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Changing practice

How using a patient journey approach helps to educate nurses about patient safety

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A children’s hospital redesigned its clinical update sessions, using a patient journey approach to improve staff perceptions of the importance of safety



Annette Marshall, BEd, RM, RGN, is patient safety adviser; Karen Sheehan, MEd, PGDip TLHP, RSCN, RGN, is cardiac clinical nurse specialist; Victoria Webb is education and development facilitator; all at division of women’s and children’s services, Bristol Royal Hospital for Children, University Hospitals Bristol Foundation Trust.


Marshall A et al (2009) How using the patient journey approach helps to educate nurses about patient safety. Nursing Times; 105: 45, early online publication.

A trust decided to use the patient journey approach in its clinical update sessions for staff in children’s services, to emphasise the importance of patient safety. The evaluation showed that using this approach is an effective way of delivering patient safety messages to nurses and allied health professionals.

This article explains the problems related to the previous didactic teaching methods and how an alternative interactive approach has increased staff perceptions of the importance of patient safety. It also demonstrates increased confidence in staff ability to use the skills and knowledge gained in practice.

Keywords: Patient journey, Patient safety, Education

  • This article has been double-blind peer reviewed



Practice points

  • The format of the new session uses the patient journey approach to highlight safety issues, through fictitious patient scenarios, and provides an opportunity for multidisciplinary learning.
  • The evaluation has shown that staff rate the new format much more positively than the previous one.
  • Using the patient journey approach raises awareness of current safety issues and encourages incident reporting and analysis. It also meets the mandatory requirements for trust clinical updates.



University Hospitals Bristol Foundation Trust recommends that all clinical staff attend an update session once every two years to maintain professional competence. The mandatory topics are:

  • Blood transfusion;
  • Record keeping and documentation;
  • Medicines management;
  • Consent;
  • Incident reporting and investigation.

However, managers felt the session that ran until October 2008 had limited value for clinical staff as it failed to keep them updated on new practice and policies.

As a result, a consultation was launched to change the session. The trust trainers’ forum (a children’s service committee dedicated to reviewing training and education) was involved and a proposal was submitted to the head of nursing to change the session.

Ethics approval was not obtained as it was felt the change would not have a detrimental effect on participants. Staff members were sent letters before the session advising them it would be in a new format and they were given a reading list. There was no selection bias as there was no control over the application process.

The new session

The main aim of the new patient safety update was to provide a patient pathway that could be adapted to include the basic themes of the clinical update session. It also aimed to help staff reflect on decision making processes relating to clinical care, by emphasising patient safety issues.

A variety of allied health services, including the Great Western Ambulance Service Trust, were involved in writing the pathway to ensure it was as realistic and relevant as possible. All nursing and allied health professional (AHP) staff in children’s services at the Bristol Royal Hospital for Children attended the training.

The session starts by separating participants into colour coded groups, usually on four tables in teams of six. The aim is to ensure a mix of staff grades and experience and to expose participants to roles and issues in different clinical areas and professions.

The day’s aims and objectives are then set out, followed by an explanation of how these will be met and the resources available.

Each workshop has a theme to ensure all the mandatory trust update areas are covered. There are five workshops in total during the session and all teams undertake them. Then a team is chosen to feed back their thoughts on the patient safety issues raised by the scenario; follow up discussions are supported by the facilitator.

To encourage incident reporting and analysis, several issues are explored that could be identified as adverse events for patients, such as a misfiled blood result and a failed communication between nurse and doctor. The latter is demonstrated with a DVD of two conversations between the nurse and doctor. The first is a rushed exchange between the two, which results in a limited handover of critical patient information. The second conversation references the SBAR (situation, background, assessment, recommendation) structured communication tool, which is being introduced across the trust. The DVD is viewed as part of a scenario, which all groups watch.

The workshops start and the facilitators (usually two) move between groups, helping them to work through the patient safety issues highlighted by the information provided (see Box 1 for an example).

One group then feeds back on the patient safety issues identified by the scenario, supported by a facilitator. A different group is selected for each scenario to ensure all staff have the opportunity to contribute to the session.


Box 1. Workshop 1 – children’s A&E

  • At 11pm a 10 year old boy is involved in an accident, in which he is knocked off his bicycle by a passing car. The ambulance service has radioed ahead to inform children’s A&E that the boy has sustained possible internal injuries.
  • On admission he is conscious and orientated but looks extremely frightened and will not give his name.
  • The patient has a CT scan, confirming abdominal injury which requires surgical intervention. Bloods are taken and analgesia is given. The theatres are all busy so the patient is transferred to the ward at 2.55am.


The trainers facilitate discussion on issues and policies to ensure the groups address the patient safety issues and ideas for improvements in practice. The findings are written on a flipchart to ensure all areas are covered, and any issues not identified can be covered and any gaps in knowledge filled. Box 2 is an example of a flipchart for workshop 1.


