Initial Psychometric Evaluation of the Nursing Quality and Safety Self-Inventory

Abstract

Few instruments are available to measure nursing students' quality and safety competencies. The authors developed and tested the psychometric properties of the Nursing Quality and Safety Self-Inventory (NQSSI), an 18-item, self-rated instrument to measure nursing students' quality and safety knowledge, skills, and attitudes. All prelicensure baccalaureate nursing students (N = 176) enrolled in a leadership and management course at a midwestern school of nursing completed the self-inventory. Construct validity was established with exploratory factor analysis using principal axis factoring with direct oblimin rotation. The instrument was found to be composed of two subscales, knowledge and attitudes, which explained 53.8% of total variance. The internal consistency coefficient (Cronbach's alpha) was 0.93 for the total inventory and ranged from 0.88 to 0.92 for the two subscales. Contrast validity and effectiveness of the NQSSI for measuring nursing students' self-rated quality and safety competencies was supported. [J Nurs Educ. 2013;52(xx)xxx-xxx.].

Full text

ABSTRACT
Few instruments are available to measure nursing stu-
dents’ quality and safety competencies. The authors devel-
oped and tested the psychometric properties of the Nurs-
ing Quality and Safety Self-Inventory (NQSSI), an 18-item,
self-rated instrument to measure nursing students’ quality
and safety knowledge, skills, and attitudes. All prelicen-
sure baccalaureate nursing students (N = 176) enrolled
in a leadership and management course at a midwestern
school of nursing completed the self-inventory. Construct
validity was established with exploratory factor analysis us-
ing principal axis factoring with direct oblimin rotation. The
instrument was found to be composed of two subscales,
knowledge and attitudes, which explained 53.8% of total
variance. The internal consistency coe cient (Cronbach’s
alpha) was 0.93 for the total inventory and ranged from
0.88 to 0.92 for the two subscales. Contrast validity and ef-
fectiveness of the NQSSI for measuring nursing students’
self-rated quality and safety competencies was supported.
[J Nurs Educ. 2013;52(5):269-274.]
The focus on the quality and safety competencies of nurses
has received signifi cant attention in the past decade. The
health care fi eld took particular note when the Institute
of Medicine’s (IOM) document, To Err is Human: Building a
Safer Health System, reported that preventable medical errors
result in approximately 44,000 to 98,000 deaths per year (Kohn,
Corrigan, & Donaldson, 2000). Several other national health
care organizations have also advocated for improvements in
quality and safety (Institute for Healthcare Improvement, 2011;
Institute for Safe Medication Practices, 2011; IOM, 2001; Kohn
et al., 2000; The Leap Frog Group, 2011).
In addressing the issues of quality and safety competencies,
many new standards and educational practices have emerged,
but the ability to measure quality and safety knowledge, skills,
and attitudes, both validly and reliably, has received little at-
tention (Schnall et al., 2008). Currently, there are limited tools
to measure nursing students’ quality and safety competencies.
A literature review was conducted, which revealed one instru-
ment that measures nurses’ patient safety attitudes, knowl-
edge, and skills, but the tool was found to have poor reliability
(Schnall et al., 2008). Traditionally, instructors, managers,
preceptors, and peers who are considered expert nurses have
often conducted assessments of nursing competencies through
subjective observation (Whelan, 2006); thus, an objective,
valid, and reliable method of measurement is needed.
Therefore, the purpose of this article is to present the devel-
opment and psychometric evaluation of the Nursing Quality and
Safety Self-Inventory (NQSSI). The NQSSI was developed to
evaluate changes in self-rated quality and safety competencies
of prelicensure nursing students as part of a larger study that
examined the effectiveness of a quality and safety simulation
(Piscotty, Grobbel, & Tzeng, 2011). The current study’s evalu-
ation of the NQSSI includes an examination of the inventory
development, construct and contrast validity, and reliability.
