The Quality and Safety Innovation Center at The College of New Jersey, under the directorship of Gerry Altmiller, provides educational programming, consultation, teaching strategies, and resources to support the advancement of nurses and nurse educators in developing expertise in quality and safety education.
The Organization for Associate Degree Nursing (OADN) values the role of the nurse educator. Being an effective educator can impact students and their patients for decades. It is for this reason that we promote incorporation of Quality and Safety Education for Nurses (QSEN) into nursing curriculum at all levels. Over the course of several months, the QSEN workgroup will post each of the six pre-licensure competencies. These posts are brief summaries of the competency with some tips for practical application in your role as a nurse educator.
This content area emphasizes key patient-centered care points that the pre-licensure graduate should be competent in upon graduation. Definition: 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.
Recognition for the need of patient-centered care can be traced back to the Institute of Medicines (IOM) Crossing the Quality Chasm which suggested that “caregivers provide care that is respectful and responsive to patient preferences, needs, and values, and that patient values guide clinical decision making” (IOM, 2001, p. 40). As seasoned caregivers, nurses realize that most of what we do rotates around the patient. But, students often get caught up in daily tasks and forget the true reason they are providing care, the patient. How do nurse educators get students to understand that if care is patient-centered, improved patient outcomes and satisfaction will follow? Below are some examples of activities with an emphasis on patient-centered care.
QSEN Competency #2: Teamwork and Collaboration
This content addresses the key competencies expected in entry-level nurses to facilitate their abilities to work effectively with the other members of the healthcare team.
Definition: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
In nursing education, it is critical that pre-licensure graduates understand their role in healthcare in relationship to the other healthcare providers. Nurses must learn to respect the value of the other disciplines recognizing where the various scopes of practices intersect or are different. In achieving this level of understanding patients will truly receive patient-centered care that fosters the provision of healthcare that is provided by the most appropriate individual or team. It is the responsibility of nurse educators to provide students with opportunities to appreciate the specific role of the other healthcare disciplines and identify how these relationships might be fostered. The following examples describe activities that were designed to meet this goal.
In this activity, students enrolled in the respiratory care, occupational therapy assist and nursing programs participate in an inter-professional educational experience. Faculty from each of the programs begin the session with brief presentations regarding the key assessment tools used by their discipline. Students from each discipline are seated at each table to facilitate sharing. Through this didactic content students begin to appreciate where their scope of practice was similar or different.
In the next phase of the activity, a case study from the National League for Nurses (NLN) Advancing Care Excellence for Seniors (ACES) involving Henry and Ertha Williams is presented. Henry is a patient with COPD and Ertha struggles with dementia. A discussion ensues at each table with students from the various disciplines discussing how they would assess and treat the patient from their discipline’s perspective.
Phase 3 of the program involves a live simulation with standardized patients. Each discipline interacts with the patient(s). It is the responsibility of the nursing students to identify when their patient could benefit from the care of a different discipline.
Pre- and post-assessment data is gathered in terms of the students’ readiness to learn about other disciplines as well as assessment of their level of understanding the scope of practice of other disciplines.
In this activity, students are trained to use the AHRQ TeamSTEPPS framework for collaborative practice within the simulation lab before entering the hospital setting. Using the Simulation Exemplar #1 found in the NLN’s Guide to Effective Interprofessional Education Experiences in Nursing Education via the following link: http://www.nln.org/docs/default-source/default-document-library/interprofessional-education-and-collaborative-practice-toolkit1.pdf, clinical case scenarios are developed in which students learn how to implement their TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) teamwork skills.
Prior to simulation, a TeamSTEPPS presentation and handout are given to the students. Terms such as “Briefing and Debriefing, SBAR (Situation, Background, Assessment, Recommendation), Huddles, Hand-off, Situational Monitoring, Conflict Resolution, CUS (Concerned, Uncomfortable, Safety) and Closing the Loop” (AHRQ, 2015) are explained . The resources for this information can be found on the following AHRQ link: https://www.ahrq.gov/teamstepps/instructor/essentials/igessentials.html
With the nursing professor acting as facilitator, a briefing is held in which students are divided into two groups: the first group as active participants in the first case scenario, while the second group serves as the observers who complete a peer evaluation tool using a TeamSTEPPS checklist. The students’ roles are then reversed for a second case scenario.