Box 2. Patient safety issues

Specific issues:

  • Supervision of 10 year old boy/identity;
  • Communication/documentation from ambulance service;
  • Patient identification;
  • Ward transfer/transferring documentation/information for the ward;
  • Medication – hypersensitivities/history.

Broad areas:

  • Communication;
  • Clinical records;
  • Patient ID policy;
  • Consent;
  • Safeguarding children;
  • Medicines administration;
  • Transfer checklist.


At the end of each workshop one particular issue is reviewed in detail, although all mandatory topics are covered.

The session uses activities based on the information available at a given point in the patient’s journey, referring to current policies and guidelines. Participants use mock notes for fictitious patients to identify potential safety issues, such as misfiled results and poor documentation. 

It is hoped that involving local experts in developing paperwork for the scenarios - such as Great Western Ambulance Service Trust, children’s A&E practitioners, pain nurse specialists and theatre practitioners – ensures the programme is realistic for staff.

From an educational perspective, the session is structured to ensure all types of learners can benefit from participation. This is done by blending learning methods (Honey and Mumford, 1992), such as workshop activities, referencing trust policies, formal and informal discussions, the internet and DVD resources.

At the end of the session, participants are given a monthly patient safety newsletter with updated policy and patient safety information and asked to disseminate this to their colleagues and departments.


We evaluated both the old and new sessions using staff surveys from the evaluation forms. The evaluations given here are based on all sessions in the first year of the new course.

The results were organised into quantitative and qualitative sections and Figs 1, 2 and 3 show some of the most relevant data. Series 1 relates to the old programme and Series 2 to the new one.

The data shows a significant difference in relevance and staff confidence in practical application between the two programmes, despite the information being inherently the same.

Qualitative results

The first issue of note was that participants in the new programme were far more likely to fill in free text sections of the evaluation surveys than those in the old one. For example, there were no general comments in evaluations of the old format and 35 in the new one (all of which were positive). This trend was mirrored for all questions, for example: “I thought the format was very appropriate and made what could have been dry/boring much more interesting and informative.”

Participants were able to identify more relevant issues covered in the new programme (nine) than in the previous one (four). There was a similar finding when looking at most useful learning, where participants identified 11 separate issues in the new programme against five in the old one, with several identifying more than one aspect of learning.

When discussing expectations that were not met, 25% of respondents on the old programme felt the sessions needed to be in greater depth. Only 12% commented on this aspect of the new programme and either gave individual positive suggestions to improve it or issues which were not in the session’s remit.

For example, one participant commented: “It would be useful to use scenarios for specific NICU [neonatalintensive care unit] issues – use on our own study days maybe/teaching sessions.” 

When asked what changes they would like to be made to the programme, participants in the old one made comments around the session’s lack of interest or depth. Staff also made suggestions about the new programme but these were more specific and more positive in tone, for example: “I wanted to practise finding things on DMS [document management system].”


The new session has been cancelled once due to lack of participants as we had felt its interactive nature required a large group. However, the previous format had many cancellations for several reasons, but would have gone ahead with 6-8 participants.

This issue has been raised with the trainers’ forum, and a decision has been made to continue with the new session even if there is only a small number of participants, to ensure the programme maintains momentum.


The new approach has improved staff perceptions of the usefulness of the sessions, and increased their confidence in using the skills and knowledge they gain in practice.

This has been achieved by changing the programme’s format and the people who deliver it, while retaining its mandatory content. It has proved to be an effective method of delivering patient safety messages. 

The pilot of four subsequent sessions had consistently positive evaluations, and the results have been consistent through following sessions and also with different trainers delivering the new programme. 

The trainers’ forum and the head of nursing agreed that this strategy will continue to be used and the model has been adapted for use on the trust induction programme. Since this is attended by medical staff it offers greater opportunities for raising awareness of patient safety across all healthcare professional teams.  

The facilitators decided to send out further evaluation forms to find out whether staff still felt the benefits from the programme a year later. The results are again extremely positive, with respondents remaining confident in the areas covered on the programme and happy to recommend it to others. This has reassured the trainers’ forum that the format will continue.


The new programme for clinical update has shown significant improvements in formal evaluation. Feedback from staff shows the new patient journey format provides a more relevant and useful session. It has achieved the aim of improving the quality of the session and the recommendations for change set out in the original proposal.

However, we do recognise that there are areas for improvement, such as encouraging greater AHP and medical staff participation. In addition, to ensure the programme’s ethos is maintained we have to continue developing new trainers and new pathways, and meeting the changing needs of all staff.



  • The patient safety and quality agenda has increased in importance recently, following the NHS next stage review (Department of Health, 2008) and AnOrganisation with a Memory (DH, 2000).
  • Nurses and allied health professionals need to stay up to date with current patient safety initiatives, and managers want to ensure value when staff attend training and development sessions.



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