The focus on the quality and safety competencies of nurses has received significant attention in the past decade. The health care field took particular note when the Institute of Medicine’s (IOM) document, To Err is Human: Building a Safer Health System, reported that preventable medical errors result in approximately 44,000 to 98,000 deaths per year (Kohn, Corrigan, & Donaldson, 2000). Several other national health care organizations have also advocated for improvements in quality and safety (Institute for Healthcare Improvement, 2011; Institute for Safe Medication Practices, 2011; IOM, 2001; Kohn et al., 2000; The Leap Frog Group, 2011).
In addressing the issues of quality and safety competencies, many new standards and educational practices have emerged, but the ability to measure quality and safety knowledge, skills, and attitudes, both validly and reliably, has received little attention (Schnall et al., 2008). Currently, there are limited tools to measure nursing students’ quality and safety competencies. A literature review was conducted, which revealed one instrument that measures nurses’ patient safety attitudes, knowledge, and skills, but the tool was found to have poor reliability (Schnall et al., 2008). Traditionally, instructors, managers, preceptors, and peers who are considered expert nurses have often conducted assessments of nursing competencies through subjective observation (Whelan, 2006); thus, an objective, valid, and reliable method of measurement is needed.
Therefore, the purpose of this article is to present the development and psychometric evaluation of the Nursing Quality and Safety Self-Inventory (NQSSI). The NQSSI was developed to evaluate changes in self-rated quality and safety competencies of prelicensure nursing students as part of a larger study that examined the effectiveness of a quality and safety simulation (Piscotty, Grobbel, & Tzeng, 2011). The current study’s evaluation of the NQSSI includes an examination of the inventory development, construct and contrast validity, and reliability.
Development of the NQSSI
The NQSSI was developed based on the work of the Quality and Safety Education for Nurses (QSEN) competencies (Cronenwett et al., 2007). Competency is composed of six areas: (a) patient-centered care, (b) teamwork and collaboration, (c) evidenced-based practice, (d) quality improvement, (e) safety, and (f) informatics (Cronenwett et al., 2007). Each competency area is then constructed to include an applicable area of knowledge, skills, and attitudes (Cronenwett et al., 2007). The six competency areas are based on the six aims of quality health care put forth by the IOM (2001).
The NQSSI is an 18-item, self-rated inventory (Table 1) developed to measure nursing students’ self-rated knowledge, skills, and attitudes regarding the six QSEN competency areas. Each item was constructed to correspond with the knowledge, skills, and attitudes area of each of the six competencies. Three questions are included under each competency to address the three areas of knowledge, skills, and attitudes.
Table 1: Nursing Quality and Safety Self-Inventory (NQSSI) Questions
Response Format and Administration
A self-report summated rating scale was chosen for measuring self-rated attributes of the quality and safety competence of the participants. Empirical evidence has suggested that self-report measures have been found to be an effective approach to measurement (Waltz, Strickland, & Lenz, 2005). The inventory is rated on a 7-point Likert-type scale with 7 = strongly agree, 1 = strongly disagree, and a neutral choice. Participants are asked to place a mark (X) into the box that corresponds with their level of agreement with each of the 18 question statements. Two examples of the statements are: “I feel confident that I have the necessary knowledge to practice patient-centered nursing care.” and “I feel confident that I have the necessary skills to integrate and utilize technology in nursing practice.”
Scores are totaled for the entire inventory by calculating a mean score. In addition, a mean score can be calculated for knowledge, skills, or attitudes, as well as for each of the six QSEN competency areas. Higher mean scores indicate greater confidence in regard to quality and safety competencies. The total scale mean score may be used to garner a global understanding of the student’s self-rated competence, or the two subscales may be used to examine knowledge or attitudes. All 18 items on the NQSSI are worded positively, which increases the ease of scoring. The NQSSI is easily administered as a paper survey and takes approximately 10 to 15 minutes to complete.
Currently, the only group that has been studied with the NQSSI is the group presented in this article. The current study was part of a larger published study that examined changes in self-rated quality and safety competencies of prelicensure nursing students in regard to a quality and safety simulation (Piscotty et al., 2011).
Design and Participants
A convenience sample of all the students enrolled in two leadership and management courses in the baccalaureate nursing program at a public midwestern university was used. The students were enrolled during the fall 2009 semester. The two groups consisted of traditional (n = 132) and accelerated second-degree (n = 44) students enrolled in the Bachelor of Science in Nursing program.