DEVELOPMENT OF THE NQSSI
Framework
The NQSSI was developed based on the work of the Qual-
ity and Safety Education for Nurses (QSEN) competencies
Initial Psychometric Evaluation of the Nursing
Quality and Safety Self-Inventory
Ronald Piscotty, MSN, RN-BC; Claudia Grobbel, DNP, RN; and Carrie Abele, PhD, RN
Received: June 2, 2012
Accepted: November 14, 2012
Posted Online: April 12, 2013
Mr. Piscotty is Special Instructor, Dr. Grobbel is Assistant Professor,
and Dr. Abele is Associate Professor, School of Nursing, Oakland Univer-
sity, Rochester, Michigan.
The authors have disclosed no potential con icts of interest,  nancial
or otherwise.
Address correspondence to Ronald Piscotty, MSN, RN-BC, Special In-
structor, School of Nursing, Oakland University, 2200 N. Squirrel Road,
3041 Human Health Building, Rochester, MI 48309; e-mail: piscotty@
oakland.edu.
doi:10.3928/01484834-20130412-03
Journal of Nursing Education • Vol. 52, No. 5, 2013 269

NURSING QUALITY AND SAFETY SELF-INVENTORY
(Cronenwett et al., 2007). Competency is composed of six
areas: (a) patient-centered care, (b) teamwork and collabora-
tion, (c) evidenced-based practice, (d) quality improvement,
(e) safety, and (f) informatics (Cronenwett et al., 2007). Each
competency area is then constructed to include an applicable
area of knowledge, skills, and attitudes (Cronenwett et al.,
2007). The six competency areas are based on the six aims of
quality health care put forth by the IOM (2001).
Items
The NQSSI is an 18-item, self-rated inventory (Table 1)
developed to measure nursing students’ self-rated knowledge,
skills, and attitudes regarding the six QSEN competency areas.
Each item was constructed to correspond with the knowledge,
skills, and attitudes area of each of the six competencies. Three
questions are included under each competency to address the
three areas of knowledge, skills, and attitudes.
Response Format and Administration
A self-report summated rating scale was chosen for measur-
ing self-rated attributes of the quality and safety competence
of the participants. Empirical evidence has suggested that self-
report measures have been found to be an effective approach
to measurement (Waltz, Strickland, & Lenz, 2005). The inven-
tory is rated on a 7-point Likert-type scale with 7 = strongly
agree, 1 = strongly disagree, and a neutral choice. Participants
are asked to place a mark (X) into the box that corresponds with
their level of agreement with each of the 18 question statements.
Two examples of the statements are: “I feel confi dent that I have
the necessary knowledge to practice patient-centered nursing
care.” and “I feel confi dent that I have the necessary skills to
integrate and utilize technology in nursing practice.”
Scores are totaled for the entire inventory by calculat-
ing a mean score. In addition, a mean score can be calculated
for knowledge, skills, or attitudes, as well as for each of the
six QSEN competency areas. Higher mean scores indicate
greater confi dence in regard to quality and safety competencies.
The total scale mean score may be used to garner a global un-
derstanding of the student’s self-rated competence, or the two
subscales may be used to examine knowledge or attitudes. All
18 items on the NQSSI are worded positively, which increases
the ease of scoring. The NQSSI is easily administered as a paper
survey and takes approximately 10 to 15 minutes to complete.
Groups Studied
Currently, the only group that has been studied with the
NQSSI is the group presented in this article. The current study
was part of a larger published study that examined changes in
self-rated quality and safety competencies of prelicensure nurs-
ing students in regard to a quality and safety simulation (Pis-
cotty et al., 2011).
