Theoretical framework

This study is based on Patricia Benner’s theory [17] which explains how a solid educational foundation and a variety of experiences help nurses grow their abilities and knowledge of patient care over time. The Dreyfus Model of Skill Acquisition, which describes five phases of proficiency—novice, advanced beginner, competent, proficient, and expert—lays the foundation for this idea. According to Patricia Benner’s perspective, nurses gain knowledge and comprehension of patient care through education and experience over time. Five levels of nursing skill are distinguished by this classification: competent, proficient, expert, advanced beginning, and novice which are progressed gradually among junior nurses in Palestine Ministry of Health hospitals. The effort can effectively assist junior nurses in their transition from novices to experts by matching the QSEN-based curriculum with Benner’s Novice to novice-to-expert theory. This strategy makes sure they acquire the know-how, abilities, and mindset needed to deliver safe, effective patient care while taking into account the particular difficulties presented by the Palestinian healthcare system.

Study design

A quasi-experimental within and between-subject design was used. Quasi-experimental designs may enhance the external validity of the study by reflecting real-world conditions more closely. This is important for translating research findings into practical applications in healthcare. The study adhered to the guidelines provided in the TREND Statement checklist.

Study settings and population

The research was conducted in two governmental hospitals. Both of the selected hospitals were educational-affiliated hospitals and are a reference for the Palestinian MOH and their diverse departments covering a range of medical specialties. These two hospitals are The PMC Hospital in Ramallah and Rafidia Hospital in Nablus.

PMC, originally named the Ramallah Governmental Hospital, is a strategically important healthcare institution in the central region of the West Bank. It includes the Bahraini Hospital for Children, the Kuwaiti Hospital for Heart and Specialized Surgeries, and the Sheikh Zayed Hospital for Emergency Care. PMC serves as a reference and teaching hospital with various departments such as pediatrics, emergency medicine, internal medicine, general surgery, orthopedics, critical care, and gynecology. The hospital has 490 beds, around 1,050 administrative and medical staff, and a dedicated nursing team of 400. Rafidia Hospital, located in Nablus City, is a governmental surgical facility founded in 1976. As one of the largest healthcare institutions in the northern region of the West Bank. It has a bed capacity of 207, and the hospital serves as a crucial healthcare center, providing specialized surgical treatments [18].

Sampling

The study examined registered nurses currently working in different departments at PMC in Ramallah and Rafidia hospitals in Nablus. The sample included a total of 164 nurses, with 100 from PMC and 64 from Rafidia Hospital. The study utilized G*Power to determine the required sample size, guided by a medium effect size of 0.5 with a significance level α of 0.05 and a statistical power of 0.8 [19]. A total of 64 participants per group were calculated as necessary for conducting a t-test to detect the expected difference between groups. Researchers employed a random sampling method to select participants based on pre-defined inclusion criteria from two hospitals. They divided the selected participants into two groups: an intervention group from PMC hospital that received the QSEN competency program, and a control group from Rafidia hospital that did not receive the program. A comprehensive list of participants was created, including PMC Nurses (N1, N2, N100) and Rafidia Nurses (N1, N2, N64), totaling 164 participants. Sixty-four participants from Rafidia Hospital were purposefully chosen for the control group, while the remaining 100 participants were selected for the intervention group, all based on predetermined inclusion criteria. Participants are required to be (a) registered nurses including five years of experience or less. (b) work in one of the following departments: internal medicine, surgical, pediatric, intensive care unit (ICU), daily care, and neurosurgery departments. On the other hand, nurses with more than five years of practical experience, midwives, and nurses in other departments were not included in the study.

Data source and measurement

The QSEN competency program is a complete method of nursing education and practice that gives nurses the KSAs required to collaborate with interdisciplinary teams to deliver safe, high-quality, PCC [8]. It places a focus on constant learning, advancement, and ethical issues in healthcare. By putting QSEN competency into practice in a hospital setting, nurses are given the tools they need to deliver PCC effectively to enhance healthcare outcomes and foster a culture of ongoing learning and QI throughout the healthcare system [20]. The researcher’s goal is to provide information on practical methods for raising nurses’ KSAs, which will subsequently improve PS and healthcare standards. The following teaching methods were employed including, Lectures; Case-Based Learning; Simulation: Group discussions; Role-playing; Problem-based learning; Flipped classroom; and Experiential Learning.

To raise PS and the caliber of healthcare, researchers have used a training tool that is specifically designed for QSEN Competency. This tool gives junior nurses the KSAs they need to provide safe and effective care by utilizing visual aids, videos, interactive software, checklists, patient stories, models and displays, and demonstrations.