The total sample consisted of 176 participants. The majority of respondents were women (n = 152 [86.4%]) and the mean age of the participants was 29.66 years (SD = 8.44, range = 21 to 55 years). The mean years of college attended were 2.53 years (SD = 2.06, range = 0 to 8 years), and the mean self-reported grade point average was 3.38 points (SD = 0.21, range = 2.85 to 3.85 points). Participants working in a health care setting reported mean years employed as 1.61 (SD = 3.98, range = 0 to 20 years). Table 2 shows the demographic characteristics of the study participants.
Table 2: Demographic Characteristics of the Study Sample (N = 176)
Institutional review board approval was obtained for the study. Students were instructed that participation in the study was voluntary. The students were also told that they could indicate if they did not wish to participate in the study at any time without penalty. During the first class meeting, all students were asked for their consent, and they were asked to complete the NQSSI. The students were given detailed oral and written instructions on how to complete the inventory.
Data were analyzed using PASW Statistics 18.0 software. Descriptive statistics were used to analyze the demographic information of the sample. Correlational analysis was used to examine the inter-item relationships. Exploratory factor analysis using principal axis factoring with direct oblimin rotation was used to examine construct validity. Reliability of the instrument was assessed using Cronbach’s alpha. Contrast validity of the instrument was determined using independent samples t tests. The alpha value for all analyses was set at p < 0.05.
The scores for each of the items on the NQSSI are described in Table 3. The scores on each of the items ranged from 1 to 7 for three items, 2 to 7 for five items, 3 to 7 for nine items, and 4 to 7 for one item. The participants’ responses ranged from strongly disagree to strongly agree. Cases with missing data were excluded list-wise, resulting in 171 cases that were eligible for factor analysis.
Table 3: Nursing Quality and Safety Self-Inventory (NQSSI) Descriptive Statistics and Item Analysis
Analysis of Inter-Item Correlations and Communalities
Inter-item correlations were examined for possible item extraction. Items that were considered for removal had to have a correlation ⩾ r = 0.80 or an item that had at least 50% or more inter-item correlations of < r = 0.30. No items had at least 50% or more inter-item correlations of < r = 0.30. Eight items had inter-item correlations ⩾ r = 0.80 (questions 4, 5, 10, 11, 13, 14, 16, and 17 [see Table 1 for question text]) On review, these items were paired under one of the competencies of (a) teamwork and collaboration (questions 4 and 5), (b) quality improvement (questions 10 and 11), (c) safety (questions 13 and 14), and (d) informatics (questions 16 and 17). The high inter-item correlation of these items indicates redundancy. Conceptually, this may indicate that it is difficult for respondents to differentiate between knowledge and skills. To perform a skill, one must have adequate knowledge, thus they are conceptually linked. These items were removed individually and as a group to examine the impact on the factor structure. No change in the factor structure or improvement in reliability was noted, thus it was decided to keep all items in the scale.
Construct Validity of the NQSSI
Exploratory factor analysis using principal axis factoring with direct oblimin rotation was used to examine construct validity and to determine the best factor solution for the 18-item scale. The factor analysis indicated a significant Bartlett’s test (X2 [153, N = 171] = 2504.25, p < 0.000), a Kaiser-Meyer-Olkin measure of 0.87, and item communalities > 0.43 for all items.
The factors for the 18-item scale were evaluated using eigenvalues, the scree plot, and parallel analysis using a Monte Carlo simulation (Pallant, 2007). Two factors were extracted using the following criteria: (a) Kaiser’s Rule of eigenvalues > 1.00, (b) parallel analysis indicating a two-factor structure, and (c) factor loadings of ⩾ 0.32 (Tabachnick & Fidell, 2006). Table 4 shows the NQSSI factor loading patterns. The two factors were named (a) knowledge and (b) attitudes. As shown in Table 4, there were strong single loadings of each item on only one of the factors.
Table 4: 18-Item Nursing Quality and Safety Self-Inventory Factor Loadings Using Principal Axis Factoring Analysis With Direct Oblimin Rotation
The factor analysis supported the hypothesis that the 18-item scale with two subscales indicates conceptual congruence with nursing students’ self-rating of quality and safety competencies. Factor 1 (knowledge) contained 12 items indicating nursing students’ confidence regarding their knowledge and skills related to quality and safety competencies. Factor 2 (attitudes) contained six items indicating nursing students’ confidence with their attitudes toward quality and safety competencies. The total variance explained by this two-factor solution was 53.8%. Table 5 shows descriptive scores of the two subscales.
