Journal of Nursing Education

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Research Briefs 

Impact of a Patient Safety Curriculum for Nurse Anesthesia Students

Laura L. Ardizzone, MS, BSN, DNP(c); William M. Enlow, BSN, MS, DNP(c); Eileen Y. Evanina, BSN, MS, DNP(c); Rebecca Schnall, BSN, MPH, PhD; Leanne Currie, MSN, DNSc

Abstract

Patient safety has become an important aspect of national health care initiatives. The purpose of this evaluation was to measure the impact of a patient safety education series for students enrolled in a nurse anesthesia program. Baseline surveys that measured patient safety competencies across three domains, attitudes, skills and knowledge, were administered to the students. A patient safety education series was delivered to the cohort and the survey was then readministered. Mean scores were compared using independent samples t tests. Attitude scores did not change from baseline to posttest. Participants scored higher on posttest means for both the patient safety skills and knowledge domains. Incorporating patient safety content into the nurse anesthesia master’s degree curriculum may enhance clinicians’ skills and knowledge related to patient safety, and the addition of a patient safety curriculum is important during the formative education process.

Abstract

Patient safety has become an important aspect of national health care initiatives. The purpose of this evaluation was to measure the impact of a patient safety education series for students enrolled in a nurse anesthesia program. Baseline surveys that measured patient safety competencies across three domains, attitudes, skills and knowledge, were administered to the students. A patient safety education series was delivered to the cohort and the survey was then readministered. Mean scores were compared using independent samples t tests. Attitude scores did not change from baseline to posttest. Participants scored higher on posttest means for both the patient safety skills and knowledge domains. Incorporating patient safety content into the nurse anesthesia master’s degree curriculum may enhance clinicians’ skills and knowledge related to patient safety, and the addition of a patient safety curriculum is important during the formative education process.

Ms. Ardizzone, Mr. Enlow, and Ms. Evanina are Doctoral Students and Assistant Professors of Clinical Nursing; Dr. Currie is Assistant Professor of Nursing, and Dr. Schnall is Faculty, Columbia University School of Nursing New York, New York.

At the time this article was written, Dr. Schnall was a doctoral candidate.

This work was supported by HRSA grant D11 HP07346, PI: Suzanne Bakken, BSN, MSN, DNSc, FAAN

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Laura L. Ardizzone, BSN, MS, DNP(c), Clinical Nursing Instructor, Columbia University School of Nursing, Nurse Anesthesia Program, 617 West 168th Street, New York, NY 10032; e-mail: lla2002@columbia.edu.

Received: March 31, 2009
Accepted: September 13, 2009

Patient safety has become an important aspect of national health care initiatives and has been described as the prevention of health care errors and the elimination or mitigation of patient injury caused by health care errors. Patient safety further contends operational systems and processes should be established that promote the interception and minimization of errors (Institute of Medicine [IOM], 2000). The groundbreaking report, To Err Is Human: Building a Safer Health System, estimated that up to 98,000 people die each year as a result of medical errors (IOM, 2000). This important report spawned a new evolution in health care delivery and demonstrated that major change was needed at many levels of health care (Clancy, Farquhar, & Sharp, 2005; Reason, 2005; Scott, Mannion, Davies, & Marshall, 2003).

In 2005, Leape and Berwick published a report to gauge the progress of health care’s safety initiatives since the initial IOM report. Their report indicated there have been small substantive changes since the IOM report; however, it also highlighted that multiple barriers exist to implementing change in the health care environment, including the culture of health care.

One technique to successfully change organizational culture is to provide clinicians with the skill set to promote a culture of safety. Hazards, near misses, and errors may not always be prevented, but with systematic education, individuals can be trained to identify methods to overcome potential barriers (Bakken, 2006).

One approach that may contribute to creating and sustaining a safety culture in health care organizations could be a comprehensive program of patient safety education during formative professional education (Clancy et al., 2005; Maddox, Wakefield, & Bull, 2001; Manojlovich, Barnsteiner, Bolton, Disch, & Saint, 2008; Scott et al., 2003). At a minimum, the strategy should occur across many facets of nursing education in both the classroom and clinical arena, and should be formalized and incorporate different teaching modalities to engage learners (Cronenwett et al., 2007).

