- Email: [email protected]
Development of the Obstetric Nursing Self-Efficacy Scale Instrument
Clinical Simulation in Nursing (2012) 8, e227-e232
www.elsevier.com/locate/ecsn
Featured Article
Development of the Obstetric Nursing Self-Efficacy Scale Instrument Mary Elizabeth Guimond, PhD, WHNP-BCa, Mary Colleen Simonelli, PhD, RNb a b
College of Nursing, University of Central Florida, Orlando, FL 32826, USA School of Nursing, Boston College, Chestnut Hill, MA 02467, USA KEYWORDS instrument development; obstetric simulation; self-efficacy instrument; simulation evaluation; Obstetric Nursing Self-Efficacy (ONSE)
Abstract Background: The objective of this study is the development of the Obstetric Nursing Self-Efficacy (ONSE) Scale instrument and the reporting of psychometric data gathered from a pilot completed in fall 2009 at 2 major universities. Method: The ONSE is an 18-item instrument designed with the use of Bandura’s social-cognitive theory. Instrument development consisted of 2 rounds of expert review. The average content validity index of the scale was .91. Results: For preliminary reliability testing, students (N ¼ 20) completed the ONSE survey after participating in a 45-hour clinical rotation in obstetric nursing. A range of split-half reliability scores was calculated at .85 to .96. For preliminary validity testing, students (N ¼ 46) completed the ONSE pre- and postsimulation. Paired t tests revealed a statistically significant improvement in self-efficacy scores for both pre- and posttest scores. Conclusion: The findings were encouraging for initial validity and reliability testing of the ONSE as an instrument to measure self-efficacy of students caring for obstetric patients. Cite this article: Guimond, M. E., & Simonelli, M. C. (2012, July/August). Development of the obstetric nursing self-efficacy Scale instrument. Clinical Simulation in Nursing, 8(6), e227-e232. doi:10.1016/ j.ecns.2011.01.007. Ó 2012 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc.
Nurses who work in obstetrics enjoy a high level of autonomy, which carries with it a large burden for maintaining the safety of both mother and fetus. Obstetricians rely on the skills of the obstetric nurse to accurately assess, intervene, and communicate changes in the patient’s condition in order to provide quality, safe care for the patients. There is evidence that physicians and nurses do not always communicate well or agree on care issues, particularly with regard to fetal assessment and oxytocin Corresponding author: [email protected] (M. E. Guimond).
administration. Because these two areas are major safety risks for obstetric care, strategies to improve collaboration should be implemented (Guise & Segel, 2008; Simpson, James, & Knox, 2006). The Obstetric Nursing Self-Efficacy (ONSE) Scale was developed to measure students’ perception of their selfefficacy to assess, intervene and communicate changes when they are caring for the obstetric patient. Currently, there are no published instruments available that examine the self-efficacy of students or novice nurses to safely care for obstetric clients. Furthermore, the few instruments
1876-1399/$ - see front matter Ó 2012 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc.
doi:10.1016/j.ecns.2011.01.007
Obstetric Nursing Self-Efficacy Scale Instrument
e228
that have been used to evaluate simulation experiences have been limited to self-confidence or self-efficacy instruments that were unrelated to the concept of safety for obstetric nurses’ care. The ONSE Scale was developed to detect changes in self-efficacy for students or novice nurses after experiencing a simulation designed to improve their Key Points assessment, intervention, The ONSE scale was and communication skills. developed to detect changes in self-efficacy for students or Theoretical novice nurses after exFramework periencingasimulation designed to improve This research was part of their assessment, intera larger study that evaluated vention, and commua simulated clinical experinication skills. ence for outcomes on knowl Students who have edge, skills, and attitudes. higher self-efficacy are The larger study used Ford’s more likely to demonmodel of learning transfer, strate resolve in achievwhich states that the learning ing success for a given outcomes of knowledge, skill or behavior. self-efficacy, and training These findings suggest performance are significant that ONSE instrument factors in the prediction of may detect improvtransfer performance (Ford ed self-efficacy after et al., 1998). Self-efficacy is simulation. particularly important to evaluate because learning through simulation incorporates processes that support social cognitive theory: vicarious capability, cognition, selfregulation, and self-reflection (Bandura & Kazdin, 2000). Perceived self-efficacy is the judgment of the likelihood of success when presented with a possible scenario. Perception of self-efficacy has an impact on the behavior of students in that they will avoid behavior or skills they do not believe they can accomplish; if they do not believe they can be successful, they likely will not be successful. Those who do not believe in their own abilities doubt their competence, which can have a negative impact on performance. Students who have higher self-efficacy are more likely to demonstrate resolve in achieving success for a given skill or behavior (Bandura, 1980). The most effective method of improving self-efficacy in nursing students has yet to be identified (Leigh, 2008). There is some evidence that supports the use of simulation as a method of developing self-efficacy. Much of this evidence exists in studies that have evaluated confidence levels among nursing students. Jeffries and Rizzolo (2006) found that students who participated in a clinical simulation reported higher levels of confidence related to their skills than did students who completed a pen-and-paper case study. Other researchers have published studies that supported the finding of improved confidence levels among students who participated in a simulated learning or clinical
experience (Bearnson & Wiker, 2005; Brannan, White, & Bezanson, 2008; Bremner, Aduddell, & Amason, 2008). Few instruments to measure self-efficacy are available in the literature. Of those available, even fewer have documented psychometric data to support their use. Goldenberg, Andrusyszyn, and Iwasiw (2005) developed an instrument to measure student perception of self-efficacy in health teaching postsimulation. Sinclair and Ferguson (2009) modified Goldenberg et al.’s Baccalaureate Nursing Student TeachingeLearning Self-Efficacy Questionnaire and were able to demonstrate increased levels of perceived self-efficacy for nursing practice among students who participated in both lecture and simulation versus those who experienced lecture alone. Goldenberg reported good reliability data (a ¼ .97) for the original instrument, but Sinclair and Ferguson did not determine reliability for their modified tool. Leigh (2008) concluded that there was insufficient evidence available in the literature to support simulation as being superior to other teaching methods for the development of self-efficacy. This could be because research and instrument development are lagging behind the integration of simulation as a teaching technique. More important, many of the instruments to measure self-confidence that have been developed are too global to adequately assess the benefits of simulation in a particular context. This is important to note because self-efficacy is task specific (Bandura, 1986). Only one study found in the literature review purported to relate to obstetrics and self-efficacy; however, the instrument was designed to measure self-efficacy related to the performance of three psychomotor skills relevant to the postpartum period and contained only six items, and the psychometric data supporting the instrument was limited (Bambini, Washburn, & Perkins, 2009). Because no appropriate instrument measuring perceived selfefficacy in obstetric nursing existed at the time of the study, it was important to develop a reliable tool.