METHOD
Design and Participants
A convenience sample of all the students enrolled in two
leadership and management courses in the baccalaureate nurs-
ing program at a public midwestern university was used. The
students were enrolled during the fall 2009 semester. The two
groups consisted of traditional (n = 132) and accelerated second-
TABLE 1
Nursing Quality and Safety Self-Inventory (NQSSI) Questions
1. I feel con dent that I have the necessary knowledge to practice patient-centered nursing care.
2. I feel con dent that I have the necessary skills to practice patient-centered nursing care.
3. I feel con dent that I have the necessary attitudes to practice patient-centered nursing care.
4. I feel con dent that I have the necessary knowledge to ensure an e ective nursing practice based on teamwork and collaboration.
5. I feel con dent that I have the necessary skills to ensure an e ective nursing practice based on teamwork and collaboration.
6. I feel con dent that I have the necessary attitudes to ensure an e ective nursing practice based on teamwork and collaboration.
7. I feel con dent that I have the necessary knowledge to achieve an evidenced-based nursing practice.
8. I feel con dent that I have the necessary skills to achieve an evidenced-based nursing practice.
9. I feel con dent that I have the necessary attitudes to achieve an evidenced-based nursing practice.
10. I feel con dent that I have the necessary knowledge to participate in quality improvement in nursing practice.
11. I feel con dent that I have the necessary skills to participate in quality improvement in nursing practice.
12. I feel con dent that I have the necessary attitudes to participate in quality improvement in nursing practice.
13. I feel con dent that I have the necessary knowledge to deliver safe nursing care.
14. I feel con dent that I have the necessary skills to deliver safe nursing care.
15. I feel con dent that I have the necessary attitudes to deliver safe nursing care.
16. I feel con dent that I have the necessary knowledge to integrate and utilize technology in nursing practice.
17. I feel con dent that I have the necessary skills to integrate and utilize technology in nursing practice.
18. I feel con dent that I have the necessary attitudes to integrate and utilize technology in nursing practice.
270 Copyright © SLACK Incorporated

PISCOTTY, GROBBEL, & ABELE
degree (n = 44) students enrolled in the Bachelor of Science in
Nursing program.
The total sample consisted of 176 participants. The majority
of respondents were women (n = 152 [86.4%]) and the mean
age of the participants was 29.66 years (SD = 8.44, range = 21 to
55 years). The mean years of college attended were 2.53 years
(SD = 2.06, range = 0 to 8 years), and the mean self-reported
grade point average was 3.38 points (SD = 0.21, range = 2.85
to 3.85 points). Participants working in a health care setting re-
ported mean years employed as 1.61 (SD = 3.98, range = 0 to
20 years). Table 2 shows the demographic characteristics of the
study participants.
Procedure
Institutional review board approval was obtained for the
study. Students were instructed that participation in the study
was voluntary. The students were also told that they could in-
dicate if they did not wish to participate in the study at any
time without penalty. During the fi rst class meeting, all students
were asked for their consent, and they were asked to complete
the NQSSI. The students were given detailed oral and written
instructions on how to complete the inventory.
Data Analysis
Data were analyzed using PASW Statistics 18.0 software.
Descriptive statistics were used to analyze the demographic in-
formation of the sample. Correlational analysis was used to ex-
amine the inter-item relationships. Exploratory factor analysis
using principal axis factoring with direct oblimin rotation was
used to examine construct validity. Reliability of the instrument
was assessed using Cronbach’s alpha. Contrast validity of the
instrument was determined using independent samples t tests.
The alpha value for all analyses was set at p ⬍ 0.05.
