Theoretical and Scientific Foundations of Nursing

OR I G I N A L A R T I C L E

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

Correspondence

Pamela B Dunagan, Division of Nursing,

Berry College, Mt. Berry, GA, USA.

Email: [email protected]

Aims and objectives: To report the development of a tool to measure nurse’s atti-

tudes about quality improvement in their practice setting and to examine preliminary

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 Cron-

bach’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 indi-

cating 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 Qual-

ity 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 Scale-

Revised edition was designed to help in understanding nurses’ attitudes and values.

It can be used to further explore broad concepts of quality improvement efforts.

K E YWORD S

nursing attitude, organisational culture, psychometric characteristics, quality improvement,

safety

Accepted: 13 August 2017

DOI: 10.1111/jocn.14054

J Clin Nurs. 2017;26:5113–5120. wileyonlinelibrary.com/journal/jocn © 2017 John Wiley & Sons Ltd | 5113

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

incorporate a culture of safety into nursing school curricula, the

Quality and Safety Education for Nurses Competencies have been

taught in participating schools of nursing in the United States since

2008. However, graduation from an accredited school of nursing

may not ensure nurses have attained an attitude which promotes

Quality and Safety Education for Nurses (QSEN) competencies.

Additionally, nursing attitudes centered around quality improvement

efforts and risks for safety have varied.

2 | BACKGROUND

In an effort to make changes which improve quality care outcomes,

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,

skills and attitudes needed to provide safe and effective care and

improve quality outcomes.

In the first phase of the project, six QSEN competencies

which incorporate five from the Institute of Medicine (IOM, 2003)

were defined by Cronenwett et al. (2007) and included patient-

centred care, teamwork and collaboration, evidence-based practice,

quality improvement, informatics and safety. The second phase of

the project included pilot schools sharing their innovative teaching

and development strategies on the QSEN website (www.qsen.org)

for use in schools of nursing to promote development of QSEN

competencies in nursing students. It has been argued that teach-

ing QSEN competencies as individual concepts or silos of knowl-

edge 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 educa-

tion and clinical practice. The Quality House model, depicted in

Figure 1, illustrates the QSEN (Cronenwett et al., 2007) competen-

cies 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 col-

laboration. Figure 1 also illustrates each component of the house

as interdependent and structurally stable only when all parts are

equally valued and maintained. Within the model, the individual

nurse is conceptualised as the foundational strength of the house.

The nurse equally values all competencies represented in the model

and is comfortable advocating for a culture of safety and quality

outcomes.

Figure 2 illustrates a broader view of collaborative unity where

each individual discipline in the healthcare team views the care of a

single patient through the lens of the model to ensure quality patient

outcomes. This model suggests a strategy in the pursuit of quality

outcomes which incorporates shared interdisciplinary goals and col-

laborative viewpoints. The assumption is that each individual from

F IGURE 1 Quality house model

What does this paper contribute to the wider

global clinical community?

• The Quality Improvement Nursing Attitude Scale

(QINAS) can be used for clinical nurse leaders who are

interested in answering questions related to nursing atti-

tudes about processes towards improvement in quality

and safety. A better understanding of nursing attitudes

concerned with nurses’ perception of their importance in

quality and safety and their power to enact principles of

safety and quality will allow nurse leaders to further

explore broad concepts of quality improvement efforts.

• The QINAS can also be used to further explore the rela-

tionships between nursing attitudes concerning quality

improvement and other organisational characteristics

such as quality improvement environment, social capital

and work engagement.

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pharmacy, medicine, nursing, dietary and administration, along with

other members of the healthcare team, views themselves as the

foundation of the quality house. Additionally, each team member

values the competencies of the house and their role in achieving

quality outcomes.

Quality and Safety Education for Nurse competencies were

developed (Cronenwett et al., 2007) with the goal to prepare future

nurses with the knowledge, skills and attitudes necessary to improve

the quality and safety of healthcare systems where they practice.

Additionally, specific definitions and objectives consistent with the

learning domains of knowledge, skills and attitudes were developed

(Quality and Safety Education for Nurses, 2016). Teaching the

knowledge and skills necessary to become a nurse has challenges.

However, one of the most challenging domains of learning to teach

has been the affective domain which involves feelings and attitudes

(Vomvoridi-Ivanovic & McLeman, 2015). Teaching a student to inter-

nalize values and beliefs in order to change or progress towards a

more positive attitude has been a challenge for nurse educators.

However, in preparing future nurses to ethically care for all clients

and improve quality outcomes, the goal of teaching values and

beliefs should be addressed in teaching strategies.