Method Procedures for Instrument Development The ONSE was created to capture behaviors related to competence in obstetric nursing and perinatal safety. Competent obstetric nurses must be able to assess the well-being of the mother and fetus, intervene when necessary, and communicate to and collaborate with providers (Cherouny, Federico, Haraden, Leavitt Gullo, & Resar, 2005; Thorman et al., 2006). Additional content for scale items was based on the activity statements related to safe and effective care nursing care published in the 2007 NCLEX-RNÓ Detailed Test Plan (National Council of State Boards of Nursing, 2007). In all, 19 items were designed to capture the degree to which respondents believed that they could perform
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a specific task. Tool development included adherence to the steps outlined by Lynn (1986) and recommendations by Polit and Beck (2007) to improve item and scale validity. Reviews for validity were conducted at multiple levels: Two rounds of expert review and two student focus groups were completed to elicit feedback for individual items and the overall scale. The ONSE Scale instrument was intended to measure selfefficacy related to obstetric nursing in the clinical setting. Therefore, it was important that subject-matter experts be recruited from undergraduate schools of nursing and hospital leadership. Our experts were, at minimum, prepared at the graduate level and had extensive experience in obstetric nursing. Three experts were prepared at the doctoral level, and the remaining three were doctoral students. Two experts were recruited from outside academic institutions. One expert represented leadership from a large metropolitan hospital. The remaining experts were clinical faculty. Several rounds of review were performed on the instrument. In the first round, six subject-matter experts reviewed the scale for omissions and deletions. During the second round, a content validity index (CVI) was calculated. Six experts rated each item on a 4-point scale (1 ¼ not relevant, 2 ¼ somewhat relevant, 3 ¼ relevant, and 4 ¼ extremely relevant). Item content validities were calculated for individual items. Four items were found to have item content validity <.78, cutoff score recommended by Polit and Beck (2006), and Polit, Beck, and Owen (2007). Two of those items related to intervening to reduce or stimulate uterine activity scored .67. The other two items related to the area of communication. One item from the communication section scored .67. The lowest scoring item, ‘‘Provide detailed assessment data when feeling rushed or stressed during consultation or handoffs,’’ was scored as .50. This item was dropped from the scale, but the other items were retained because of concern that they reflected the newest practices and that all experts may not have fully recognized the importance of every item. Once the lowest scoring item was dropped, the average CVI for the scale was calculated at .91. A average CVI for the scale of .90 is considered to demonstrate excellent content validity (Polit et al., 2007). Pretesting of the instrument occurred in the summer semester of 2009 at the University of Central Florida with senior students who had completed the Nursing Care of Families didactic and clinical. Two student focus groups were held to refine the instrument. In the first round, 15 students participated and provided feedback about the language, format, and readability of the instrument. During the focus groups, students were asked to respond to the following questions:
Which items seemed confusing, too similar? Mark where you are bored, tired, or irritated? Can you see where others might get tired? Do the choices work for you?
Table 1
Sample Items: Obstetric Nursing Self-Efficacy Scale
How sure are you that you can: 1. Obtain an obstetric history? 2. Identify signs of fetal well-being (or status) on a fetal heart monitor tracing? 3. Recognize changes in maternal vital signs that require intervention (hypo/hypertension, fever, tachycardia)? 4. Collaborate with other members of the team to stabilize maternal vital signs? 5. Anticipate and/or recommend course of action to physician or nurse midwife when seeking consultation when feeling STRESSED or RUSHED? 6. Accurately communicate planned course of action during a consultation or handoff.?
