Iran Journal of Nursing

Introduction
Maintaining patient safety (PS) is one of professional and ethical duties of health care providers. Nurses, as the largest professional group in the health system, have a potential and significant power in influencing health care quality. Their competency in PS is essential to ensure quality and safe care. PS competency is defined as " the attitudes, skills, and knowledge that health care workers must have to protect patients from unnecessary risks and hazards”. Education plays a vital role in improving PS and providing high quality health and nursing care. Education is provided by traditional or online methods. It is clear that educational strategies, in addition to consolidating knowledge and skills, need to create motivation, encourage interactions between learners, facilitate learning, and have the necessary flexibility. There are various e-learning methods such as web-based learning, computer-assisted learning and online learning. Although these methods have advantages, they are some disadvantages such as lack of proper communication with the teacher, difficulty in using the system and interact with technology, the necessity for active participation of the individual in training, and increased time required to get feedback from homework. This study aims to evaluate the effectiveness of online PS education on the competence of nurses in ICUs.
Materials & Methods
This is a quasi-experimental study with a pre-test/post-test design that was conducted in 2020 in Tehran, Iran. Participants were 50 nurses working in the ICUs who were selected by a stratified method from Hazrate Rasoole Akram Hospital and Firoozgar Hospital affiliated to Iran University of Medical Sciences. Inclusion criteria were at least a bachelor's degree in nursing, at least six months of clinical experience in the ICU, ability to use computer or having a smartphone and Internet access. Exclusion criteria were: Leaving the ICU before completing the study for any reason and not using the educational content. The educational program was provided online, focusing on PS issues. The educational contents were presented in the form of text, audio, image, and video. The program included a test designed to assess the nurses' learning, which was given to the nurses once every four days for two months. Before and three months after the intervention, data were collected using a patient safety competency self-evaluation (PSCSE) questionnaire which has three subscales of PS knowledge, attitude and skills. In the knowledge subscale, two dimensions of “concept of the components of PS culture” and “concept of error and cause analysis" are measured by 6 items. in the attitude subscale, four dimensions of "PS promotion/prevention strategy”, “responsibility of health care professionals for PS culture”, “error reporting and disclosing”, and “Components of PS culture" are measured by 14 items. in the skills subscale, six dimensions "error reporting and error response”, “communication related to error”, “resource utilization/evidence-based practice”, “safe nursing practice”, “infection prevention”, “Precise communication during handoffs" are measured by 21 items. The total score ranges 41-205. The highest score in each subscale indicates high PS knowledge, skill or attitude. The highest overall score indicates high competence in PS. In our study, the face validity of PSCSE was examined based on the opinions of 20 nurses and the necessary corrections were made. The content validity of the questionnaire was determined by using the opinions of three experts. The instrument's internal stability was determined by calculating Cronbach's alpha, which was obtained 0.868 for the knowledge subscale, 0.824 for the attitude subscale, 0.911 for the skills subscale, and 0.922 for the overall scale. Data were analyzed by descriptive statistics (frequency, mean, and standard deviation) and inferential statistics (paired t-test, Wilcoxon test) in SPSS software, version 22.
Results
The mean age of the nurses was 32.7±5.73 years. Most of the nurses were female (88%) and married (56%). Their mean work experience in the ICU was 2.57±3.47 years. Furthermore, 46% had permanent employment, 68% had rotating shifts, and 62% had an experience of in-service training related to PS about 2.62±2.28 years ago. Furthermore, 80% had no any errors in patient care in the last three months. The mean scores of PS knowledge (21.75±3.28), attitude (61.52±4.19), and skill (84.66 ±53.7) after the intervention were significantly higher compared to their pretest scores (P<0.001). The mean of total competency score (167.93±11.61) after the intervention was also significantly higher. Results showed that the educational program improved the nurses' competence by 17.86%. The education had the highest effect on PS knowledge, followed by PS skills and attitudes.
Discussion
Online education can increase PS knowledge, skills, and attitudes in ICU nurses and can ultimately promote their competence in PS. Nursing managers can use e-learning method to provide in-service training and retraining courses on familiarity with patients safety concepts, which can help manage medical errors caused by nurses. This learning method is recommended for nurses working in ICUs, especially during the Covid-19 pandemic.

Ethical Considerations
Compliance with ethical guidelines
The ethics committee of Iran University of Medical Science, approved this study.(Code:IR.IUMS.REC.1398.373). 

Funding
This project was funded by Iran University of Medical Sciences, Tehran. 

Authors' contributions
All authors contributed equally in preparing all parts of the research.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
We would like to thank the supporting Administration as well as all staff of the study setting who helped us conduct this study.


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