RESULTS
The scores for each of the items on the NQSSI are described
in Table 3. The scores on each of the items ranged from 1 to 7
TABLE 2
Demographic Characteristics of the
Study Sample (N = 176)
Characteristic n%
Gender
Female 152 86.4
Male 24 13.6
Cohort
Traditional group 132 75
Second degree 44 25
Education level
High school 9 5.1
Some college 99 56.3
College degree 66 37.5
No response 2 1.1
Experience in health care
Experience 86 48.8
No experience 89 50.6
No response 1 0.6
Role
Nurse assistant 42 23.9
Nurse technician 8 4.5
Other 35 19.9
Not applicable 89 50.6
No response 2 1.1
Type of health care work setting
Inpatient 57 32.4
Outpatient 6 3.4
Other 22 12.5
Not applicable 88 50
No response 3 1.7
TABLE 3
Nursing Quality and Safety Self-Inventory (NQSSI)
Descriptive Statistics and Item Analysis
Item MSDr
aRangeb
18-item NQSSI
(reliability = 0.93)
5.63 0.62
Question 1 5.56 1 0.54 2 to 7
Question 2 5.32 1 0.62 1 to 7
Question 3 6.34 0.69 0.51 4 to 7
Question 4 5.71 0.87 0.66 3 to 7
Question 5 5.59 0.88 0.72 3 to 7
Question 6 6.18 0.72 0.60 3 to 7
Question 7 5.01 1 0.71 2 to 7
Question 8 5.09 0.95 0.76 1 to 7
Question 9 5.87 0.80 0.55 3 to 7
Question 10 5.12 1.10 0.67 2 to 7
Question 11 5.12 1.06 0.65 2 to 7
Question 12 5.84 0.98 0.61 3 to 7
Question 13 5.73 0.89 0.66 2 to 7
Question 14 5.69 0.94 0.64 1 to 7
Question 15 6.39 0.71 0.56 3 to 7
Question 16 5.43 0.96 0.66 3 to 7
Question 17 5.39 0.97 0.69 3 to 7
Question 18 6.04 0.85 0.62 3 to 7
a The corrected item–total correlation.
b Possible range of scores is 1 to 7.
Journal of Nursing Education • Vol. 52, No. 5, 2013 271

NURSING QUALITY AND SAFETY SELF-INVENTORY
for three items, 2 to 7 for fi ve items, 3 to 7 for nine items, and
4 to 7 for one item. The participants’ responses ranged from
strongly disagree to strongly agree. Cases with missing data
were excluded list-wise, resulting in 171 cases that were eli-
gible for factor analysis.
Analysis of Inter-Item Correlations and
Communalities
Inter-item correlations were examined for possible item extrac-
tion. Items that were considered for removal had to have a correla-
tion ⭓ r = 0.80 or an item that had at least 50% or more inter-item
correlations of ⬍ r = 0.30. No items had at least 50% or more
inter-item correlations of ⬍ r = 0.30. Eight items had inter-item
correlations ⭓ r = 0.80 (questions 4, 5, 10, 11, 13, 14, 16, and 17
[see Table 1 for question text]) On review, these items were paired
under one of the competencies of (a) teamwork and collaboration
(questions 4 and 5), (b) quality improvement (questions 10 and 11),
(c) safety (questions 13 and 14), and (d) informatics (questions 16
and 17). The high inter-item correlation of these items indicates
redundancy. Conceptually, this may indicate that it is diffi cult for
respondents to differentiate between knowledge and skills. To per-
form a skill, one must have adequate knowledge, thus they are con-
ceptually linked. These items were removed individually and as a
group to examine the impact on the factor structure. No change in
the factor structure or improvement in reliability was noted, thus it
was decided to keep all items in the scale.
Construct Validity of the NQSSI
Exploratory factor analysis using principal axis factoring with
direct oblimin rotation was used to examine construct validity
and to determine the best factor solution for the 18-item scale.
The factor analysis indicated a signifi cant Bartlett’s test (X2 [153,
N = 171] = 2504.25, p ⬍ 0.000), a Kaiser-Meyer-Olkin measure
of 0.87, and item communalities ⬎ 0.43 for all items.
The factors for the 18-item scale were evaluated using ei-
genvalues, the scree plot, and parallel analysis using a Monte
Carlo simulation (Pallant, 2007). Two factors were extracted
using the following criteria: (a) Kaiser’s Rule of eigenvalues
⬎ 1.00, (b) parallel analysis indicating a two-factor structure,
and (c) factor loadings of ⭓ 0.32 (Tabachnick & Fidell, 2006).
