The perception and communication of patient safety concerns among nursing students: A multicenter cross-sectional study

Objective:This study explored how nursing students in Austria perceive and communicate patient safety concerns during clinical internships and which individual and contextual factors influence their willingness to speak up. 
Methods: A multicenter cross-sectional survey was conducted between February and June 2024 at twelve universities of applied sciences in Austria. Nursing students completed a validated questionnaire assessing experiences with patient safety concerns, speaking-up behaviour, perceived barriers and enablers, and the clinical speak-up climate. Multivariate analyses were used to examine factors associated with speaking up and remaining silent.
Results: Of 797 complete responses included in the analysis, 79% encountered safety concerns, yet 58\% withheld their voice at least once. Fear of negative consequences (62%) and uncertainty about reactions (51%) were the most common barriers. Prior healthcare experience was associated with higher vignette realism (p = .024) and lower discomfort (p = .017). Concern frequency strongly predicted both speaking up (OR = 3.54, p < .001) and withholding voice (OR = 5.89, p < .001). Psychological safety and an encouraging environment reduced withholding voice, whereas resignation increased the odds of both behaviors. Specialty effects were modest: students in neurology spoke up less (OR = 0.50, p = .027), while those in outpatient and long-term care withheld voice less (OR = 0.63, p = .038). Despite recognizing high risk in the vignette, students reported low likelihood of intervening.
Conclusions: Nursing students frequently recognize patient safety risks but often do not act on them. This disconnect highlights the need for early educational interventions that strengthen communication skills, reduce fear, and counter resignation by fostering psychologically safe learning environments.