leadership and development Associate Editors: M  ichael R. Bleich, PhD, RN, NEA-BC, FNAP, FAAN Jan Jones-Schenk, DHSc, RN, NE-BC, FAAN Author: Michael R. Bleich, PhD, RN, NEA-BC, FNAP, FAAN Implementation Science as a Leadership and Doctor of Nursing Practice Competency abstract Leaders must distinguish between diffusion as a change strategy, education as a stimulus for change, and implementation strategies associated with implementation science. This article provides an operational definition for implementation science, the distinguishing characteristics in leading transformational change, and the degrees of implementation. [J Contin Educ Nurs. 2019;50(11):491-492.] I n a recent conversation with a colleague who interviewed individuals for a leadership position, she noted that each candidate described their leadership style as transformational. When asked to give an example of a transformation they had led— and its impact at the organizational level—few could cite a substantive transformational change at an organizational level. My colleague lamented that many see themselves as transformative leaders, but few actually are. Is the ability to actually move an organization in the direction of a desired change—given its culture, people with diverse backgrounds and educational levels, and other complexities— far more rare than commonplace? Yet, health care organizations need to respond to change more than ever, making implementation science—the science of change—a requisite competency. Dr. Dean Fixsen (2019), articulated three developmental levels on the journey to implementation science. The first level, letting it happen (change) aligns with the diffusion theory of change popularized by Everett Rogers who studied how innovations (change) spread through an organization, simplified here by describing change as a domino effect. Fixsen described the second level as helping it (change) happen, equated with dissemination science. Professional development educators know the power of education in advancing change, such that when groups are armed with education on a topic, an added stimulus to change occurs. Yet, education— as essential as it is as a stimulus for change—does not always equate to behavioral modification, individually or collectively. This leads to the third level of change mastery and implementation science. Implementation science is necessary because it is the science of making nonoptional things happen. Leaders must guide organizational change, ensuring compliance and uniformity of actions, safeguard- Dr. Bleich is Senior Professor and Director, Virginia Commonwealth University School of Nursing, Langston Center for Innovation in Quality and Safety, and President and Chief Executive Officer, NursDynamics, Ballwin, Missouri. The author has disclosed no potential conflicts of interest, financial or otherwise. Address correspondence to Michael R. Bleich, PhD, RN, NEA-BC, FNAP, FAAN, Senior Professor and Director, Virginia Commonwealth University School of Nursing, Langston Center for Innovation in Quality and Safety, and President and Chief Executive Officer, NursDynamics, 221 Jasmin Park Court, Ballwin, MO 63021; e-mail: mbleich350@gmail.com. doi:10.3928/00220124-20191015-03 The Journal of Continuing Education in Nursing · Vol 50, No 11, 2019 ing the quality and safety of patients, and managing resources. IMPLEMENTATION SCIENCE DEFINED Bauer, Damschroder, Hagendorn, Smith, and Kilbourne (2015) offered a useful and concise definition of implementation science. They defined implementation science as “the scientific study of methods to promote the systematic uptake of research findings and other EBPs [evidence-based practices] into routine practice, and, hence, it improves the quality and effectiveness of health services” (p. 1). In the definition are salient key points— namely, that leaders should use evidence and research when available to drive change. A second point is that the leader/change agent should make the client group (those affected by the expected change) keenly aware of what is at stake with regard to quality and effectiveness. The third point is that there is a science to implementation. The science comprises methods to drive the systematic uptake of research and evidence-based practices in practice settings, one of the outcomes now associated with the Doctor of Nursing Practice degree and an expectation of leaders in all clinical settings. Implementation science drives nonoptional change, standardizes high-risk and high-stakes clinical interventions, and advances innovations within an organization. The science itself addresses the knowledge gap that exists between interventions that research has shown to be effective and its translation into practice in varying clinical settings. Increasingly, inter491 vention researchers must build into their studies a science-based implementation strategy, as well as philanthropic organizations, to ensure that their efforts reach the point of intended impact (Easterling & Metz, 2016). DEGREES OF IMPLEMENTATION A highly recommended resource for professional development educators is the work of Fixsen, Naoom, Blase, Friedman, and Wallace (2005), which provided a useful synthesis of implementation science research. Their summary reflects that implementation takes place with differing levels of engagement, similarly to the letting it change, helping it change, and making it happen levels mentioned earlier. Paper implementation—often required by regulators— refers to changes that result from the adoption of policies and procedures, where a needed paper trail documents change. Organizational leaders should be competent in preparing policies, procedures, algorithms, and protocols to give direction and insight into practice. Process implementation advances paper implementation. Educators play a pivotal role as leaders who provide training as the backdrop for specifying the rationale for change, the expectations linked to innovations, and simulation or competency expectations to ensure that the client system affected by the change is able to perform, without the guarantee that they will perform or change their practice. Process implementation eliminates the variable relating to knowing what to do, as it has been measured and evaluated. 492 The third level of implementation is where the change is actually implemented and takes hold in the organization, known as performance implementation. This is where the consolidated framework for implementation research model developed by Damschroder et al. (2009) is a useful reference for educators and leaders. This model depicts the variables at play during the implementation of innovations with supportive evidence being generated by implementation scientists. Implementation is influenced by (a) intervention characteristics, which vary in factors such as adaptability, advantage, and complexity; (b) the outer settings, with factors such as patient experience and expectations, incentives, and pressure from peer organizations; (c) the inner setting, with its unique structural characteristics and networks; (d) the characteristics of the individuals involved, such as their knowledge and identification with the organization; and (e) the process of implementation, such as how it was planned, executed, and other factors. When taken completely, it immediately becomes clear that multiple and often confounding variables are required for effective change management, offering a partial explanation for the often dismally slow uptake of innovations in health care settings. As the Doctor of Nursing Practice enters the workforce in expanding roles, it should be with the ability to discern and lead innovations and change, from paper to practice. SUMMARY The professional development educator, whether in the practice or academic setting, who is teach- ing implementation science content should move beyond the comfort zone of the process implementation described above. Yes, education at the process level is key to the implementation of innovations—it can incentivize and motivate learners to take heed of answering the “what” and “why” of change needed. However, widespread change that takes hold organizationwide is the skill and competency set needed by leaders. Novice leaders may not possess awareness of all the variables to consider in driving change that must happen. Offering leaders training in the models and resources presented in this article is a starting point for advancing their competence in implementation science. REFERENCES Bauer, M.S., Damschroder, L., Hagendorn, H., Smith, J., & Kilbourne, A.M. (2015). An introduction to implementation science for the non-specialist. Retrieved from https:// bmcpsychology.biomedcentral.com/track/ pdf/10.1186/s40359-015-0089-9 Damschroder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A., & Lowery, J.C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4(50). Easterling, D., & Metz, A. (2016). Getting real with strategy: Insights from implementation science. The Foundation Review, 8, 