Table 4 shows the NQSSI factor loading patterns. The two fac-
tors were named (a) knowledge and (b) attitudes. As shown in
Table 4, there were strong single loadings of each item on only
one of the factors.
The factor analysis supported the hypothesis that the 18-item
scale with two subscales indicates conceptual congruence with
nursing students’ self-rating of quality and safety competencies.
Factor 1 (knowledge) contained 12 items indicating nursing stu-
dents’ confi dence regarding their knowledge and skills related to
quality and safety competencies. Factor 2 (attitudes) contained
six items indicating nursing students’ confi dence with their atti-
tudes toward quality and safety competencies. The total variance
explained by this two-factor solution was 53.8%. Table 5 shows
descriptive scores of the two subscales.
Reliability of the NQSSI
The internal consistency coeffi cient (Cronbach’s alpha) of
the NQSSI was 0.93, which indicates satisfactory reliability.
The NQSSI had strong item–total correlations that indicate the
ability to discriminate between high and low scores (Table 3).
The reliabilities of the new subscales are satisfactory and ranged
from 0.88 to 0.92 (Table 5).
Contrast Validity
Contrast validity was tested using the cohort of nursing stu-
dents (accelerated versus traditional) and the mean total and
TABLE 4
18-Item Nursing Quality and Safety Self-Inventory
Factor Loadings Using Principal Axis Factoring Analysis
With Direct Oblimin Rotation
Scale Item Factor 1: Knowledge Factor 2: Attitudes
Question 1 0.72 –0.14
Question 2 0.75 –0.07
Question 3 0.00 0.66
Question 4 0.64 0.10
Question 5 0.71 0.10
Question 6 0.07 0.71
Question 7 0.83 –0.05
Question 8 0.85 –0.01
Question 9 –0.05 0.79
Question 10 0.47 0.29
Question 11 0.45 0.30
Question 12 0.01 0.79
Question 13 0.74 –0.02
Question 14 0.73 –0.02
Question 15 0.04 0.70
Question 16 0.58 0.17
Question 17 0.60 0.19
Question 18 0.03 0.79
Note. Factor loadings ⬎ 0.30 are shown in bold.
TABLE 5
Mean, Standard Deviation, and Internal
Reliabilities for Each Subscale of the Nursing
Quality and Safety Self-Inventory
Subscale MSD
Internal
Consistency
Cronbach’s
Alpha
Factor 1: Quality and safety
knowledge (12 items)
5.40 0.71 0.92
Factor 2: Quality and safety
attitudes (6 items)
6.11 0.63 0.88
272 Copyright © SLACK Incorporated

PISCOTTY, GROBBEL, & ABELE
subscale scores. The con-
trasted groups approach to
establishing validity is appro-
priate when it is hypothesized
that two or more groups may
score differently on the mea-
sure (Waltz et al., 2004). In
our study, it was hypothe-
sized that the accelerated stu-
dents would have statistically
signifi cantly higher mean to-
tal and subscale scores than
traditional students. This
may be due to the fact that
the accelerated students have
already completed an under-
graduate degree and have al-
ready established a career. An
alternate explanation may be
that the accelerated students
were at the end (last semes-
ter) of their nursing program
versus the traditional students
who were in the second semester of their junior year. The ac-
celerated students had completed all of their acute care clini-
cal experiences, whereas the traditional students had not. The
independent samples t test revealed that there were statistically
signifi cant (p ⬍ 0.05) higher mean total and subscale scores
between the accelerated and traditional students, suggesting
contrast validity (Table 6).
Possible Covariates
Certain demographic characteristics should be evaluated
when examining self-reported quality and safety competen-
cies. These characteristics include variables such as age, years
of education, and years of experience in a health care setting.