If I put a ruler across the page, are the responses about the right distance apart? Are there any that you think everyone will say they are completely sure about? Or completely unsure? What should I add? What would encourage you to complete this tool? Items on the instrument were reviewed or revised on the basis of the students’ responses to the questions. For example, the students indicated that further explanation was needed for the word timely. The item was reworded to include a specific definition of timely, that is, before the occurrence of an adverse event. For other items, students suggested that some words needed special emphasis in order for the item to be understood. Capitalization and boldface were applied to words requiring emphasis. In addition, students suggested that they had difficulty discerning between the response options slightly sure and somewhat sure. The response option somewhat sure was changed to moderately sure. A group of key informants (N ¼ 3) reviewed the instrument to ensure issues identified in the focus group had been addressed. The key informants were students who had been a part of the original group. Findings from the key informants group indicated that the revised instrument was acceptable and appeared to have face validity.
Description, Administration and Scoring of the Instrument The ONSE scale consists of 18 items for which students rated their belief in their ability to perform behaviors related to obstetric nursing care. Students were asked to rate their belief (self-efficacy) in their ability to perform specific behaviors in an obstetric setting. The rating scale has five responses (4 ¼ completely sure, 3 ¼ very sure, 2 ¼ moderately sure, 1 ¼ slightly sure, and 0 ¼ not at all sure). A total self-efficacy score was calculated from the sum of the scores for each of the 18 items on the scale. Table 1 contains sample items from the instrument.
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Results
coefficients were calculated as .96, .96, and .85, respectively. The split-half reliability coefficients that were calculated exceeded the .70 threshold for reliability as recommended by Nunnally (1978).
Preliminary Testing: Reliability Preliminary testing for the reliability of the instrument occurred in the fall semester of 2009 at a large public university in the southeastern United States serving more than 53,000 students. The college of nursing is a limitedaccess upper-division program that admits approximately 180 students per year to the main campus. The sample was derived from students enrolled in the Nursing Care of Families course. Students enrolled in the course have completed the following courses: Essentials of Nursing Practice and Health Assessment. This clinical practice course is the clinical practice course is corequisite to the Nursing Care of Families theory course. In addition, these students are coenrolled in Adult Health 1 theory and clinical, Pathophysiology, and Pharmacology. A typical clinical group consists of 10 students. Clinical groups completed a 45-hour rotation in obstetrics at three different starting dates during the 15-week semester. Institutional review board permission was obtained, and on the 1st day of the Nursing Care of the Family laboratory course, all students were oriented to the procedures for the study. On completion of the 45-hour obstetric clinical rotation, an e-mail containing the URL for the ONSE questionnaire via the course management system was sent to members of each clinical group (N ¼ 60). Consent was assumed if the survey was completed. A reminder e-mail containing the link to the survey was sent to each group via course e-mail 1 week after the initial invitation to participate. A third reminder e-mail was sent to all students during the final week of the course, prior to the posting of final exam grades. The ONSE survey was constructed with the use of a secure online survey generator. The generator provides a passwordprotected environment in which survey data can be collected. For each of the three periods, data were collected at the online site and downloaded for analysis. The data files were merged, yielding a 33% participation rate (N ¼ 20). Items for a scale should demonstrate homogeneity and correlate with the total scale score. A split-half reliability was performed to test the homogeneity of the scale. The split half is the appropriate test because there was no alternative form of the test and retesting of the same population was not done (Streiner & Norman, 2007). More important, the sample size was not adequate to provide a stable estimate of covariance for an a coefficient. As N decreases, the margin of error for a increases (Duhachek, Coughlan, & Iacobucci, 2005). Because there are several ways to divide the scale, it is possible to calculate a range reliability score. Thus, two rounds of random split-half coefficients were calculated with the syntax function in SPSS version 18. In addition, one odd-even split was performed with the automated scale reliability function in SPSS. Split-half reliability
Preliminary Testing: Validity A second round of testing of the instrument occurred in the fall semester of 2009 at a private Catholic (Jesuit) university in the northeast United States. Currently 14,623 students are enrolled, with 9,060 being full-time undergraduate students. Approximately 400 students are enrolled in the school of nursing’s undergraduate program. The sample was derived from junior undergraduate students (N ¼ 47). Students enrolled in the Childbearing Nursing Clinical lab course had completed all of their math and science requirements. They had completed nursing courses in Pharmacology, Health Assessment, Professional Nursing, as well as Adult Health theory and clinical courses prior to this experience. Childbearing Nursing theory and clinical courses were taught concurrently with Adult Health II theory and clinical courses. During the 15-week semester, students attended two 3-hour weekly lecture coursesdone for each specialtydand participate in an 8-hour hospital-based clinical experience for each specialty. Clinical groups for the Childbearing course had a 1:8 faculty-student ratio for this semester, and every week during the semester, two students from each clinical group were assigned to simulation, leaving the hospital faculty-tostudent ratio at 1:6. This rotation allowed each student to participate in two simulations during the semester. Institutional review board approval was obtained, and on the 1st day of the clinical course orientation, all students were oriented to the procedures for the study. As students were being exposed to simulation scenarios at times prior to content coverage in their theory course, it was decided that a 2-hour simulation preparation class would be held prior to their rotation through the simulation lab. Students completed the ONSE survey immediately before participating in the simulation preparation class. At the end of the simulation experience, the students completed the ONSE survey again. A second, more advanced simulation experience was held approximately 4 weeks after the first exposure. During the second exposure, the students completed the ONSE survey during the simulation preparation class associated with the advanced simulation. The fourth completion of the ONSE survey was at the end of the second simulation day. The data from the second round of testing helped to establish validity in that the ONSE was tested with the same group of students at two times. Presimulation and postsimulation results were compared by means of a paired t test. The mean score for the presimulation surveys for Time 1 was 43.49 (SD ¼ 10.38), and the mean for Time 2 was 57 (SD ¼ 7.76). There was a statistically significant increase in the scores from Time 1 to Time 2, t(46) ¼
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6.858, p ¼ .000. On the postsimulation surveys, the mean score for Time 1 was 59.26 (SD ¼ 7.52), and the mean for Time 2 was 62.80 (SD ¼ 8.08). There was a statistically significant increase from Time 1 to Time 2, t(45) ¼ 2.178, p ¼ .03. The mean scores on the ONSE improved over time. Overall, this supports that perception of selfefficacy in obstetric nursing was improving over time. This finding supports validity for the tool as one would expect that self-efficacy should improve as students progress in the course. In addition, the change in means from 2.38 for moderately sure to 3.16 for very sure is important because it represents a full point increase in self-efficacy from presimulation ONSE 1 to presimulation ONSE 2. Self-efficacy scores improved with one simulation and lecture, and this finding supports the contention that the simulation may play a role in improving self-efficacy.