97-115. Fixsen, D. (2019, February 4). The science of implementation—Dr. Dean Fixsen—episode 11 [Video file]. Retrieved from https://www. youtube.com/watch?v=t4k8pk9Bgps Fixsen, D.L., Naoom, S.F., Blase, K.A., Friedman, R.M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Retrieved from https://nirn.fpg.unc. edu/sites/nirn.fpg.unc.edu/files/resources/ NIRN-MonographFull-01-2005.pdf Copyright © SLACK Incorporated Reproduced with permission of copyright owner. Further reproduction prohibited without permission. Nurse Educator Practice and Quality Improvement Leaders Survey of Expectations of DNP Graduates' Quality Improvement Expertise Margaret Hammersla, PhD, ANP-BC; Anne Belcher, PhD, RN; Lucy Rose Ruccio, BSN, RN; Jeff Martin, MBA; and Debra Bingham, DrPH, RN, FAAN Downloaded from http://journals.lww.com/nurseeducatoronline by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 01/09/2022 ABSTRACT Background: Input from practice leaders will improve how doctor of nursing practice (DNP) education is meeting the needs of the employer and improving patient outcomes. Purpose: This article describes the expectations practice leaders have of new DNP graduates' ability to contribute to quality improvement (QI) efforts within health care organizations. Methods: A survey of practice leaders and QI experts investigated the importance and use of QI knowledge and skills. Practice leaders were also asked about the expectations of DNP graduates at the time of hire. Results: The results of this study support the need for nurses pursuing a DNP in advanced nursing practice to have education and training beyond their area of specialization, specifically in QI methods and tools. Conclusions: Faculty need to provide DNP students education that includes concepts in QI and leadership to meet the expectations of future employers and the needs of a complex and changing health care system. Keywords: DNP program, doctor of nursing practice, employer, health care organization, quality improvement Cite this article as: Hammersla M, Belcher A, Ruccio LR, Martin J, Bingham D. Practice and quality improvement leaders survey of expectations of DNP graduates' quality improvement expertise. Nurse Educ. 2021;46(6):361-365. doi: 10.1097/NNE.0000000000001009 T he focus of the doctor of nursing practice (DNP) degree is intended to prepare nurses to translate research into practice and develop and lead implementation efforts that will improve the quality of health care, whereas a PhD degree is intended to prepare researchers who are able to identify new interventions and strategies to address health care needs.1 Indeed, the need for the DNP degree was supported by widespread recognition that there is a need for practice leaders who have the knowledge, skills, and attitudes to more effectively and Author Affiliations: Assistant Professor (Dr Hammersla), College of Nursing, Montana State University, Bozeman; Associate Professor (Dr Belcher), School of Education, Johns Hopkins; and DNP Graduate Research Assistant (Ms Ruccio), Business Improvement Analyst (Mr Martin), and Associate Professor (Dr Bingham), School of Nursing, University of Maryland Baltimore, Institute for Perinatal Quality Improvement, Quincy, MA. Funding was provided by the Maryland Health Service Cost Review Commission, Nurse Support Program Grant managed by the Maryland Higher Education Commission. The authors declare no conflicts of interest. Correspondence: Dr Hammersla, Montana State University PO Box 173560, Bozeman, MT 59717 (Margaret.Hammersla@Montana.edu). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: January 27, 2021 Published ahead of print: March 12, 2021 DOI: 10.1097/NNE.0000000000001009 efficiently translate research into practice. The Institute of Medicine (IOM) highlighted research that described a 17-year gap between the publication of research findings and translation of that research into practice.2 In addition, the Hastings Center, a national health care ethics think tank, formed a quality improvement (QI) expert panel emphasizing that QI needs be intentionally and strategically implemented. The IOM later released Health Professions Education: A Bridge to Quality, which stated: “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, QI approaches, and informatics.”3(p3) These data and recommendations have helped support the rapid growth of DNP education in the United States. In 2006, as an example, the University of Maryland School of Nursing's (UMSON's) DNP program opened and was one of the first in the nation. There are now DNP programs in all 50 states as well as the District of Columbia.4 Ninety-eight new DNP programs are in the planning stage nationally.4 The expansion of DNP programs has occurred at the same time as the rapid evolution of the fields of implementation and improvement science. As DNP education expands and evolves, there is a recognition that there are limited data on the impact of DNP graduates on health care structures, processes, and outcomes.5 Nurse Educator • Vol. 46 • No. 6, pp. 361–365 • Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved. www.nurseeducatoronline.com 361 The Quality and Safety Education in Nursing (QSEN) DNP task force was formed to begin to answer this and other questions.5 As a first step, Tovar et al5 conducted a survey of 117 faculty who teach in a US DNP program and 30 DNP students. Two findings with statistically significant agreement among DNP faculty and graduates were that nurses have an important role in a hospital's QI efforts, and employers expect DNP graduates to be prepared to facilitate health care transformation in their setting.5 A related finding, which did not reach statistical significance, was that faculty were more likely than DNP graduates to strongly agree that employers expected graduates to be prepared to participate in, but not lead, QI initiatives. This finding highlights the need for more research to identify the level and type of QI preparation that employers desire among DNP graduates. The Commission on Collegiate Nursing Education accreditation standards include recommendations that education programs include the community of interest at several points in program development, implementation, and evaluation. Some schools have developed formal academic-practice partnerships to strengthen relationships and obtain needed feedback. The American Association of Colleges of Nursing (AACN) has created a toolkit to provide support for how to form these partnerships. This toolkit includes guiding principles for building successful partnerships and recommends that they be mutually beneficial and serve as “a mechanism for advancing nursing practice to improve the health of the public.”6 Most of the literature on academic-practice partnerships is focused on prelicensure education. These partnerships are a mechanism for schools to increase dialogue and gain insights that ensure ongoing coordination between health care system leadership and the faculty responsible for the DNP curriculum. Input from practice partners will likely improve the evaluation of how current DNP education is meeting the needs of the employer and improving patient outcomes. Yet, there is limited research that describes how practice partners inform DNP curricular decisions and strengthen the rigor of DNP programs. Dols et al,7 in an online survey of 90 DNP program directors, found that locating and accessing sites and agencies that would allow students to conduct projects were challenging. Issues included finding responsible practice mentors and allowing students to implement projects during a predetermined time frame.7 A project was usually well accepted if it would make a significant difference to the site and patients served. Program directors indicated that developing a partnership with the site enhanced the experience for all.7 VanderKooi et al8 conducted a study using an enhanced actualized DNP model generated by Burson et al9 to address project placements, rigor, and completion. They discovered that implementation of the model resulted in, among other effects, high satisfaction for students, mentors, and faculty, and a stronger academic-practice partnership reflected in additional student placements.8 362 There also are limited data and consensus on the specific QI and implementation knowledge, attitudes, and skills of faculty to guide DNP students. The QSEN Institute published Graduate Level Competencies in 2012.10 However, these are geared for all graduate nurses and not specific to doctorate education or the DNP degree specifically. DNP Essential II requires that graduates be proficient in QI to create sustainable organizational change.11 Durham et al12 published a review of the literature on the QI knowledge of DNP faculty that aligns with practice partner goals and prepares students to lead health care transformation. The major categories of QI content were: (1) faculty's knowledge of measurement and monitoring improvement, sustainability, spread and scaling, and reporting; (2) faculty development; (3) and