Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s1):13515 Investigating the factors influencing nursing students’ competency in patient safety Dyah Wiji Puspita Sari, Muh Abdurrouf, Iwan Ardian, Intan Rismatul Azizah Department of Nursing Management, Faculty of Nursing, Sultan Agung Islamic University, Semarang, Indonesia Abstract Patient safety competencies among nursing students remain challenging and are influenced by various factors, including stud- ent characteristics. This study aimed to assess the correlation bet- ween the cumulative Grade Point Average (GPA), interest, learn- ing motivation, learning style, critical thinking ability, level of patient safety knowledge, and patient safety competencies. A cross-sectional study was conducted involving 232 professional nursing students from a private university in Semarang City, Central Java, Indonesia. Participants were selected using a purpo- sive sampling technique. Data on patient safety competencies were collected through observational sheets, while independent variables were assessed using structured questionnaires. Data were analyzed using chi-squared tests for bivariate analysis and logistic regression for multivariate analysis. Bivariate analysis indicated significant correlations between patient safety compe- tencies and cumulative GPA, interest, learning motivation, critical thinking ability, and the level of patient safety knowledge. Multivariate logistic regression identified interest (OR=2.927) as the strongest influencing factor, followed by GPA (OR=2.424), learning style (OR=1.915), knowledge level (OR=1.904), learning motivation (OR=0.490), and critical thinking ability (OR=0.309). These findings highlighted important implications for nursing education and clinical practice, emphasizing the critical need for integrating patient safety into nursing curricula. Educational strategies should prioritize fostering student interest, enhancing academic performance, accommodating diverse learning styles, promoting critical thinking, and boosting motivation, thereby ultimately improving student competencies and patient safety outcomes. Introduction Nursing students have not yet achieved patient safety compe- tencies.1,2 The level of competence among postgraduate nursing students in implementing patient safety across the six domains is low.3 Factors influencing the low level of patient safety compe- tence among students include the curriculum, the number of semester credit units, learning strategies, and student characteris- tics such as age, gender, duration of admission to the clinic, and educational level.4 In developing the educational process, it is essential to consider these determinant factors in teaching and learning activities, especially in clinical education. These factors are individual aspects that encompass interest, learning motiva- tion, learning styles, and cognitive abilities.5 Nursing students with low patient safety competence are at risk of making mistakes when providing treatment or actions to patients. More than half of the nursing students in the last year were found to be incompetent in terms of their level of knowledge about patient safety.4 This low level of knowledge decreases the implementation of patient safety, which could increase the risk of patient safety incidents.6 Studies have shown that nursing students generally have satis- factory levels of patient safety competency, although there are still areas for improvement. For instance, a study involving 191 nurs- ing students in Northern Cyprus found that while their overall knowledge, skills, and attitudes towards patient safety were satis- factory, they scored the lowest in the knowledge dimension.7 Another study in Iran demonstrated that educational interventions could improve patient safety competencies over time, particularly Correspondence: Dyah Wiji Puspita Sari, Department of Nursing Management, Faculty of Nursing, Sultan Agung Islamic University, Semarang, Indonesia. E-mail: daiyah_04@yahoo.com Key word: critical thinking; interest; learning; motivation; patient safety competency. Contributions: DWPS, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; MA, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; IA, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; IRA, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. Conflict of interest: the authors declare no potential conflict of interest. Ethics approval and consent to participate: this study was approved by the Ethics Research Committee of Sultan Agung Islamic University, Semarang, Indonesia (no. 079/A. I/FIK-SA/XI/2021) on November 19, 2021. Before the study, all respondents signed written informed consent after being explained the procedures, rights, and obligations during the research. Consent for publication: written informed consent was obtained for anonymized patient information to be published. Availability of data and materials: all data generated or analysed during this study are included