Discussion Lessons Learned The second round of preliminary testing had a 99% response rate (one case was lost on the posttests) versus the 33% rate on the first round. This finding was important because the initial test of the instrument was administered by means of an online survey tool. A technical problem related to the online survey resulted in paper-and-pencil administration of the ONSE during the second round of testing. Despite reminders to complete the instrument, the online group had a much lower response rate than the group who completed the survey using a traditional paper-andpencil method. Although online survey collection systems offer the benefit of convenience and automatic data compilation, this finding of a lower response rate influenced the decision to administer the instrument with pen-andpaper during the larger study. It was determined that inclass administration would likely yield a higher response rate.
Limitations The study is limited because no demographic information was collected at either site. As a result, it was not possible to analyze student characteristics. It may have been beneficial to determine whether reliability and validity varied with age, gender, ethnic background, or grade point average. Therefore, the psychometrics of the instrument require further evaluation using demographic variables for student populations.
Reliability and Validity The study evaluated the reliability and validity of a measure for self-efficacy in two populations of undergraduate
students. The strength of the study is the development of a context-specific tool and the participation of students from vastly different academic institutions. Public secular and private institutions may not attract students from similar socioeconomic backgrounds. In addition, there may be regional differences between the northern and southern U.S. student populations. However, the reliability for the instrument was high in both populations, and the scale validity was encouraging.
Conclusions These findings suggest that ONSE Scale instrument may detect improved self-efficacy after simulation. It is also possible that the instrument may be useful for measuring outcomes when methods of instruction other than simulation are used. In addition, given the safety implications of obstetric nurses’ ability to assess, intervene, and communicate, the instrument’s value in measuring self-efficacy of novice nurses should be explored.
References Bambini, D., Washburn, J., & Perkins, R. (2009). Outcomes of clinical simulation for novice nursing students: Communication, confidence, clinical judgment. Nursing Education Perspectives, 30(2), 79-82. doi:10.1043/1536-5026-030.002.0079. Bandura, A. (1980). Gauging the relationship between self-efficacy judgment and action. Cognitive Therapy and Research, 4, 263-268. doi: 10.1007/BF01173659. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall. Bandura, A., & Kazdin, A. E. (2000). Social-cognitive theory. Encyclopedia of psychology. In A. E. Kazdin (Ed.), Encyclopedia of psychology, Vol. 7 (pp. 329-332). New York, NY: Oxford University Press. Bearnson, C. S., & Wiker, K. M. (2005). Human patient simulators: A new face in baccalaureate nursing education at Brigham Young University. Journal of Nursing Education, 44(9), 421-425. Retrieved March 7, 2011, from http://www.journalofnursingeducation.com. Brannan, J. D., White, A., & Bezanson, J. L. (2008). Simulator effects on cognitive skills and confidence levels. Journal of Nursing Education, 47(11), 495-500. doi:10.3928/01484834-20081101-01. Bremner, M. N., Aduddell, K. F., & Amason, J. S. (2008). Evidence-based practices related to the human patient simulator and first year baccalaureate nursing students’ anxiety. Online Journal of Nursing Informatics, 12(1), Article 2. Retrieved February 15, 2011, from http://ojni.org/ 12_1/bremner.html Cherouny, P. H., Federico, F. A., Haraden, C., Leavitt Gullo, S., & Resar, R. (2005). Idealized design of perinatal care: IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement. Duhachek, A., Coughlan, A. T., & Iacobucci, D. (2005). Results on the standard of error of the coefficient alpha index of reliability. Marketing Science, 24(2), 294-301. doi:10.1287/mksc.1040.0097. Ford, J. K., Smith, E. M., Weissbein, D. A., Gully, S. M., & Salas, E. (1998). Relationships of goal orientation, metacognitive activity and practice strategies with learning outcomes on transfer. Journal of Applied Psychology, 83, 218-233. doi:10.1037/0021-9010.83.2.218.