While QSEN competencies have been integrated into the curric-

ula of schools of nursing, research is needed to investigate how

knowledge, skills and attitudes around the QSEN competencies are

enacted once the student graduates. Of particular interest are atti-

tudes which are the most challenging to change. No tools have been

developed measuring attitudes of nurses concerning QSEN compe-

tencies. The purpose of this article was to report the development

and preliminary psychometric testing of the Quality Improvement

Nurse Attitude Scale (QINAS) to measure nurse’s attitudes about

quality and safety as delineated by the QSEN competencies (Cronen-

wett et al., 2007).

3 | DEVELOPMENT OF THE INSTRUMENT

Using the Quality House Model (Hook & Dunagan, 2013a) and the

QSEN concepts (Cronenwett et al., 2007; Dolansky & Moore,

2013) as the conceptual framework, the author (P.B.D.) identified

the concept of quality improvement nurse attitude. Conceptually,

quality improvement attitude was defined as the ability of the

nurse to value each of the six competencies of the quality house,

recognise the interdependency among the competencies and have

a positive attitude about the nurses’ individual role in quality

improvement.

Data are reported for the original version of the QINAS. The

original QINAS is an investigator developed scale (P.B.D.). All twenty

three items were generated to be consistent with the QSEN compe-

tencies in the affective domain and contained portions of one or

more of the QSEN attitudinal learning objectives (Cronenwett et al.,

2007). To measure attitudes about the interdependence of the com-

petencies, the investigator intentionally combined two or more of

the competencies with single items.

Fifteen items measured one stand-alone competency concerning

the attitude domain. There were five items measuring quality

improvement, five items measuring evidence-based practice, two

items measuring patient-centred care and two items measuring infor-

matics. No items were developed measuring safety as a stand-alone

competency. The remaining eight items were developed using attitu-

dinal learning objective combinations of three to five competencies.

Quality improvement was included in seven of the eight items.

Safety was included in four of the eight items. Patient-centred care

was included in five of the eight items. Teamwork and collaboration

were included in seven of the eight items. Informatics was included

in three of the eight items, and evidence-based practice was

included in three of the eight items.

F IGURE 2 Collaborative house model

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With respect to scoring, the original QINAS is a twenty three

item summated Likert rating scale. Each item is rated from strongly

disagree to strongly agree with one item reverse scored. The possible

range of scores is 23–115. Conceptually, higher scores indicate more

positive nursing attitudes concerning the value of quality competen-

cies and the nurse’s role in quality improvement.

4 | METHODS

4.1 | Design, sample and setting

A descriptive study design focused on preliminary psychometric eval-

uation was used to examine the face validity (if participants felt the

instrument measured the construct), internal consistency reliability

and acceptability (ability of respondents to complete the instrument)

of the twenty three item QINAS. The study was conducted at a

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-

istered professional nurse providing bedside care, (ii) employed part-

time or full-time within the facility and (iii) have intranet access to

email messages. There were no exclusion criteria for the study.

4.2 | Procedures

Following IRB approval from the college where the study was con-

ducted and administrative approval from the hospital where the

study participants were recruited, all registered nurses were

informed about the study via email through the intranet of one

healthcare facility. Within the email, information was provided about

the purpose of the study, time commitment required to complete

the instrument and that all data would be handled with confidential-

ity. The email also contained a link to the web-based informed con-

sent and QINAS survey. Data collection occurred over a 12 week

period.

4.3 | Data analysis

Data were analysed using descriptive statistics and Cronbach’s alpha

for internal consistency reliability. The criterion for acceptable inter-

nal consistency reliability was 0.70 or higher (DeVellis, 2016; Nun-

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

the survey asking participants their thoughts about the QINAS as a

good measure of their perception of value of nurses in the role of

promoting quality outcomes using the QSEN competencies.

The narrative texts were analysed using Creswell’s (2007) proce-

dures. The texts appeared to centre around two additional major

ideas about quality improvement attitudes that were not evident in

the QINAS: feeling unimportant and not having their voice heard.

These nurses felt their voice was either not heard at all, or if a risk

for safety was voiced, no plan was implemented to change the situa-

tion. They also suggested nursing opinions were not solicited con-

cerning quality improvement efforts; leaving nurses feeling like they

were unimportant in the process.

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

by the nurses was an associate degree in nursing (52%), baccalaure-

ate degree in nursing (40%), master’s degree in nursing (2%) and

nursing diploma (6%). Thirty-two per cent of the sample reported

having had education regarding the Quality and Safety for Education

Competencies (2016).

5.2 | Internal consistency reliability

The Cronbach’s alpha reliability was high at 0.97. Additional evi-

dence for internal consistency reliability was demonstrated by the

majority of the interitem correlations and item-to-total correlations

ranging from 0.30–0.90. None of the alpha if item deleted statistics

(which is used to suggest weak item removal from the scale) sug-

gested any of the items were weak or not homogenous with the

rest. The item-level analysis revealed the Likert response format was

not fully used with almost all participants indicating they agreed or

strongly agreed with most items. Table 1 reports the number of par-

ticipants either disagreeing or strongly disagreeing with items. For

the reverse-coded item twenty three, agree and strongly agree are

reported in Table 1. This ceiling effect (Polit & Yang, 2016) reduced

the variability in the scores of the QINAS for each item. Items were

analysed for redundancy, and even highest correlated items were

not found to be redundant.