The context of QSEN competency involves evaluating whether nurses have acquired the KSAs necessary for safe and high-quality patient care through utilizing the following methods, clearly defining learning outcomes, using diverse assessment methods, direct observation, written assessments, and skills assessment.

A self-completion questionnaire was developed to collect information on the participants’ demographic data as well as their QSEN competency results from the program. It included a variety of questions to assess nurses’ competencies in a range of important areas, including patient-centered care, Teamwork, EBP, QI, Safety, and Informatics, and also to assess nurses’ KSAs regarding patient-centered care. The questionnaire consisted of structured questions with defined response formats, making it easier for participants to complete. The questionnaire was given to both the intervention group, which received the QSEN competency program, and the control group, which did not get the program. Through a comparative analysis of responses from the two distinct groups, the efficacy of the QSEN competency program was systematically evaluated. The assessment of the QSEN competency program’s potential impact was realized through the administration of a structured questionnaire to the nursing participants on two occasions first, before the initiation of the intervention program, and subsequently after its completion.

The study utilized a self-administered questionnaire that contains three parts, Part I (Social Demographics) includes six questions: The nurse’s age, sex, marital status, higher education (master’s degree or high diploma), years of experience, and name of the university graduated from. Part II: Clinical Performance Evaluation Questionnaire (CPEQ) that originated [21]. The CPEQ is a tool used to measure the clinical performance of healthcare professionals. It is a self-administered questionnaire comprising 32 items divided into six domains, including PCC items 8 items, teamwork 7 items, EBP 2 items 3 items, safety 6 items, and informatics 6 items. The internal consistency measured by Cronbach’s alpha of 0.70 indicates good internal consistency, test-retest correlations varied from 0.57 to 0.85. There were 127 items in the completed survey. Five-point ratings on items about care experiences ranged from "not at all" (1) to "a very large extent" (5). Reverse coding was used to identify negative elements, and a higher score indicated a better experience overall. Scales were converted to scores, with 100 representing the best outcome, on a scale of 0 to 100. Part three: Patient-centered Care Scale (KSAI-PCCS) that was developed by Esslin [22]. The KSAI-PCCS is a comprehensive tool designed to assess nurses’ patient-centered KSAs. The KSAI-PCCS is a 54-item instrument with three subscales: Knowledge (19 items), Skills (17 items), and Attitudes (18 items)—KSA. The instrument subjectively measures the three domains of PCC competencies for nursing practice. On a scale of 0 to 5 rate the frequency of ability and application of knowledge, skills, and attitudes specific to patient-centered care, where 0 = never, 1 = very rarely, 2 = rarely, 3 = occasionally, 4 = frequently, and 5 = very frequently. Cronbach’s alpha for each of the KSA subscales was greater than .70 with a minimum score of 10 and a maximum of 50. The higher score indicates strong knowledge, well-developed skills, and positive attitudes toward patient-centered care and vice versa.

The QSEN competency program serves as a key component of the research study. This tool is designed to implement the QSEN competency program, which focuses on enhancing the knowledge and skills of nurses in the areas of quality and safety in healthcare. The tool includes structured interventions, educational resources, and training modules aimed at improving nurses’ abilities to provide high-quality, safe patient care. Through the QSEN competency program, participants receive targeted education and training, ultimately enhancing their competence in these critical areas. This intervention tool assesses the impact of the QSEN competency program on nurses’ performance and their ability to deliver quality and safe healthcare services. The QSEN competency initiative is a national initiative that aims to transform nursing education by integrating six core competencies: PCC, Teamwork and Collaboration, EBP, QI, Safety, and Informatics.

This QSEN competency program was extracted from QSEN competency institutions, the WHO PS Assessment Manual, and the literary work authored by Christie in 2014, titled "Introduction to QSEN, Core Competencies, intricately strives to elevate the standards of nursing education and, concomitantly, enhance patient care. The QSEN competency program modules created by the QSEN competency institutions aim to enhance nursing education and patient care by providing a comprehensive understanding of quality and safety in healthcare. The modules cover essential topics, including the critical role of nurses, the imperative of quality and safety, and the enhancement of nursing competence in these areas. Through lectures, interactive discussions, case study analysis, and application tools for patient safety, participants actively engage in learning. The program is flexible, allowing customization to meet the specific needs and goals of both the research and participants. Learning outcomes in the QSEN competency model align with Bloom’s Taxonomy, encompassing various cognitive skill levels, and focus on six competencies: patient-centered care, teamwork and collaboration, EBP, QI, safety, and informatics [23].