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Goldenberg, D., Andrusyszyn, M. A., & Iwasiw, C. (2005). The effect of classroom simulation on nursing students’ self-efficacy related to health teaching. Journal of Nursing Education, 44(6), 310-314. Guise, J.-M., & Segel, S. (2008). Teamwork in obstetric critical care. Best Practice & Research Clinical Obstetrics & Gynaecology, 22, 937-951. doi:10.1016/j.bpobgyn.2008.06.010. Jeffries, P. R., & Rizzolo, M. A. (2006). Designing and implementing models or the innovative use of simulation to teach nursing care of ill adults and children: A national, multi-site, multimethod study. In P. R. Jeffries (Ed.), Simulation in nursing education: From conceptualization to evaluation (pp. 147-159). New York: National League for Nursing. Leigh, G. T. (2008). High-fidelity patient simulation and nursing students’ self-efficacy: A review of the literature. International Journal of Nursing Education Scholarship, 5(1). Retrieved February 15, 2011, from. http:// www.bepress.com/ijnes/vol5/iss1/art37/. Lynn, M. R. (1986). Determination and quantification of content validity. Nursing Research, 35(6), 382-385. National Council of State Boards of Nursing. (2007). 2007 NCLEX-RNÓ detailed test plan: Item writer/item reviewer/nurse educator version. Retrieved February 15, 2011, from https://www.ncsbn.org/2007_ NCLEX_RN_Detailed_Test_Plan_Educator.pdf Nunnally, J. C. (1978). Psychometric theory. New York: McGraw-Hill.
Polit, D. F., & Beck, C. T. (2006). The content validity index: Are you sure you know what’s being reported? Critique and recommendations. Research in Nursing and Health, 29, 489-497. doi:10.1002/nur.20147. Polit, D. F., Beck, C. T., & Owen, S. V. (2007). Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Research in Nursing & Health, 30, 459-467. doi:10.1002/nur.20199. Simpson, K. R., James, D. C., & Knox, G. E. (2006). Nurse-physician communication during labor and birth: Implications for patient safety. Journal of Obstetric, Gynecologic & Neonatal Nursing, 35, 547-556. doi:10.1111/j.1552-6909.2006.00075.x. Sinclair, B., & Ferguson, K. (2009). Integrating simulated teaching/learning strategies in undergraduate nursing education. International Journal of Nursing Education Scholarship, 6(1), 1-11. doi:10.2202/1548923X.1676. Streiner, D. L., & Norman, G. R. (2007). Selecting the items. In D. L. Streiner, & G. R. Norman (Eds.), Health measurement scales: A practical guide to their development and use (pp. 61-76). New York: Oxford University Press. Thorman, K. E., Capitulo, K. L., Dubow, J., Hanold, K., Noonan, M., & Wehmeyer, J. (2006). Perinatal patient safety from the perspective of nurse executives: A round table discussion. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 35(3), 409-416. doi: 10.1111/j.1552-6909.2006.00058.x.
pp e227-e232 Clinical Simulation in Nursing Volume 8 Issue 6
www.elsevier.com/locate/ecsn
Featured Article
Development of the Obstetric Nursing Self-Efficacy Scale Instrument Mary Elizabeth Guimond, PhD, WHNP-BCa, Mary Colleen Simonelli, PhD, RNb a b
College of Nursing, University of Central Florida, Orlando, FL 32826, USA School of Nursing, Boston College, Chestnut Hill, MA 02467, USA KEYWORDS instrument development; obstetric simulation; self-efficacy instrument; simulation evaluation; Obstetric Nursing Self-Efficacy (ONSE)
Abstract Background: The objective of this study is the development of the Obstetric Nursing Self-Efficacy (ONSE) Scale instrument and the reporting of psychometric data gathered from a pilot completed in fall 2009 at 2 major universities. Method: The ONSE is an 18-item instrument designed with the use of Bandura’s social-cognitive theory. Instrument development consisted of 2 rounds of expert review. The average content validity index of the scale was .91. Results: For preliminary reliability testing, students (N ¼ 20) completed the ONSE survey after participating in a 45-hour clinical rotation in obstetric nursing. A range of split-half reliability scores was calculated at .85 to .96. For preliminary validity testing, students (N ¼ 46) completed the ONSE pre- and postsimulation. Paired t tests revealed a statistically significant improvement in self-efficacy scores for both pre- and posttest scores. Conclusion: The findings were encouraging for initial validity and reliability testing of the ONSE as an instrument to measure self-efficacy of students caring for obstetric patients. Cite this article: Guimond, M. E., & Simonelli, M. C. (2012, July/August). Development of the obstetric nursing self-efficacy Scale instrument. Clinical Simulation in Nursing, 8(6), e227-e232. doi:10.1016/ j.ecns.2011.01.007. Ó 2012 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc.
Nurses who work in obstetrics enjoy a high level of autonomy, which carries with it a large burden for maintaining the safety of both mother and fetus. Obstetricians rely on the skills of the obstetric nurse to accurately assess, intervene, and communicate changes in the patient’s condition in order to provide quality, safe care for the patients. There is evidence that physicians and nurses do not always communicate well or agree on care issues, particularly with regard to fetal assessment and oxytocin Corresponding author: [email protected] (M. E. Guimond).
administration. Because these two areas are major safety risks for obstetric care, strategies to improve collaboration should be implemented (Guise & Segel, 2008; Simpson, James, & Knox, 2006). The Obstetric Nursing Self-Efficacy (ONSE) Scale was developed to measure students’ perception of their selfefficacy to assess, intervene and communicate changes when they are caring for the obstetric patient. Currently, there are no published instruments available that examine the self-efficacy of students or novice nurses to safely care for obstetric clients. Furthermore, the few instruments
1876-1399/$ - see front matter Ó 2012 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc.
