Qi Wu,Zhi-Jian Liu,Xiao-Li Pang,Ling Cheng Shan-shan Wang,Wei Wang

1Graduate School of Tianjin University of Traditional Chinese Medicine, Tianjin China; 2 School of Nursing, Tianjin University of Traditional Chinese Medicine,Tianjin,China.

Abstract Objective: To describe the status quo of humanistic care ability, the knowledge-attitude-practice of Patient Safety and professional commitment among Undergraduate Nursing Students in clinical practice, and to determine the effects of professional commitment and patient safety knowledge-attitude-practice on humanistic care ability.Methods: Two hundred and thirty-two undergraduate nursing students in clinical practice were investigated with the general questionnaire, Caring Ability Inventory (CAI), Patients Safety knowledge-attitude-practice (KAP)Questionnaire and the Nursing Professional Commitment Scale. Results: The score of humanistic care ability of nursing undergraduates was 185.19 ± 20.95, patients safety KAP score was 106.94 ± 11.62, professional commitment score was 74.93±10.44.Undergraduate nursing students' humanistic care ability were positively correlated with professional commitment and patients safety KAP (P＜0.05).Multiple Linear regression analysis showed that professional commitment, patient safety KAP entered the humane care equation (F = 24.051, P ＜0.001), and explained 39.1% of the total variation in humane care.Intermediate effect analysis shows that patient safety played a partial mediating role in professional commitment and humane care. Conclusion: The professional commitment and patient safety KAP of undergraduate nursing students were positively related to their humanistic care ability.Improving the professional commitment and knowledge and patients safety KAP of nursing students can strengthen their humanistic care ability to provide high-quality nursing for patients.

Keywords: Undergraduate internship nursing students, Humanistic care ability, Patient safety, Professional commitment

Introduction

WHO defines patient safety as reducing unnecessary health care-related harm to an acceptable minimum Degree of risk control process [1].Nightingale also believes that the first requirement for the hospital is that patients should be treated without any harm.A study [2] found that when caregivers incorporate awareness of patient safety into nursing services in every aspect of the process, it not only protects the patient's safety, but also reflects the humane care service.However,clinical practice is a necessary stage of nursing teaching.In addition to understanding the actual situation of nursing major, nursing students'safety knowledge and practice level will become an important factor affecting nursing quality.

At the same time, studies have shown that [3], the professional commitment of nursing students is beneficial to their humanities.Professional commitment refers to the positive attitude and identity of individuals who agree with their majors and are willing to make corresponding efforts [4].When nursing students are willing to engage in the nursing profession, the higher the level of commitment of the nursing profession,the stronger the development of the behavior and willingness to work hard for the development of nursing and the improvement of human health [5], which in itself will inspire their drive to care for others [3].Studies have shown that the improvement of humanistic care ability of nursing students can promote the occurrence of altruistic behaviors and enhance their sense of professional value [6].Moreover, the humanistic care ability of nursing students is closely related to the quality of nursing service[7].

Therefore, this study takes undergraduate internship nursing students (hereinafter referred to as nursing students) as the research object and discusses relationship between professional commitment of nursing students, patient safety KAP and humane care,and influencing factors of humane care of nursing students.It is hoped that the conclusions of this study can promote the healthy development of nursing students 'careers, improve patients' safety competence,raising high-quality nursing staff provides a certain reference, thereby promoting the development of nursing education.

Objects and methods

Research objects and design

In June 2019, a questionnaire survey was conducted among 232 nursing students who graduated from the nursing class of a medical school in Tianjin.Inclusion criteria: four-year degree undergraduate nursing students, internship time ≥ 8 months, internship hospitals are Grade Ⅲ A hospital, informed consent for this study.Exclusion criteria: off-site internship,refusal to participate in research.

At the homecoming conference for nursing students,researchers explained the purpose and significance of this study to the subjects, distributed questionnaires,and asked them to read carefully and complete the questionnaires with their informed consent.The questionnaires were filled in anonymously, and then collected on the spot.

Instruments

General Demographics Questionnaire.According to the purpose of the research,the General Demographics Questionnaire based on the literature review and clinical experience, including gender, birthplace, age,profession,the relationship with father,the relationship with mother, the relationship with small partners,whether they had received education in patient safety,whether they had received knowledge in humanistic care,etc.