5.3 | Construct validity

Six participants answered the item concerning face validity of the

tool. Face validity was supported as these participants indicated the

tool was meaningful and a thorough measure of their experiences

about quality outcomes.

6 | TOTAL SCORE AND INDIVIDUAL ITEM STATISTICS

The total score for the QINAS was 97.5 with a standard deviation of

14.3. The total score suggests that overall, the sample had moder-

ately high positive attitudes about quality improvement. Item-level

statistics for the QINAS are reported in Table 1. Data indicated the

participants highly valued the interdependent competencies exempli-

fied in item eleven “I value technologies that support clinical deci-

sion-making, error prevention, and care coordination” and item

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seventeen “When I plan care for my patient, I believe best practice,

patient preferences, and interdisciplinary contributions are essential

to safe quality care.”

Items with lower mean scores indicated nurses’ attitudes about

their contributions towards quality improvement were less positive.

This was evident in item twenty when nurses reported they did not

TABLE 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

Item # Item

Number of participants who disagree or strongly disagree M SD

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

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immediately consider a systemwide problem when risk for compro-

mise of patient safety was observed. The mean score for item three

was also one of the lowest indicating nurses did not believe they

had value in institutional efforts to improve care. Item twenty three

had the lowest mean score suggesting nurses felt they had no power

to influence practice of other nurses who deviated from the

standard of care.

7 | OPEN-ENDED QUESTION SUMMARY

The study survey also asked nurses to respond to the following two

open-ended items: “Tell me of a time when you have experienced feel-

ings about quality improvement efforts and Tell me about a time when

you have experienced feelings about your role in quality improvement.”

Of the 57 participants, eight nurses provided statements about their

feelings in experiencing quality improvement efforts and six nurses

provided statements concerning their role in quality improvement.

In the first open-ended item, nurses were asked to report about

times when they experienced feelings about quality improvement

efforts. Nurses stated not having their voice heard with statements

of feeling unimportant and my opinion was not requested. One nurse

said, many nurses have good ideas but they aren’t voiced or listened to.

Nurses also expressed attitudes of negativity about quality improve-

ment efforts saying: Many times the management creates quality

improvement efforts without consulting the nursing staff. . .leads to

impractical ways of actually improving quality care of patients. Another

nurse said, I did not like it at first and sentiments about wishing

things would not change so rapidly.

In the second open-ended item when asked about a time when

they experienced feelings about their role in quality improvement,

nurses stated their feelings of unimportance in the role of quality

improvement. Two nurses had positive ideas such as willing to

implement the changes and realizing caring for patients involved

quality improvement effort. However, other statements were nega-

tive: I do not feel management as a whole really worries about the bed-

side quality improvement and I feel like I should speak up when I

observe something unsafe, unfortunately, a lot continues to happen and

I document that I have expressed concerns and move on. Two nurses

witnessed unsafe practices one being with medication administration

and after reporting it, felt nothing was done.

8 | DISCUSSION

The aim of this article was to explain the development of a tool to

measure nurse’s attitudes about use of QSEN competencies in their

practice setting. A second aim was to examine preliminary psycho-

metric characteristics of the QINAS. The discussion will first focus

on the preliminary psychometric characteristics of the tool and the

implications for nursing practice as indicated in previous studies.

Second, the focus will be on the findings of the study and recom-

mendations for revision of the scale.

The results of the study indicated the QINAS had high reliability;

however, the Cronbach’s alpha of .97 potentially could indicate

redundancy among items or a ceiling effect. The Likert response for-

mat was not fully used which is consistent with a ceiling effect (Polit

& Yang, 2016) where the upper end of a scale does not adequately

discriminate among persons with high scores. This also constrains

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.

Data provided strong support for face validity and acceptance of

the QINAS. Additionally, nurse educators who have attended training

and are experienced in teaching QSEN competencies reviewed the

document for content. The QINAS contributes to the body of nurs-

ing knowledge as an instrument that can be used to explore the

extent to which nurses value the QSEN competencies both individu-

ally and interdependently and their role in organisational efforts

towards quality improvement.