doi:10.1016/j.ecns.2011.01.007
Obstetric Nursing Self-Efficacy Scale Instrument
e228
that have been used to evaluate simulation experiences have been limited to self-confidence or self-efficacy instruments that were unrelated to the concept of safety for obstetric nurses’ care. The ONSE Scale was developed to detect changes in self-efficacy for students or novice nurses after experiencing a simulation designed to improve their Key Points assessment, intervention, The ONSE scale was and communication skills. developed to detect changes in self-efficacy for students or Theoretical novice nurses after exFramework periencingasimulation designed to improve This research was part of their assessment, intera larger study that evaluated vention, and commua simulated clinical experinication skills. ence for outcomes on knowl Students who have edge, skills, and attitudes. higher self-efficacy are The larger study used Ford’s more likely to demonmodel of learning transfer, strate resolve in achievwhich states that the learning ing success for a given outcomes of knowledge, skill or behavior. self-efficacy, and training These findings suggest performance are significant that ONSE instrument factors in the prediction of may detect improvtransfer performance (Ford ed self-efficacy after et al., 1998). Self-efficacy is simulation. particularly important to evaluate because learning through simulation incorporates processes that support social cognitive theory: vicarious capability, cognition, selfregulation, and self-reflection (Bandura & Kazdin, 2000). Perceived self-efficacy is the judgment of the likelihood of success when presented with a possible scenario. Perception of self-efficacy has an impact on the behavior of students in that they will avoid behavior or skills they do not believe they can accomplish; if they do not believe they can be successful, they likely will not be successful. Those who do not believe in their own abilities doubt their competence, which can have a negative impact on performance. Students who have higher self-efficacy are more likely to demonstrate resolve in achieving success for a given skill or behavior (Bandura, 1980). The most effective method of improving self-efficacy in nursing students has yet to be identified (Leigh, 2008). There is some evidence that supports the use of simulation as a method of developing self-efficacy. Much of this evidence exists in studies that have evaluated confidence levels among nursing students. Jeffries and Rizzolo (2006) found that students who participated in a clinical simulation reported higher levels of confidence related to their skills than did students who completed a pen-and-paper case study. Other researchers have published studies that supported the finding of improved confidence levels among students who participated in a simulated learning or clinical
experience (Bearnson & Wiker, 2005; Brannan, White, & Bezanson, 2008; Bremner, Aduddell, & Amason, 2008). Few instruments to measure self-efficacy are available in the literature. Of those available, even fewer have documented psychometric data to support their use. Goldenberg, Andrusyszyn, and Iwasiw (2005) developed an instrument to measure student perception of self-efficacy in health teaching postsimulation. Sinclair and Ferguson (2009) modified Goldenberg et al.’s Baccalaureate Nursing Student TeachingeLearning Self-Efficacy Questionnaire and were able to demonstrate increased levels of perceived self-efficacy for nursing practice among students who participated in both lecture and simulation versus those who experienced lecture alone. Goldenberg reported good reliability data (a ¼ .97) for the original instrument, but Sinclair and Ferguson did not determine reliability for their modified tool. Leigh (2008) concluded that there was insufficient evidence available in the literature to support simulation as being superior to other teaching methods for the development of self-efficacy. This could be because research and instrument development are lagging behind the integration of simulation as a teaching technique. More important, many of the instruments to measure self-confidence that have been developed are too global to adequately assess the benefits of simulation in a particular context. This is important to note because self-efficacy is task specific (Bandura, 1986). Only one study found in the literature review purported to relate to obstetrics and self-efficacy; however, the instrument was designed to measure self-efficacy related to the performance of three psychomotor skills relevant to the postpartum period and contained only six items, and the psychometric data supporting the instrument was limited (Bambini, Washburn, & Perkins, 2009). Because no appropriate instrument measuring perceived selfefficacy in obstetric nursing existed at the time of the study, it was important to develop a reliable tool.