According to earlier research using this method [24, 25] which reported that the items used have a Cronbach’s alpha(s) ≥ 0.70 with strong recommendations of the current content.

Five nursing specialists assessed the questionnaire and endorsed its content validity. No changes were required to the chosen tool or the intervention program after the panel assessed the items, which were found to be representative of all domains of interest. With an overall Content Validity Index (CVI) of 0.88, the expert panel determined that the majority of the items were extremely relevant.

Although the CPEQ and KSAI-PCCS are validated instruments widely used to measure clinical performance and patient-centered care competencies, their specific reliability and validity have not been extensively tested in the Palestinian healthcare context. So, cultural adaptation was modified according to pilot testing. Future research should prioritize conducting context-specific validation studies to ensure the appropriateness and robustness of these tools in similar settings.

Data collection procedure

In both the PMC and Rafidia Hospital, comprehensive approval was obtained from the Ministry of Health. Interviewed hospital administrators, which determined the objectives of the study and the expected impact of the program on nursing performance QSEN competency. A meeting was also held with nursing directors to arrange appropriate lists for filling out the questionnaire, both in Rafidia, which be without the intervention of the education program, and in the complex that will receive training on the QSEN competency program. A thoughtful process for collecting samples, taking into account the inclusion criteria. The nursing staff was then classified into the intervention group at the PMC or the control group at Rafidia Hospital. Five groups (20 nurses for each group) were set up at PMC to receive the QSEN competency program, which included pre-tests, a 4-hour QSEN competency intervention, and post-tests. At Rafidia Hospital, 64 nurses, in the control group, underwent pre- and post-questionnaire assessments with a two-week interval for the control group without the intervention program. The intervention group participated in the QSEN competency training program for four hours for each group, and homogeneity testing ensured comparability between groups. All nursing staff were informed of the objectives of the study, signed a participation agreement, and could withdraw at any time, and QSEN competency-focused training sessions began in October 2023. Following the QSEN competency intervention, final assessments of nursing competencies were conducted by redistributing the questionnaire, facilitating the assessment of the impact of the program on participants. In both groups, the pre- and post-questionnaires were numbered with the same number for the same person emphasizing the systematic nature of the study implementation.

Ethical statements

All participants were asked for their informed consent. Participants were made aware of their freedom to leave the research at any time and without consequence. Anonymity and confidentiality were maintained by protecting the identity of the participants. Data were stored in secure, password-protected databases. Full data were given regarding the intervention duration, questionnaire completion needed from 15–20 minutes to be filled out, and reminders about the upcoming session. The institutional review board (IRB) from the University and MOH authorized the study under number (#2023/A/137/N). The researcher obtained approval to use the instruments.

Statistical methods

Statistical Package for SocialSience (SPSS) version 28 was used to analyze the collected data. Descriptive statistics were employed to summarize and present the main features of the dataset (measures such as mean, median, mode, range, and standard deviation). Each variable of interest, including junior nurses’ KSAs, was subjected to descriptive analysis. This step allowed for a comprehensive overview of the central tendencies and variability within the dataset. Besides, reliability tests were conducted to assess the consistency and stability of the measurement instruments, particularly the questionnaire used to collect data on junior nurses’ KSAs; paired sample statistics were utilized to compare the performance of junior nurses before and after the implementation of the QSEN competency-based program. For descriptive statistics; the Shapiro-Wilk test was used to evaluate the normally distributed population of the collected data. Inferential statistics used the paired t-test of the Mann-Whitney U test if the data were normally distributed, and the Wilcoxon Signed Rank test if the data were not normally distributed.

Participants’ characteristics

Most of the participants worked in the general surgery department (36%), about (59.5%) were females, (60.7%) were married women. There were no statistically significant differences between the two groups in these characteristics, except for their level of education and place of study. The majority of participants held a first university degree and were graduates of either An-Najah National University (25.3%) or the Ibn Sina Institute (24%), with statistically significant differences observed between the groups in these respects.

The study revealed that participants had an average age of around 28 years and an average of approximately 4 years in their current job. There was no statistically significant difference between the control and interventional groups in terms of these variables. Most variables between the two groups did not show statistically significant differences. The Mann-Whitney U test was employed to assess potential differences in quality and safety competence scores between the two groups at baseline since the data were not normally distributed Table 1.