These variables may have an effect on self-reported quality and
safety competencies and should be evaluated. The relationships
between these variables and mean total scores on the NQSSI
were examined. Age (Pearson’s r = 0.17, p = 0.03) and years
employed in a health care setting (Pearson’s r = 0.18, p = 0.02)
were found to have a signifi cant positive relationship with mean
total scores on the NQSSI. This relationship indicates that as
participants’ age increased and as participants worked longer
in health care settings, their NQSSI scores tended to be high-
er. A signifi cant negative relationship was found between the
numbers of years spent in college (Pearson’s r = –0.29, p ⬍
0.001) with mean total scores on the NQSSI. This indicates that
the more years the participants reported they were in college,
the lower their scores on the NQSSI tended to be. This may
be attributed to the fact that students who have long tenures in
college may not have been exposed to work settings and the
resultant quality and safety standards.
DISCUSSION
The results from our study provide support for the reliability
and validity of the NQSSI as an instrument to measure self-
rated quality and safety competencies of nursing students. The
NQSSI assesses nursing students’ self-rated quality and safety
knowledge and attitudes related to the six QSEN competencies.
The reliability of the NQSSI is much stronger in contrast to that
reported on the Patient Safety Attitudes, Skills, and Knowledge
Scale (Schnall et al., 2008). The Patient Safety Attitudes, Skills,
and Knowledge Scale was developed based on the six aims
from the IOM, but it had poor reliability (Schnall et al., 2008).
The NQSSI has two subscales that are conceptually congru-
ent with the knowledge and attitudes of the QSEN competen-
cies. Although either subscale could be used independently, it is
recommended that the total scale be used to garner a holistic as-
sessment of nursing students’ self-rated quality and safety com-
petencies. The NQSSI also showed good internal consistency,
with evidence of contrast validity.
CONCLUSION
The study fi ndings support that the NQSSI is an effective
measure for assessing nursing students’ self-rated quality and
safety competencies. Researchers who attempt to design effec-
tive interventions to improve nursing quality and safety in nurs-
ing students can use the NQSSI to measure effectiveness. This
study has laid a foundation for further testing of the validity
and reliability of the NQSSI and offers opportunities for further
exploration of instrument development for measuring nursing
quality and safety competencies.
Relatively few measures assess nursing students’ quality and
safety competencies. The NQSSI is a new instrument that may
be used with differing types of nursing students in diverse set-
tings. The NQSSI can be used in a variety of ways to measure
nursing students’ self-rated quality and safety competencies.
For example, the NQSSI can be utilized in clinical experience
or simulation settings as pretest–posttest measures of confi -
dence with quality and safety competencies. By further testing
TABLE 6
Independent t Test Results on Mean Total and Subscale Scores Between
Accelerated and Traditional Cohorts
Scale n M SD df t P 95% CI
Totala
Accelerated 44 5.98 0.45 102 –5.32 ⬍ 0.001*[–0.64, –0.29]
Traditional 130 5.52 0.62
Knowledgea
Accelerated 44 5.80 0.51 104 –5.43 ⬍ 0.001*[–0.74, –0.34]
Traditional 130 5.26 0.71
Attitudes
Accelerated 44 6.34 0.47 171 –2.83 ⬍ 0.005*[–0.52, –0.09]
Traditional 129 6.03 0.66
Note. CI = con dence interval.
a Equal variances not assumed.
* p ⬍ 0.05.
Journal of Nursing Education • Vol. 52, No. 5, 2013 273

NURSING QUALITY AND SAFETY SELF-INVENTORY
with diverse samples, the NQSSI may become an important tool
available to schools of nursing to effectively measure and moni-
tor self-rated quality competencies over time. It is hoped that
this tool will be utilized and validated further to measure self-
rated quality and safety competencies with a variety of nursing
professionals in diverse settings due to the general nature of
its content; however, further studies are needed to support this
generalization.
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