- Email: [email protected]
Speaking up to Authority in a Simulated Medication Error Scenario
Clinical Simulation in Nursing (2020)
-,
1-4
www.elsevier.com/locate/ecsn
Review Article
Speaking up to Authority in a Simulated Medication Error Scenario Linda Creadon Shanks, PhD, DNP, RNa,*, Sheau-Huey Chiu, PhD, RNa, Michele I. Zelko, DNP, RNC-OBa, Eileen Fleming, MSN, RN, NE-BCb, Sandy Germano, BSN, RN, NE-BCb a b
Department of Nursing, The University of Akron, School of Nursing, Akron, OH 44325-3701 Department of Nursing, Summa Health System, Akron, OH 44309 KEYWORDS speaking up; patient safety; standardized patients; medication errors; simulation
Abstract Background: Health care professionals need to communicate with each other when there are patient safety concerns. However, speaking up can be difficult because the health care environment is highly hierarchical. Many times health care professionals choose to remain silent or fail to bring a patient safety issue to another team member’s attention. Sample: Senior nursing students from a Midwestern University. Method: Nonequivalent groups design with standardized patient simulation as intervention. Results: Both groups reported higher self-confidence in speaking up to authority from before to after test, but differences were not significant. Conclusion: Although this study yielded nonsignificant differences with the use of standardized patient simulation, the trend in increasing self-reported confidence in speaking up to an authority when a patient safety concern arose in the intervention group was encouraging. The effects of standardized patients on students’ confidence in speaking up merit further testing with a larger sample and random assignment. Cite this article: Shanks, L. C., Chiu, S.-H., Zelko, M. I., Fleming, E., & Germano, S. (2020, -). Speaking up to authority in a simulated medication error scenario. Clinical Simulation in Nursing, Vol(X), 1-4. https://doi.org/ 10.1016/j.ecns.2020.01.008. Ó 2020 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Background Patient safety is a global health care concern (Sheikh et al., 2019). Many countries (including the United States) have acknowledged and initiated measures to reduce errors in Funding: This work was supported by the Delta Omega Chapter of Sigma Nursing, 209 Carroll St., Akron, OH 44325-3701. * Corresponding author: [email protected] (L. C. Shanks).
health care. A patient’s care is managed by a multidisciplinary health care team. Teamwork and collaboration, a competency of Quality and Safety Education for Nurses (QSEN), is an important component in keeping the patient safe (QSEN Institute, 2015). One essential element in teamwork and collaboration is effective communication (QSEN Institute, 2015). Health care professionals need to communicate with each other when there are concerns. However, speaking up can be difficult in health care because the
1876-1399/$ - see front matter Ó 2020 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ecns.2020.01.008
Speaking up in a Medication Error Scenario health care environment is highly hierarchical. As a result, many times health care professionals choose to remain silent about or fail to bring a patient safety issue to another team member’s attention (Okuyama, Wagner, & Bijnen, 2014). In a metasynthesis of international qualitative studies by Morrow, Gustavson, and Jones Key Points (2016), ‘‘hierarchies and Speaking up can be power dynamics’’ in the difficult for healthcare work environment have professionals due to been identified as a theme highly hierarchical affecting speaking up when healthcare safety concerns arise (p. environment. 43). In the same study, other Open communication issues impacting speaking is important in proup, including ineffective moting patient safety. communication and conflict Intervention with stanamong interdisciplinary dardized patients led teams, were identified. It is to an increase in stunot uncommon for nurses dents’ reported confito hesitate to speak up dence in speaking up when a health care providto authority. er’s practice puts the patient at risk for harm (Maxfield, Grenny, Lavandero, & Groah, 2011). To prepare the next generation of nurses to provide safe nursing care, nursing educators strive to provide learning activities that teach students to establish a safe practice environment. The use of simulation has been a part of nursing education in the United States. More than half of the State Boards of Nursing have regulations regarding the use of simulation in nursing education (Bradley et al., 2019). Standardized patient (SP) simulation has been acknowledged as beneficial in acquiring knowledge, learning how to speak to other health care personnel, and acquiring clinical skills (Oh, Jeon, & Koh, 2015). In addition, Andrea and Kotowski (2017) found that SPs improved undergraduate nursing students’ confidence when providing mental health care and when obtaining a health history, respectively. However, little is known about the effect of SP simulation on undergraduate nursing students’ confidence in speaking up to authority. Therefore, this pilot study with SP simulation was conducted to examine nursing students’ self-reported confidence level in speaking up to authority when a patient safety issue occurs.