a team model to address growth in programs.12 There is consensus that QI and implementation/ translation science need to be included in DNP education and that school of nursing faculty, and students benefit from strong academic-practice partnerships. There are limited data available that provide insights into employers' expectations of DNP graduates. There are also conflicting data as to the role DNP graduates should perform related to QI in health care. Our review of the literature indicated that more research is needed to describe the expectations of practice partners who support DNP programs and how these expectations are related to the specific QI knowledge and skills in which employers want DNP graduates to be proficient. Purpose The purpose of this study was to describe the expectations of practice partners and health care leaders of new DNP graduates' ability to contribute to QI efforts in health care organizations. The goal of this work is to support local and national efforts to identify practice expectations related to QI knowledge and skills among DNP graduates. This understanding will inform curriculum development and will allow DNP graduates to enter a workforce prepared to contribute in an immediate and meaningful way, reducing onboarding costs and potentially improving short-term employee satisfaction and retention. Methods This inquiry was conducted in 3 phases. All phases of the research were reviewed by the University of Maryland Institutional Review Board and deemed non–human subjects research. Phase 1: Online Survey of Practice Leaders' Perceptions A survey of practice leaders working in health care organizations in the Baltimore/Washington area hospitals that employ 1 or more DNP graduates was conducted to determine employers' perceptions of (a) DNP graduates' training in QI, leadership, area of advanced nursing practice, and translation of this knowledge and these skills into their Nurse Educator • Vol. 46 • No. 6. Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved. www.nurseeducatoronline.com work environment and (b) employer expectations of DNP graduates with regard to their role in QI and the degree to which they meet these expectations. The phase 1 practice leaders' perceptions survey asked respondents to rank a variety of QI skills and strategies in level of importance to their organization. The survey builds on and includes several questions from a survey conducted earlier that explored the QI expertise of faculty teaching in the UMSON DNP program.13 The questions from that faculty survey were included in the phase 1 survey because of their common relevance in shaping professional development education in the areas of QI and implementation science. To establish content validity, the survey was reviewed by 3 faculty members with experience in DNP education. The phase 1 survey was administered to a targeted convenience sample using an online survey platform. The survey was emailed to 97 health care practice leaders in the area who have hired DNP graduates since 2016. Returned surveys were deidentified, and the findings reported in aggregate. Phase 2: Online Survey of QI Experts' Perceptions On completion of the first online survey, a second survey was sent to 55 local and national QI experts to rank the level of importance and frequency of use of common QI skills and strategies. The same list of QI knowledge and skills from the phase 1 survey was used for the phase 2 survey. In addition, the participants were asked about how frequently they used those knowledge and skills in their own QI work. The goal of the phase 2 survey was to compare employers' opinions of the importance of various QI topics with those of experts in the field. The survey was also administered using online survey software. Returned surveys were deidentified, and the findings reported in aggregate. Phase 3: Focus Group to Explore Practice Leaders' Perceptions On completion of both online surveys, 2 focus groups were conducted with employers of DNP graduates to further explore practice leaders' perception of QI expectations. The first focus group was face-to-face with 3 health care agency leaders, and the second was held via Zoom with 7 leaders. Both sessions were recorded for the purpose of creating deidentified transcripts of the discussion. The focus groups utilized a loosely structured format. After introductions, participants were asked about their use of key knowledge and skills in QI, experiencewith DNP graduates, and assessment of DNP graduates' expertise with QI and leadership. Participants were also askedto provide feedback on the program outcomes based on current and future needs of the practice settings. Participants in the focus groups included primarily chief nursing officers, vice presidents, directors of quality and safety, and others at the vice president or director level from large academic medical centers or community hospitals. Results Phase 1: Practice Leaders' Perceptions Seventeen individuals completed the survey and are included in the results (18% response rate). Survey results represent responses from large academic medical centers (n = 4, 23%), community hospitals (n = 10 [59%]), continuing care retirement centers (n = 1 [6%]), academia (n = 1 [6%]), and integrated health delivery systems (n = 1 [6%]). With regard to expectations of DNP graduates for engagement in QI process, the majority of employers (n = 9 [52%]) of DNP graduates expect them to independently develop QI ideas and then work with senior managers in developing and implementing plans for QI. Respondents indicated the level of importance to their organization of an inventory list of QI skills and strategies. The skills and strategies that were most frequently rated as very important included ethical considerations in QI (n = 14 [82.4%]), safety in health care (n = 14 [82.4%]), and implementation strategies and tactics (n = 13 [76.5%]). The QI skills and strategies that were most frequently rated as not important were driver diagrams (n = 2, 11.8%) and logic models (n = 2 ]11.8%]) (see Supplemental Digital Content, http://links.lww.com/NE/A921, Table 1, for complete information on responses). Phase 2: QI Experts' Perceptions Eighteen individuals completed the survey (40% response rate) with 2 individuals not providing ratings for everyquestion. Respondents indicated the level of importance of the same inventory of QI skills and strategies to conducting rigorous QI projects. The QI skills and strategies that most often received a ranking of very important were safety in health care (n = 14 [82.6%]), data collection and analysis (n = 12 [70.6%]), and implementation strategies and tactics (n = 12 [70.6%]). The skills/strategies of QI project aims and safety in health care were rated as either very important or important by 100% of respondents. The skills rated most frequently as not important were driver diagrams (n = 4 [23.5%]) and logic models (n = 5 [29.4%]) (see Supplemental Digital Content, http://links.lww.com/NE/A922, Table 2, for complete information on responses). The QI skills and strategies that were most often rated as always used included data collection and analysis (n = 14 [77.8%]), QI project management (n = 13 [76.5%]), and implementation strategies (n = 11 [64.7%]). Safety in health care and team building were also highly ranked concepts, with 100% of respondents rating them as always used (n = 9 [53%]) or often used (n = 8 [47%]). Driver diagrams and logic models received the lowest use ratings with 29.4% (n = 5) and 35.3% (n = 6) rating them as rarely used (Supplemental Digital Content, http:// links.lww.com/NE/A923, Table 3, has complete information on responses). Phase 3: Focus Groups The focus groups included 10 employers representing 5 area hospitals. Issues identified regarding new DNP graduates included their lack of leadership experience, experience with Nurse Educator • Vol. 46 • No. 6. www.nurseeducatoronline.com Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved. 363 system-level operations of a hospital, and understanding of how QI works in a health care setting. In addition, as students, they go to the setting with projects that are important to them, whereas it would be more advantageous to them and to the agency if they joined a project already in progress. One leader described the use of a nurse scientist in her setting who decides whether the student has a project that is in line with the agency's vision and mission so the student has a meaningful experience and the agency benefits from the project. Another leader, who is contacted directly by the DNP student, arranges for herself, her director of quality, and the clinical educator to meet with the student and determine if the proposed project is in line with the needs of the agency and if it is sustainable. This leader also hired a coordinator to work with the faculty to identify the nature of the project, support that the student will need from the agency, and support given by the nursing program. That support might