The specialty practice of anesthesia has long been recognized as a leader in patient safety initiatives (Gaba, 2000). The Anesthesia Patient Safety Foundation, established in 1985, was the first independent multidisciplinary organization created specifically to prevent adverse clinical outcomes, particularly those related to human error (Anesthesia Patient Safety Foundation, 2009).

Anesthesia providers also have transformed their practice via the dissemination of the results of the American Society of Anesthesiologists Closed Claims Project, which maintains a database that consists of in-depth investigations of “closed” insurance claims from anesthesia-related errors. The purpose of the closed claims database is to analyze reported errors and develop strategies for prevention of future errors (American Society of Anesthesiologists, 2009; Petty, Kremer, & Biddle, 2002; Reason, 2005). Despite these efforts, nurse anesthesia educational programs have individualized curricular designs in which they integrate patient safety content into their curriculum, and there has been a limited evaluation of these designs (Council on Accreditation, 2004).

Leaders in nursing education recently have addressed patient safety as a necessary component of baccalaureate nurse education and have proposed competencies. However, a specific curricular blueprint or standardized methods for evaluation of current curricular designs has not been established (American Association of Colleges of Nursing, 2008; Cronenwett et al., 2007; Gregory, Guse, Dick, & Russell, 2007; Maddox et al., 2001).

In 2006, we implemented a curricular innovation to provide patient safety education and use informatics technology to encourage patient safety and enhance evidence-based practice. The patient safety curriculum was provided to all students enrolled in BS-MS (bachelor of science-master of science) entry to practice program, master’s specialties, and doctor of nursing practice studies; the curriculum was tailored where needed. The series provided to the nurse anesthesia cohort occurred during students’ second year and included three lectures that provided anesthesia-specific safety content. Lecture one consisted of an introduction to patient safety and promotion of mindfulness in health care settings. Lecture two discussed hazard, near-miss, and error reporting as well as ethical principles as they relate to disclosure for anesthesia-specific cases. The last lecture included a discussion of modeling of health care errors and monitoring of quality indicators in health care (Clancy et al., 2005; Madigosky, Headrick, Nelson, Cox, & Anderson, 2006).

In addition to the main lecture series, adverse event modeling techniques were integrated throughout the second year curriculum for two class projects. Subsequent to the lecture series, the cohort of students was invited to report hazard and near-miss incidents using a Web-based portal for each clinical day during 9 months of full-time clinical education (Currie et al., 2007).

Methods

A 52-question survey that measured attitudes, skills, and knowledge about patient safety was developed. Senior-level graduate nurse anesthesia students who were in full-time clinical residency in major academic medical centers were invited to complete the survey immediately before and 8 months after the patient safety curriculum was delivered.

The survey included 31 general patient safety items and 21 anesthesia-specific patient safety items. Seventeen of the general patient safety items were derived from a survey developed by Madigoksy et al. (2006) that measured medical students’ attitudes, skills, and knowledge about patient safety and medical errors. The additional 14 general patient safety items were derived from recommendations by Shojania, Duncan, McDonald, Wachter, and Markowitz (2001) and agreed on by the project team.

The survey used a 5-point Likert scale to measure three domains. Domain one measured students’ attitudes or opinions about errors and included 15 general patient safety questions in which students were asked to rate their opinion of each item (1 = strongly disagree, 5 = strongly agree).

Domain two consisted of 22 questions in which students were asked to rate their competency level for skills related to error reporting and participation in patient safety activities (1 = not competent, 5 = expert). Twelve skill-item questions were general patient safety items, and the remaining 10 were anesthesia-specific questions.

Domain three evaluated students’ knowledge related to aspects of patient safety culture. This domain was evaluated via 13 questions, and students were asked to rate their level of knowledge about patient safety content (1 = not knowledgeable, 5 = very knowledgeable). Four of the domain three questions were general patient safety items, and the remaining nine questions were anesthesia-specific items.