Sample The setting for this study was a large Midwestern public university. Nursing students enrolled in an undergraduate senior leadership practicum course were invited to participate. The course is eight weeks in length and runs twice each semester. The students in the first eight weeks served as the control group and the students in the second eight
2 weeks were assigned to the intervention group. For the control group, 33 consented and completed the pre-test but two were lost at post-test. For the intervention group, 29 consented and completed the pre-test but seven were lost at post-test.
Method A nonequivalent groups design with standardized patient simulation as an intervention was used. As part of this senior practicum course, all students received the same information in class on speaking up for patient safety and interprofessional communication based on the Agency for Healthcare Research and Quality (AHRQ) TeamSTEPPS curriculum tools (n.d.) specifically the SBAR (situation, background, assessment, recommendation) and CUS (concerned, uncomfortable, safety issue). The simulation involved SPs and pharmacist and physician actors. Only students in the intervention group participated in the scenario where safety concerns arose which required speaking up to a person in authority. Training with the SPs and actors occurred a week before the actual simulation. This study was approved by the University Institutional Review Board on July 13, 2016, approval number 2016020. Two instruments were used: a researcher designed demographic sheet including age and gender; and an adapted student Health Professional Education in Patient Safety Survey (H-PEPSS) instrument. The original HPEPSS instrument assesses the perceived self-confidence of new health care practitioners in six areas of patient safety with 38 items and each item scores from strongly disagree to strongly agree (1-5) (Ginsburg, Castel, Tregunno, & Norton, 2012). The higher the scores, the greater the selfconfidence in identifying patient safety risks, being aware of human and environment factors affecting safety, and reporting compromised patient safety or near misses (Ginsburg et al., 2012). Internal consistency of the original H-PEPSS instrument using Cronbach’s alpha exceeded 0.80 (Ginsburg et al., 2012). For this study, after obtaining the consent from the authors of the original instrument, question 37 regarding speaking up to authority was reworded for clarification to read ‘‘I feel I can question the decisions or actions of those with more authority.’’ Responses to both instruments were collected via an online survey system. On the first day of class all students in the first and second groups were asked to voluntarily participate in this study focusing on student confidence in patient safety. Students who agreed to participate signed a consent form, completed a demographic form and the Adapted Student H-PEPSS. No identifying information was collected. Students who chose not to participate still received the same class lecture. All students in the second group (the second eight weeks of the semester), in addition to receiving the same lecture, were required to complete the simulation activity, even if they were not participating in the study. The simulation occurred pp 1-4 Clinical Simulation in Nursing Volume Vol
Speaking up in a Medication Error Scenario the third week of the eight-week course during class time. Each simulation scenario took no more than 20 minutes. During the last week of class, students in both study groups completed the Adapted Student H-PEPSS in a classroom without the presence of the investigators. The medication error scenario used in this study was a sound-alike medication in a patient with diabetes scenario. Standardized patients from the Wasson Center at a Midwest medical university played the role of the patient. These SPs are trained at the Wasson Center from a beginning orientation when they first become a patient for the Wasson Center and then another training before they participate in encounters. A week before the simulation, they also received a simulation-specific training (including a standardized script) provided by the investigators. The study was conducted in a simulation laboratory which holds seven beds with privacy curtains and has sufficient space for multiple simulations to run concurrently. For each simulation session, two students were paired with one SP and four simulation stations were running concurrently. During the simulation, the students were required to identify a sound-alike medication before medication administration. If the safety concern (incorrect medication) was identified, the students needed to pick up the phone in the simulation laboratory and call pharmacy and ask for the correct medication. If the student did not catch the error and the incorrect medication was administered, the SP cued the student to the error by stating that is not the correct medication he or she had been using, thus the student needed to make a phone call to the physician who was behind a one-way mirror. The investigators played the roles of the physician and pharmacist. After the simulation experience, students waited in a different room. Debriefing by trained and experience facilitators occurred as a group after all students had completed the simulation.