Method Procedures for Instrument Development The ONSE was created to capture behaviors related to competence in obstetric nursing and perinatal safety. Competent obstetric nurses must be able to assess the well-being of the mother and fetus, intervene when necessary, and communicate to and collaborate with providers (Cherouny, Federico, Haraden, Leavitt Gullo, & Resar, 2005; Thorman et al., 2006). Additional content for scale items was based on the activity statements related to safe and effective care nursing care published in the 2007 NCLEX-RNÓ Detailed Test Plan (National Council of State Boards of Nursing, 2007). In all, 19 items were designed to capture the degree to which respondents believed that they could perform
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a specific task. Tool development included adherence to the steps outlined by Lynn (1986) and recommendations by Polit and Beck (2007) to improve item and scale validity. Reviews for validity were conducted at multiple levels: Two rounds of expert review and two student focus groups were completed to elicit feedback for individual items and the overall scale. The ONSE Scale instrument was intended to measure selfefficacy related to obstetric nursing in the clinical setting. Therefore, it was important that subject-matter experts be recruited from undergraduate schools of nursing and hospital leadership. Our experts were, at minimum, prepared at the graduate level and had extensive experience in obstetric nursing. Three experts were prepared at the doctoral level, and the remaining three were doctoral students. Two experts were recruited from outside academic institutions. One expert represented leadership from a large metropolitan hospital. The remaining experts were clinical faculty. Several rounds of review were performed on the instrument. In the first round, six subject-matter experts reviewed the scale for omissions and deletions. During the second round, a content validity index (CVI) was calculated. Six experts rated each item on a 4-point scale (1 ¼ not relevant, 2 ¼ somewhat relevant, 3 ¼ relevant, and 4 ¼ extremely relevant). Item content validities were calculated for individual items. Four items were found to have item content validity <.78, cutoff score recommended by Polit and Beck (2006), and Polit, Beck, and Owen (2007). Two of those items related to intervening to reduce or stimulate uterine activity scored .67. The other two items related to the area of communication. One item from the communication section scored .67. The lowest scoring item, ‘‘Provide detailed assessment data when feeling rushed or stressed during consultation or handoffs,’’ was scored as .50. This item was dropped from the scale, but the other items were retained because of concern that they reflected the newest practices and that all experts may not have fully recognized the importance of every item. Once the lowest scoring item was dropped, the average CVI for the scale was calculated at .91. A average CVI for the scale of .90 is considered to demonstrate excellent content validity (Polit et al., 2007). Pretesting of the instrument occurred in the summer semester of 2009 at the University of Central Florida with senior students who had completed the Nursing Care of Families didactic and clinical. Two student focus groups were held to refine the instrument. In the first round, 15 students participated and provided feedback about the language, format, and readability of the instrument. During the focus groups, students were asked to respond to the following questions:
Which items seemed confusing, too similar? Mark where you are bored, tired, or irritated? Can you see where others might get tired? Do the choices work for you?
Table 1
Sample Items: Obstetric Nursing Self-Efficacy Scale
How sure are you that you can: 1. Obtain an obstetric history? 2. Identify signs of fetal well-being (or status) on a fetal heart monitor tracing? 3. Recognize changes in maternal vital signs that require intervention (hypo/hypertension, fever, tachycardia)? 4. Collaborate with other members of the team to stabilize maternal vital signs? 5. Anticipate and/or recommend course of action to physician or nurse midwife when seeking consultation when feeling STRESSED or RUSHED? 6. Accurately communicate planned course of action during a consultation or handoff.?
If I put a ruler across the page, are the responses about the right distance apart? Are there any that you think everyone will say they are completely sure about? Or completely unsure? What should I add? What would encourage you to complete this tool? Items on the instrument were reviewed or revised on the basis of the students’ responses to the questions. For example, the students indicated that further explanation was needed for the word timely. The item was reworded to include a specific definition of timely, that is, before the occurrence of an adverse event. For other items, students suggested that some words needed special emphasis in order for the item to be understood. Capitalization and boldface were applied to words requiring emphasis. In addition, students suggested that they had difficulty discerning between the response options slightly sure and somewhat sure. The response option somewhat sure was changed to moderately sure. A group of key informants (N ¼ 3) reviewed the instrument to ensure issues identified in the focus group had been addressed. The key informants were students who had been a part of the original group. Findings from the key informants group indicated that the revised instrument was acceptable and appeared to have face validity.
Description, Administration and Scoring of the Instrument The ONSE scale consists of 18 items for which students rated their belief in their ability to perform behaviors related to obstetric nursing care. Students were asked to rate their belief (self-efficacy) in their ability to perform specific behaviors in an obstetric setting. The rating scale has five responses (4 ¼ completely sure, 3 ¼ very sure, 2 ¼ moderately sure, 1 ¼ slightly sure, and 0 ¼ not at all sure). A total self-efficacy score was calculated from the sum of the scores for each of the 18 items on the scale. Table 1 contains sample items from the instrument.
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Results
coefficients were calculated as .96, .96, and .85, respectively. The split-half reliability coefficients that were calculated exceeded the .70 threshold for reliability as recommended by Nunnally (1978).