Table 5: Mean, Standard Deviation, and Internal Reliabilities for Each Subscale of the Nursing Quality and Safety Self-Inventory
Reliability of the NQSSI
The internal consistency coefficient (Cronbach’s alpha) of the NQSSI was 0.93, which indicates satisfactory reliability. The NQSSI had strong item–total correlations that indicate the ability to discriminate between high and low scores (Table 3). The reliabilities of the new subscales are satisfactory and ranged from 0.88 to 0.92 (Table 5).
Contrast validity was tested using the cohort of nursing students (accelerated versus traditional) and the mean total and subscale scores. The contrasted groups approach to establishing validity is appropriate when it is hypothesized that two or more groups may score differently on the measure (Waltz et al., 2004). In our study, it was hypothesized that the accelerated students would have statistically significantly higher mean total and subscale scores than traditional students. This may be due to the fact that the accelerated students have already completed an undergraduate degree and have already established a career. An alternate explanation may be that the accelerated students were at the end (last semester) of their nursing program versus the traditional students who were in the second semester of their junior year. The accelerated students had completed all of their acute care clinical experiences, whereas the traditional students had not. The independent samples t test revealed that there were statistically significant (p < 0.05) higher mean total and subscale scores between the accelerated and traditional students, suggesting contrast validity (Table 6).
Table 6: Independent t Test Results on Mean Total and Subscale Scores Between Accelerated and Traditional Cohorts
Certain demographic characteristics should be evaluated when examining self-reported quality and safety competencies. These characteristics include variables such as age, years of education, and years of experience in a health care setting. These variables may have an effect on self-reported quality and safety competencies and should be evaluated. The relationships between these variables and mean total scores on the NQSSI were examined. Age (Pearson’s r = 0.17, p = 0.03) and years employed in a health care setting (Pearson’s r = 0.18, p = 0.02) were found to have a significant positive relationship with mean total scores on the NQSSI. This relationship indicates that as participants’ age increased and as participants worked longer in health care settings, their NQSSI scores tended to be higher. A significant negative relationship was found between the numbers of years spent in college (Pearson’s r = −0.29, p < 0.001) with mean total scores on the NQSSI. This indicates that the more years the participants reported they were in college, the lower their scores on the NQSSI tended to be. This may be attributed to the fact that students who have long tenures in college may not have been exposed to work settings and the resultant quality and safety standards.
The results from our study provide support for the reliability and validity of the NQSSI as an instrument to measure self-rated quality and safety competencies of nursing students. The NQSSI assesses nursing students’ self-rated quality and safety knowledge and attitudes related to the six QSEN competencies. The reliability of the NQSSI is much stronger in contrast to that reported on the Patient Safety Attitudes, Skills, and Knowledge Scale (Schnall et al., 2008). The Patient Safety Attitudes, Skills, and Knowledge Scale was developed based on the six aims from the IOM, but it had poor reliability (Schnall et al., 2008).
The NQSSI has two subscales that are conceptually congruent with the knowledge and attitudes of the QSEN competencies. Although either subscale could be used independently, it is recommended that the total scale be used to garner a holistic assessment of nursing students’ self-rated quality and safety competencies. The NQSSI also showed good internal consistency, with evidence of contrast validity.
The study findings support that the NQSSI is an effective measure for assessing nursing students’ self-rated quality and safety competencies. Researchers who attempt to design effective interventions to improve nursing quality and safety in nursing students can use the NQSSI to measure effectiveness. This study has laid a foundation for further testing of the validity and reliability of the NQSSI and offers opportunities for further exploration of instrument development for measuring nursing quality and safety competencies.
Relatively few measures assess nursing students’ quality and safety competencies. The NQSSI is a new instrument that may be used with differing types of nursing students in diverse settings. The NQSSI can be used in a variety of ways to measure nursing students’ self-rated quality and safety competencies. For example, the NQSSI can be utilized in clinical experience or simulation settings as pretest–posttest measures of confidence with quality and safety competencies. By further testing with diverse samples, the NQSSI may become an important tool available to schools of nursing to effectively measure and monitor self-rated quality competencies over time. It is hoped that this tool will be utilized and validated further to measure self-rated quality and safety competencies with a variety of nursing professionals in diverse settings due to the general nature of its content; however, further studies are needed to support this generalization.
