Profession and Society

Development of a Self-Report Instrument to Measure

Patient Safety Attitudes, Skills, and Knowledge
Rebecca Schnall, Patricia Stone, Leanne Currie, Karen Desjardins, Rita Marie John, Suzanne Bakken
Purpose: To describe the development and psychometric testing of the Patient Safety Atti-
tudes, Skills and Knowledge Scale (PS-ASK).
Methods: Content validity of a 35-item instrument was established by a panel of experts. The
instrument was pilot tested on 285 nursing students. Principal components analysis (PCA)
with varimax rotation was conducted, and Cronbachs alphas were examined. Paired
samples t-tests were used to show responsiveness of the scales pre- and post-patient safety
curriculum.
Results: The final instrument consists of 26 items and three separate scales: attitudes, skills,
and knowledge. The attitudes and skills scales each had a three-factor solution. The knowl-
edge items had a one-factor solution. Both skills and knowledge were significantly increased
at Time 2 (p<0.001).
Conclusions: The skills and knowledge subscales had satisfactory internal consistency reli-
ability, evidence for construct validity, and responsiveness for use as independent scales
in future studies. The attitudes subscale needs further refinement before implementation.
Comparison with other measures of patient safety skills (e.g., observation) and knowledge
are warranted.
Clinical Relevance: A tool to measure clinicians attitudes, skills, and knowledge about
patient safety might be useful to evaluate nurses and other clinicians during educational
preparation and in practice.
[Key words: patient safety, instrument development, nursing]
JOURNAL OF NURSING SCHOLARSHIP, 2008; 40:4, 391394. C 2008 SIGMA THETA TAU INTERNATIONAL.
* * *
V
arious national committees have indicated serious
problems related to safety in the U.S. healthcare
system. Improving patient safety is critical to opti-
mizing healthcare delivery (Kohn, Corrigan, & Donaldson,
2000). Nursing care is seen as vital in the delivery of safe
care (Page, 2004). As a result, there is increased interest in
developing appropriate curricula related to patient safety
for nurses. Additionally, accreditation guidelines and stan-
dards of practice indicate evidence that patient safety com-
petencies for nursing personnel are considered to be valuable
(Cronenwett et al., 2007). Equipping nurses with attitudes,
skills, and knowledge to improve patient safety is critical to
enhancing patient care and decreasing morbidity and mor-
tality rates.
In response to the growing recognition of the impor-
tance of patient safety, the Columbia University School of
Nursing has initiated a set of curricular innovations entitled
Wireless Informatics for Safe and Evidence-based Advanced
Practice Nurse Care (WISE-APN) to increase patient-safety
competencies. To evaluate the effectiveness of these curric-
ular changes, a tool was needed to measure participants
attitudes, skills, and knowledge. Although several well-
validated tools exist for measuring healthcare providers at-
titudes and beliefs about the safety culture within their orga-
nizations (Colla, Bracken, Kinney, &Weeks, 2005; Ladden,
Bednash, Stevens, & Moore, 2006; Modak, Sexton, Lux,
Helmreich, & Thomas, 2007; Sexton et al., 2006); and one
Rebecca Schnall, RN, MPH, MBA, Alpha Zeta, Doctoral Student, School
of Nursing; Patricia Stone, RN, PhD, Alpha Zeta, Associate Professor of
Nursing; Leanne Currie, RN, DNSc, Alpha Zeta, Assistant Professor of
Nursing; Karen Desjardins, MPH, DrNP, ANP, GNP, Alpha Zeta, Assis-
tant Professor of Clinical Nursing; Rita Marie John, DrNP, CPNP, Alpha
Zeta, Assistant Professor of Clinical Nursing; Suzanne Bakken, RN, DNSc,
FAAN, Alpha Zeta, Alumni Professor of Nursing and Professor of Medi-
cal Informatics; all at Columbia University, New York, NY. This work was
based on a 3-year project supported by the Wireless Informatics for Safe
and Evidence-based Advanced Practice Nurse (WISE-APN) Care, funded
by the Health Resources and Service Administration D11 HP07346. Corre-
spondence to Ms. Schnall, 617 West 168th Street, Room 227, New York,
NY 10032. E-mail: rb897@columbia.edu
Accepted for publication July 29, 2008.
Journal of Nursing Scholarship Fourth Quarter 2008 391
Patient Safety Self Assessment
tool developed for medical students was found (Madigosky,
Headrick, Nelson, Cox, & Anderson, 2006), no validated
tool for measuring clinicians patient safety attitudes, skills,
and knowledge was found. The purpose of this paper is to
report on the development and psychometric testing of a
self-report instrument to measure clinicians patient safety
attitudes, skills, and knowledge (PS-ASK).
