From leadership research to district action: Educational Level and Length of Work Experience as Correlates of Adverse-Event Reporting and Patient-Safety Perception Among Nurses in Croatian General and County Hospitals: A National Cross-Sectional Study

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Evidence and transfer

Education-related source: verify which participants, institutions and outcomes were actually studied before district adoption. Source publication type: research-article. License and identity checks do not establish study quality or causality.

Original authors’ abstract, reproduced under the source license:

Abstract Background/Objectives: Formal level of education and length of professional experience are widely thought to shape both how often nurses report adverse events and how safe they perceive their workplace to be for patients. Large multicentre data from Central and Eastern European secondary-care systems are scarce. This study examined whether educational level and length of work experience are associated with (a) the self-reported frequency of adverse-event reporting and (b) the perceived level of patient safety in a national sample of nurses working in Croatian general and county hospitals. Methods: We conducted a cross-sectional, multicentre survey in 2023 across all 22 general and county hospitals in the Republic of Croatia. A 99-item paper questionnaire—81 items distributed across six previously validated scales (Cronbach’s α 0.730–0.951)—was distributed proportionally to the eligible nursing workforce (N = 6661). Of the 1657 questionnaires distributed, 1518 were returned fully completed (response rate 91.6%). Two outcomes were examined in parallel: self-reported frequency of adverse-event reporting in the past 12 months and global perceived level of patient safety on the respondent’s ward. Group comparisons used Pearson’s chi-square and Kruskal–Wallis H tests; effect sizes were estimated using the phi coefficient and Cramér’s V. A multivariable logistic regression was additionally fitted to test whether the associations held after mutual adjustment. The study followed the STROBE reporting guidelines. Results: Educational level was associated with the frequency of adverse-event reporting (χ2 = 32.54, df = 8, p < 0.001; Cramér’s V = 0.10) and with safety perception (χ2 = 16.07, df = 8, p = 0.041; V = 0.07). Length of total work experience was associated with reporting (χ2 = 23.01, df = 12, p = 0.028; V = 0.07) and safety perception (χ2 = 34.84, df = 12, p < 0.001; V = 0.09). After mutual adjustment, bachelor’s (adjusted OR 1.41, 95% CI 1.10–1.81; p = 0.006) and master’s or doctoral education (adjusted OR 1.82, 95% CI 1.27–2.62; p = 0.001) remained associated with active reporting relative to secondary-level qualification. A notable finding was that 930 nurses (61.3%) had not filed any adverse-event report in the past 12 months. Conclusions: Educational level and length of work experience are associated with both the reporting of adverse events and the perception of patient safety among Croatian hospital nurses, but the two characteristics relate to the outcomes in different ways. Higher education is associated with more frequent reporting and a more favourable view of patient safety. Length of experience shows a mid-career peak in reporting but a less favourable perception of safety in late-career nurses. Continued investment in formal nursing education, together with mid- and late-career retention strategies, may strengthen both reporting behaviour and the lived safety culture in Central and Eastern European secondary-care systems. The findings inform nursing leadership, continued education planning, and national patient-safety policy in Central and Eastern European secondary-care systems. Keywords: adverse events, patient safety, nursing education, work experience, safety perception, safety culture, incident reporting, cross-sectional studies, nursing workforce, Croatia

Study methods

A national, cross-sectional, multicentre, quantitative survey was conducted in 2023 in all 22 general and county hospitals in the Republic of Croatia. The study followed the STROBE Statement for cross-sectional studies (Supplementary Material S1). The aim, population, hypotheses, and statistical plan were specified prior to data collection as part of the doctoral research protocol approved by the participating institutions.

Limitations

The principal strengths of this study are its national scope—all 22 general and county hospitals in Croatia were included—the high response rate (91.6%), the use of six previously validated scales with confirmed internal consistency (Cronbach’s α 0.730–0.951), and the pre-specified analytic plan documented in the underlying doctoral protocol. The two outcomes were examined in parallel rather than separately, allowing for a comparative interpretation of education and experience gradients, which constitutes the main contribution of this paper. Limitations include the cross-sectional design, which precludes causal inference—all associations reported here are correlational and cannot establish directionality between sociodemographic characteristics and reporting or safety-perception outcomes; reliance on self-reported frequency rather than verified hospital reporting-system data, which is subject to recall and social-desirability biases; convenience sampling within each hospital; the single-country sampling frame, which limits generalisability to other Central and Eastern European systems with different reporting infrastructures or workforce profiles; and the under-representation of male nurses, which mirrors the Croatian workforce structure but limits sex-stratified analyses. The pooling of master’s and doctoral participants into a single VSS+DR category was necessary because of the small number of doctoral-level nurses; as the Croatian workforce continues to develop, future analyses should examine the doctoral subgroup separately. Finally, one chi-square test marginally exceeded the conventional 20% expected-frequency-below-five threshold and is reported with the corresponding caveat.

A 90-day district inquiry

Days 1–15 · Appraise. Read the source methods, recruitment, comparator, outcomes and limitations. Record how the study setting differs from your district and which claim the design can support.
Days 16–30 · Design. Choose one school improvement question with teachers. Protect a short shared planning cycle, agree an instructional change and use a common rubric for examining student work. Agree participation, privacy protections, baseline and stopping rules before starting.
Days 31–60 · Observe. Collect the pre-agreed measures, keep a log of implementation changes and invite confidential voluntary feedback. Preserve existing support for staff and learners.
Days 61–90 · Decide. Review implementation fidelity, teacher time and independently scored student work against a recorded baseline. Examine access differences and competing explanations before attributing changes to leadership. Make a dated decision to stop, revise or extend the inquiry.

Board decision brief

Present the local problem, source setting, evidence limits, intervention, responsible owner, total cost, measured changes and uncertainty. Separate staff perceptions, implementation measures and student learning outcomes.

Attribution and reuse

Ivana Herak; Marijana Neuberg; Valentina Vincek; Valentina Novak; Anita Lukić. Educational Level and Length of Work Experience as Correlates of Adverse-Event Reporting and Patient-Safety Perception Among Nurses in Croatian General and County Hospitals: A National Cross-Sectional Study. Nursing Reports (2026-06-26). https://doi.org/10.3390/nursrep16070220

Prepared 2026-11-07. Source authorship and DOI are preserved. The abstract and source passages are attributed extracts; this editorial guide is offered under the same CC BY 4.0 license.