The 31 general patient safety items were used for all cohorts of students in this curricular innovation project, including combined BS-MS students, nurse practitioner students, nurse anesthesia students, and doctor of nursing practice students. Concurrent to our activities, the combined BS-MS survey was validated via factor analysis. The combined BS-MS tool had the 31 core general patient safety items and 4 BS-MS-specific items, such as fall injury and pressure ulcer prevention skills.

Psychometric analysis was performed on the 35-item BS-MS tool, which resulted in a 26-item survey including 22 general patient safety items and the 4 cohort-specific skills (Schnall et al., 2008). Results of the psychometric testing were domain one (attitudes) had three subscales: error detection (four items, alpha = 0.57), time investment (two items, alpha = 0.76), and creating a culture of safety (three items, alpha = 0.49). The skills domain also had three sub-scales: error analysis (six items, alpha = 0.84), decision support technology (three items, alpha = 0.82), and threats to patient safety (four items, alpha = 0.71). The knowledge domain had a Cronbach’s alpha of 0.86 (four items). The full results of the psychometric testing were reported previously by Schnall et al. (2008).

This curricular project was designated exempt by the institutional review board. All surveys were reported in an anonymous fashion. Mean pretest and posttest scores for the 22 items that were validated and used as part of the larger survey for this cohort were compared between the two samples and across the three domains using independent samples t tests with the significance level set at alpha = 0.01.

Results

Twenty-seven students completed the baseline surveys (pretest), and 23 students completed the postsurveys (posttest). Table 1 displays the overall scores. The overall mean score from pretest to posttest increased, but this change was not statistically significant (pretest = 2.80, posttest = 3.06).

Results of Pretest and Posttest Surveys

Table 1: Results of Pretest and Posttest Surveys

Analysis of specific domains indicated overall attitudes scores (domain one) did not change from pretest to posttest (3.59 for both). Mean scores for skills (domain two) increased between the two time points (pretest = 2.34, posttest = 2.59). In the knowledge domain, mean scores also increased (pretest = 2.58, posttest = 2.98). None of the results showed a statistically significant difference.

Individual questions also were examined for pretest-posttest mean differences. Of interest, several individual questions showed relatively large differences. For example, the question from the attitudes domain, “In my clinical experience so far, clinical faculty and staff communicate to me that patient safety is a high priority,” students’ responses indicated they agreed less strongly with this statement from pretest to posttest (pretest = 4.48, posttest = 4.04).

Specific questions in the skills domain that had interesting results included how “competent” students felt about the following: “Participating as a team member in a failure mode and effect team,” “Participating as a team member of a root cause analysis,” and “Participating in morbidity and mortality conferences.” Overall trends for these questions showed an increase in self-reported competency for students from the pretest to posttest.

In the knowledge domain, students reported an increase in “knowledge” compared to pretest means for the following: “Defining the key aspects of safety culture,” and “Summarizing the published evidence about [the] relationship between nurse staffing and overall hospital morbidity and mortality.” Table 2 displays pretest and posttest data for the 31 general patient safety items and notes which items were eliminated after the factor analysis on the BS-MS student data and used in the overall analysis.

General Patient Safety Survey Items for Attitudes, Skills, and Knowledge Domains

Table 2: General Patient Safety Survey Items for Attitudes, Skills, and Knowledge Domains

Discussion

This study examined the impact of a formal patient safety curriculum on attitudes, skills, and knowledge related to patient safety for a small cohort of nurse anesthesia students enrolled in graduate studies. Attitude scores did not change between the pretest and posttest time points (9 months), but the cohort scored higher on posttest means for the skills and knowledge domains related to patient safety.

As other researchers have identified, changing attitudes and beliefs is a daunting task (Leape & Berwick, 2005). The nurse anesthesia cohort includes practicing clinicians with 1 to several years of experience. Perhaps the lack of change in the attitudes score represents the difficulty with changing the culture after it has been ingrained in a clinician’s practice. Indeed, three structured lectures on patient safety and reporting hazards and near misses are a small part of raising awareness of patient safety. However, our results indicate structured lectures can increase skills and knowledge related to patient safety.