The mean item findings indicated nurses believed quality

improvement competencies are needed to provide quality care. These

findings are consistent with previous research studies. Although only

30% of the sample indicated having had education regarding the

quality and safety for education competencies, mean item findings

indicated nurses do value care competencies towards the goal of

quality outcomes. Additionally, the findings suggesting nurses in this

setting (i) did not consider a risk for compromised safety of a patient

as a systemwide problem, (ii) felt powerless when other nurses devi-

ated from care standards and (iii) did not feel valued in efforts to

improve care were all also consistent with recent studies (Davis, Har-

ris, Mahishi, Bartholomew, & Kenward, 2016; Lyndon et al., 2015;

Maxfield, Lyndon, Kennedy, O’Keeffe, & Zlatnik, 2013).

Answers to the open-ended items from the survey validated the

low mean score items and also suggested nurses felt their opinions

are not solicited making them unimportant in quality improvement

efforts and statements made by nurses towards risk reduction were

not heard. This was also consistent with the previous literature that

has shown nurses do not consistently report clinical situations in

which patients are put at risk and errors are not reported in organi-

sational cultures (Davis et al., 2016; Lyndon et al., 2015). Further-

more, nurses have accepted problems as common occurrences and

feel powerless to influence practice of other nurses who deviate

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

when a risk for compromised safety was experienced. This item sug-

gested organisational cultures understanding the limits of human fac-

tors in caring for patients and systemwide vulnerabilities may be

influential in nurses’ making decisions to speak up when risks for

safety are seen. Internationally, studies have indicated an organisa-

tional culture of safety fosters speaking up when care risk is recog-

nised (Abdi, Delgoshaei, Ravaghi, Abbasi, & Heyrani, 2015; Cleary,

Walter, Horsfall, & Jackson, 2013).

An organisation which does not proclaim to promote an open,

no-blame culture in which attempts are made to learn from errors

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and near misses may not be able to meet quality initiatives and

impact patient care areas meaningful to patients (Hardy & Jaynes,

2011). Therefore, nurses who work in a culture of blame tend to

hide errors rather than reporting them. This punitive type environ-

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 patient-

centred 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.

9 | RECOMMENDATION FOR REVISION OF THE INSTRUMENT

The results from this preliminary psychometric study of the QINAS

revealed new insight about the affective domain for QSEN compe-

tencies 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 five-

item Likert rating scale. The twenty three items from the original

QINAS were retained. Each item was rated from strongly disagree to

strongly agree with two items reverse scored (item twenty three and

thirty two) representing the possible range of scores for the QINAS-

R between 35–175. Higher scores indicated higher positive nursing

attitudes concerning value of quality competencies and the nurse’s

perception of their role in quality improvement and the organisa-

tional culture in which they practice.

10 | LIMITATIONS

There were several limitations to this preliminary psychometric

study. One limitation is that the assessment was conducted at a sin-

gle for-profit healthcare institution with a limited number of regis-

tered nurses. The findings likely reflect one organisational structure

and climate. The findings might have been different in other health-

care institutions. Additionally, the sample was homogenous with

mostly White females in the south-eastern United States. Possibly

non-White individuals or males would have differing attitudes con-

cerning safety and quality improvement efforts. Further evidence for

validity of the scale needs to be obtained, and further studies (both

international and domestic) are needed which evaluate the psycho-

metric properties of the revised thirty five-item scale including factor

analysis. The sample size of 57 was minimally acceptable for psycho-

metric evaluation. Sources recommend up to 10 subjects per item

for psychometric evaluation of a scale (DeVellis, 2016). Item-level

estimates should be interpreted with caution.

The item-level analysis suggested that the Likert response format

was not fully used with most participants indicating they strongly

agreed, agreed or neither agreed nor disagreed with the items. Con-

sequently, a ceiling effect may have occurred. Understanding of

nurses’ choice of agreement with items may reflect social desirability

which is explained as the participants’ tendency to misinterpret their

opinions in a positive light consistent with what nurses should think.

TABLE 2 Newly developed items and the intended dimensions they address

Item # Item Dimensions addressed

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 When patient safety is

compromised, I feel that it is

reliably reported.

Organisational culture

29 I feel that we have a “culture of

safety” in my unit.

Organisational culture

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

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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 com-

petencies 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 atti-

tudes and values. Moreover, it can be used in further investigations

to explore the broad concept of quality improvement efforts.

ACKNOWLEDGEMENTS

The author would like to thank Drs. Laura Kimble and Victor Bis-

sonette for their support and contributions to the development of

this article. The author would also like to thank Mrs. Ann Hook for

her major contribution in development of the Quality House Model.

CONTRIBUTION

Study design, data collection and analysis and manuscript was pre-

pared by PD.

ORCID

Pamela B Dunagan http://orcid.org/0000-0001-9145-4881

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How to cite this article: Dunagan PB. The quality

improvement attitude survey: Development and preliminary

psychometric characteristics. J Clin Nurs. 2017;26:5113–5120.

https://doi.org/10.1111/jocn.14054

5120 | DUNAGAN

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A articles are governed by the applicable C

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