include equipment or personnel, which has to be factored into the budget. When a particular health care setting cannot provide the needed resources, the nursing program may have to support the project financially. The leaders in both focus groups viewed a list of tools, skills, and concepts to identify which ones are used in their setting. Many of the leaders cited their first choice as the QI project charter and the second choice as data collection and analysis. Specific comments with regard to the charter are that it includes defining scope, which is a vital aspect of the project, and gives direction and a template for consistency. The leaders also discussed a high-reliability organization, human error theory, and error proofing. With regard to leadership, even though the students are professional in presenting and involving the stakeholders in their project, they lack the knowledge and experience to lead groups on QI projects. Students need to understand trended data, evidence-based practice, and measurement. For example, one leader commented that students often want to develop their own tools rather than to use existing valid and reliable instruments. Discussion The results of this study support the need for nurses pursuing a DNP in advanced nursing practice to have education and training beyond their area of specialization, specifically in QI methods and tools. Practice partners who are hiring DNP-prepared nurses are expecting them to be leaders in the organizations and contribute to the organization's mission beyond providing direct patient care. Data from the surveys and focus groups indicate that practice leaders who hire DNP graduates expect them to, at a minimum, identify QI areas on which to focus to improve health care structures, processes, and outcomes. These data also suggest that practice leaders want DNP graduates to be part of the QI project implementation team. These expectations are consistent with the DNP Essentials (II) that states nurses graduating from a DNP program should have expertise in analyzing organizations, identifying issues within a system, and facilitating organization-wide changes in the delivery of quality care.11 364 However, the practice leaders reported that new DNP graduates often lacked the level of leadership experience and understanding of how to implement QI within a complex organization that was needed. From a curricular standpoint, this finding supports the need for students to have a targeted leadership practicum experience to supplement their clinical courses. In particular, these data suggest the need for schools with DNP programs to include more education about organizational systems and how to develop and lead QI projects. The use of QI methods and tools as the basis of the DNP project supports students in acquiring skills that will enhance their ability to develop and implement improvement initiatives. For example, DNP QI projects provide the student with the opportunity to apply theoretical learning about leadership, organizational theory, and their area of advanced practice in a real-world setting. This also is supported by the AACN White Paper that recommended that the DNP project focus on a change that impacts health care outcomes and has a system or population focus.14 Our data from all phases of the study also indicate there was strong agreement that the ability to develop QI project aims is of high level of importance. The practice leaders indicated that DNP graduates should be able to clearly define and communicate the scope and purpose of the DNP project aims and how they relate to the organization's mission and vision. Although there was an agreement on the relative importance of the majority of topics, there was considerable difference in the importance of driver diagrams and logic models, with the QI experts rating them as less important than did the practice partners. Driver diagrams are used to help the QI leader and team identify improvement priorities. Logic models help show the relationship among goals, resources, activities, and outputs. These 2 tools are particularly useful for an organization's leaders to gain insights into the structures, processes, and outcomes that need to be improved. However, the use of these tools may be beyond the scope of QI professionals' normal work, which may explain the lower ranking compared with QI experts. It is also possible that as many current QI professionals did not receive formal education in QI frameworks and tools, they are not as familiar with these tools and have their own way of working through these processes. More research is needed to fully understand why QI experts rated these tools of lower importance than the practice partners. These findings suggest that DNPprojects could be better coordinated with the project site leaders and their team members as much as practical. Better coordination could help students focus on solving the problems identified by the practice leaders. Limitations There were a few limitations to the study. First this was a small convenience sample with a low response rate of individuals invited to participate. However, the leaders included in the surveys and focus groups represent the major health Nurse Educator • Vol. 46 • No. 6. Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved. www.nurseeducatoronline.com care organizations in the Baltimore/Washington, DC, area. These leaders hire DNP graduates from multiple schools in the area. The expectations of leaders in other large urban areas are likely similar. Finally, the majority of the participants were from large hospitals with limited representation from smaller hospitals and no representations of DNP graduate expectations in primary care and other outpatient care settings. Our data also showed that QI experts agreed in most instances with the findings from the QI leader survey findings. Conclusion Further research should focus on how to build more effective academic-practice partnerships related to DNP projects. One way to enhance these relationships is for faculty to adjust curriculum when possible to better meet the needs of their practice partners. A survey is an effective way for faculty to learn which skills and knowledge their practice partners find to be of greatest importance. If faculty disagree with the priorities of their practice partners, they can also use these findings to identify areas where there is need for ongoing dialogue. Stronger academic-practice partnerships will support the ability to achieve the common goals of ensuring patients and populations have access to evidence-based structures and processes that have been shown to improve outcomes. Faculty and students need to begin the project with collaboration, partnership, and sustainability in mind. Better understanding what expectations of graduates are when hired by health care organizations will allow DNP programs to prepare students to contribute in meaningful ways to the health care system. Nurses are expected to be systems thinkers and need the knowledge, skills, and abilities for them to not only care for individual patients but also work within complex organizations to create systematic changes that will improve patient outcomes on a population level. Faculty need to provide DNP students with an educational experience that includes concepts in both QI and leadership to meet the expectations of future employers and the needs of a complex and changing health care system. Acknowledgments The authors acknowledge the hard work and dedication of the AdvISE Steering Committee. References 1. Trautman DE, Idzik S, Hammersla M, Rosseter R. Advancing scholarship through translational research: the role of PhD and DNP prepared nurses. Online J Issues Nurs. 2018;23(2):2. doi:10.3912/OJIN. Vol23No02Man02 2. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press; 2001. 3. Institute of Medicine (US) Committee on the Health Professions Education Summit; AC Greiner, E Knebel, eds. In: Health Professions Education: A Bridge to Quality. National Academies Press; 2003. https:// www.ncbi.nlm.nih.gov/books/NBK221528/. Accessed February 26, 2021. doi: 10.17226/10681 4. American Association of Colleges of Nursing. Fact sheet: the doctor of nursing practice. AACN. 2017. https://www.aacnnursing. org/Portals/42/News/Factsheets/DNP-Factsheet.pdf. Accessed June 1, 2020. 5. Tovar E, Ossege J, Farus-Brown S, Zonsius M, Morrow L. DNP program faculty and graduates' knowledge and use of QI and safety processes. 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Graduate-level QSEN competencies knowledge, skills and attitudes. 2012. https://www. aacnnursing.org/Portals/42/AcademicNursing/CurriculumGuidelines/ Graduate-QSEN-Competencies.pdf. Accessed June 1, 2020. 11. American Association of Colleges of Nursing. The essentials of doctoral education for advanced nursing practice. AACN. 2006. https:// www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf. Accessed June 1, 2020. 