Results Descriptive statistics were used to explore student demographics and independent t-tests were used to examine demographic differences between the groups to determine baseline group equivalency as well as to examine within and between group differences. A total of 64 students consented (control: 33; intervention: 31) and completed demographic data. No between-group demographic difference was found. At the post-test, 51 (control: 29; intervention: 22) completed the survey. In regard to students’ overall self-confidence in speaking up to authority, the total score from the Adapted H-PEPSS scores was used. The average levels of self-confidence in both groups from the pre-test to post-test increased and the increase was larger in the intervention group but the increases were not statistically significant either from pre- to post-test for each group (control: Pre: 152.1 13.2 to post:
3 158.4 20.4, p ¼ .16; intervention: Pre: 151 15 to post: 160.5 23.1, p ¼ .076) or between groups at pre-test and post-test (p ¼ .78 for pre and 0.73 for post). When examining the student responses to question 37 of the H-PEPSS, students in the intervention group indicated more confidence in questioning the decisions or actions of those with authority, but the differences were not significant either from pre- to post-test for each group (control: Pre: 3.26 0.7 to post: 3.52 1, p ¼ .27; intervention: Pre: 3.26 1 to post: 3.73 0.9, p ¼ .077) or between the groups at pre-test (p ¼ .79) and post-test (p ¼ .077).
Discussion Patient safety is a top priority in health care. One way to promote patient safety is to utilize open communication. A 2018 AHRQ report shows that on average 79 % of the staff felt free to speak up when something does not seem right, but only 50% felt free to question the decision or action of those with more authority (Famolaro et al., 2018). The results of this pilot study showed a similar finding that students in both groups felt more confident in speaking up at the end of the clinical rotation. This finding is also similar to the study by Luctkar-Flude, Wilson-Keates, and Larocque (2012) that students in the SP and community volunteer groups felt more prepared for clinical even though there were no differences in self-efficacy scores across modalities used. These results contradict those mentioned by Okuyama et al. (2014) and Morrow et al. (2016) that the hierarchical health care environment discourages speaking up when a safety concern arises. Although this pilot study yielded nonsignificant differences, the trend of increasing self-reported confidence in speaking up to authority when a patient safety concern arose from pre-test to post-test in the intervention group was encouraging. Several possible explanations for the nonsignificant results merit consideration. First, attrition and self-selection bias may have contributed to the results. Convenience sampling was used and more students in the intervention group compared with the control group did not complete the post-test. Second, one simulated scenario may not be enough to deliver a detectable change with the small sample size. Third, it is possible that variability in students’ knowledge of safe practices and their life experiences may exist.
Conclusion Patient safety receives great attention in health care in the United States and globally. Medication safety is the current patient safety challenge identified by the World Health Organization (Sheikh et al., 2019). The pilot study reported here was conducted to study the effect of a simulated medication error scenario with SP in a hierarchical health care environment on self-reported confidence in undergraduate pp 1-4 Clinical Simulation in Nursing Volume Vol
Speaking up in a Medication Error Scenario nursing students. No significant between-group difference in students’ confidence was found due to the small sample size. It is recommended that future studies include a larger sample and random assignment.
Acknowledgment The authors would like to acknowledge the Delta Omega Chapter of Sigma Theta Tau International for their financial support and the staff and the standardized patients from the William G Wasson, M.D. Center for Clinical Skills Training, Assessment, and Scholarship for help with development of the simulation.