During a de-briefing, the TeamSTEPPS checklists are reviewed with the students, feedback obtained and the student feelings about communication and the importance of teamwork and collaboration are discussed. The students are then able to apply their knowledge in the hospital setting and understand the value of teamwork and collaboration in promoting patient safety.
In this activity, we link the information from the perioperative unit in the didactic class to a clinical experience found within second and third semester medical-surgical courses. The information is introduced in first semester during the perioperative unit with a discussion of all interdisciplinary professions that work within the perioperative environment, from pre- to post-operative care. During second semester, each student is assigned a day of observation within the OR. They are able to follow a patient from the pre-operative suite to the intraoperative room and finally through the post-anesthesia care unit (PACU). The ultimate objective is for the student nurse to then return with the patient to the nursing unit on which the patient will be admitted. During third semester, each nursing student is again assigned a day within the perioperative unit, with the intention that they will spend this experience shadowing RN’s who are instrumental in the care of the patient, whether that is the surgical nurse or the PACU nurse.
Through the introduction prior to the experience, the students become aware of the many different interdisciplinary personnel who work within the perioperative unit. They develop an understanding of the roles of these individuals and the responsibilities assigned to each. During the second semester, students are able to observer and interact with each of these healthcare team members, solidifying their understanding of what nurses are responsible for in the OR, but also how RN’s interact with other team members. During the third semester, the student is able to focus more thoroughly on the role of the RN because they have developed a familiarity with the environment through their previous educational experiences. By working with a specific nurse throughout the care of the patient undergoing an operative procedure, the student gains a better understanding of the ways the RN manages the care of the patient throughout this experience. Additionally, the student is able to more fully comprehend the role of the nurse within the perioperative environment and the ways these roles and responsibilities intertwine with other professionals working toward the same outcome.
Developed by the OADN QSEN Task Force
QSEN Competency #3: Safety
This content area emphasizes the key elements of safety that the pre-licensure graduate should be competent in upon graduation.
QSEN Definition: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
The patient safety movement was spurred forth following the 1999 publication of the Institute of Medicine’s To Err is Human. The report shockingly noted that as many as 98,000 people were dying in hospitals each year as a result of preventable medical errors (IOM, 1999, p. 1). Despite efforts to improve these statistics, the BMJ recently reported that medical error is the third leading cause of death in the US (The BMJ, 2016). Nurses, who have the opportunity and challenge to work at the “sharp end of care”, must begin to develop the competencies necessary to promote a culture of safety early in their nursing educational journey. Below are some examples of curricular activities with an emphasis on safety.
Enhancing Medication Safety through remediation and reflection submitted by Donna McCabe, DNP, APRN-BC, GNP. This strategy seeks to improve acquisition of safety KSAs with medication dosage calculation through remediation and reflection.
A learning module contributed by Carol F. Durham, EdD, RN, ANEF and Jennifer Dwyer, MS, RN, BC, CNRN, FNP BC, entitled “Learning Module 17- Patient Safety: Our Intent Is To Do No Harm- So Why Do Errors Happen?”, highlights QSEN competencies which promote safe patient care and provides video, handout, and tools for classroom use.
A Just Culture Safety Exercise for faculty and/or students: Contributed by Mary Anne Tagulinao RN, BSN, MN, CRH and Joanne Iverson RN, BSN, MN. This exercise provides a case study approach and discussion around Just Culture.
This ANA video, “Nursing: The Infrastructure of Safety (Reducing Nurse Fatigue)”, provides an excellent background to spur student discussion of the role of nurse fatigue on the provision of safe care.
The Nursing Education and Technology Project (NEAT) repository was developed as a collaborative effort between 10 schools of nursing across the U.S. as a means to address common teaching and learning needs related to Patient Safety and Health Disparities. To view the learning modules, users must first create a free account. To view the lessons below, once logged in, click on “preview this learning object”.
Beyond the Five Rights: Medication Administration Safety
Culture of Safety: Part One- Moving Beyond Blame
Culture of Safety: Part Two-Culture Change
Culture of Safety: Why Do Things Go Wrong
Culture of Safety: The Role of Nurses
Raising a Red Flag: Reporting Near Misses in Health Care
The Quality and Safety Monitor Assignment submitted by Laurie J. Palmer, MS, RN, AOCN provides a structured checklist which allows the student nurse an opportunity to analyze potential and actual risks which affect the provision of safe care, communicate observations related to safety hazards, and to value one’s role in preventing error.