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Table 1. Comparison of the participants’ characteristics among control vs. interventional groups (n = 65 vs. 99 respectively).

https://doi.org/10.1371/journal.pone.0317448.t001

Baseline averages level of quality and safety competence subscales among participants

Before the educational process began, it was observed that participants in the control group had higher average scores in quality and safety competence compared to those in the interventional group. Specifically, in Patient-Centered Care (17.72 ±4.87 vs. 13.99±5.24), Teamwork & Collaboration (14.93± 4.36 vs. 11.83±4.09), Evidence-Based Practice (4.10± 1.26 vs. 3.27±1.27), Quality Improvement (6.16± 2.04 vs. 4.92±1.98), Safety (13.40±3.99 vs. 10.78±4.38), and Informatics (13.89±2.83 vs. 9.92±4.05). These differences in average scores between the two groups were statistically significant (p < 0.001) and could be related to the pre-existing knowledge and experience of the participants in the control group who might have had more prior education or work experience related to quality and safety competence (Table 2).

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Table 2. Baseline averages quality and safety competence subscales among the participants.

https://doi.org/10.1371/journal.pone.0317448.t002

The post-test averages the level of quality and safety competence subscales among the participants

Participants in the interventional group showed higher average scores in quality and safety competence subscales compared to those in the control group. Specifically, in Patient-Centered Care (22.89± 2.26 vs. 18.28±4.24), Teamwork & Collaboration (19.52± 2.36 vs. 16.57±3.72), Evidence-Based Practice (5.60±0.73 vs. 4.15±1.25), Quality Improvement (8.45± 1.08 vs. 6.48±1.81), Safety (17.12 ±1.52 vs. 13.60±3.41), and Informatics (16.82±1.99 vs. 15.06±2.31). These differences in average scores between the two groups were statistically significant (p < 0.001) (Table 3).

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Table 3. Mann Whitney U test to assess the difference between the level of quality and safety competence subscales among the participants (Control vs. Interventional) in the study.

https://doi.org/10.1371/journal.pone.0317448.t003

The difference between the baselines and posttest after intervention of average level of quality and safety competence subscales among the control group participants

The study found that among participants in the control group, the average levels of quality and safety competence subscales were nearly unchanged between the baseline (pretest) and post-test after intervention. Specifically, in Patient-Centered Care (17.68±4.78 vs. 18.14±4.37), Teamwork & Collaboration (15.13± 4.24 vs. 16.46±3.82), Evidence-Based Practice (4.17± 1.22 vs. 4.12±1.26), Quality Improvement (6.21± 2.01vs. 6.50±1.85), Safety (13.38± 3.89 vs. 13.57±3.48), and Informatics (13.89± 2.83 vs. 14.97±2.38). These differences between pretest and post-test scores after intervention among the control group participants were not statistically significant in all subscales of quality and safety competence, except for the Teamwork & Collaboration subscale, where a statistically significant increase was observed (p = 0.023). The post-test score was slightly higher compared to the baseline score (Table 4).

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Table 4. Wilcoxon Signed Rank Test to assess the difference between the pretest and post-test after intervention of average level of quality and safety competence subscales among the interventional group participants.

https://doi.org/10.1371/journal.pone.0317448.t004

Difference between the pretest and posttest after intervention of an average level of quality and safety competence subscales among the interventional group

Participants in the interventional group showed higher average levels of quality and safety competence subscales in the post-test compared to the baseline (pretest). Specifically, in Patient-Centered Care (22.77±2.33 vs. 13.72±5.17), Teamwork & Collaboration (19.48±2.36 vs. 11.81±4.09), Evidence-Based Practice (5.57± 0.75 vs. 3.28±1.27), Quality Improvement (8.42±1.09 vs. 4.93±1.98), Safety (17.07±1.53 vs. 10.71±4.38), and Informatics (16.77±2.03 vs. 9.82±4.07). However, these differences between the baseline (pretest) and post-test scores after the intervention among the interventional group participants were not statistically significant in all subscales of quality and safety competence (p > 0.05).

Impact of QSEN on the knowledge, skills, and attitudes of junior nurses working in the Palestinian Ministry of Health

The distributions of knowledge, skills, and attitudes were found to be not normally distributed according to Kolmogorov-Smirnov and Shapiro-Wilk tests. Approximately 70% of participants in the control group had knowledge scores ranging from 29 to 79 out of 100, while in the intervention group, scores ranged from 30 to 70 out of 100. Similarly, for skills, around 70% of participants in the control group scored between 21 to 69 out of 100, compared to 26 to 60 out of 100 in the intervention group. In terms of attitudes specifically, approximately 70% of participants in the control group had scores between 24 to 77 out of 100, while in the intervention group, scores ranged from 25.5 to 66 out of 100.