References Agency for Healthcare Research and Quality. Team STEPPS. Retrieved from https://www.ahrq.gov/teamstepps/index.html. Andrea, J., & Kotowski, P. (2017). Using standardized patients in an undergraduate nursing health assessment class. Clinical Simulation in Nursing, 13(7), 309-313. https://doi.org/10.1016/j.ecns.2017.05.003. Bradley, C. S., Johnson, B. K., Dreifuerst, K. T., White, P., Conde, S. K., Meakim, C. H., ., & Childress, R. M. (2019). Regulation of simulation use in United States prelicensure nursing programs. Clinical Simulation in Nursing, 33(C), 17-25. https://doi.org/10.1016/j.ecns.2019. 04.004. Famolaro, T., Yount, N., Hare, R., Thorton, S., Meadows, K., Fan, L., ., & Sorra, J. (2018). Hospital Survey on Patient Safety Culture 2018 User Database Report. Rockville, MD: Agency for Healthcare Research and Quality. AHRQ Publication No. 18-0025-EF. Retrieved from https://
4 www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/ patientsafetyculture/2018hospitalsopsreport.pdf. Ginsburg, L., Castel, E., Tregunno, D., & Norton, P. (2012). The H-PEPSS: an instrument to measure health professionals’ perceptions of patient safety competence at entry into practice. BMJ Quality & Safety, 21(8), 676-684. https://doi.org/10.1136/bmjqs-2011-000601. Luctkar-Flude, M., Wilson-Keates, B., & Larocque, M. (2012). Evaluating high-fidelity human simulators and standardized patients in an undergraduate nursing health assessment course. Nurse Education Today, 32(4), 448-452. https://doi.org/10.1016/j.nedt.2011.04.011. Maxfield, D., Grenny, J., Lavandero, R., & Groah, L. (2011). The Silent Treatment. Why Safety Tools and Checklist aren’t Enough to Save Lives. Patient Safety and Quality Healthcare. Retrieved from https://www. aacn.org/∼/media/aacn-website/nursing-excellence/healthy-workenvironment/silenttreatmentexecutivesummary.pdf?la=en. Morrow, K. J., Gustavson, A. M., & Jones, J. (2016). Speaking up behaviours (safety voices) of healthcare workers: a metasynthesis of qualitative research studies. International Journal of Nursing Studies, 64, 42-51. https://doi.org/10.1016/j.ijnurstu.2016.09.014. Oh, P. J., Jeon, K. D., & Koh, M. S. (2015). The effects of simulation-based learning using standardized patients in nursing students: a meta-analysis. Nursing Education Today, 35(5), e6-e15. https://doi.org/10.1016/ j.nedt.2015.01.019. Okuyama, A., Wagner, C., & Bijnen, B. (2014). Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Services Research, 14, 61, Retrieved from http://www.biomedcentral.com/1472-6963/14/61. QSEN Institute. (2015). QStudent #6: Teamwork & collaboration. Retrieved from http://qsen.org/teamwork-collaboration/. Sheikh, A., Rudan, I., Cresswell, K., Dhingra-Kumar, N., Tan, M. L., Hakkinen, M. L., & ., World Health Organization’s Management Team on Research Priorities for Medication Safety. (2019). Agreeing on global research priorities for medication safety: an international prioritisation. Journal of Global Health, 9(1), 010422. https://doi.org/10. 7189/jogh.09.010422.
pp 1-4 Clinical Simulation in Nursing Volume Vol
-,
1-4
www.elsevier.com/locate/ecsn
Review Article
Speaking up to Authority in a Simulated Medication Error Scenario Linda Creadon Shanks, PhD, DNP, RNa,*, Sheau-Huey Chiu, PhD, RNa, Michele I. Zelko, DNP, RNC-OBa, Eileen Fleming, MSN, RN, NE-BCb, Sandy Germano, BSN, RN, NE-BCb a b
Department of Nursing, The University of Akron, School of Nursing, Akron, OH 44325-3701 Department of Nursing, Summa Health System, Akron, OH 44309 KEYWORDS speaking up; patient safety; standardized patients; medication errors; simulation
Abstract Background: Health care professionals need to communicate with each other when there are patient safety concerns. However, speaking up can be difficult because the health care environment is highly hierarchical. Many times health care professionals choose to remain silent or fail to bring a patient safety issue to another team member’s attention. Sample: Senior nursing students from a Midwestern University. Method: Nonequivalent groups design with standardized patient simulation as intervention. Results: Both groups reported higher self-confidence in speaking up to authority from before to after test, but differences were not significant. Conclusion: Although this study yielded nonsignificant differences with the use of standardized patient simulation, the trend in increasing self-reported confidence in speaking up to an authority when a patient safety concern arose in the intervention group was encouraging. The effects of standardized patients on students’ confidence in speaking up merit further testing with a larger sample and random assignment. Cite this article: Shanks, L. C., Chiu, S.-H., Zelko, M. I., Fleming, E., & Germano, S. (2020, -). Speaking up to authority in a simulated medication error scenario. Clinical Simulation in Nursing, Vol(X), 1-4. https://doi.org/ 10.1016/j.ecns.2020.01.008. Ó 2020 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Background Patient safety is a global health care concern (Sheikh et al., 2019). Many countries (including the United States) have acknowledged and initiated measures to reduce errors in Funding: This work was supported by the Delta Omega Chapter of Sigma Nursing, 209 Carroll St., Akron, OH 44325-3701. * Corresponding author: [email protected] (L. C. Shanks).