in this published article. Acknowledgments: the authors would like to express their gratitude to all participants in this study and the hospital for their help completing this research. Received: 22 December 2024. Accepted: 17 March 2025. Early access: 5 June 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13(s1):13515 doi:10.4081/hls.2025.13515 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13(s1):13515] [page 143] in areas such as addressing broader patient safety issues and com- fort in speaking about patient safety.8 Indonesia is a developing country, and many healthcare workers lack a comprehensive und- erstanding of patient safety concepts and definitions.9 No stand- ardized modules or guidelines are available for patient safety tra- ining, leading to significant knowledge gaps.10,11 Patient safety training in Indonesia is not well established and does not meet the needs of healthcare workers. Effective comm- unication and building a patient safety culture were identified as priority areas for training.11 Clinical education plays a crucial role in achieving patient-safety competencies among nursing students. Studies have shown a significant relationship between implement- ing clinical education and achieving patient safety goals.12 The prevalence of patient safety competency in Indonesia is hindered by inadequate training, insufficient integration of clinical educa- tion, systemic issues in incident reporting, and government sup- port. Addressing these challenges through comprehensive training programs, improved clinical education models, and more sub- stantial government involvement is essential for enhancing patient safety competencies in Indonesia.11,12 Therefore, implementing teaching and learning activities must be carefully considered and adjusted for the factors that affect each student.5 However, research in this area has been limited. This study aimed to investigate the correlation between nursing stud- ents’ determinant factors, including the cumulative grade point average (GPA), interest, learning motivation, learning style, level of acquired knowledge, critical thinking skills, and students’ pati- ent safety competencies. Materials and Methods Study design This study was conducted between 2021 and 2022. It emplo- yed a descriptive cross-sectional design to investigate the associa- tion between the cumulative GPA, interest, learning style, learning motivation, critical thinking ability, level of patient safety know- ledge, and patient safety competencies. Participants The respondents were 232 nursing students recruited using a purposive sampling technique. Inclusion criteria included students at the clinical stage in a teaching hospital who were willing to be respondents and had signed the informed consent form. The exclu- sion criteria were students who did not pass the subject of clinical practice and nursing students who had worked in hospitals. This study was conducted at a private teaching hospital in Semarang, Indonesia. Data collection Six instruments were used to collect data in this study. These included cumulative GPA, student interest, learning motivation, critical thinking ability, level of knowledge, and learning style assessed using a high and low scale. Learning style was measured based on kinesthetic and audiovisual scales. GPA was measured using a questionnaire on demographic cha- racteristics in the form of closed-ended questions. Students were requested to choose one of the available answers based on the classification of the cumulative GPA, as determined in the Regulation of the Minister of Education and Culture of the Republic of Indonesia No. 3 of 2020, according to the National Standards for Higher Education. Students’ interests were collected using a learning interest questionnaire in the form of closed ques- tions. The overall scores on this questionnaire were divided into low and high.13 Learning motivation was measured using a ques- tionnaire comprising 19 statements. Similarly, critical thinking skills were measured using a questionnaire containing 17 state- ments with 5 answer choices. The level of acquired knowledge about patient safety was measured using a patient safety question- naire with 15 statements.14 The instrument used to measure patient safety competencies, developed by Sari,15 was adapted from the Joint Commission International. All instruments were tested for validity and reliability, with valid and reliable results. The interest, motivation, and learning style questionnaires were declared valid with p-values of 0.541-0.939, 0.581-0.906, and 0.455-0.916, respectively. Similarly, the critical thinking and level of acquired knowledge questionnaires were also declared valid, with p-value ranges of 0.518-0.913 and 0.459-0.832, respectively. Dependent variable data were collected using an observation sheet, and indep- endent variable data were collected using a structured question- naire. No names were indicated on the questionnaire or observa- tion