12. Durham ML, Cotler K, Corbridge SJ. Facilitating faculty knowledge of DNP quality improvement projects: key elements to promote strong practice partnerships. J Am Acad Nurse Pract. 2019;31(11): 665-674. doi:10.1097/JXX.0000000000000308 13. Bingham D, Hammersla M, Belcher A, et al. Survey of Nursing faculty preparation for guiding DNP quality improvement projects. J Dr Nurs Pract. In press. Accepted for publication, January 2021. 14. American Association of Colleges of Nursing. The doctor of nursing practice: current issues and clarifying recommendations. AACN. 2015. https://www.pncb.org/sites/default/files/2017-02/AACN_ DNP_Recommendations.pdf. Accessed June 2, 2020. Nurse Educator • Vol. 46 • No. 6. www.nurseeducatoronline.com Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved. 365 Accepted: 13 August 2017 DOI: 10.1111/jocn.14054 ORIGINAL ARTICLE The quality improvement attitude survey: Development and preliminary psychometric characteristics Pamela B Dunagan PhD, RN, Director and Assistant Professor of Nursing Division of Nursing, Berry College, Mt. Berry, GA, USA Aims and objectives: To report the development of a tool to measure nurse’s attitudes about quality improvement in their practice setting and to examine preliminary Correspondence Pamela B Dunagan, Division of Nursing, Berry College, Mt. Berry, GA, USA. Email: pdunagan@berry.edu psychometric characteristics of the Quality Improvement Nursing Attitude Scale. Background: Human factors such as nursing attitudes of complacency have been identified as root causes of sentinel events. Attitudes of nurses concerning use of Quality and Safety Education for nurse’s competencies can be most challenging to teach and to change. No tool has been developed measuring attitudes of nurses concerning their role in quality improvement. Design: A descriptive study design with preliminary psychometric evaluation was used to examine the preliminary psychometric characteristics of the Quality Improvement Nursing Attitude Scale. Registered bedside clinical nurses comprised the sample for the study (n = 57). Methods: Quantitative data were analysed using descriptive statistics and Cronbach’s alpha reliability. Total score and individual item statistics were evaluated. Two open-ended items were used to collect statements about nurses’ feelings regarding their experience in quality improvement efforts. Results: Strong support for the internal consistency reliability and face validity of the Quality Improvement Nursing Attitude Scale was found. Total scale scores were high indicating nurse participants valued Quality and Safety Education for Nurse competencies in practice. However, item-level statistics indicated nurses felt powerless when other nurses deviate from care standards. Additionally, the sample indicated they did not consistently report patient safety issues and did not have a feeling of value in efforts to improve care. Conclusions: Findings suggested organisational culture fosters nurses’ reporting safety issues and feeling valued in efforts to improve care. Participants’ narrative comments and item analysis revealed the need to generate new items for the Quality Improvement Nursing Attitude Scale focused on nurses’ perception of their importance in quality and safety and their power to enact principles. Relevance to the practice: The Quality Improvement Nursing Attitude ScaleRevised edition was designed to help in understanding nurses’ attitudes and values. It can be used to further explore broad concepts of quality improvement efforts. KEYWORDS nursing attitude, organisational culture, psychometric characteristics, quality improvement, safety J Clin Nurs. 2017;26:5113–5120. wileyonlinelibrary.com/journal/jocn © 2017 John Wiley & Sons Ltd | 5113 5114 | DUNAGAN 1 | INTRODUCTION Although the goal to lessen patient harm and promote patient safety and quality outcomes within health care is of utmost importance, numerous nursing errors continue to be made. With the goal to What does this paper contribute to the wider global clinical community? • Quality Improvement Nursing Attitude Scale (QINAS) can be used for clinical nurse leaders who are incorporate a culture of safety into nursing school curricula, the interested in answering questions related to nursing atti- Quality and Safety Education for Nurses Competencies have been tudes about processes towards improvement in quality taught in participating schools of nursing in the United States since and safety. A better understanding of nursing attitudes 2008. However, graduation from an accredited school of nursing concerned with nurses’ perception of their importance in may not ensure nurses have attained an attitude which promotes quality and safety and their power to enact principles of Quality and Safety Education for Nurses (QSEN) competencies. safety and quality will allow nurse leaders to further Additionally, nursing attitudes centered around quality improvement efforts and risks for safety have varied. The explore broad concepts of quality improvement efforts. • The QINAS can also be used to further explore the relationships between nursing attitudes concerning quality 2 | BACKGROUND improvement and other organisational characteristics such as quality improvement environment, social capital In an effort to make changes which improve quality care outcomes, and work engagement. the American Association of Colleges of Nursing implemented the QSEN project (Barnsteiner et al., 2010). The project addressed the challenge of preparing future registered nurses with the knowledge, equally valued and maintained. Within the model, the individual skills and attitudes needed to provide safe and effective care and nurse is conceptualised as the foundational strength of the house. improve quality outcomes. The nurse equally values all competencies represented in the model In the first phase of the project, six QSEN competencies which incorporate five from the Institute of Medicine (IOM, 2003) and is comfortable advocating for a culture of safety and quality outcomes. were defined by Cronenwett et al. (2007) and included patient- Figure 2 illustrates a broader view of collaborative unity where centred care, teamwork and collaboration, evidence-based practice, each individual discipline in the healthcare team views the care of a quality improvement, informatics and safety. The second phase of single patient through the lens of the model to ensure quality patient the project included pilot schools sharing their innovative teaching outcomes. This model suggests a strategy in the pursuit of quality and development strategies on the QSEN website (www.qsen.org) outcomes which incorporates shared interdisciplinary goals and col- for use in schools of nursing to promote development of QSEN laborative viewpoints. The assumption is that each individual from competencies in nursing students. It has been argued that teaching QSEN competencies as individual concepts or silos of knowledge within existing nursing curricula limits the student’s ability to apply the concepts in clinical decision-making (Hook & Dunagan, 2013b). The use of an interdependent model is needed to teach students how to learn an integrative view of clinical competencies. Moreover, students’ understanding of the integrated model enables them to visualise relationships among the QSEN competencies, understand the nurse’s contribution towards quality outcomes and enact interdependent competencies in nursing practice following graduation. Using problem-based learning (Savery & Duffy, 1995) and Mezirow’s (1995) transformative learning theory, an interdependent QSEN competency model was developed to support nursing education and clinical practice. The Quality House model, depicted in Figure 1, illustrates the QSEN (Cronenwett et al., 2007) competencies of safety and increased organisational quality improvement as an overarching roof supported by the pillars of patient-centred care, evidence-based practice, informatics, and teamwork and collaboration. Figure 1 also illustrates each component of the house as interdependent and structurally stable only when all parts are FIGURE 1 Quality house model | DUNAGAN FIGURE 2 5115 Collaborative house model pharmacy, medicine, nursing, dietary and administration, along with 3 | DEVELOPMENT OF THE INSTRUMENT other members of the healthcare team, views themselves as the foundation of the quality house. Additionally, each team member Using the Quality House Model (Hook & Dunagan, 2013a) and the values the competencies of the house and their role in achieving QSEN concepts (Cronenwett et al., 2007; Dolansky & Moore, quality outcomes. 