Several of the individual questions had large changes between the pretest and posttest time points. For example, the question that examined the attitude toward staff knowledge (“In my clinical experience so far, clinical faculty and staff communicate to me that patient safety is a high priority”) had a large decrease from pretest to posttest. This result may reflect the research by Leape and Berwick (2005), in which the major barrier to promoting safety culture was organizational culture. It is possible that after students, who are also clinicians, were educated about patient safety, they identified more flaws in the system. In addition, this result might be interpreted in relation to current nursing workforce literature that acknowledges the nursing workforce is overburdened in the clinical arena with a multitude of responsibilities and thus they may not have had formal patient safety education (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Buerhaus, 2008).

One solution to alleviate this burden is to adopt a patient safety education curriculum that occurs systematically prior to the clinician entering the workforce rather than ad hoc “on-the-job training.” On-the-job training can be difficult to schedule and adopt as overloaded clinicians have limited time to devote to additional training (Clancy et al., 2005; Cronenwett et al., 2007; Gregory et al., 2007; Manojlovich et al., 2008). For questions in the skills and knowledge domains that showed an increase in scores, the lecture series and integration of patient safety modeling throughout the curriculum may have given students increased understanding and confidence in the use of these activities.

With regard to the survey that was used, the psychometric testing was simultaneous with the administration of our survey; therefore, we were unable to benefit from the refinement of the tool by Schnall et al. (2008) during the administration of the survey. Further modifications of the tool to quantify attitude changes over time are warranted, and the revised survey by Schnall et al. (2008) should be used and repeated on a larger cohort.

The format of the patient safety curriculum may be a limitation to this evaluation. In response, the faculty has made some curricular modifications to address these issues in our program. New curriculum is being developed in the nurse anesthesia program that will make the patient safety education series more interactive instead of a one-sided lecture series. It is well documented that problem-based learning techniques as well as alternate methods of knowledge delivery in addition to lecture formats are effective and engage learners (Beers, 2005; Brunton, Morrow, Hoad-Reddick, McCord, & Wilson, 2000; Ghosh, 2007; Lu, Lin, & Li, 2009). The patient safety series will be woven throughout the curricular design so students gain knowledge and skills related to patient safety and use these skills throughout the program via case studies, small group learning, and presentations.

We provided a formal teaching strategy that educates professional nurses about patient safety. This training gives professional nurses the skill set to review hazards and near misses in a logical manner. Our results, along with previous inquiries of other health care specialties, indicates necessary components of patient safety curriculum should be formally taught, cultivated, and emphasized during the formative education process of our next generation of clinicians (Currie et al., 2007; Madigosky et al., 2006). Establishing a patient safety culture is a necessary component of the health care system, and the development and use of a formalized patient safety curriculum is important and may be effective during the educational process.

References

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Results of Pretest and Posttest Surveys

Pretest Score Mean (SD) (n= 27)Posttest Score Mean (SD) (n= 23)Mean Difference (95% CI)p
Overall survey2.80 (0.35)3.06 (0.45)0.26 (−0.51 to −0.004)0.046
Attitudes3.59 (0.27)3.59 (0.23)0 (−0.15 to 0.15)0.99
Skills2.34 (0.52)2.59 (0.65)0.25 (−0.60 to 0.09)0.15
Knowledge2.58 (0.77)2.98 (0.71)0.4 (−0.83 to 0.03)0.07