Nursing Professional Commitment Scale.The scale was compiled by Taiwan scholar Lü Guiyun,et al.[8],and the revised version was selected in 2006.There are 3 dimensions of willingness of professional efforts,willingness to stay in a professional career, and recognition of professional value, with a total of 23 items.Each item was scored on a five-point Likert scale ranging from 1 (extremely uncertain) - 5 (very certain), of which entries 10-17 are negative Scoring,the total score range between 23-115.The higher the score indicated the higher the professional commitment of nursing students.The Cronbach'α coefficient of Nursing Professional Commitment Scale is 0.93.

Questionnaire on knowledge-attitude-practice of Patients Safety in School Nursing Students.The questionnaire was developed by Jiang He [9], and it is based on the framework of"knowledge-attitude-practice".There are 12 entries in the knowledge section, 9 entries in the attitude section,and 10 entries in the behavior section.This scale is scored on a five-point Likert scale ranging from 1 - 5,a higher score indicated a better patients safety KAP among nursing students.The Cronbach'α coefficient of the questionnaire was 0.895.

Humanistic care ability scale for college nursing students.The scale was compiled by Nkongho and and Chinesized by Ma YL [10].This scale includes three dimensions comprising 37 items: understanding,courage and patient.Each item was scored on a seven-point Likert scale ranging from 1 (completely disagree) - 7 (completely agree).Thirteen items need to be scored in reverse, with a total score of 37-259.A higher score indicated better caring ability.The foreign norms [11] showed that the total caring ability score was less than 203.1, which was low, 203.1-220.3,which was medium, and 220.3, which was high.Chen Y [12] investigated the norms formulated by 8,574 Chinese nursing students and found that the total score of humanistic care ability was less than 171.55, which was considered as low level, while that of more than 210.53 was considered as high level.The Cronbach'α coefficient of this scale was 0.925.

Statistical methods

Statistical analysis was performed using SPSS 23.0 software.Descriptive statistics were used to describe the demographic characteristics and studied variables including frequencies, percentages, means and standard deviations.Comparison between two groups used two independent samples t test, comparison between multiple groups used single factor variance analysis.Using Pearson correlation, researchers identified the relationship between professional commitment, patient safety KAP and humane care.The multiple linear regressions were performed to analysis predictor of humanistic care.Using Bootstrap mediation effect test, researchers evaluated the mediation effect of patient safety KAP.The difference was statistically significant withP＜0.05.

Results

General information of the nursing students

A total of 250 questionnaires were distributed this time,and 232 valid questionnaires were recovered,representing a 92.8% effective response rate.All participants were consisted of 212 girls(91.4%)and 20 boys (8.6%).Their average age was (22.40 ± 0.90)years old.More than half (62.07%) of the participants were from rural.11.21% received education in patient safety,14.22%received knowledge in humanistic care.

Level of nursing professional commitment, patient safety KAP,and humane care(Table 1)

Table 1 Total scores and scores of each dimension of nursing students'professional commitment,patient safety KAP,and humanistic care （±S）

Table 1 Total scores and scores of each dimension of nursing students'professional commitment,patient safety KAP,and humanistic care （±S）

Scale Dimensions Total score Average score Professional Commitment over all 74.93±10.44 3.25±0.45 willingness of professional efforts 27.32±5.60 3.04±0.62 willingness to stay in a professional career 26.00±5.06 3.25±0.63 recognition of professional value 21.60±3.24 3.60±0.54 Patients Safety KAP over all 106.94±11.62 3.44±0.37 knowledge 39.00±6.09 3.25±0.51 attitude 31.46±3.47 3.50±0.39 practice 36.49±5.74 3.65±0.57 humanistic care over all 185.19±20.95 5.01±0.57 understanding 74.71±10.16 5.34±0.73 courage 53.22±12.39 4.09±0.95 patient 57.26±6.90 5.73±0.69

The association between humanistic care ability and general demographic data among nursing students

According to the t-test and analysis of variance,we can know that the relationship between the nursing students and their father, the relationship between nursing students and mother, the relationship between partners affect their humanistic care ability, the difference is statistically significant (P＜0.05).The more harmonious the relationship with the father, the more harmonious the relationship with the mother indicated the more harmonious the relationship with the partners, the stronger the humanistic care ability.The influence of humanistic care education on the humanistic care ability of nursing students was different, and the difference was statistically significant (P＜ 0.05).There was no significant difference in the influence of gender, age and place of origin of nursing students on their humanistic care ability(P＞0.05),as shown in Table 2.

Correlation between nursing professional commitment,patient safety KAP and human care

Pearson correlation analysis shows that a significant positive correlation was found between the professional commitment, patient safety KAP and humane care.See Table 3.