2013) as the conceptual framework, the author (P.B.D.) identified Quality and Safety Education for Nurse competencies were the concept of quality improvement nurse attitude. Conceptually, developed (Cronenwett et al., 2007) with the goal to prepare future quality improvement attitude was defined as the ability of the nurses with the knowledge, skills and attitudes necessary to improve nurse to value each of the six competencies of the quality house, the quality and safety of healthcare systems where they practice. recognise the interdependency among the competencies and have Additionally, specific definitions and objectives consistent with the a positive attitude about the nurses’ individual role in quality learning domains of knowledge, skills and attitudes were developed improvement. (Quality and Safety Education for Nurses, 2016). Teaching the Data are reported for the original version of the QINAS. The knowledge and skills necessary to become a nurse has challenges. original QINAS is an investigator developed scale (P.B.D.). All twenty However, one of the most challenging domains of learning to teach three items were generated to be consistent with the QSEN compe- has been the affective domain which involves feelings and attitudes tencies in the affective domain and contained portions of one or (Vomvoridi-Ivanovic & McLeman, 2015). Teaching a student to inter- more of the QSEN attitudinal learning objectives (Cronenwett et al., nalize values and beliefs in order to change or progress towards a 2007). To measure attitudes about the interdependence of the com- more positive attitude has been a challenge for nurse educators. petencies, the investigator intentionally combined two or more of However, in preparing future nurses to ethically care for all clients the competencies with single items. and improve quality outcomes, the goal of teaching values and beliefs should be addressed in teaching strategies. Fifteen items measured one stand-alone competency concerning the attitude domain. There were five items measuring quality While QSEN competencies have been integrated into the curric- improvement, five items measuring evidence-based practice, two ula of schools of nursing, research is needed to investigate how items measuring patient-centred care and two items measuring infor- knowledge, skills and attitudes around the QSEN competencies are matics. No items were developed measuring safety as a stand-alone enacted once the student graduates. Of particular interest are atti- competency. The remaining eight items were developed using attitu- tudes which are the most challenging to change. No tools have been dinal learning objective combinations of three to five competencies. developed measuring attitudes of nurses concerning QSEN compe- Quality improvement was included in seven of the eight items. tencies. The purpose of this article was to report the development Safety was included in four of the eight items. Patient-centred care and preliminary psychometric testing of the Quality Improvement was included in five of the eight items. Teamwork and collaboration Nurse Attitude Scale (QINAS) to measure nurse’s attitudes about were included in seven of the eight items. Informatics was included quality and safety as delineated by the QSEN competencies (Cronen- in three of the eight items, and evidence-based practice was wett et al., 2007). included in three of the eight items. 5116 | DUNAGAN With respect to scoring, the original QINAS is a twenty three for safety was voiced, no plan was implemented to change the situa- item summated Likert rating scale. Each item is rated from strongly tion. They also suggested nursing opinions were not solicited con- disagree to strongly agree with one item reverse scored. The possible cerning quality improvement efforts; leaving nurses feeling like they range of scores is 23–115. Conceptually, higher scores indicate more were unimportant in the process. positive nursing attitudes concerning the value of quality competencies and the nurse’s role in quality improvement. 4 | METHODS 4.1 | Design, sample and setting 5 | RESULTS 5.1 | Sample characteristics The sample (n = 57) was primarily female (91%) and white (93%) with a mean age of 36 (SD = 10.8) years. The highest degree held A descriptive study design focused on preliminary psychometric eval- by the nurses was an associate degree in nursing (52%), baccalaure- uation was used to examine the face validity (if participants felt the ate degree in nursing (40%), master’s degree in nursing (2%) and instrument measured the construct), internal consistency reliability nursing diploma (6%). Thirty-two per cent of the sample reported and acceptability (ability of respondents to complete the instrument) having had education regarding the Quality and Safety for Education of the twenty three item QINAS. The study was conducted at a Competencies (2016). south-eastern hospital after approval from the Institutional Review Board and the Hospital Institutional Review Committee. Nurses who met the following inclusion criteria were eligible to participate (i) reg- 5.2 | Internal consistency reliability istered professional nurse providing bedside care, (ii) employed part- The Cronbach’s alpha reliability was high at 0.97. Additional evi- time or full-time within the facility and (iii) have intranet access to dence for internal consistency reliability was demonstrated by the email messages. There were no exclusion criteria for the study. majority of the interitem correlations and item-to-total correlations ranging from 0.30–0.90. None of the alpha if item deleted statistics 4.2 | Procedures (which is used to suggest weak item removal from the scale) suggested any of the items were weak or not homogenous with the Following IRB approval from the college where the study was con- rest. The item-level analysis revealed the Likert response format was ducted and administrative approval from the hospital where the not fully used with almost all participants indicating they agreed or study participants were recruited, all registered nurses were strongly agreed with most items. Table 1 reports the number of par- informed about the study via email through the intranet of one ticipants either disagreeing or strongly disagreeing with items. For healthcare facility. Within the email, information was provided about the reverse-coded item twenty three, agree and strongly agree are the purpose of the study, time commitment required to complete reported in Table 1. This ceiling effect (Polit & Yang, 2016) reduced the instrument and that all data would be handled with confidential- the variability in the scores of the QINAS for each item. Items were ity. The email also contained a link to the web-based informed con- analysed for redundancy, and even highest correlated items were sent and QINAS survey. Data collection occurred over a 12 week not found to be redundant. period. 5.3 | Construct validity 4.3 | Data analysis Six participants answered the item concerning face validity of the Data were analysed using descriptive statistics and Cronbach’s alpha tool. Face validity was supported as these participants indicated the for internal consistency reliability. The criterion for acceptable inter- tool was meaningful and a thorough measure of their experiences nal consistency reliability was 0.70 or higher (DeVellis, 2016; Nun- about quality outcomes. nally & Bernstein, 1994). Item-level statistics including “alpha if item deleted” and item-to-total correlations were used to evaluate strength of items. Individual item total means were examined. Face validity and acceptability were also assessed using a single item in 6 | TOTAL SCORE AND INDIVIDUAL ITEM STATISTICS the survey asking participants their thoughts about the QINAS as a good measure of their perception of value of nurses in the role of The total score for the QINAS was 97.5 with a standard deviation of promoting quality outcomes using the QSEN competencies. 14.3. The total score suggests that overall, the sample had moder- The narrative texts were analysed using Creswell’s (2007) proce- ately high positive attitudes about quality improvement. Item-level dures. The texts appeared to centre around two additional major statistics for the QINAS are reported in Table 1. Data indicated the ideas about quality improvement attitudes that were not evident in participants highly valued the interdependent competencies exempli- the QINAS: feeling unimportant and not having their voice heard. fied in item eleven “I value technologies that support clinical deci- These nurses felt their voice was either not heard at all, or if a risk sion-making, error prevention, and care coordination” and item | DUNAGAN 5117 T A B L E 1 Means and standard deviations for the original QINAS survey items – listed by item mean – highest to lowest and number of participants who disagree or strongly disagree with items Number of participants who disagree or strongly disagree M SD Item # Item 11 I value technologies that support clinical decision-making, error prevention and care coordination. 1 4.49 .77 17 When I plan care for my patient, I believe best practice, patient preferences and interdisciplinary contributions are essential to safe quality care. 0 4.49 .69 15 I believe I should be able to effectively communicate with all members of the healthcare team in order to provide quality care. 0 4.47 .69 7 I value active partnership with patients in planning, implementation and evaluation of care. 0 4.45 .69 8 I respect and encourage individual expression of patient values, preferences and expressed needs in the care of my patients. 