General Patient Safety Survey Items for Attitudes, Skills, and Knowledge Domains

Domain & Survey ItemPretest Score Mean (SD)Posttest Score Mean (SD)Mean Difference
Attitudes Domain
1. Making errors in health care is inevitablea3.19 (1.27)2.91 (1.28)−0.28
2. After an error occurs, an effective strategy is to work harder to be more carefula,b1.93 (1.0)1.87 (0.63)−0.06
3. Competent clinicians do not make errors that lead to patient harma,b4.19 (0.74)4.22 (0.60)0.03
4. Clinicians routinely share information about errors and what caused thema2.63 (1.15)2.52 (0.90)−0.11
5. Existing reporting systems do little to reduce future errors2.85 (0.93)2.91 (0.97)0.06
6. There is a gap between what we know as “best care” and what we provide on a day-to-day basis3.30 (0.91)3.39 (0.78)0.09
7. Most errors are due to things that clinicians cannot do anything aboutb3.44 (0.97)3.87 (0.76)0.43
8. Only clinicians can determine the causes of clinical errorsb2.04 (0.59)2.00 (0.67)−0.04
9. Clinicians routinely report errorsa,b3.96 (0.59)4.00 (0.67)0.04
10. In my clinical experience so far, faculty and staff communicate to me that patient safety is a high prioritya4.48 (0.51)4.04 (0.56)−0.44
11. Learning how to improve patient safety is an appropriate use of time in nursing educational programs4.37 (0.49)4.35 (0.65)−0.02
12. Clinicians should routinely spend part of their professional time working to improve patient care4.44 (0.58)4.26 (0.62)−0.18
13. The culture of health care makes it easy for clinicians to deal constructively with errorsb3.70 (0.78)3.72 (0.83)0.02
14. If I saw an error, I would keep it to myselfb3.74 (0.86)3.78 (0.80)0.04
15. If there is no harm to the patient, there is no need to report an errorb4.22 (0.64)3.91 (0.60)−0.31
Skills Domain
16. Accurately entering an error report2.37 (0.84)2.83 (0.83)0.46
17. Interpreting aggregate error report data2.04 (0.94)2.22 (0.80)0.18
18. Disclosing an error to a patient or family member2.00 (0.96)2.17 (0.78)0.17
19. Disclosing an error to a physiciana2.67 (0.73)2.91 (0.73)0.24
20. Disclosing an error to a preceptor or faculty membera3.04 (0.81)3.04 (0.77)0
21. Disclosing an error to a peera3.37 (0.69)3.35 (0.65)−0.02
22. Supporting and advising a peer who must decide how to respond to an error2.96 (0.90)3.00 (0.93)0.04
23. Participating as a team member of a failure mode and effect analysis1.74 (0.90)2.04 (1.02)0.30
24. Participating as a team member of a root cause analysis1.44 (0.70)1.78 (0.85)0.34
25. Participating in morbidity and mortality conferences1.93 (0.83)2.39 (1.16)0.46
26. Asking patients to recall and restate what they have been told during the informed consent process2.74 (0.86)2.78 (0.95)0.04
27. Using antimicrobial handwashing substances3.96 (0.82)3.87 (0.82)−0.09
Knowledge Domain
28. Distinguishing among errors, adverse events, near misses, and hazards3.15 (0.82)3.39 (0.89)0.24
29. Defining the characteristics of high reliability organizations2.31 (0.93)2.74 (0.92)0.43
30. Defining the key dimensions of patient safety culture2.48 (0.89)2.91 (0.85)0.43
31. Summarizing the published evidence about relationships between nurse staffing and overall hospital morbidity and mortality2.35 (0.98)2.87 (0.76)0.52
Authors

Ms. Ardizzone, Mr. Enlow, and Ms. Evanina are Doctoral Students and Assistant Professors of Clinical Nursing; Dr. Currie is Assistant Professor of Nursing, and Dr. Schnall is Faculty, Columbia University School of Nursing New York, New York.

At the time this article was written, Dr. Schnall was a doctoral candidate.

This work was supported by HRSA grant D11 HP07346, PI: Suzanne Bakken, BSN, MSN, DNSc, FAAN

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Laura L. Ardizzone, BSN, MS, DNP(c), Clinical Nursing Instructor, Columbia University School of Nursing, Nurse Anesthesia Program, 617 West 168th Street, New York, NY 10032; e-mail: .lla2002@columbia.edu

10.3928/01484834-20091113-01

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