¶ … Blueprint for Evaluating Patient Safety Competency in Nursing Students
Ever since the report To Err is Human was published in 2000 by Kohn and colleagues, healthcare stakeholders in Western countries have intensified reform efforts designed to increase patient safety. The report revealed that nearly 100,000 patients were dying annually from medical errors in the 1990s, a statistic that caught the attention of legislators, healthcare policymakers, clinicians, patients, and the general public. Additional research revealed that nurses were considered to be the source of most medical errors and also the best defense against errors, but nurses had little, if any, control over patient care planning (Lachman, 2007). Systems were therefore a major determinant of patient safety.
Patient safety and nursing ethics are also inseparable (Lachman, 2007, p. 401). While avoiding specific recommendations, provision three in the American Nurses Association Code of Ethics states that nursing professionals must protect the safety of patients; however, fulfilling this goal requires nurses to report procedures, practices, or staff endangering patient safety to management. A similar conclusion can be reached with provision six, which states that nurses should promote a moral environment. These Code of Ethics provisions reveal that patient safety and ethics are not mutually exclusive and ethics should be a core element of any nursing education curriculum.
Contemporary patient safety guidelines have been published by a number of stakeholders, including the Joint Commission (2015), American Association of Colleges of Nursing (AACN, 2012), and the Institute of Medicine (2010). The Institute of Medicine (2010) recommends increasing the prevalence of bachelor-prepared RNs and residency programs, reforms which are intended to increase the breadth and depth of nursing competencies and stabilize the workforce. The AACN (2012) developed guidelines for nursing education curriculums, which are designed to teach nursing students the knowledge, skills, and attitudes needed for improving and ensuring care quality and safety. In particular, well-trained nurses should be able to analyze how national patient safety regulations and guidelines will affect systems and practice, design and implement quality improvement projects, and understand the value of national patient safety initiatives in relation to system and practice improvements. While the Institute of Medicine and AACN recommendations for patient safety are conceptual in nature, The Joint Commission (2015) has published specific and detailed recommendations for ensuring patient safety in acute care facilities seeking accreditation. For example, primary source verification of nursing education need not be done in most cases if the independent practitioner has a current license to practice, since licensing boards will verify primary education sources before licensure is granted. Accordingly, this test blueprint will focus on the following four learning goals:
1. Understand the relationship between nursing ethics and patient safety
2. Understand the relationship between primary nursing education and patient outcomes
3. Understand how implementation will affect systems and practice
4. Utilize National Patient Safety Goals published by The Joint Commission
Test questions for the learning goal of understanding the relationship between nursing ethics and patient safety will be two multiple-choice questions, one each for the cognitive process dimensions of remembering and understanding for a total point value of 2. Multiple-choice questions are appropriate for these two dimensions because they are useful for measuring the ability of learners to accumulate knowledge, comprehend the knowledge, and applying this knowledge to real-life situations (IAR, 2011). Multiple-choice questions are widely used because scoring is quick and easy, distracters provide opportunities for additional diagnostic information, and a lot of information can be covered efficiently. Writing multiple-choice questions, however, can sometimes be difficult because identifying good distractors can be hard.
