Patient Safety Competency Test Blueprint for Nursing Students
This paper presents a test blueprint for evaluating patient safety competency in nursing students, grounded in four learning goals derived from major healthcare standards bodies. Drawing on the ANA Code of Ethics, Institute of Medicine recommendations, AACN graduate-level QSEN competencies, and The Joint Commission's National Patient Safety Goals, the blueprint maps multiple-choice and essay questions to Bloom's Taxonomy cognitive process dimensions — from remembering and understanding through applying, analyzing, evaluating, and creating. Sample test items with model answers are provided for each learning goal, demonstrating how assessment design can reinforce the knowledge, skills, and attitudes nursing students need to promote patient safety in clinical practice.
- Introduction: Patient Safety and Nursing Education: Policy context linking nursing errors, ethics, and reform
- Nursing Ethics and Patient Safety: ANA Code of Ethics provisions and sample test items
- Primary Nursing Education and Patient Outcomes: IOM BSN recommendations and competency assessment questions
- National Patient Safety Goals: Systems and Practice: Essay question on bar coding and systems implementation
- Utilizing The Joint Commission Website: Creating and locating goals via Joint Commission resources
- Test Blueprint Structure and Bloom's Taxonomy: Question distribution formula and appendix grid breakdown
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What makes this paper effective
- The blueprint explicitly connects each test item to a Bloom's Taxonomy cognitive process dimension and a specific learning objective/outcome verb, making the assessment rationale transparent and reproducible.
- Sample questions with answer keys (including distractor analysis) are provided for every learning goal, giving readers a concrete, ready-to-use model rather than an abstract framework.
- The paper draws on credible, authoritative sources — the ANA Code of Ethics, IOM Future of Nursing report, AACN QSEN competencies, and Joint Commission National Patient Safety Goals — and aligns each learning goal to a specific policy recommendation.
Key academic technique demonstrated
The paper demonstrates criterion-referenced assessment design: each test item is reverse-engineered from a stated learning goal and a chosen cognitive level, rather than written ad hoc. This technique, rooted in Bloom's Taxonomy, ensures that the assessment instrument measures exactly what the curriculum intends to teach.
Structure breakdown
The paper opens with a policy rationale grounding patient safety in both ethics and regulation, then states four learning goals. Subsequent sections address each goal in sequence, specifying cognitive dimensions, sample questions, and model answers. The appendix provides a Bloom's Taxonomy grid quantifying question distribution across cognitive domains. This logical scaffolding — from rationale to goals to items to blueprint math — mirrors standard instructional design practice.
Introduction: Patient Safety and Nursing Education
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 both the source of most medical errors and the best defense against errors, yet 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 3 of 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 6, 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 that 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), the 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 intended to increase the breadth and depth of nursing competencies and stabilize the workforce. The AACN (2012) developed guidelines for nursing education curricula 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 holds a current license to practice, since licensing boards verify primary education sources before licensure is granted. Accordingly, this test blueprint focuses on the following four learning goals:
- Understand the relationship between nursing ethics and patient safety
- Understand the relationship between primary nursing education and patient outcomes
- Understand how implementation will affect systems and practice
- Utilize National Patient Safety Goals published by The Joint Commission
Nursing Ethics and Patient Safety
Test questions for the learning goal of understanding the relationship between nursing ethics and patient safety consist of 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 learners' ability to accumulate knowledge, comprehend that knowledge, and apply it to real-life situations (IAR, 2011). Multiple-choice questions are widely used because scoring is quick and easy, distractors provide opportunities for additional diagnostic information, and a large amount of content can be covered efficiently. Writing multiple-choice questions can, however, sometimes be difficult because identifying good distractors is challenging.
An appropriate learning objective/outcome for the first cognitive process dimension of remembering is recall, which can be evaluated effectively 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:
- Provision 2
- Provision 3
- Provision 6
- All of the above (correct answer)
A second multiple-choice test item was proposed to evaluate learner ability to understand the relationship between patient safety and nursing ethics — the first learning goal. This question is based on the cognitive process dimension of understanding and uses 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 healthcare, based on professional values (Lachman, 2009b). The values a person fosters help define their ethical principles; therefore, nurses are encouraged to apply their professional values and ethics to the care environment to help ensure patient safety. The following multiple-choice test item evaluates understanding of 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:
- Through fidelity to professional values, thereby creating a moral care environment (correct answer)
- By advancing the nursing profession through contributions to practice and knowledge development
- By encouraging nurses to take care of themselves, including personal safety within the care environment
- Through engagement with professional nursing associations, which help define professional values
Primary Nursing Education and Patient Outcomes
The second learning goal — 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. 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) proposed that healthcare reformers implement changes encouraging individuals interested in nursing careers to obtain a bachelor's degree, rather than entering the profession through an associate degree or diploma program. The report suggested that 80% of all entry-level nurses should hold a bachelor's degree by the year 2020, up from approximately 37% in 2008. This recommendation rests on the belief that BSN-prepared nurses benefit from a more well-rounded education and are better positioned to contribute to areas of the profession beyond direct 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 define:
Q: Define nursing residency programs:
- Nursing students spend time observing experienced nurses providing healthcare services
- Nursing students reside in a Sigma Theta Tau sorority house during college
- Nursing graduates engage in providing healthcare services under the close supervision of experienced nursing staff for a defined period (correct answer)
- Experienced nurses go on sabbatical to an academic institution to improve professional competencies
The following multiple-choice test item uses the cognitive process dimension of applying, with the learning objective/outcome of interpret:
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…"
- BSN-prepared nurses will have access to more advanced continuing medical education (CME) courses
- BSN-prepared nurses will more likely have the skills needed to engage in lifelong learning
- Increasing the proportion of BSN-prepared nurses will create a better-educated workforce
- BSN-prepared nurses can apply directly to graduate school programs, whereas diploma- or associate degree-prepared nurses typically cannot (correct answer)
Among the many safety recommendations published by the AACN (2012) is one that elaborates on the contributions of 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 they are. Instead, successful efforts to reduce or eliminate medical errors will likely depend on careful analysis of systems and the development of reforms that eliminate unsafe practices through system changes. To evaluate this safety recommendation, the cognitive process dimension of analyzing and the learning objective/outcome of distinguish form the basis for the following multiple-choice test item:
Q: The best approach for improving patient and clinician safety will focus on:
- Human factors
- Human limitations
- Design principles
- All of the above (correct answer)
References
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
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.
Kohn, K. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To Err is Human: Building a Safer Health System. Washington, D.C.: National Academy Press.
Lachman, V. D. (2007). Patient safety: The ethical imperative. Medsurg Nursing, 16(6), 401–3.
Lachman, V. D. (2009a). Practical use of the nursing code of ethics: Part I. Medsurg Nursing, 18(1), 55–7.
Lachman, V. D. (2009b). Practical use of the nursing Code of Ethics: Part II. Medsurg Nursing, 18(3), 191–4.
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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