Quality and Safety Education for Nurses

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Quality and Safety Education for Nurses

  • 2007 Jowers Lecture
  • Linda Cronenwett, PhD, RN, FAAN
  • December 5, 2007

Greetings from the University of North Carolina - Chapel Hill School of Nursing

    • Quality and Safety Education for Nurses (QSEN)
      • Linda Cronenwett
      • Principal Investigator,
      • Professor and Dean
      • Gwen Sherwood
      • Co-Investigator,
      • Professor and Associate
      • Dean for Academic Affairs

U.S. Institute of Medicine Quality Chasm Reports

  • To Err Is Human: Building a Safer Health System (2000)
  • Crossing the Quality Chasm: A New Health System for the 21st Century (2001)
  • Health Professions Education: A Bridge to Quality (2003)
  • Patient Safety: Achieving a New Standard for Care (2004)
  • Identifying and Preventing Medication Errors (2007)

Development of Safety Sciences

  • Worldwide, scientists in other industries uncovering knowledge about the interventions that produced safe systems
    • Lean, zero defect production systems
    • Aviation
    • Nuclear energy
  • Health care remains committed to the ideal of the individual professional as source of quality and safety

Impetus for Change

  • Variations in outcomes shown to be related to systems of care rather than individual patient characteristics
  • U.S. hospitals adopt quality improvement and safety science methods in the late 1990’s
  • Health care professionals in hospitals taught, one by one, about quality and safety
  • Yet --
    • No health professions education on QI/safety

Impetus for Change in Nursing

  • People become nurses in order to relieve suffering and contribute to the overall health of communities and individuals
  • Quality care is an essential value
  • As nurses work in systems where quality is eroded, joy in work diminishes
  • Less joy in work leads to work force shortages
  • Health professionals run our systems -- they can improve our systems if they possess the competencies required to make improvement a part of daily work

Health Professions Education: A Bridge to Quality (2003)

  • All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.

Relative Focus of Education in the Health Professions

  • Professional knowledge
  • Individual learning
  • Individual consequences for error
  • Disciplinary focus
  • Systems knowledge
  • Team/Group learning
  • Learning from error
  • Interprofessional/
  • patient focus

Medicine’s Translation of General Competencies (Adopted February, 1999 by ACGME)

  • Patient Care
  • Medical Knowledge
  • Practice-based Learning and Improvement
  • Professionalism
  • Interpersonal and Communication Skills
  • Systems-based Practice


  • To alter nursing’s professional ‘identity’ so that when we think of what it means to be a respected nurse, we think not only of caring, knowledge, honesty and integrity….
  • But also, that it means that we value, possess, and collectively support the development of quality and safety competencies

Quality and Safety Education for Nurses (QSEN)

  • Long-Range Goal
    • To reshape professional identity formation in nursing so that it includes commitment to the development and assessment of quality and safety competencies
  • Phase I: October 2005 – March 2007
  • Phase II: April 2007 – September 2008

QSEN Personnel

    • QSEN Leaders based in UNC-Chapel Hill
    • QSEN Faculty – Experts in quality and safety from throughout the U.S.
    • QSEN Advisory Board – Leaders of organizations that set standards for nursing regulation, certification, and accreditation of nursing programs

QSEN Core Faculty

      • Jane Barnsteiner U Pennsylvania
      • Lisa Day UC San Francisco
      • Joanne Disch U Minnesota
      • Carol Durham UNC – Chapel Hill
      • Pamela Ironside Indiana U
      • Jean Johnson George Washington U
      • Pamela Mitchell* U Washington, Seattle
      • Shirley Moore Case Western Reserve
      • Dori Taylor Sullivan Sacred Heart, CT
      • Judith Warren U Kansas
  • * Phase II: Deborah Ward U Washington, Seattle

QSEN Advisory Board Members

      • Paul Batalden IHI, ACGME
      • Geraldine Bednash AACN
      • Karen Drenkard AONE
      • Leslie Hall HPEC, ACT
      • Polly Johnson NCSBN
      • Maryjoan Ladden ACT
      • Audrey Nelson ANA Safe Patient Handling
      • Joanne Pohl NONPF
      • Elaine Tagliareni NLN
  • * Phase II: Jeanne Floyd ANCC

QSEN Phase I

    • Define the territory (desired competencies)
    • Describe the knowledge, skills, and attitudes (KSAs) expected to be developed in prelicensure curricula
    • Disseminate/seek feedback and build consensus for inclusion of competencies in prelicensure curricula
    • Develop teaching strategies for classroom, group work, simulation, clinical site teaching, interprofessional learning
    • Create website resource for faculty