Multi-factor analysis of humanistic care ability of nursing students

Taking humanistic care as the dependent variable, the variables with statistical significance of single factor analysis, the total score of professional commitment of nursing students and the total score of patient safety knowledge and practice were included in the multivariate linear regression analysis.Variance analysis showed thatF= 24.051,P＜0.001, theregression equation was statistically significant.Finally,factors entering the regression equation included professional commitment and patient safety KAP, the correlation coefficient wasR= 0.625, and the determination coefficient wasR2=0.391(Table 4).

Table 2:Comparison of humanistic care scores of nursing students with different characteristics

Table 3:Correlation between nursing professional commitment,patient safety KAP and human care(r)

Table 4:Regression analysis results of humanistic care ability of nursing students

Table 5:Mediating effects of nursing students'patient safety KAP

Mediation Effect of nursing students'Patient Safety KAP on Professional Commitment and humanistic care

The Bootstrap method was used to examine the mediating effect of patient safety KAP, and SPSS compiled by Hayes Macro program PROCESS plug-in[13].The researcher selected model 4, random sampling 5000 times under 95% confidence interval,and calculated the mediation effect.If the 95%confidence interval of the mediation effect did not include 0, there was a mediation effect.The results showed that the 95% confidence interval of the mediating effect of professional commitment on humane care does not include 0, indicating that it existed mediation effect, in which the median effect value accounts for 53% of the total effect value.See Table 5.

Discussion

Situations of nursing professional commitment,patient safety KAP,and humane care

The results of this study showed that the professional commitment score of nursing students was (74.93 ±10.44), which was at a medium level, are Slightly higher than Liu D's [14]survey of specialist internship nurses.The patient safety KAP score was (106.94 ±11.62),which was at a medium level.The humane care ability score (185.19 ± 20.95) was lower than the low level of the foreign norm [11].But compared with China's normal model [12], the humane care ability score was at a moderately low level.In professional commitment scale,the average Entries score of nursing students' professional value recognition dimension were the highest,followed by the willingness to stay in a professional career and the willingness to work hard,probably due to the fact that the majority of nursing students full recognized the value of the nursing profession, but the nursing work environment, work load, job burnout and career development prospects and other factors affect the nursing students'willingness of professional efforts and willingness of staying in a professional career.At the same time,these factors were also some of the reasons for the high turnover rate of human resources in the nursing industry[15].

Among the dimensions of patient safety KAP of nursing students, the average Entries score of their behavior dimension was the highest, followed by nursing students' attitude and knowledge of patient safety, which was similar to the research results of Jiang He[9].The reason may be that the content of the knowledge part of the questionnaire were more written,such as “methods for analyzing the cause of adverse events”, “WHO's Medical School Patient Safety ‘11 Patient Safety Issues' in the Course Guide”, etc.But entries in the Attitude and Behavior section was closer to real life, such as “Patients should be encouraged to ask questions about treatment of operations in a timely manner”, and “After the occurrence of adverse events,I can timely take the initiative to report the teacher”etc.

In terms of humane care, the average score of the"courage "dimension of nursing students was low,consistent with the research by Guo Huifang [16].The possible reason was that courage was one of the essential qualities in nursing practice.In the caring process, caregivers need to take the initiative to carry out caring, and they need to be adventurous and to overcome fear to do what is right [17].However,nursing students can rarely handle unknown events independently during the internship process.

According to the above content,it suggested that the education on the patient safety of nursing students should be combined with clinical practice to enhance their safety awareness.Nursing educators should strengthen the cultivation of self-confidence of nursing students to reduce the timidity of nursing students'exposure to the clinic, to make them have more courageous to face complex clinical situations by using methods such as scenario simulation and objective structured examinations.

Analysis of the impact of family, school and related courses on the humanistic care ability of nursing students

The results of this study showed that the relationship between nursing students and fathers, mothers, and small partners,whether you have received education in patient safety and whether you have received education in human care were the factors of humanistic care ability of nursing students (P＜ 0.05).The more harmonious the relationship with the parents indicated the better the humanistic care ability.It may be related to the fact that nursing students who receive more care in a harmonious and warm family atmosphere can better understand the meaning of care, thus enhancing their humanistic care ability [18].And the more harmonious the relationship with the partners, the stronger the humanistic care ability of the nursing students, the reason may be that the nursing students develop some skills related to care, such as trust,reciprocity, conflict resolution, self-discovery and so on, while caring for their peers, which is consistent with the research results of Tan YH [19].The caring atmosphere felt by the nursing students may affect their care awareness, attitude and ability [12], where mutual care among nurses promoted care for patients[8], humanistic care atmosphere in schools promoted and maintained the development of caring ability of nursing students [11], which significantly affect the humanistic care ability of nursing students[20].