Preliminary Testing: Reliability Preliminary testing for the reliability of the instrument occurred in the fall semester of 2009 at a large public university in the southeastern United States serving more than 53,000 students. The college of nursing is a limitedaccess upper-division program that admits approximately 180 students per year to the main campus. The sample was derived from students enrolled in the Nursing Care of Families course. Students enrolled in the course have completed the following courses: Essentials of Nursing Practice and Health Assessment. This clinical practice course is the clinical practice course is corequisite to the Nursing Care of Families theory course. In addition, these students are coenrolled in Adult Health 1 theory and clinical, Pathophysiology, and Pharmacology. A typical clinical group consists of 10 students. Clinical groups completed a 45-hour rotation in obstetrics at three different starting dates during the 15-week semester. Institutional review board permission was obtained, and on the 1st day of the Nursing Care of the Family laboratory course, all students were oriented to the procedures for the study. On completion of the 45-hour obstetric clinical rotation, an e-mail containing the URL for the ONSE questionnaire via the course management system was sent to members of each clinical group (N ¼ 60). Consent was assumed if the survey was completed. A reminder e-mail containing the link to the survey was sent to each group via course e-mail 1 week after the initial invitation to participate. A third reminder e-mail was sent to all students during the final week of the course, prior to the posting of final exam grades. The ONSE survey was constructed with the use of a secure online survey generator. The generator provides a passwordprotected environment in which survey data can be collected. For each of the three periods, data were collected at the online site and downloaded for analysis. The data files were merged, yielding a 33% participation rate (N ¼ 20). Items for a scale should demonstrate homogeneity and correlate with the total scale score. A split-half reliability was performed to test the homogeneity of the scale. The split half is the appropriate test because there was no alternative form of the test and retesting of the same population was not done (Streiner & Norman, 2007). More important, the sample size was not adequate to provide a stable estimate of covariance for an a coefficient. As N decreases, the margin of error for a increases (Duhachek, Coughlan, & Iacobucci, 2005). Because there are several ways to divide the scale, it is possible to calculate a range reliability score. Thus, two rounds of random split-half coefficients were calculated with the syntax function in SPSS version 18. In addition, one odd-even split was performed with the automated scale reliability function in SPSS. Split-half reliability
Preliminary Testing: Validity A second round of testing of the instrument occurred in the fall semester of 2009 at a private Catholic (Jesuit) university in the northeast United States. Currently 14,623 students are enrolled, with 9,060 being full-time undergraduate students. Approximately 400 students are enrolled in the school of nursing’s undergraduate program. The sample was derived from junior undergraduate students (N ¼ 47). Students enrolled in the Childbearing Nursing Clinical lab course had completed all of their math and science requirements. They had completed nursing courses in Pharmacology, Health Assessment, Professional Nursing, as well as Adult Health theory and clinical courses prior to this experience. Childbearing Nursing theory and clinical courses were taught concurrently with Adult Health II theory and clinical courses. During the 15-week semester, students attended two 3-hour weekly lecture coursesdone for each specialtydand participate in an 8-hour hospital-based clinical experience for each specialty. Clinical groups for the Childbearing course had a 1:8 faculty-student ratio for this semester, and every week during the semester, two students from each clinical group were assigned to simulation, leaving the hospital faculty-tostudent ratio at 1:6. This rotation allowed each student to participate in two simulations during the semester. Institutional review board approval was obtained, and on the 1st day of the clinical course orientation, all students were oriented to the procedures for the study. As students were being exposed to simulation scenarios at times prior to content coverage in their theory course, it was decided that a 2-hour simulation preparation class would be held prior to their rotation through the simulation lab. Students completed the ONSE survey immediately before participating in the simulation preparation class. At the end of the simulation experience, the students completed the ONSE survey again. A second, more advanced simulation experience was held approximately 4 weeks after the first exposure. During the second exposure, the students completed the ONSE survey during the simulation preparation class associated with the advanced simulation. The fourth completion of the ONSE survey was at the end of the second simulation day. The data from the second round of testing helped to establish validity in that the ONSE was tested with the same group of students at two times. Presimulation and postsimulation results were compared by means of a paired t test. The mean score for the presimulation surveys for Time 1 was 43.49 (SD ¼ 10.38), and the mean for Time 2 was 57 (SD ¼ 7.76). There was a statistically significant increase in the scores from Time 1 to Time 2, t(46) ¼
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6.858, p ¼ .000. On the postsimulation surveys, the mean score for Time 1 was 59.26 (SD ¼ 7.52), and the mean for Time 2 was 62.80 (SD ¼ 8.08). There was a statistically significant increase from Time 1 to Time 2, t(45) ¼ 2.178, p ¼ .03. The mean scores on the ONSE improved over time. Overall, this supports that perception of selfefficacy in obstetric nursing was improving over time. This finding supports validity for the tool as one would expect that self-efficacy should improve as students progress in the course. In addition, the change in means from 2.38 for moderately sure to 3.16 for very sure is important because it represents a full point increase in self-efficacy from presimulation ONSE 1 to presimulation ONSE 2. Self-efficacy scores improved with one simulation and lecture, and this finding supports the contention that the simulation may play a role in improving self-efficacy.
Discussion Lessons Learned The second round of preliminary testing had a 99% response rate (one case was lost on the posttests) versus the 33% rate on the first round. This finding was important because the initial test of the instrument was administered by means of an online survey tool. A technical problem related to the online survey resulted in paper-and-pencil administration of the ONSE during the second round of testing. Despite reminders to complete the instrument, the online group had a much lower response rate than the group who completed the survey using a traditional paper-andpencil method. Although online survey collection systems offer the benefit of convenience and automatic data compilation, this finding of a lower response rate influenced the decision to administer the instrument with pen-andpaper during the larger study. It was determined that inclass administration would likely yield a higher response rate.
Limitations The study is limited because no demographic information was collected at either site. As a result, it was not possible to analyze student characteristics. It may have been beneficial to determine whether reliability and validity varied with age, gender, ethnic background, or grade point average. Therefore, the psychometrics of the instrument require further evaluation using demographic variables for student populations.
Reliability and Validity The study evaluated the reliability and validity of a measure for self-efficacy in two populations of undergraduate
students. The strength of the study is the development of a context-specific tool and the participation of students from vastly different academic institutions. Public secular and private institutions may not attract students from similar socioeconomic backgrounds. In addition, there may be regional differences between the northern and southern U.S. student populations. However, the reliability for the instrument was high in both populations, and the scale validity was encouraging.
Conclusions These findings suggest that ONSE Scale instrument may detect improved self-efficacy after simulation. It is also possible that the instrument may be useful for measuring outcomes when methods of instruction other than simulation are used. In addition, given the safety implications of obstetric nurses’ ability to assess, intervene, and communicate, the instrument’s value in measuring self-efficacy of novice nurses should be explored.
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