health care. A patient’s care is managed by a multidisciplinary health care team. Teamwork and collaboration, a competency of Quality and Safety Education for Nurses (QSEN), is an important component in keeping the patient safe (QSEN Institute, 2015). One essential element in teamwork and collaboration is effective communication (QSEN Institute, 2015). Health care professionals need to communicate with each other when there are concerns. However, speaking up can be difficult in health care because the
1876-1399/$ - see front matter Ó 2020 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ecns.2020.01.008
Speaking up in a Medication Error Scenario health care environment is highly hierarchical. As a result, many times health care professionals choose to remain silent about or fail to bring a patient safety issue to another team member’s attention (Okuyama, Wagner, & Bijnen, 2014). In a metasynthesis of international qualitative studies by Morrow, Gustavson, and Jones Key Points (2016), ‘‘hierarchies and Speaking up can be power dynamics’’ in the difficult for healthcare work environment have professionals due to been identified as a theme highly hierarchical affecting speaking up when healthcare safety concerns arise (p. environment. 43). In the same study, other Open communication issues impacting speaking is important in proup, including ineffective moting patient safety. communication and conflict Intervention with stanamong interdisciplinary dardized patients led teams, were identified. It is to an increase in stunot uncommon for nurses dents’ reported confito hesitate to speak up dence in speaking up when a health care providto authority. er’s practice puts the patient at risk for harm (Maxfield, Grenny, Lavandero, & Groah, 2011). To prepare the next generation of nurses to provide safe nursing care, nursing educators strive to provide learning activities that teach students to establish a safe practice environment. The use of simulation has been a part of nursing education in the United States. More than half of the State Boards of Nursing have regulations regarding the use of simulation in nursing education (Bradley et al., 2019). Standardized patient (SP) simulation has been acknowledged as beneficial in acquiring knowledge, learning how to speak to other health care personnel, and acquiring clinical skills (Oh, Jeon, & Koh, 2015). In addition, Andrea and Kotowski (2017) found that SPs improved undergraduate nursing students’ confidence when providing mental health care and when obtaining a health history, respectively. However, little is known about the effect of SP simulation on undergraduate nursing students’ confidence in speaking up to authority. Therefore, this pilot study with SP simulation was conducted to examine nursing students’ self-reported confidence level in speaking up to authority when a patient safety issue occurs.
Sample The setting for this study was a large Midwestern public university. Nursing students enrolled in an undergraduate senior leadership practicum course were invited to participate. The course is eight weeks in length and runs twice each semester. The students in the first eight weeks served as the control group and the students in the second eight
2 weeks were assigned to the intervention group. For the control group, 33 consented and completed the pre-test but two were lost at post-test. For the intervention group, 29 consented and completed the pre-test but seven were lost at post-test.
Method A nonequivalent groups design with standardized patient simulation as an intervention was used. As part of this senior practicum course, all students received the same information in class on speaking up for patient safety and interprofessional communication based on the Agency for Healthcare Research and Quality (AHRQ) TeamSTEPPS curriculum tools (n.d.) specifically the SBAR (situation, background, assessment, recommendation) and CUS (concerned, uncomfortable, safety issue). The simulation involved SPs and pharmacist and physician actors. Only students in the intervention group participated in the scenario where safety concerns arose which required speaking up to a person in authority. Training with the SPs and actors occurred a week before the actual simulation. This study was approved by the University Institutional Review Board on July 13, 2016, approval number 2016020. Two instruments were used: a researcher designed demographic sheet including age and gender; and an adapted student Health Professional Education in Patient Safety Survey (H-PEPSS) instrument. The original HPEPSS instrument assesses the perceived self-confidence of new health care practitioners in six areas of patient safety with 38 items and each item scores from strongly disagree to strongly agree (1-5) (Ginsburg, Castel, Tregunno, & Norton, 2012). The higher the scores, the greater the selfconfidence in identifying patient safety risks, being aware of human and environment factors affecting safety, and reporting compromised patient safety or near misses (Ginsburg et al., 2012). Internal consistency of the original H-PEPSS instrument using Cronbach’s alpha exceeded 0.80 (Ginsburg et al., 2012). For this study, after obtaining the consent from the authors of the original instrument, question 37 regarding speaking up to authority was reworded for clarification to read ‘‘I feel I can question the decisions or actions of those with more authority.’’ Responses to both instruments were collected via an online survey system. On the first day of class all students in the first and second groups were asked to voluntarily participate in this study focusing on student confidence in patient safety. Students who agreed to participate signed a consent form, completed a demographic form and the Adapted Student H-PEPSS. No identifying information was collected. Students who chose not to participate still received the same class lecture. All students in the second group (the second eight weeks of the semester), in addition to receiving the same lecture, were required to complete the simulation activity, even if they were not participating in the study. The simulation occurred pp 1-4 Clinical Simulation in Nursing Volume Vol