Additionally, students who were educated in patient safety had a higher level of humanistic care than those who did not.The reason may be that the training of patient safety cultural created a cultural atmosphere of patient safety, where emphasized the people-oriented and respected patients in the nursing process, which reflected the humane care.And people who has received education in humanistic care have a high level of humanistic care ability, which was consistent with the research results of Zhang X [21].After receiving humanistic education, the nursing students silently put knowledge into action, which will improve their humane care and patient satisfaction with nursing students.Therefore, nursing educators should build the atmosphere of school humane care, make full use of family and peer' influence, and strengthen patient safety education and humane care education during the period of nursing students in school and in the hospital,to promote the improvement of humanistic care ability of nursing students.

Impact of professional commitment, KAP of patient safety of nursing students on humane care

The results of this study showed that the higher the level of professional commitment of nursing students,the higher the level of patient safety KAP,the stronger their humane care ability.Nursing is a profession of caring and dedication, when nursing students like this subject and love this profession, they may care about others further more.Nursing students who are loving,patient, empathetic, and dedicated may are more committed to the nursing profession [3, 22], which shows that the professional commitment of nurses is in line with their humanistic care ability.And they are mutual influence and mutual promotion.In professional commitment, the correlation coefficient between "willingness of professional efforts","recognition of professional value" and humanistic care ability is high, suggesting that the greater the willingness to work for the nursing profession and the higher recognition of the value of the nursing profession indicated the stronger humanistic care ability.At the same time, after providing patients with corresponding levels of humanistic care services,nursing students can also feel their self-worth and strengthen professional identity [23].In the patient safety KAP of nursing students, the correlation coefficient between the "attitude" dimension and humane care is the highest, indicating that the primary condition for the implementation of humane care for patients is to establish the correct state of focusing on patient safety among nursing students.Studies [24]indicated that nurses having a high level of safety perception can provide patients with more high quality nursing services, ensuring the safety of patient and fully reflecting humanistic care in nursing services.

Further analysis of the mediation effect showed that nursing students' patient safety KAP played a partial intermediary role between professional commitment and humanistic care.That is, the professional commitment of nursing students can directly promote the improvement of their humane care, also can through its patient safety KAP indirectly improve the humane care ability, and both two paths are positive influence.The result showed that nursing students with different levels of professional commitment had different levels of knowledge, attitude and practice in patient safety.Professional commitment is a reflection of inner psychological state of nursing students [25],when the nursing students recognize the profession and are willing to work hard for the profession, they will more emphasize patient care and humanistic care in the nursing work.Tonks [26] also emphasized that the future nurses must be people-oriented, taking into account the safety of patients and the cultivation of compassionate humanistic awareness.

In summary,nursing managers and educators should rationally plan the humane care ability training program for nursing students to enable nursing students to objectively understand the nursing profession, cultivate their professional identity and willingness in working for the nursing profession, and improve their awareness and attitude towards patient safety, and internalize patient safety in practice with a view to promote good human care ability and optimize the nursing talent team in a harmonious humanistic care atmosphere.

Conclusion

The results of this study show that the humanistic care ability of nursing students is significantly related to their professional commitment, patient safety KAP,and the professional commitment of nursing students and patient safety KAP are important predictors of humanistic care.Therefore, nursing students should recognize the important significance of professional commitment and patient safety KAP level in humanistic care practice.Nursing educators and managers must pay attention to the creation of a school and clinical humanistic atmosphere, encourage nursing students to participate in humanistic activities such as voluntary activities, nursing home assistance, etc., and improve their humane care ability.The lectures of professional commitment and patient safety must also be developed to allow them to realize the professionalism and necessity of nursing, which can cultivate their excellent professional commitment and implement patient safety knowledge into action,improve humanistic care ability, and then promote the development of nursing students themselves and the development of nursing career.In addition, the research results show that professional commitment has both direct and indirect effects on human care,and the analysis of mediation effects shows that the mediation path is not unique.There are other variables that play a mediation effect between professional commitment and human care.In future studies,we can explore other mediating variables and further analyze their mechanism of action between professional commitment and humanistic care, so as to provide a more powerful basis for improving humanistic care ability of nursing students.