Design and Testing
To develop the PS-ASK, the authors adapted 17 skill
and attitude items from Madigosky et al.s 28-item scale
designed to measure medical students knowledge, skills,
and attitudes about patient safety and medical fallibility
and created an additional set of items. Adaptations to
the medical student scale consisted of replacing the word
physician with clinician and changing the scale associated
with skill from rating of comfort level to rating of compe-
tence level. No psychometric properties were reported for
Madigoskys scale. The attitude items used by Madigosky
et al. (2006) were originally developed by Benbassat et al.
(2001) in an attempt to measure fear of litigation and
attitudes toward self-regulation, defensive practice, and
disclosure of errors among medical students and physicians
(Benbassat, Pilpel, & Schor, 2001). The reliabilities of the
scales in their study ranged from =.54 -.69.
Following Reasons model of human error (Reason,
2000), we developed 33 additional items to reflect patient-
safety curriculum objectives and evidence-based, patient-
safety practices of relevance to nursing and APN care
(Shojania, Duncan, McDonald, & Wachter, 2001). To fur-
ther establish content validity, the 50 items were reviewed
by a panel of nurse researchers, patient-safety experts,
clinicians on the WISE-APN research team and external
advisory-board members. All reviewers were familiar with
Table 1. Attitude Items, Means, and Factor Loadings (N=274)
Error Time Creating a
detection investment culture of safety
4 items 2 items 3 items
(1=strongly disagree to 5=strongly agree) Mean (SD) =.57 =.76 =.49
If there is no harm to the patient there is no need to report an error
a
4.32 (0.79) .63
Only clinicians can determine the causes of clinical errors
a
4.10 (0.77) .59
Most errors are due to things that clinicians cant do anything about
a
4.08 (0.75) .55
If I saw an error, I would keep it to myself
a
4.23 (0.78) .55
Learning how to improve patient safety is an appropriate use of time in nursing educational programs 4.58 (0.58) .88
Clinicians should routinely spend part of their professional time working to improve patient care 4.47 (0.69) .87
The culture of health makes it easy for clinicians to deal constructively with errors
a
3.42 (0.88) .73
There is a gap between what we know as best care and what we provide on a day to day basis 3.52 (1.02) .66
Existing reporting systems do little to reduce future errors 2.60 (0.83) .61
Test means (SD) N=145 4.30 (0.45) 4.59 (0.59) 3.07 (0.62)
Retest means (SD) N=145 4.20 (0.43) 4.70 (2.13) 3.53 (0.69)
Paired samples, t test, test-retest (p) N=145 2.43 (.02) 0.65 (>.05) 6.71 (<.001)
Percentage variance explained 16.0 15.5 14.5
a
Reverse coded
the curricular objectives; the result was a 35-itemscale com-
prising 17 items adapted from the Madigoskys medical-
student scale and 18 new items. All items were rated on a
5-point Likert scale. The attitudes scale comprised 15 items;
8 items were negatively worded and reverse coded so that
a higher score was associated with more positive attitudes.
The skills scale had 16 items and the knowledge scale had
4 items.
Aprincipal components factor analysis (PCA) with vari-
max rotation was conducted for each of PS-ASKs three
sets of items (attitudes, skills, and knowledge). Reliability
was computed using Cronbachs alpha coefficient for each
of the resulting scales and subscales. Inter-item correlations
were examined and items with a high correlation (>.7) were
deleted. The sample for the PCA consisted of 285 of 324
nursing students in year 1 of the combined BS-MS APN
program in 2006 and 2007 prior to RN licensure. The sam-
ple for the responsiveness analysis (paired sample t-tests)
was a subset (N=145) of the 200708 class that completed
the tool at the beginning and end of the patient-safety cur-
riculum approximately 6 months apart.
Findings
The PCA of attitude items resulted in a three-factor,
nine-itemsolution (Table 1) that explained a total of 45.9%
of the variance. Four items were eliminated because of
inconsistencies with our curriculum; two additional items
were deleted because of low factor loading. Cronbachs al-
phas for the factor scales were Error Detection (four items),
=.57; Time Investment (two items), =.76, and Creating
a Culture of Safety (three items), =.49. Creating a cul-
ture of safety was the only factor with a significant positive
change in the responsiveness analysis.
