, there was no signifi-

cant mediating effect of systems thinking on the relationships

between either skills or overall patient safety competency and missed

nursing care (Figure 1b,d).

4 | DISCUSSION

In this study, we found that higher patient safety competency had a

significant inverse effect on missed nursing care such that nurses who

reported higher patient safety competency also reported less missed

nursing care. However, in sub-scale analysis only the skills sub-scale

of patient safety competency was significantly associated with missed

nursing care, suggesting that of the three patient safety competency

attributes, skills are the most relevant to missed nursing care. This

makes sense because skill competency is the most closely related to

nurses' direct behaviour and directly influences nursing care provided

to patients through communication, resource utilization, evidence-

based practice, infection prevention and safe nursing practices, which

are all components of skill competency (Lee et al., 2014). The results

further suggest that nurses with lower skill competency may be more

likely to miss nursing care.

Similar to previous studies, nurses' patient safety competency

attitudes, skills and knowledge (in that order) were found to be high

(Jang, 2018; Jang & Lee, 2017). However, we found that the level of

knowledge, skills and overall patient safety competency of clinical

nurses was higher and the attitude competency was lower compared

to nursing students in a previous study (Jang, 2018). In addition, com-

pared to a study also conducted in Korea with nursing educators

(e.g., school clinical instructors and hospital nurse preceptors), all

scores related to patient safety competency in this study were found

to be at lower level (Jang & Lee, 2017). Through comparison with pre-

vious studies (Hwang, 2015; Jang & Lee, 2017), we expected that the

level of patient safety competency of clinical nurses would increase as

education, training and career experience increased. Our finding that

clinical nurses' scores of attitude competency were lower than that of

nursing students may be due to changes in attitude that can occur

over time when nurses work in environments that do not support pro-

fessional nursing practice (Manojlovich, 2005). Attitude plays an

important role in establishing a patient safety culture, such as under-

standing the activities that promote patient safety and prevent errors,

and duties as a health-care professional (Lee et al., 2014). Previous

studies have reported that missed nursing care negatively affects the

quality of nursing and causes more adverse events (Min et al., 2020;

Recio-Saucedo et al., 2018). Our findings suggest that by increasing

patient safety competency, it may be possible to reduce the amount

of nursing care that is missed and eventually reduce the risk of nega-

tive effects on patients.

However, the story becomes more nuanced because we also

tested the mediating effect of systems thinking on the relationship

between patient safety competency and missed nursing care. Another

major finding of this study was that systems thinking showed a signifi-

cant mediating effect on the relationship between patient safety

knowledge competency and missed nursing care, and patient safety

attitude competency and missed nursing care, but not patient safety

competency overall or the skill sub-scale. In other words, both patient

safety knowledge and attitude competencies contributed to a

decrease in missed nursing care through nurses' use of systems think-

ing. This finding suggests that nurses who use a systems thinking

approach do not have to also have patient safety competency skills,

as long as they have patient safety knowledge and attitudes. Systems

thinking has been applied not only in the health-care field (Wilkinson

et al., 2018), but in many other fields as well (Zhang et al., 2020) and

is considered as a way to enhance safety and quality. Accordingly,

studies have been conducted to analyse the effects of educational

programs to increase systems thinking for medical students

(Aboumatar et al., 2012) and nursing students (Bacon et al., 2018).

The Quality and Safety Education for Nurses (QSEN) programme also

emphasizes systems thinking as one of the key concepts in developing

quality and safety competencies in nursing (Dolansky & Moore, 2013).

Education programs related to patient safety or systems thinking are

not included as a requirement in Korea (Korean Accreditation Board

of Nursing Education, 2019). This fact may explain why we found that

the mean score of systems thinking of clinical nurses was lower com-

pared to that of nursing students in other countries (Bacon

et al., 2018; Fura & Wisser, 2017).

The impact of educational methods that can reinforce systems

thinking and demonstrate an effect on outcomes such as patient

safety and quality of care require further study. In particular, the

effectiveness of such education can be investigated by testing direct

effects of the relationship of nurses' systems thinking on patient out-

comes, after an educational programme has been implemented. In

addition, it may be possible to reinforce patient safety in the overall

hospital environment by promoting the value of systems thinking not

only to nurses but also to all health-care professionals who participate

in the treatment of patients.

TABLE 3 Multiple linear regression analysis of patient safety competency, systems thinking and missed nursing care (N = 432)

Patient safety competency

Coefficient (p) (95% CI) Systems thinking

Knowledge Skills Attitudes Coefficient (p) (95% CI)

Missed nursing care �0.004(.881) �0.126(.014) �0.001(.974) �0.058(.214)

(�0.062, 0.053) (�0.225, �0.026) (�0.085, 0.082) (�0.149, 0.034)

Note: Adjusted for gender, age, education level, hospital type, unit type and duration of unit experience. CI indicates confidence intervals.

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4.1 | Limitations

This study has several limitations. First, the relationships among

patient safety competency, systems thinking and missed nursing care

do not reflect causal relationships due to the cross-sectional survey

design. Longitudinal studies are needed to confirm the effects of

nurses' patient safety competency and systems thinking on nursing

performance. Second, the findings from this study may not be gener-

alizable to nurses in other countries or in other hospital settings. Spe-

cifically, there may be differences in nursing practice and the scope of

F IGURE 1 (a–d) Relationships among patient safety competency, systems thinking and missed nursing care. Mediating effect of systems thinking

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nursing across countries that affect the perception of unfinished nurs-

ing care. Third, self-report may not accurately reflect nurses' true

practice behaviours. Further observational studies or patient surveys

may enable more objective results to emerge. Fourth, since we only

used the first part of the missed nursing care tool, there were limits in

our ability to make direct comparisons with studies that used the full

instrument.

5 | CONCLUSION

In conclusion, this study provides additional evidence of the multi-

faceted nature of patient safety competency. The knowledge, skills

and attitudes sub-scales of patient safety competency showed some-

what different effects in the relationship between missed nursing care

and systems thinking, suggesting that each attribute may tap into a

separate aspect of patient safety. Strategies to increase systems

thinking should be applied as a way to reduce missed care and

increase patient safety. Through ongoing investigation, the differential

effects of the sub-scales of patient safety competency on systems

thinking and other factors may be further revealed and used to

develop strategies to strengthen the required competencies of nurses,

so that missed nursing care is progressively reduced.

ACKNOWLEDGEMENTS

The authors deeply thank the nurses who participated in this

research.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

AUTHORSHIP STATEMENT

All listed authors meet the authorship criteria and that all authors are

in agreement with the content of the manuscript.

HEC and MM designed the study. HEC collected the data. HEC

and MM analysed the data. HEC and MM prepared the manuscript.

All authors approved the final version for submission.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the

corresponding author upon reasonable request.

ORCID

Hyoung Eun Chang https://orcid.org/0000-0003-0124-1271

Milisa Manojlovich https://orcid.org/0000-0002-6101-5535

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How to cite this article: Chang, H. E., & Manojlovich, M.

(2023). Clinical nurses' patient safety competency, systems

thinking and missed nursing care: A cross-sectional survey.

International Journal of Nursing Practice, 29(2), e13130. https://

doi.org/10.1111/ijn.13130

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