0 4.43 .69 18 When evaluating safety risks for my patient, I consider ALL of the following: the input from the patient, family members, other healthcare professionals, documented information in the electronic medical record and current evidence. 0 4.42 .72 1 I believe I should participate in structuring the work environment to facilitate integration of new evidence into standards of practice. 0 4.42 .77 9 I value how research contributes to my practice by providing evidence for best practice. 0 4.40 .74 16 I respect other healthcare team member’s perspectives and expertise in making decisions about patient care. 0 4.38 .71 2 I enjoy being a part of change on my unit to improve quality of care. 0 4.36 .71 6 I believe that continuous quality improvement is an essential part of the daily work of the bedside nurse. 0 4.36 .69 14 I believe quality outcomes are dependent on the following: my personal acceptance of patient contributions to care, accurate use of electronic medical records, nursing research, and ongoing collaboration with team members. 0 4.36 .76 4 I believe that consistent deviation from standards of care negatively affects the quality of care. 1 4.32 .89 10 I believe I should participate in structuring the work environment to facilitate integration of new evidence into standards of practice. 0 4.32 .78 12 I believe I should be involved in the design, selection and use of information technologies to support patient care 0 4.28 .79 19 I believe technology and use of the electronic medical record provides me the opportunity to collaborate with other nurses and healthcare professionals in order to achieve safe quality outcomes for my patients. 1 4.26 .83 21 I believe nurses should not deviate from best practice to save time or work effort. 0 4.26 .69 13 I believe I have a role in analysing unsafe practices, errors and designing system improvements. 1 4.21 .83 3 I believe I have value in the institutional efforts to improve care. 1 4.19 .85 5 I believe good patient care is dependent on the use of tools which measure quality improvement. 2 4.11 .76 22 I often seek to examine patient preferences and current research to guide me in my efforts to reduce patient harm or enhance quality outcomes. 0 4.11 .81 20 When I see a risk for compromised safety of my patient, I immediately consider if this is a systemwide problem. 1 3.96 .85 23R When I see other nurses deviating from the standard of care, I feel powerless (reversed would be powerful) to influence their practice. 10 Agreed or strongly agreed 3.43 1.12 seventeen “When I plan care for my patient, I believe best practice, Items with lower mean scores indicated nurses’ attitudes about patient preferences, and interdisciplinary contributions are essential their contributions towards quality improvement were less positive. to safe quality care.” This was evident in item twenty when nurses reported they did not 5118 | DUNAGAN immediately consider a systemwide problem when risk for compro- The results of the study indicated the QINAS had high reliability; mise of patient safety was observed. The mean score for item three however, the Cronbach’s alpha of .97 potentially could indicate was also one of the lowest indicating nurses did not believe they redundancy among items or a ceiling effect. The Likert response for- had value in institutional efforts to improve care. Item twenty three mat was not fully used which is consistent with a ceiling effect (Polit had the lowest mean score suggesting nurses felt they had no power & Yang, 2016) where the upper end of a scale does not adequately to influence practice of other nurses who deviated from the discriminate among persons with high scores. This also constrains standard of care. true variability of the items. The wording for individual items was reviewed for redundancy, and even highest correlated items were not found to be redundant. 7 | OPEN-ENDED QUESTION SUMMARY Data provided strong support for face validity and acceptance of the QINAS. Additionally, nurse educators who have attended training The study survey also asked nurses to respond to the following two and are experienced in teaching QSEN competencies reviewed the open-ended items: “Tell me of a time when you have experienced feel- document for content. The QINAS contributes to the body of nurs- ings about quality improvement efforts and Tell me about a time when ing knowledge as an instrument that can be used to explore the you have experienced feelings about your role in quality improvement.” extent to which nurses value the QSEN competencies both individu- Of the 57 participants, eight nurses provided statements about their ally and interdependently and their role in organisational efforts feelings in experiencing quality improvement efforts and six nurses towards quality improvement. provided statements concerning their role in quality improvement. The mean item findings indicated nurses believed quality In the first open-ended item, nurses were asked to report about improvement competencies are needed to provide quality care. These times when they experienced feelings about quality improvement findings are consistent with previous research studies. Although only efforts. Nurses stated not having their voice heard with statements 30% of the sample indicated having had education regarding the of feeling unimportant and my opinion was not requested. One nurse quality and safety for education competencies, mean item findings said, many nurses have good ideas but they aren’t voiced or listened to. indicated nurses do value care competencies towards the goal of Nurses also expressed attitudes of negativity about quality improve- quality outcomes. Additionally, the findings suggesting nurses in this ment efforts saying: Many times the management creates quality setting (i) did not consider a risk for compromised safety of a patient improvement efforts without consulting the nursing staff. . .leads to as a systemwide problem, (ii) felt powerless when other nurses devi- impractical ways of actually improving quality care of patients. Another ated from care standards and (iii) did not feel valued in efforts to nurse said, I did not like it at first and sentiments about wishing improve care were all also consistent with recent studies (Davis, Har- things would not change so rapidly. ris, Mahishi, Bartholomew, & Kenward, 2016; Lyndon et al., 2015; In the second open-ended item when asked about a time when Maxfield, Lyndon, Kennedy, O’Keeffe, & Zlatnik, 2013). they experienced feelings about their role in quality improvement, Answers to the open-ended items from the survey validated the nurses stated their feelings of unimportance in the role of quality low mean score items and also suggested nurses felt their opinions improvement. Two nurses had positive ideas such as willing to are not solicited making them unimportant in quality improvement implement the changes and realizing caring for patients involved efforts and statements made by nurses towards risk reduction were quality improvement effort. However, other statements were nega- not heard. This was also consistent with the previous literature that tive: I do not feel management as a whole really worries about the bed- has shown nurses do not consistently report clinical situations in side quality improvement and I feel like I should speak up when I which patients are put at risk and errors are not reported in organi- observe something unsafe, unfortunately, a lot continues to happen and sational cultures (Davis et al., 2016; Lyndon et al., 2015). Further- I document that I have expressed concerns and move on. Two nurses more, nurses have accepted problems as common occurrences and witnessed unsafe practices one being with medication administration feel powerless to influence practice of other nurses who deviate and after reporting it, felt nothing was done. from standards of care (Lyndon et al., 2015). One of the lowest rated mean scores was from an item which suggested nurses did not even consider systemwide vulnerabilities 8 | DISCUSSION when a risk for compromised safety was experienced. This item suggested organisational cultures understanding the limits of human fac- The aim of this article was to explain the development of a tool to tors in caring for patients and systemwide vulnerabilities may be measure nurse’s attitudes about use of QSEN competencies in their influential in nurses’ making decisions to speak up when risks for practice setting. A second aim was to examine preliminary psycho- safety are seen. Internationally, studies have indicated an organisa- metric characteristics of the QINAS. The discussion will first focus tional culture of safety fosters speaking up when care risk is recog- on the preliminary psychometric characteristics of the tool and the nised (Abdi, Delgoshaei, Ravaghi, Abbasi, & Heyrani, 2015; Cleary, implications for nursing