IOM/QSEN Competencies

  • Patient-centered care: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs
  • Teamwork and collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care
  • Cronenwett, Sherwood, Barnsteiner et al, 2007

IOM/QSEN Competencies

  • Evidence-based practice: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care
  • Quality improvement: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems
  • Cronenwett, Sherwood, Barnsteiner et al, 2007

IOM/QSEN Competencies

  • Safety: Minimize risk of harm to patients and providers through both system effectiveness and individual performance
  • Informatics: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making
  • Cronenwett, Sherwood, Barnsteiner et al, 2007

QSEN Assumptions

    • Competency definitions could serve the profession as:
      • Curricular threads
      • Foci of accreditation of nursing programs
      • Foci of licensure or certification exams
      • Foci of transition to work (residency) program development
      • Foci of criteria for recertification or relicensure

Current Assessments of Quality and Safety Education

  • Smith, E. L., Cronenwett, L., & Sherwood, G. (2007). Current assessments of quality and safety education in nursing. Nursing Outlook, 55 (3), 132-137.


  • The overwhelming majority of schools reported that they
    • include content/learning experiences
    • are satisfied with students’ competency achievement, and
    • have the faculty expertise to teach
  • the competencies patient-centered care, teamwork and collaboration, and safety


  • EBP, QI and Informatics are the competencies where a significant minority (25-43%) of schools reported desire for more content/learning experiences (but it was a minority, not majority, reporting they need to do something more)
  • These same competencies elicited mean ratings below “satisfied” for level of satisfaction with student competency achievement
  • These same competencies elicited lower ratings of faculty expertise to teach the topics

Prelicensure Knowledge, Skills and Attitudes (KSAs) by Competency

  • Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P, & Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122-131.

Example: Patient-centered care

  • Knowledge
  • Skills
  • Attitudes
  • Examine common barriers to active involvement of patients in their own health care process
  • Describe strategies to empower patients or families in all aspects of the health care process
  • Remove barriers to presence of families and other designated surrogates based on patient preferences
  • Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management
  • Respect patient preferences for degree of active engagement in care process
  • Respect patient’s right to access to personal health records
  • Cronenwett, Sherwood, Barnsteiner et al, 2007

Example: Safety

  • Knowledge
  • Skills
  • Attitudes
  • Discuss effective strategies for reducing reliance on memory
  • Describe processes used in understanding causes of error and allocation of responsibility (such as, root cause analysis)
  • Use appropriate strategies for reducing reliance on memory (such as, forcing functions and checklists)
  • Use organizational error reporting systems for near miss and error reporting
  • Engage in root cause analysis rather than blaming when errors or near misses occur
  • Appreciate the cognitive and physical limits of human performance
  • Value own role in preventing errors
  • Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team
  • Cronenwett, Sherwood, Barnsteiner et al, 2007

Examples: Focus Group Feedback

  • Faculty didn’t understand many KSAs (particularly related to safety, informatics and QI)
  • Faculty said “we’re not doing it – but we want to - tell us how”
  • Students/new grads said ‘Not only did we not learn this content, our faculty couldn’t have taught it”
  • Faculty report that nursing students can graduate never having had a meaningful patient-centered conversation with a physician

QSEN Publications

  • NCSBN Leader to Leader article April 2007
  • Special issue of Nursing Outlook May-June 2007 - five articles plus commentaries from AACN and NLN Presidents
    • Mailed to every nursing education program in country (using NCSBN mailing list)
  • Two NO articles the most frequently downloaded articles from January-June 2007

Policy Strategies

  • Shared products with professional organizations involved in licensure and certification or in accreditation of prelicensure programs

What and How Do We Guide Student Learning?

  • www.qsen.org
  • and
  • Pilot School Learning Collaborative

QSEN Assumptions

    • Faculty and students are committed to quality and safety in all they do
    • Learning experiences aimed only at knowledge acquisition will be insufficient for development of competencies
    • Invitations to select from and experiment with a variety of curricular strategies will yield greater long-term gains than being highly prescriptive

Teaching Resource: QSEN Website

  • www.qsen.org
    • Competency definitions and KSAs
    • Annotated references by competency
    • Teaching strategies for classroom, clinical, skills/simulation labs, and interprofessional learning
    • Opportunity for all faculty to upload ideas and evaluations of teaching strategies
  • Share your teaching strategies NOW