392 Fourth Quarter 2008 Journal of Nursing Scholarship
Patient Safety Self Assessment
Table 2. Skills Item Means and Factor Loadings (N=282)
Error Decision support Threats to
analysis technology patient safety
6 items 3 Items 4 Items
(1=not competent to 5=expert) Mean (SD) =. 84 =. 82 =.71
Participating as a team member of a Failure Mode & effect analysis 1.29 (0.73) .74
Interpreting aggregate error report data 1.35 (0.75) .73
Participating as a team member of a root- cause analysis 1.24 (0.65) .70
Accurately entering an error report 1.43 (0.85) .64
Participating in morbidity and morality conferences 1.39 (0.82) .60
Supporting and advising a peer who must decide how to respond to an error 2.33 (1.16) .56
Using computer-based provider order entry 1.22 (0.66) .82
Using computer-based falls risk assessment 1.19 (0.55) .77
Using barcode medication administration system 1.28 (0.74) .77
Using antimicrobial handwashing substances 3.93 (1.10) .80
Using pressure relieving bedding materials to prevent pressure ulcers 2.23 (1.23) .68
Asking patients to recall and restate what they have been told during the 2.08 (1.16) .53
informed consent process
Disclosing an error to a patient and/or family member 1.65 (0.91) .43
Test means (SD) N=144 1.47 (0.59) 1.20 (0.51) 2.31 (1.02)
Retest means (SD) 2.24 (0.69) 2.66 (0.87) 3.15 (0.64)
Paired samples, t test, test/retest (p) 11.29 (<.001) 18.91 (<.001) 9.61 (<.001)
Percentage variance explained 28.5 20.5 15.9
The PCAof skill items resulted in a three-factor, 13-item
solution (Table 2) that explained 64.9% of the variance.
Internal consistency reliabilities ranged from.71 (Threats to
Patient Safety, four items) to .84 (Error Analysis, six items).
In terms of responsiveness of the instrument, paired sample
t tests showed significant differences over time (p<.001).
The PCA of four knowledge items (Table 3) related
to patient safety yielded results consistent with a one-
factor solution that explained 70.6% of the total variance
(=.86). The knowledge scores at the second administration
(N=142) were significantly higher (M=3.21, SD=0.73,
p<.001) supporting the responsiveness of the knowledge
scale.
Discussion
These results are preliminary. Notably, the Cronbachs
alphas of the attitudes subscales are low, as they were in
Benbassat et al.s (2001) original study; further refinement is
necessary. Nonetheless, the Cronbachs alphas of the skills
subscales and the knowledge scale are acceptable. Conse-
quently, others may consider using the skills and knowledge
scales without including the attitudes scale.
Overall the scores on the attitudes scale at the first ad-
ministration were high (M=3.56, SD=0.34), indicating that
the attitudes toward patient safety were positive. Neverthe-
less the scores for the second administration did decrease
slightly (M=3.48, SD=0.32). Although statistical differ-
ences in the responsiveness of the attitudes subscales exist,
the differences are not meaningful given the poor reliability
of the subscale.
The scale was designed to measure clinicians patient-
safety attitudes, skills, and knowledge and a limitation of
the study is that it was conducted on a sample of nurs-
ing students from a single nursing program. As such, this
might limit the generalizability of the psychometric find-
ings. Although the sample size is adequate for PCA, findings
might vary with a larger sample size. Further psychometric
Table 3. Knowledge Items, Means, and Factor Loadings
(N=285)
Knowledge
(1=not knowledgeable to 4 Items
5=very knowledgeable) Mean (SD) =.86
Dening the characteristics of high reliability
organizations
1.64 (0.92) .87
Distinguishing among errors, adverse
events, near misses, and hazards
1.89 (0.95) .84
Dening the key dimensions of patient-
safety culture
1.93 (0.96) .84
Summarizing the published evidence about
relationship between nurse stafng and
overall hospital morbidity and morality
1.56 (.89) .81
Test Means (SD) N=142 1.68 (0.68)
Retest means (SD) N=142 3.21 (0.73)
Paired samples, t test, test/retest (p) 20.21 (<.001)
N=142
Percentage variance explained 70.63
Journal of Nursing Scholarship Fourth Quarter 2008 393
Patient Safety Self Assessment
analyses in other samples (e.g., nurses, physicians, allied
health professionals) are needed.
Conclusions
These analyses provide preliminary evidence for the
construct validity and internal consistency reliability of the
skills and knowledge subscales of the PS-ASK in a sample
of pre-licensure students in the first year of a combined BS-
MS APN program. Significant differences in scores on the
skills and knowledge scales before and after completion of
the patient-safety curriculumshowthe responsiveness of the
scales. Refinement of the attitudes scale is needed and com-
parisons with other types of measures of clinicians patient
safety competencies (e.g., observation) and knowledge are
warranted.
As nursing-school leaders accept the charge to incorpo-
rate patient safety into their curriculum, assessment of the
effect of these educational programs will be needed. This
scale, after further development, might provide a useful tool
for that assessment.
Clinical Resources
Agency for Healthcare Research and Quality
(AHRQ) on Medical Errors and Patient Safety.
http://www.ahrq.gov/qual/ errorsix.htm/?id=19714
The IOM Health Care Quality Initiative. http://
www.iom.edu/CMS/8089.aspx
VA National Center for Patient Safety. http://www.
va.gov/ncps/
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