Speaking up in a Medication Error Scenario the third week of the eight-week course during class time. Each simulation scenario took no more than 20 minutes. During the last week of class, students in both study groups completed the Adapted Student H-PEPSS in a classroom without the presence of the investigators. The medication error scenario used in this study was a sound-alike medication in a patient with diabetes scenario. Standardized patients from the Wasson Center at a Midwest medical university played the role of the patient. These SPs are trained at the Wasson Center from a beginning orientation when they first become a patient for the Wasson Center and then another training before they participate in encounters. A week before the simulation, they also received a simulation-specific training (including a standardized script) provided by the investigators. The study was conducted in a simulation laboratory which holds seven beds with privacy curtains and has sufficient space for multiple simulations to run concurrently. For each simulation session, two students were paired with one SP and four simulation stations were running concurrently. During the simulation, the students were required to identify a sound-alike medication before medication administration. If the safety concern (incorrect medication) was identified, the students needed to pick up the phone in the simulation laboratory and call pharmacy and ask for the correct medication. If the student did not catch the error and the incorrect medication was administered, the SP cued the student to the error by stating that is not the correct medication he or she had been using, thus the student needed to make a phone call to the physician who was behind a one-way mirror. The investigators played the roles of the physician and pharmacist. After the simulation experience, students waited in a different room. Debriefing by trained and experience facilitators occurred as a group after all students had completed the simulation.
Results Descriptive statistics were used to explore student demographics and independent t-tests were used to examine demographic differences between the groups to determine baseline group equivalency as well as to examine within and between group differences. A total of 64 students consented (control: 33; intervention: 31) and completed demographic data. No between-group demographic difference was found. At the post-test, 51 (control: 29; intervention: 22) completed the survey. In regard to students’ overall self-confidence in speaking up to authority, the total score from the Adapted H-PEPSS scores was used. The average levels of self-confidence in both groups from the pre-test to post-test increased and the increase was larger in the intervention group but the increases were not statistically significant either from pre- to post-test for each group (control: Pre: 152.1 13.2 to post:
3 158.4 20.4, p ¼ .16; intervention: Pre: 151 15 to post: 160.5 23.1, p ¼ .076) or between groups at pre-test and post-test (p ¼ .78 for pre and 0.73 for post). When examining the student responses to question 37 of the H-PEPSS, students in the intervention group indicated more confidence in questioning the decisions or actions of those with authority, but the differences were not significant either from pre- to post-test for each group (control: Pre: 3.26 0.7 to post: 3.52 1, p ¼ .27; intervention: Pre: 3.26 1 to post: 3.73 0.9, p ¼ .077) or between the groups at pre-test (p ¼ .79) and post-test (p ¼ .077).
Discussion Patient safety is a top priority in health care. One way to promote patient safety is to utilize open communication. A 2018 AHRQ report shows that on average 79 % of the staff felt free to speak up when something does not seem right, but only 50% felt free to question the decision or action of those with more authority (Famolaro et al., 2018). The results of this pilot study showed a similar finding that students in both groups felt more confident in speaking up at the end of the clinical rotation. This finding is also similar to the study by Luctkar-Flude, Wilson-Keates, and Larocque (2012) that students in the SP and community volunteer groups felt more prepared for clinical even though there were no differences in self-efficacy scores across modalities used. These results contradict those mentioned by Okuyama et al. (2014) and Morrow et al. (2016) that the hierarchical health care environment discourages speaking up when a safety concern arises. Although this pilot study yielded nonsignificant differences, the trend of increasing self-reported confidence in speaking up to authority when a patient safety concern arose from pre-test to post-test in the intervention group was encouraging. Several possible explanations for the nonsignificant results merit consideration. First, attrition and self-selection bias may have contributed to the results. Convenience sampling was used and more students in the intervention group compared with the control group did not complete the post-test. Second, one simulated scenario may not be enough to deliver a detectable change with the small sample size. Third, it is possible that variability in students’ knowledge of safe practices and their life experiences may exist.