Website Sessions

QSEN Assumptions

    • Each competency can be, indeed needs to be, taught or reinforced in multiple methods and sites
  • Classroom
  • Skills/simulation Lab
  • Clinical Teaching Sites
  • Interprofessional Courses
  • Nursing Courses
  • Papers
  • Readings
  • PBL
  • Reflective practice
  • Case Studies
  • Web Modules

QSEN Phase II: Prelicensure Education

  • Pilot School Learning Collaborative
  • Goal: Engage prelicensure faculty members in developing and testing teaching strategies for the QSEN competencies
  • Call for proposals mailed to all nursing education programs in March, 2007
  • 15 schools selected July 2007 from 53 applications

QSEN Learning Collaborative

  • Augustana College (SD)
  • Catholic University (DC)
  • Charleston Southern Univ (SC)
  • Curry College (MA)
  • Emory University (GA)
  • Lasalle University (PA)
  • St. John’s College of Nursing/Southwest Baptist (MO)
  • University of Colorado at Denver
  • University of Massachusetts-Boston
  • University of Nebraska Medical Center
  • University of South Dakota, Sioux Falls
  • University of Tennessee Health Science Center, Memphis
  • University of Wisconsin-Madison
  • University of Pittsburgh Medical Center-Shadyside School of Nursing (PA)
  • Wright State University (OH)

QSEN Learning Collaborative

  • All have committed practice partners
  • Associate degree, diploma, BSN programs in schools without graduate programs, and BSN programs in universities
  • Our “edgerunners”
    • Some focusing on simulation
    • Some focusing on innovations in clinical teaching
    • Some focusing on curriculum as a whole

QSEN Learning Collaborative

  • Collaborative meetings (October, 2007 and June, 2008)
  • Evaluate one class of graduating students’ perceptions of competency achievement
  • Produce a curricular map with the quality and safety KSAs integrated into their pre-licensure curriculum
  • Develop and evaluate teaching strategies for classroom, clinical, and simulation/skills laboratories
  • Share teaching strategies through submissions to the QSEN website
  • Document specific challenges encountered in the process of curricular change
  • Share successful strategies for overcoming challenges with others in collaborative conferences and conference calls

QSEN Assumptions

  • Nurses in practice settings are critical partners in accomplishing competency development
  • Examples:
    • Staff are role models for how these competencies define what it means to be a respected and qualified nurse
    • Students and faculty know the safety and QI initiatives – always know the ‘next likely error’ in the setting
    • Students learn from staff what “good care” is and how “local care” compares to that standard

QSEN Assumptions

    • Students use information technology during clinical practice
    • Students see team skills in action in communications between nurses and other health professionals
    • Students see patients and families involved as partners in care
    • Health professions students in a setting interact with each other in improvement work
    • Transition to practice programs build on the competency development from pre-licensure programs

Quality and Safety Education for Nurses

  • Graduate Education

Phase I: Graduate Education

  • Sought feedback from major APN organizations about KSAs: Can they represent all of nursing?
  • Added NONPF representative to Advisory Board

QSEN Phase II: Graduate Education

  • April, 2007 workshop
  • Representatives of nurses in advanced practice responsible for:
      • Standards of practice
      • Accreditation of education programs
      • Certification of APNs
  • QSEN faculty and advisory board
  • NONPF (2)
  • NACNS (2)
  • ACNM (1)
  • ONCC (1)
  • CCNE (2)
  • APNA (1)
  • Council on Accreditation of CRNAs (1)
  • ANCC (2)
  • ANA (2)
  • AACN Cert Board (1) (critical care)
  • Ped Nurs Cert Board 2)

Graduate Education

  • Initial conversation:
    • Focus on advanced practice rather than all advanced roles
    • Focus on advanced practice rather than the type of program in which the graduate student is prepared
    • Focus on goal of assisting faculty who wish to develop quality and safety competencies already identified as essential elements

Graduate Education Workshop Topics

  • Are the competency definitions relevant to APNs? All of nursing?
  • Which of the prelicensure KSAs are also relevant objectives for APN education?
  • What new KSAs, if any, should be added at the graduate level?
  • Will KSAs vary by specialty and role or can they encompass all APNs?