sheet to ensure anonymity. Data analysis The tabulated results were used for statistical analysis. The data were analyzed using IBM’s Statistical Package for the Social Sciences (SPSS) Version 21.0. A descriptive analysis was perform- ed on the demographic characteristics of respondents, sub-varia- bles of the cumulative GPA, interest, learning style, learning motivation, critical thinking ability, level of patient safety know- ledge, and patient safety competencies. These are represented as percentages, based on the findings of each research variable. An inferential analysis using a chi-square test and multivariate analys- is was performed using logistic regression. Ethical consideration This study was approved by the Ethics Research Committee of Sultan Agung Islamic University, Semarang, Indonesia (no. 079/A. I/FIK-SA/XI/2021) on November 19, 2021. Before the study, all respondents signed written informed consent after receiving an explanation of the procedures, rights, and obligations involved in the research. Informed consent was obtained through ensuring anonymity, confidentiality, fidelity, and autonomy. Results Most respondents were female (203, 87.5%), while 29 (12.5%) were male. All respondents were aged 21 to 25. Furthermore, all participants had received orientation and training on patient safety (Table 1). Bivariate analysis showed that patient safety competencies were related to the cumulative GPA (p=0.017, OR=2.548; 95% CI: 1.181-5.499), interest (p=0.004, OR=3.211; 95% CI: 1.455-7.130), learning motivation (p=0.039, OR=0.45; 95% CI: 0.210-0.962), critical thinking (p=0.004, OR=0.309; 95% CI: 0.139-0.686), and level of patient safety knowledge (p=0.010, OR=2.718; 95% CI: 1.270-5.819). Furthermore, patient safety competence was not related to learning styles (p=0.358). The results of bivariate analys- is are presented in Table 2. Variables in bivariate analysis with a score of <0.25 were included in the logistic regression, namely cumulative GPA, interest, learning motivation, critical thinking ability, and level of patient safety knowledge. Table 3 shows the results of the multivariate logistic regression analysis. It was found that students’ characteristics affecting patient safety competencies Special issue Pathways of Change [page 144] [Healthcare in Low-resource Settings 2025;13(s1):13515] were GPA (p<0.004, OR=2.424; 95% CI: 1.324), interest (p<0.001, OR=2.927; 95% CI: 1.556), learning motivation (p<0.023, OR=0.490; 95% CI: 0.265), critical thinking ability (p<0.001, OR=0.309; 95% CI: 0.163), and level of patient safety knowledge (p<0.038, OR=1.904; 95% CI: 1.035). Discussion The results of the logistic regression test indicated that among all variables correlated with patient safety goals, the strongest influences were, in order of interest, GPA, learning style, level of knowledge, learning motivation, and critical thinking. These find- ings have key implications for nursing education and practice. The study showed that cumulative GPA, interest, learning motivation, critical thinking skills, and the level of patient safety knowledge were associated with the implementation of patient safety compe- tencies of nursing students. A previous study also showed a rela- tionship between the cumulative GPA and the intelligence of nurs- ing students in achieving competence.16 Another study reported that students’ interest affects their involvement and motivation in learning,17 and interest influences learning achievement.18 Previous research has shown a positive and significant relationship between learning motivation and achievement, with a correlation coeffici- ent of 0.462.19 Learning motivation affects learning achievement,20 Special issue Pathways of Change Table 3. Analysis results of the multivariate logistic regression test. Variable Coefficient S.E. Wald df p-value OR 95% CI GPA 0.885 0.308 8.241 1 0.004 2.424 1.324 Interest 1.074 0.322 11.108 1 0.001 2.927 1.556 Learning motivation -0.713 0.313 5.168 1 0.023 0.490 0.265 Learning style 0.650 0.318 4.189 1 0.041 1.915 1.028 Critical thinking -1.175 0.325 13.077 1 0 0.309 0.163 Level of knowledge 0.644 0.311 4.293 1 0.038 1.904 1.035 Constant -2.648 1.049 6.369 1 0.012 0.071 Table 1. Frequency distribution of nursing student characteristics at University Hospital in Semarang City (n=232). Variable Frequency (f) Percentage (%) Gender Male 29 12.5 Female 203 87.5 Age 21-25 years 232 100 25-30 years 0 0 Hospital orientation Yes 232 100 No 0 0 Exposure patient safety Received 232 100 Never received 0 0 Table 2. Patient safety competence-related factors in pre-licensure nursing students (n=232). Variable Indicator scalePatient safety competence p-value Odds ratio 95% CI High Low f % f % GPA High 86 72.3 33 27.7 0.006 2.144 1.241-3.702 Low 62 54.9 51 45.1 Interest High 85 72.6 32 27.4 0.005 2.192 1.268-3.792 Low 63 54.8 52 45.2 Learning Motivation High 55 55 45 45.0 0.015 0.513 0.298-0.882 Low 93 70.5 39 29.5 Learning Style Kinesthetics 85 66.4 