The average knowledge level was slightly higher in the control group (54.06±25.06) compared to the experimental group (50.37±20.16), but this difference was not statistically significant (p = 0.29). Regarding skills and attitudes, the average scores in these areas were also slightly higher in the control group (skills, 45.1±23.99, attitudes, 50.67±26.57) compared to the intervention group (skills, 43.77±17.73, attitudes, 45.88±23.99). However, these differences were not statistically significant (p > 0.05). Therefore, both groups had similar average levels of skills and attitudes before the educational interventions. These findings suggest that there was no significant disparity between the groups before the educational procedures, allowing for a meaningful comparison of the impact of the interventions.

To assess the impact of an educational procedure on quality and safety knowledge, skills, and attitudes among participants in the intervention group, a Mann-Whitney U test was employed due to non-normal distribution. Table 3 confirms that post-procedure, participants in the intervention group exhibited significantly higher levels of knowledge compared to those in the control group (77.02±16.39 vs. 49.19±26.91, p < 0.001). Similarly, post-procedure, participants in the intervention group also demonstrated significantly higher levels of quality and safety skills (70.16±13.91 vs. 44.61±25.13, p < 0.001) and attitudes (75.47 ±13.94 vs. 46.16± 27.41, p < 0.001) compared to the control group. These findings indicate a substantial positive impact of the educational intervention on knowledge, skills, and attitudes related to quality and safety.

The Wilcoxon Signed Rank Test was used to examine the difference in average levels of quality and safety knowledge, skills, and attitudes between baseline (pretest) and posttest among participants in the control group of the study since the data was not normally distributed. The analysis revealed that there was minimal change in the average levels of quality and safety knowledge (54.06 ±25.06 vs. 49.19±26.91), skills (45.10± 23.99 vs. 44.61±25.13), and attitudes (50.67± 26.57 vs. 46.16±27.41) from baseline to posttest among participants in the control group. These differences were not statistically significant (p > 0.05), indicating that the intervention did not lead to measurable improvements in these areas among the control group.

The study utilized the Wilcoxon Signed Rank Test to assess changes in average levels of quality and safety knowledge, skills, and attitudes from pretest to post-test among participants in the interventional group since the data was not normally distributed. Results indicate significant improvements in quality and safety knowledge (50.37±20.16 to 77.02±16.39), skills (43.77±17.73 to 70.16±13.91), and attitudes (45.89±20.22 to 75.47±13.94) following the intervention compared to baseline measures. These differences were statistically significant (p < 0.05), highlighting the effectiveness of the intervention in enhancing participants’ understanding and capabilities in quality and safety practices Table 5.

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Table 5. Wilcoxon Signed Rank Test to assess the difference between the pretest and post-test after intervention of average level of quality and safety knowledge, skills, and attitude among the interventional group participants in the study.

https://doi.org/10.1371/journal.pone.0317448.t005

Implications for research and practice

This study has several recommendations that focus on the urgent need for deliberate integration of QSEN core competencies into local and regional nursing school curricula, along with validation of these skills for hospital administration. Furthermore, it is recommended that the Ministry of Health (MOH) should formalize the QSEN competency assessment as an ongoing part of every registered nurse’s professional development plan. Allocate resources towards the evaluation and development of nurse preceptors to enhance their understanding and demonstration of QSEN competencies and KSAs. Further research is necessary to explore specific interventions in educational QSEN competency programs within hospitals, targeting improvements in nurses’ patient-centered care competencies, as assessed by the KSAI-PCCS.

To sum up, the QSEN program has significantly enhanced the knowledge, skills, and attitudes of junior nurses at the Palestinian Ministry of Health, contributing to improved patient care. Continued investment in QSEN education and its principles is crucial for sustaining and advancing healthcare quality and safety. Future research should focus on long-term impacts and broader applications to further validate and enhance the program’s effectiveness.

Strengths and limitations

This study encapsulates a pioneering issue conducted in Palestine, assessing the effects of a QSEN-based program on the knowledge, skills, and attitudes (KSAs) of junior nurses employed by the Palestinian Ministry of Health. While the research yielded significant results, several limitations were noted. The current study’s findings are subject to limitations that warrant careful interpretation. The variability in baseline competencies of knowledge, skills, and attitudes among junior nurses likely influenced the degree of improvement observed, with potential ceiling effects in high-performing participants and amplified gains in those with lower initial competencies. Additionally, the small sample size may have limited the statistical power to detect significant effects and reduced the generalizability of the findings to the wider population of junior nurses in Palestine. Additionally, the reliability and validity of instruments were described. However, the reliability and validity of these tools in the Palestinian context were not extensively tested, which is a limitation. To address these issues, future research should employ stratified analyses, covariate adjustments, and larger, multicenter samples to enhance the robustness and applicability of the results.