Graduate Education KSAs

  • On the following slides:
  • Green represents language of prelicensure KSA
  • Black represents that same KSA in language proposed for APN education
  • Blue represents an item without a correlary in the prelicensure KSAs

Example: Patient-centered Care

  • Knowledge
  • Skills
  • Attitudes
  • Discuss principles of effective communication
  • ----------------------
  • Integrate principles of effective communication with knowledge of quality and safety competencies
  • Describe process of reflective practice
  • Participate in building consensus or resolving conflict in the context of patient care
  • ---------------------
  • Provide leadership in building consensus or resolving conflict in the context of patient care
  • Create or change organizational cultures so that patient and family preferences are assessed and supported
  • Respect patient preferences for degree of active engagement in care process
  • ------------------------
  • Valued shared decision-making with empowered patients and families, even when conflict occurs
  • Value cultural humility
  • Value the process of reflective practice

Example: Teamwork and Collaboration

  • Knowledge
  • Skills
  • Attitudes
  • Describe own strengths, limitations, and values in functioning as a member of a team
  • ----------------------
  • Analyze own strengths, limitations, and values as a member of a team
  • Analyze impact of own advanced practice role and its contributions to team functioning
  • Clarify roles and accountabilities under conditions of potential overlap in team-member functioning
  • ---------------------
  • Guide the team in managing areas of overlap in team member functioning
  • Initiate and sustain effective health care teams
  • Acknowledge own potential to contribute to effective team functioning
  • ------------------------
  • Acknowledge own contributions to effective or ineffective team functioning
  • Appreciate the importance of inter-professional collaboration

Example: Evidence-based Practice

  • Knowledge
  • Skills
  • Attitudes
  • Explain the role of evidence in determining best clinical practice
  • -----------------------
  • Analyze how the strength of available evidence influences the provision of care (assessment, dx, tx, and evaluation)
  • Determine evidence gaps within the practice specialty
  • Read original research and evidence reports related to area of practice
  • -----------------------------
  • Critically appraise original research and evidence summaries related to area of practice
  • Exhibit contemporary knowledge of best evidence related to practice specialty
  • Appreciate the importance of regularly reading relevant professional journals
  • ----------------------------
  • Value knowing the evidence base for practice area
  • Value public policies that support evidence-based practice
  • Recognize importance of search skills in locating best evidence

Example: Quality Improvement

  • Knowledge
  • Skills
  • Attitudes
  • Describe strategies for learning about the outcomes of care in the setting in which one is engaged in practice
  • -----------------------------
  • Describe strategies for improving outcomes of care in the setting in which one is engaged in practice
  • Explain common causes of variation in outcomes of care in the practice specialty
  • Seek information about outcomes of care for populations served in care setting
  • ------------------------------
  • Use a variety of sources of information to review outcomes of care and identify potential areas for improvement
  • Assert leadership in shaping the dialogue and providing leadership for the introduction of best practices
  • Appreciate how unwanted variation affects care
  • -----------------------------
  • Appreciate the importance of data that allows one to estimate the quality of local care
  • Appreciate that all improvement is change but not all change is improvement

Example: Safety

  • Knowledge
  • Skills
  • Attitudes
  • Discuss effective strategies to reduce reliance on memory
  • ---------------------------
  • Evaluate effective strategies to reduce reliance on memory
  • Describe best practices that promote patient and provider safety in the practice specialty
  • Participate appropriately in analyzing errors and designing system improvements
  • -----------------------------
  • Design and implement microsystem changes in response to identified hazards and errors
  • Report errors and support members of the health care team to be forthcoming about errors and near misses
  • Value own role in preventing errors
  • ------------------------------
  • Value own role in reporting and preventing errors
  • Appreciate the importance of being a safety mentor and role model
  • Value the use of organizational error reporting systems

Example: Informatics

  • Knowledge
  • Skills
  • Attitudes
  • Describe examples of how technology and information management are related to quality and safety of patient care
  • ---------------------------
  • Describe and critique taxonomic and terminology systems used in national efforts to enhance interoperability of information and knowledge management systems
  • Navigate the electronic health record
  • -----------------------------
  • Model behaviors that support implementation and appropriate use of electronic health records
  • Participate in the design of clinical decision-making supports and alerts
  • Value technologies that support clinical decision-making, error prevention, and care coordination
  • ------------------------------
  • Appreciate the need for consensus and collaboration in developing systems to manage information for patient care
  • Appreciate the contribution of technological alert systems

Participant Responses

  • Are the competency definitions relevant to APNs? All of nursing?
  • Which of the prelicensure KSAs are also relevant objectives for APN education?
  • What new KSAs, if any, should be added at the graduate level?
  • Will KSAs vary by specialty and role or can they encompass all APNs?

Graduate Education: Next Steps

  • Draft 2 under review by all participants and their organizations
  • Feedback received in November, awaiting full analysis
  • Dissemination

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