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Nursing Quality and Safety Self-Inventory (NQSSI) Questions
I feel confident that I have the necessary knowledge to practice patient-centered nursing care.
I feel confident that I have the necessary skills to practice patient-centered nursing care.
I feel confident that I have the necessary attitudes to practice patient-centered nursing care.
I feel confident that I have the necessary knowledge to ensure an effective nursing practice based on teamwork and collaboration.
I feel confident that I have the necessary skills to ensure an effective nursing practice based on teamwork and collaboration.
I feel confident that I have the necessary attitudes to ensure an effective nursing practice based on teamwork and collaboration.
I feel confident that I have the necessary knowledge to achieve an evidenced-based nursing practice.
I feel confident that I have the necessary skills to achieve an evidenced-based nursing practice.
I feel confident that I have the necessary attitudes to achieve an evidenced-based nursing practice.
I feel confident that I have the necessary knowledge to participate in quality improvement in nursing practice.
I feel confident that I have the necessary skills to participate in quality improvement in nursing practice.
I feel confident that I have the necessary attitudes to participate in quality improvement in nursing practice.
I feel confident that I have the necessary knowledge to deliver safe nursing care.
I feel confident that I have the necessary skills to deliver safe nursing care.
I feel confident that I have the necessary attitudes to deliver safe nursing care.
I feel confident that I have the necessary knowledge to integrate and utilize technology in nursing practice.
I feel confident that I have the necessary skills to integrate and utilize technology in nursing practice.
I feel confident that I have the necessary attitudes to integrate and utilize technology in nursing practice.
Demographic Characteristics of the Study Sample (N = 176)
| Traditional group||132||75|
| Second degree||44||25|
| High school||9||5.1|
| Some college||99||56.3|
| College degree||66||37.5|
| No response||2||1.1|
|Experience in health care|
| No experience||89||50.6|
| No response||1||0.6|
| Nurse assistant||42||23.9|
| Nurse technician||8||4.5|
| Not applicable||89||50.6|
| No response||2||1.1|
|Type of health care work setting|
| Not applicable||88||50|
| No response||3||1.7|
Nursing Quality and Safety Self-Inventory (NQSSI) Descriptive Statistics and Item Analysis
|18-item NQSSI (reliability = 0.93)||5.63||0.62|
|Question 1||5.56||1||0.54||2 to 7|
|Question 2||5.32||1||0.62||1 to 7|
|Question 3||6.34||0.69||0.51||4 to 7|
|Question 4||5.71||0.87||0.66||3 to 7|
|Question 5||5.59||0.88||0.72||3 to 7|
|Question 6||6.18||0.72||0.60||3 to 7|
|Question 7||5.01||1||0.71||2 to 7|
|Question 8||5.09||0.95||0.76||1 to 7|
|Question 9||5.87||0.80||0.55||3 to 7|
|Question 10||5.12||1.10||0.67||2 to 7|
|Question 11||5.12||1.06||0.65||2 to 7|
|Question 12||5.84||0.98||0.61||3 to 7|
|Question 13||5.73||0.89||0.66||2 to 7|
|Question 14||5.69||0.94||0.64||1 to 7|
|Question 15||6.39||0.71||0.56||3 to 7|
|Question 16||5.43||0.96||0.66||3 to 7|
|Question 17||5.39||0.97||0.69||3 to 7|
|Question 18||6.04||0.85||0.62||3 to 7|
18-Item Nursing Quality and Safety Self-Inventory Factor Loadings Using Principal Axis Factoring Analysis With Direct Oblimin Rotation
|Scale Item||Factor 1: Knowledge||Factor 2: Attitudes|
Mean, Standard Deviation, and Internal Reliabilities for Each Subscale of the Nursing Quality and Safety Self-Inventory
|Subscale||M||SD||Internal Consistency Cronbach’s Alpha|
|Factor 1: Quality and safety knowledge (12 items)||5.40||0.71||0.92|
|Factor 2: Quality and safety attitudes (6 items)||6.11||0.63||0.88|
Independent t Test Results on Mean Total and Subscale Scores Between Accelerated and Traditional Cohorts
| Accelerated||44||5.98||0.45||102||−5.32||< 0.001*||[−0.64, −0.29]|
| Accelerated||44||5.80||0.51||104||−5.43||< 0.001*||[−0.74, −0.34]|
| Accelerated||44||6.34||0.47||171||−2.83||< 0.005*||[−0.52, −0.09]|