Conclusion Patient safety receives great attention in health care in the United States and globally. Medication safety is the current patient safety challenge identified by the World Health Organization (Sheikh et al., 2019). The pilot study reported here was conducted to study the effect of a simulated medication error scenario with SP in a hierarchical health care environment on self-reported confidence in undergraduate pp 1-4 Clinical Simulation in Nursing Volume Vol
Speaking up in a Medication Error Scenario nursing students. No significant between-group difference in students’ confidence was found due to the small sample size. It is recommended that future studies include a larger sample and random assignment.
Acknowledgment The authors would like to acknowledge the Delta Omega Chapter of Sigma Theta Tau International for their financial support and the staff and the standardized patients from the William G Wasson, M.D. Center for Clinical Skills Training, Assessment, and Scholarship for help with development of the simulation.
References Agency for Healthcare Research and Quality. Team STEPPS. Retrieved from https://www.ahrq.gov/teamstepps/index.html. Andrea, J., & Kotowski, P. (2017). Using standardized patients in an undergraduate nursing health assessment class. Clinical Simulation in Nursing, 13(7), 309-313. https://doi.org/10.1016/j.ecns.2017.05.003. Bradley, C. S., Johnson, B. K., Dreifuerst, K. T., White, P., Conde, S. K., Meakim, C. H., ., & Childress, R. M. (2019). Regulation of simulation use in United States prelicensure nursing programs. Clinical Simulation in Nursing, 33(C), 17-25. https://doi.org/10.1016/j.ecns.2019. 04.004. Famolaro, T., Yount, N., Hare, R., Thorton, S., Meadows, K., Fan, L., ., & Sorra, J. (2018). Hospital Survey on Patient Safety Culture 2018 User Database Report. Rockville, MD: Agency for Healthcare Research and Quality. AHRQ Publication No. 18-0025-EF. Retrieved from https://
4 www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/ patientsafetyculture/2018hospitalsopsreport.pdf. Ginsburg, L., Castel, E., Tregunno, D., & Norton, P. (2012). The H-PEPSS: an instrument to measure health professionals’ perceptions of patient safety competence at entry into practice. BMJ Quality & Safety, 21(8), 676-684. https://doi.org/10.1136/bmjqs-2011-000601. Luctkar-Flude, M., Wilson-Keates, B., & Larocque, M. (2012). Evaluating high-fidelity human simulators and standardized patients in an undergraduate nursing health assessment course. Nurse Education Today, 32(4), 448-452. https://doi.org/10.1016/j.nedt.2011.04.011. Maxfield, D., Grenny, J., Lavandero, R., & Groah, L. (2011). The Silent Treatment. Why Safety Tools and Checklist aren’t Enough to Save Lives. Patient Safety and Quality Healthcare. Retrieved from https://www. aacn.org/∼/media/aacn-website/nursing-excellence/healthy-workenvironment/silenttreatmentexecutivesummary.pdf?la=en. Morrow, K. J., Gustavson, A. M., & Jones, J. (2016). Speaking up behaviours (safety voices) of healthcare workers: a metasynthesis of qualitative research studies. International Journal of Nursing Studies, 64, 42-51. https://doi.org/10.1016/j.ijnurstu.2016.09.014. Oh, P. J., Jeon, K. D., & Koh, M. S. (2015). The effects of simulation-based learning using standardized patients in nursing students: a meta-analysis. Nursing Education Today, 35(5), e6-e15. https://doi.org/10.1016/ j.nedt.2015.01.019. Okuyama, A., Wagner, C., & Bijnen, B. (2014). Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Services Research, 14, 61, Retrieved from http://www.biomedcentral.com/1472-6963/14/61. QSEN Institute. (2015). QStudent #6: Teamwork & collaboration. Retrieved from http://qsen.org/teamwork-collaboration/. Sheikh, A., Rudan, I., Cresswell, K., Dhingra-Kumar, N., Tan, M. L., Hakkinen, M. L., & ., World Health Organization’s Management Team on Research Priorities for Medication Safety. (2019). Agreeing on global research priorities for medication safety: an international prioritisation. Journal of Global Health, 9(1), 010422. https://doi.org/10. 7189/jogh.09.010422.
pp 1-4 Clinical Simulation in Nursing Volume Vol