1. Nurses’ Perceived Skills and Attitudes About Updated Safety Concepts: Associations with Medication Administration Errors and Practices QSEN National Forum 2016 San Antonio, TX Gail Armstrong, PhD, DNP, ACNS-BC, CNE University of Colorado College of Nursing Lorraine C. Mion, PhD, RN, FAAN Vanderbilt University

2. Acknowledgements My Vanderbilt University Dissertation Committee: – Dr. Lorraine Mion, PhD, RN, FAAN – Dr. Linda Norman, DNS, RN, FAAN – Dr. Mary Dietrich, PhD – Dr. Jane Barnsteiner, PhD, RN, FAAN Collaborative Alliance for Nursing Outcomes (CALNOC) – Dr. Diane Brown, PhD, RN, CPHQ, FNAHQ, FAAN Senior Scientist – Dr. Carolyn Aydin, PhD Research Scientist & CALNOC Data Management Services Director

3. Significance of the Problem Significance of patient safety and MAEs – Human Cost 13% of hospitalized patient incur some harm from care ( Landrigan, 2010) Recent data suggests that medical harm is the 4 th cause of death in the US, with 400,000 preventable deaths/year. ( CDC, 2013) Profound disruption, discontinuation of patients’, families’ lives Second victim costs (Wu, 2000) – Cost to the System $8.9 billion/year (IOM, 2004) Extended LOS that may or may not be reimbursed (Doran, 2010) – Cost to the Nursing Profession 26% - 32% of MAE occur at the administration phase – only 3% of these errors are caught. Nurses at the “sharp end” of care. (Keohane, 2008)

4. Updated Safety Concepts Application of concepts of safety science to goal of achieving a trustworthy system of healthcare delivery. (Berwick et al, 2005) Minimizes risk of harm to patients and providers through both system effectiveness and individual performance. (Cronenwett et al, 2007) Appreciation of contribution of human factors to understand complex work environments, reshaping work processes, and analyzing complexity of errors. (Ebright, 2010)

5. Gaps Research on updated safety concepts has been focused on pre-licensure students and improved systematic error analyses. Medication Administration Error (MAE) research has focused on: – Nurse-level variables Education, observable behaviors – Unit-level variables Physical environment, work-flow, work processes – System-level variables Capital Inputs (Bar-code Medication Administration, Computer Physician Order Entry)

6. Research Aims 1)To develop and validate a scale assessing nurses’ perceived skills and attitudes toward updated safety concepts based on a literature review 2)To examine associations between nurses’ perceived skills and attitudes regarding updated safety concepts 3)To explore the influence of nurse perceived skills and attitudes a) unit-level MAE rates and b) unit- level adherence to safe medication administration practices.

7. Conceptual Model for Study Modified Minnick Roberts Outcome Production Framework CAPITAL INPUTS & PHYSICAL ENVIRONMENT BCMA CPOE ORGANIZATIONAL CHARACTERISTICS Magnet Status UHC Participation Partner with Academic Center RN ATTITUDES RN SKILLS PATIENT OUTCOMES MAEs NURSE BEHAVIOR Adherence to Safe Med Admin Practices 3 2 3 3 3

8. Methodology – Design Cross-sectional – Setting Hospitals who participation in Collaborative Alliance for Nursing Outcomes (CALNOC) Units that had collected medication administration data in the previous 18 months – Sample Aims 1 (Scale Development) = Seven agencies, 41 units, 239 RNs Aims 2 & 3 (Association with MAEs) = Four agencies, 15 units, 159 RNs – Statistics Descriptive statistics Spearman’s Rho for associations

9. Measures – Nurses’ Skills and Attitudes About Updated Safety Concepts Nurses Attitudes and Skills Around Updated Safety Concepts (NASUS Scale) – Medication Administration Errors Unit-Level Data from CALNOC – Adherence to Safe Medication Practices Unit-Level Data from CALNOC