An appropriate learning objective/outcome for the first cognitive process dimension of remembering is recall, which can easily be evaluated using multiple-choice questions. Provision 3 states that "the nurse promotes, advocates for, and strives to protect the health, safety and rights of the patient" (Lachman, 2009a). Provision 6 implies that nurses should foster a moral care environment (Lachman, 2009b), while provision 2 encourages patient-centered care which in turn depends on the principle of nonmaleficence (Lachman, 2009a). To test whether learners can recall this information, the following multiple-choice question could be used:
Q: The ANA Code of Ethics provisions most relevant to patient safety are the following:
1. Provision 2
2. Provision 3
All of the above*
A second multiple-choice test item was proposed in the test blueprint (Appendix A) to evaluate learner ability to understand the relationship between patient safety and nursing ethics, the first learning goal. This question will be based on the cognitive process dimension of understanding and use the learning objective/outcome of explaining. Provision 6 of the Code of Ethics urges nurses to create and maintain a care environment conducive to quality health care, based on professional values (Lachman, 2009b). The values a person fosters helps define their ethical principles; therefore, nurses are encouraged to impose their professional values and ethics (morality) on the care environment to help ensure patient safety. What follows is a multiple-choice test item designed to evaluate understanding on this topic, using the learning objective/outcome of explain:
Q: Please explain how provision 6 of the Code of Ethics urges nursing professionals to ensure patient safety in the care environment:
1. Through fidelity to professional values, thereby creating a moral care environment*
2. By advancing the nursing profession through contributions to practice and knowledge development
3. By encouraging nurses to take care of themselves, including personal safety within the care environment
4. Through engagement with professional nursing associations, which help define professional values
The second learning goal of understanding the relationship between primary nursing education and patient outcomes will be evaluated using three multiple-choice test items for a total point value of 3 (Appendix A). The cognitive process dimensions of remembering, applying, and analyzing will be tested using the learning objective/outcome verbs define, interpret, and distinguish, respectively. The Institute of Medicine (2010) has proposed that healthcare reformers implement changes that encourage individuals interested in a career in nursing to obtain a bachelors degree, rather than enter the profession through an associate degree or diploma program. They suggest that 80% of all entry level nurses should have a bachelor degree by the year 2020, up from about 37% in 2008. This recommendation is based on the belief that BSN-prepared nurses will benefit from a more well-rounded education and be in a better position to contribute to other areas of the profession aside from patient care, such as health policy, financing, quality improvement, and leadership. Another recommendation is to increase the prevalence of residency programs following graduation from an academic nursing program. The following multiple-choice test item evaluates the cognitive process dimension of remembering using the learning objective/outcome verb of defining:
Q: Define nursing residency programs:
1. Nursing students spend time observing experienced nurses providing healthcare services
2. Nursing students reside in a Sigma Theta Tau sorority house during college
3. Nursing graduates engage in providing healthcare services under the close supervision of experienced nursing staff for a defined period*
4. Experienced nurses go on sabbatical to an academic institution to improve professional competencies
What follows is another multiple-choice test item using the cognitive process dimension of applying, with the learning objective/outcome of interpreting:
Q: Interpret the Institute of Medicine (2010) statement "An increase in the proportion of nurses with a BSN also would create a workforce poised to achieve higher levels of education & #8230;"
1. BSN-prepared nurses will have access to more advanced continuing medical education credit (CME) courses
2. BSN-prepared nurses will more likely have the skills needed to engage in lifelong learning
3. Increasing the proportion of BSN-prepared nurses will create a better-educated workforce
4. BSN-prepared nurses can apply directly to graduate school programs, whereas diploma- or associate degree-prepared nurses typically cannot*
Among the many safety recommendations published by the AACN (2012) is one that elaborates on the contributions from clinicians and systems. The distinction between individual and systems contributions to medical errors is important, because human beings will always make mistakes, regardless of how well-trained. Instead, successful efforts to reduce or eliminate medical errors will likely depend on careful analysis of systems and the development of reforms to eliminate unsafe practices through system changes. To evaluate this safety recommendation the cognitive process dimension of analyzing and the learning objective/outcome of distinguishing will be the basis for a multiple-choice test item, which follows:
Q: The best approach for improving patient and clinician safety will focus on:
1. Human factors
2. Human limitations
3. Design principles
4. All of the above*
The last two test items in the test blueprint are essay questions (Appendix A). One essay question will be used to evaluate the learning goal of understanding how implementation of the National Patient Safety Goals published by The Joint Commission (2015) will affect systems and practice. The first goal for critical access hospitals is to utilize at least two patient identifiers before administering medications or procedures, or collecting specimens. Which identifiers to use are critical and include the patient's name, but not a patient's room or floor…
AACN (American Association of Colleges of Nursing). (2012). Graduate-level QSEN competencies knowledge, skills, and attitudes. Retrieved from http://www.aacn.nche.edu/faculty/qsen/competencies.pdf.
Clark, C.C. (2008). Classroom Skills for Nurse Educators. Sudbury, MA: Jones and Bartlett Publishers.
IAR (Instructional Assessment Resources). (2011). Assess Students: Multiple-choice questions. Retrieved from https://www.utexas.edu/academic/ctl/assessment/iar/students/plan/method/exams-mchoice-bloom.php.
Institute of Medicine. (2010). The future of nursing: Focus on education. Retrieved from https://www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Nursing%20Education%202010%20Brief.pdf.
The Joint Commission. (2015). National Patient Safety Goals: 2015 National Patient Safety Goals. Retrieved from http://www.jointcommission.org/standards_information/npsgs.aspx.
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