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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
Professor and Associate
Dean for Academic Affairs

U.S. Institute of Medicine

Quality Chasm Reports
To Err Is Human: Building a Safer Health System

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

Development of Safety Sciences

Worldwide, scientists in other industries

uncovering knowledge about the interventions

that produced safe systems
Lean, zero defect production systems
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

U.S. hospitals adopt quality improvement and
safety science methods in the late 1990s
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 evidencebased practice, quality improvement
approaches, and informatics.

Relative Focus of Education in the

Health Professions

Individual learning

consequences for
Disciplinary focus

Systems knowledge

Team/Group learning

Learning from error

patient focus

Medicines Translation of General

(Adopted February, 1999 by ACGME)

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

To alter nursings 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

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
Geraldine Bednash
Karen Drenkard
Leslie Hall
Polly Johnson
Maryjoan Ladden
Audrey Nelson

Joanne Pohl
Elaine Tagliareni
* Phase II: Jeanne Floyd

ANA Safe Patient

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

Cronenwett, Sherwood, Barnsteiner et al, 2007

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
patients preferences, values, and needs

Teamwork and collaboration: Function

effectively within nursing and interprofessional teams, fostering open

communication, mutual respect, and shared
decision-making to achieve quality patient

IOM/QSEN Competencies

Cronenwett, Sherwood, Barnsteiner et al, 2007

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

IOM/QSEN Competencies
Cronenwett, Sherwood, Barnsteiner et al, 2007

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

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
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




Examine common
barriers to active
involvement of patients
in their own health care

Remove barriers to
presence of families and
other designated
surrogates based on
patient preferences

Respect patient
preferences for degree of
active engagement in
care process

Describe strategies to
empower patients or
families in all aspects of
the health care process

Engage patients or
designated surrogates in
active partnerships that
promote health, safety
and well-being, and selfcare management

Respect patients right to

access to personal health

Cronenwett, Sherwood, Barnsteiner et al, 2007

Example: Safety
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
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 didnt understand many KSAs (particularly

related to safety, informatics and QI)

Faculty said were not doing it but we want to - tell
us how
Students/new grads said Not only did we not learn
this content, our faculty couldnt 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

What and How Do We

Guide Student Learning?
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

Teaching Resource: QSEN Website

Competency definitions and KSAs

Annotated references by competency
Teaching strategies for classroom, clinical,
skills/simulation labs, and interprofessional
Opportunity for all faculty to upload ideas and
evaluations of teaching strategies

Website Sessions

QSEN Assumptions
Each competency can be, indeed needs to be,
taught or reinforced in multiple methods and
Skills/simulation Lab




Clinical Teaching Sites

Nursing Courses




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

QSEN Learning Collaborative

Augustana College (SD)
Catholic University (DC)
Charleston Southern Univ

University of Nebraska

Curry College (MA)
Emory University (GA)
Lasalle University (PA)
St. Johns College of
Nursing/Southwest Baptist
University of Colorado at
University of MassachusettsBoston

Medical Center
University of South Dakota,
Sioux Falls
University of Tennessee
Health Science Center,
University of WisconsinMadison
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
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


Staff are role models for how these competencies

define what it means to be a respected and qualified
Students and faculty know the safety and QI
initiatives always know the next likely error in the
Students learn from staff what good care is and
how local care compares to that standard

QSEN Assumptions

Students use information technology during clinical

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

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

QSEN Phase II: Graduate Education

April, 2007 workshop
Representatives of

nurses in advanced
practice responsible for:

Standards of
Accreditation of
education programs
Certification of APNs

QSEN faculty and

advisory board


ONCC (1)


CCNE (2)

ACNM (1)

APNA (1)

Council on
Accreditation Board (1)
of CRNAs (1) (critical care)
ANCC (2)
ANA (2)

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
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
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

Discuss principles of
---------------------Integrate principles of
communication with
knowledge of quality
and safety
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

Respect patient
preferences for degree of
active engagement in
care process
-----------------------Valued shared decisionmaking with empowered
patients and families,
even when conflict occurs

Create or change
Value cultural humility
organizational cultures
so that patient and family Value the process of
preferences are
reflective practice
assessed and supported

Example: Teamwork and Collaboration




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

Clarify roles and

accountabilities under
conditions of potential
overlap in team-member
--------------------Guide the team in
managing areas of
overlap in team member

Acknowledge own
potential to contribute to
effective team functioning
-----------------------Acknowledge own
contributions to effective
or ineffective team

Analyze impact of own

advanced practice role
and its contributions to
team functioning

Initiate and sustain

effective health care

Appreciate the
importance of interprofessional collaboration

Example: Evidence-based Practice

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)

Read original research
and evidence reports
related to area of
----------------------------Critically appraise
original research and
evidence summaries
related to area of

Determine evidence
Exhibit contemporary
gaps within the practice 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
Recognize importance of
search skills in locating
best evidence

Example: Quality Improvement



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

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

Assert leadership in
Explain common
shaping the dialogue and
causes of variation in
providing leadership for
outcomes of care in the the introduction of best
practice specialty

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

Example: Safety
Discuss effective
strategies to reduce
reliance on memory
--------------------------Evaluate effective
strategies to reduce
reliance on memory

Participate appropriately
in analyzing errors and
designing system
----------------------------Design and implement
microsystem changes in
response to identified
hazards and errors

Describe best practices

that promote patient and
provider safety in the
Report errors and support
practice specialty
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
Describe examples of
how technology and
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

Navigate the electronic
health record
----------------------------Model behaviors that
support implementation
and appropriate use of
electronic health records


Value technologies that

support clinical decisionmaking, error prevention,
and care coordination
-----------------------------Appreciate the need for
consensus and
collaboration in developing
systems to manage
Participate in the design
of clinical decision-making information for patient care
supports and alerts
Appreciate the contribution
of technological alert

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