10. Development of the Nurses’ Attitudes and Skills About Updated Safety (NASUS) (Aim #1) 1)Schnall’s Patient-Safety Attitudes, Skills and Knowledge (PS-ASK) tool 2) Chenot & Daniel’s Health Professions Patient Safety Assessment Curriculum Survey (HPPSACS). The NASUS Scale Used:  The attitude section of the HPPSACS tool  The Error Analysis skill subscale of the PS-ASK tool  The Knowledge subscale of the PS-ASK tool  Adapted for bedside RNs

11. Content Validity Index Nine Experts in Quality & Safety (2 MDs, 7 RNs) 34 items → 24 items – 5 items deleted because of low CVI scores – 5 knowledge items deleted because of questions about whether the NASUS items were the best core elements in the knowledge domain to represent updated safety concepts – Self-assessment of knowledge (especially among healthcare professionals) is unreliable.

12. Recruitment CNOs at 34 facilities – 3 waves of letters via US Postal Service – 3 waves of emails – 11 responses /23 no responses 7 agreed to participate Final Sample = 239 RNs from 41 Units and 7 Agencies

13. Findings: Aim #1 – Scale Development MeasureCronbach’s α Skill Subscale.73 Attitude Subscale.67 NASUS Scale.73 Item median ranges = 32 to 89 Target item-total correlation =.3 One Skill item <.3: #4 focuses on reporting error to a manager Eight Attitude Subscale questions <.3: -#s 6, 7, 9 and 15 focus on the occurrence of errors in healthcare, stress of the healthcare environment and the gap between errors and best practice -#s 11, 12 and 14 focus on reporting practices and the value of these practices -#13 focus on who should share errors with patients and families.

14. Unit # AgencyParticip % 1A26% 243% 3B35% 432% 531% 625% 726% 827% 938% 10C33% 1126% 1230% 13D31% 1426% 1527% Aim #2: To examine associations between nurses’ perceived skills and attitudes regarding updated safety concepts Aim #3: To explore the influence of nurse perceived skills and attitudes a) unit- level MAE rates and b) unit- level adherence to safe medication administration practices.

15. Findings: Aim #2 Skill Subscale – unit medians = 52 to 65 – individual medians = 33 to 92 Attitude Subscale – unit medians = 67-68 – individual medians = 31 to 86 Association of Skills Subscale to Attitude Subscale (Spearman’s rho >.40 = clinically significant) – One agency reached.40 – Seven/Fifteen units reached.40 – Strength of association ranged from.03 to.61 – Two units indicated inverse relationships between nurses’ skills and attitudes

16. Findings: Aim #3 MAE Rates Safe Medication Practice Adherence Attitude Subscale r s = 0.10 (p =.714) r s = 0.11 (p =.687) Skill Subscaler s = 0.47 (p=.077) r s =0.32 (p =.241) Correlation Statistics for Unit-Level Aggregated Nurses’ Perceived Skills Subscale and Attitudes Subscale Scores with their Respective Unit’s Safe Medication Practice Adherence and MAE* rates (n=15 units) r s = Spearman’s Rho * MAE = Medication Administration Error-Free Rates

17. Strengths Partnering with CALNOC – Nurses have control over the outcome variables First instrument to assess gap in education and skills around updated safety concepts Impact of nurses’ attitudes on how they experience the “quality burden” is important Competency models are increasingly using knowledge, skills and attitude models

18. Limitations Homogeneous, small sample Bedside nurses suffer from survey fatigue NASUS may lend itself to biased self-reporting as particularly the Skills Subscale relied on perceived skill level Lack of variability in the organizational variables and outcome variables limited analyses

19. Implications for Future Research The NASUS Scale would benefit from the inclusion of relevant knowledge items Further modification and testing with a larger sample of units. – Inclusion in a staff engagement survey Continued exploration of the interplay between agency-level, unit-level and clinician-level variables in impacting MAEs. – Larger sample = more variability in organizational variables – Inclusion of more clinician-level variables

20. Many thanks! Gail.Armstrong@ucdenver.edu