43 33.6 0.358 1.286 0.751-2.203 Audiovisual 63 60.6 41 39.4 Critical Thinking High 65 54.2 55 45.8 0.002 0.413 0.237 - 0.719 Low 83 74.1 29 25.9 Level of knowledge High 86 71.6 35 28.9 0.016 1.942 1.128 -3.342 Low 62 55.9 49 44.1 [Healthcare in Low-resource Settings 2025;13(s1):13515] [page 145] including the achievement of patient safety competencies. A cross- sectional study in South Korea showed that critical thinking is positively correlated with the performance and achievement of nursing students’ academic competencies.21 Nurses’ compliance with patient safety principles is influenced by their level of patient safety knowledge, attitudes, and perceptions about safety issues.22 This study’s findings emphasize that nursing education institu- tions must enhance student quality factors, such as average cumulative GPA, interest, learning motivation, critical thinking abilities, and knowledge, to improve patient safety outcomes. These characteristics will enhance students’ execution of patient safety, consequently diminishing the likelihood of patient safety incidents.6 Averted patient safety incidents will strengthen the qua- lity of recognition services.23 The findings of this study are pertinent to research indicating that students’ determining factors include interests, learning motivation, learning styles, and critical thinking, all of which are associated with attaining student competence.5 However, a limita- tion of this study is that it only examined the factors determining students’ achievements in patient safety competencies. Future rese- arch should broaden its scope to include factors beyond those rela- ted to students, such as the influences of clinical educators and the learning facilities. Critical thinking skills are crucial for healthcare professionals as they directly influence patient safety, particularly in critical situations. Nurses, especially those in intensive care units, need to develop strong critical thinking abilities to manage complex patient care scenarios effectively. Nursing programs emphasize the development of critical thinking as a core compe- tency, which is necessary for accreditation and ensuring high-qua- lity patient care. This focus on critical thinking is reflected in the curriculum design and assessment methods used in healthcare education.24 Engaging students in interactive and innovative learn- ing experiences, such as simulations and case-based learning, enhances their critical thinking skills and prepares them for real- world clinical challenges; these methods help students apply theo- retical knowledge to practical scenarios, improving their decision- making and problem-solving abilities.25,26 Interest and critical thinking in students significantly predict patient safety goals because they directly impact students’ capacity to make sound clinical decisions, prevent errors, and ensure high-quality patient care. Educational programs that prioritize the development of these skills through interactive and innovative learning experiences are essential for preparing health care professionals to meet patient safety standards. Implications Nurses should participate in ongoing professional develop- ment to improve their patient safety skills. This includes staying current with the latest information on patient safety and actively engaging in training that enhances critical thinking and problem- solving abilities. Therefore, experienced nurses should mentor nursing students and emphasize the importance of interest, motiva- tion, and critical thinking in patient safety. By sharing their experi- ences and strategies, they can help students understand and effecti- vely apply patient safety principles. Nurses should actively seek feedback and reflect on their practices to identify areas of improve- ment. By fostering a culture of safety and promoting an environ- ment in which patient safety is a priority, they contribute to reduc- ing safety incidents. This research has implications for nursing students, who should strive to maintain a high cumulative GPA, as it correlates with better patient safety competencies. This means dedicating adequate time and effort to their studies and seeking help when necessary to achieve academic excellence. Students should actively engage in their learning process by developing a strong interest in patient safety and maintaining high motivation levels. This includes participating in extracurricular activities and seeking opportunities for practical experience. Collaboration among healthcare institutions, educational organizations, and community groups can foster initiatives aimed at improving nurs- ing education and patient safety. This may include joint programs, funding for research, and public awareness campaigns. Limitations This study focused solely on student characteristics, excluding potentially influential factors such as clinical educators, learning facilities, and educational methods. 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