practice as indicated in previous studies. Walter, Horsfall, & Jackson, 2013). Second, the focus will be on the findings of the study and recommendations for revision of the scale. An organisation which does not proclaim to promote an open, no-blame culture in which attempts are made to learn from errors | DUNAGAN and near misses may not be able to meet quality initiatives and impact patient care areas meaningful to patients (Hardy & Jaynes, 5119 T A B L E 2 Newly developed items and the intended dimensions they address 2011). Therefore, nurses who work in a culture of blame tend to Item # Item Dimensions addressed hide errors rather than reporting them. This punitive type environ- 24 I believe that my managers value information about the work habits that affect the quality of care in my unit. Organisational culture 25 I believe that issues and problems involving patient safety and quality care are adequately addressed by my unit manager or other leader in a timely manner. Organisational culture 26 I feel that I am involved in a process of quality improvement in important ways. My involvement 27 I feel that issues with patient safety are seen as a “system problem” by my managers. Organisational culture 28 Organisational culture 9 | RECOMMENDATION FOR REVISION OF THE INSTRUMENT When patient safety is compromised, I feel that it is reliably reported. 29 I feel that we have a “culture of safety” in my unit. Organisational culture The results from this preliminary psychometric study of the QINAS 30 I feel that my voice is heard when I express my views about the quality of care in my unit. My voice 31 When I see a risk for compromised safety I report it by documentation. My involvement and my voice 32 When I see a risk for compromised safety I keep it to myself. My involvement and my voice 33 When I see a risk for compromised safety I tell a supervisor. My involvement and my voice 34 When I see a risk for compromised safety I express concern to another employee. My involvement 35 When I see a risk for compromised safety I hope it will get better. My involvement ment does not promote accountability, honesty and integrity. Studies concerning attitudes of nurses about their beliefs, values and roles in the process of quality improvement warrant increased attention because nurses are consistently caring for patients in need of safe, quality care. Additionally, organisations that realise the importance of cultural honesty and openness should conduct studies to explore nurse’s attitudes concerning their role in improving care. By being able to measure nursing values centred around patientcentred care, teamwork and collaboration, evidence-based practice, safety, quality improvement and use of informatics, studies can be conducted exploring relationships to other outcome measures of health care. revealed new insight about the affective domain for QSEN competencies and the need to generate additional items for the QINAS focused on nurses’ perception of their importance in quality and safety and their power to enact quality and safety principles. Twelve additional items were generated within three dimensions: nurse’s perception about their voice being heard (my voice), nurse’s perception about how safety and quality improvement is addressed at their organisation (organisational culture), and their involvement in an organisational structure concerning quality improvement (my involvement). Table 2 reports the newly developed items and the intended category they address. The twelve additional items were added to the original QINAS to create the revised QINAS (QINAS-R). The QINAS-R is a thirty fiveitem Likert rating scale. The twenty three items from the original QINAS were retained. Each item was rated from strongly disagree to mostly White females in the south-eastern United States. Possibly strongly agree with two items reverse scored (item twenty three and non-White individuals or males would have differing attitudes con- thirty two) representing the possible range of scores for the QINAS- cerning safety and quality improvement efforts. Further evidence for R between 35–175. Higher scores indicated higher positive nursing validity of the scale needs to be obtained, and further studies (both attitudes concerning value of quality competencies and the nurse’s international and domestic) are needed which evaluate the psycho- perception of their role in quality improvement and the organisa- metric properties of the revised thirty five-item scale including factor tional culture in which they practice. analysis. The sample size of 57 was minimally acceptable for psychometric evaluation. Sources recommend up to 10 subjects per item for psychometric evaluation of a scale (DeVellis, 2016). Item-level 10 | LIMITATIONS estimates should be interpreted with caution. There were several limitations to this preliminary psychometric was not fully used with most participants indicating they strongly study. One limitation is that the assessment was conducted at a sin- agreed, agreed or neither agreed nor disagreed with the items. Con- gle for-profit healthcare institution with a limited number of regis- sequently, a ceiling effect may have occurred. Understanding of tered nurses. The findings likely reflect one organisational structure nurses’ choice of agreement with items may reflect social desirability The item-level analysis suggested that the Likert response format and climate. The findings might have been different in other health- which is explained as the participants’ tendency to misinterpret their care institutions. Additionally, the sample was homogenous with opinions in a positive light consistent with what nurses should think. 5120 | DUNAGAN It could be that nurses have been educated and do value the QSEN competencies. Ultimately, an alternative response format could be needed. Future uses of the instrument might involve changing the responses to three choices which are differing levels of agreement. The Cronbach’s alpha of .97 is a potential limitation as it signifies redundancy. However, a review of the highest correlated items did not reveal an obviously redundant item. 11 | CONCLUSION Providing care which lessens patient harm and promotes patient safety and quality outcomes is the goal of healthcare institutions. After almost a decade of using competencies for promoting quality and safety in practice, nurses are still unclear in their role in the effort and believe their organisation culture is not safe for reporting risks to safety. Organisations valuing safety and quality outcomes and appreciating accountability, honesty and integrity in their efforts to achieve them need to understand whether nurses value the competencies to reach quality outcomes and whether nurses feel their role is important in progress towards the goal within a beneficial organisational culture of healthcare practice. The QINAS-Revised edition has been designed to help in understanding these nurse attitudes and values. 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(Health care setting selected: ambulatory care, acute inpatient hospital, post-acute (Skilled Nursing Facility) • Compare the settings for strengths and weaknesses as sites for an EBP QI project. Be specific and provide examples. Explain the practice problems that you explored based on your interests and identified needs of the health care settings you investigated. (The practice problem selected infection control and use of hand hygiene to decrease spread of infection) • • • Explain why each problem is a potential focus for an EBP QI project. Be specific and provide examples. For each health care setting, describe the stakeholders whose approval would be required to initiate an EBP QI project and implement the results. Stakeholders for ambulatory care: admitting-administrative personnel, nurses, anesthesiologist, health care providers, CRNA (certified registered nurse anesthetist Stakeholders for acute inpatient hospital – nurses, healthcare providers, hospital administration personnel, Chief nursing officer, Chief Financial Officer, nurses, respiratory therapist, occupational therapist, physical therapy, speech language pathologist, nutritionist, certified nurse assistant, laboratory personnel, Imagining department, radiologist. Stakeholders for post -acute-SNF (Skilled nursing facility)- Admitting department personnel, Registered nurses, certified nurse assistant, Licensed practical nurses, healthcare providers, administration, occupational therapy, physical therapy, speech language pathologist, pharmacist, lab and imagining services • Compare similarities and differences in stakeholder requirements across the settings. • Identify the one proposed health care setting/practice site and one proposed practice problem you have selected as the focus of a hypothetical presentation to stakeholders,and explain your choices. (One proposed health care setting skilled nursing facility, infection control and hand hygiene practices).
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