This video is located on the NurseTim site, created by Karen Rotolo, MSN, RN and Debbie Riggs, MSN, RN, CCRN who are on the faculty at the Mercy College of Nursing and the University of Pittsburgh Medical Center. They collaborated on the development of the QSEN strategy expanding SBAR as a communication strategy. This activity, created for medical surgical nursing students, can be completed in the conference setting.
The North Carolina Board of Nursing has extensive training regarding the concept of a “Just Culture”. The site has a list of concepts and definitions, in addition to a “Compliant Evaluation Tool”.
An NLN created resource, entitled, “Supplemental Materials for Integrating QSEN and ACES: An NLN Simulation Leader Initiative”, that incorporates QSEN competencies into the "Millie” unfolding case study that was developed for the NLN's Advancing Care Excellence for Seniors (ACE.S) project. Tables that correlate the KSAs for each QSEN competency with the learning activities suggested in each scenario are provided, along with enhanced simulation templates for the three scenarios. Access to the ACES “Millie” unfolding case study can be found here: http://www.nln.org/professional-development-programs/teaching-resources/ace-s/unfolding-cases/millie-larsen
Enhancing Patient Safety in Nursing Education through Patient Simulation
This chapter in Patient Safety and Quality: An Evidence-based Handbook for Nurses (2008) (see Additional Resources below) specifically addresses the use of simulation as a teaching tool for patient safety. A sample simulation scenario is included.
NurseTim presents...NCLEX ® Nuggets: Safety as an Emphasis in Lab and Simulation
This is a short video that provides a strategy that can be used in the simulation/lab setting that links the use of the NCLEX blueprint to what is being taught in the lab/simulation setting.
Agency for Healthcare Research and Quality
The Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, prepared this handbook for nurses on patient safety and quality. The Handbook also includes a section on nurses’ work environment and working conditions.
This site offers definitions of commonly used patient safety terms and additional information about the source and context of the term.
The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition, can help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.
Features the Patient Safety Network case reports of safety errors from a variety of settings. Each case study includes expert commentary, take home points, and references.
TeamSTEPPS is an evidence-based teamwork system aimed at optimizing patient care by improving communication and teamwork skills among health care professionals, including frontline staff. It includes a comprehensive set of ready-to-use materials, including video clips and scenarios for discussion, and a training curriculum to successfully integrate teamwork principles into a variety of settings. Topics addressed include traits for effective leadership, situation awareness, protecting the team with mutual support, and effective communication.
CUSP contains a series of modules which can be modified for individual needs. Each module contains training tools and resources to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. It builds the capacity to address safety issues by combining clinical best practices and the science of safety for the goal of quality improvement. The CUSP Toolkit module “Implement Teamwork and Communication” helps learners understand the importance of effective communication and transparency, identify barriers to communication, and isolate and apply the effective teamwork and communication tools.
The Joint Commission:
Shares the importance, benefits, and safety actions of daily safety briefings, also known as safety huddles.
Learn about the Joint Commission’s patient safety focused initiatives.
World Health Organization:
Resources from WHO to aid in the implementation of a patient safety curriculum.
The BMJ. (2016). Medical error is the third biggest cause of death in the US, say experts. [Press release]. Retrieved from http://www.bmj.com/company/wp-content/uploads/2016/05/medical-errors.pdf)
IOM (Institute of Medicine). 2000. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press.
Originators of competency highlight: Laurie Palmer, MSN, RN, AOCN; Madelyn Danner, MSN, RN, CCRN, CEN, CNE; Julie Benson, MHA, MN, CNE, ARNP; Mary Adams, MSN, RN, CNE
QSEN Competency # 4-Evidence Based Practice (EBP)
Definition: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.
Nursing students today have a multitude of information readily available, however they often lack the knowledge and skills to effectively interpret that evidence or implement its use in clinical practice. A significant gap between evidence and nursing practice is acknowledged and an emphasis on the need for instruction of nursing students in these skills (Ashktorab, T., Pashaeypoor, S., Rassouli, M., Alavi-Majd, H., 2015) has been identified. This content area addresses the evaluation and use of quality evidence as the basis for clinical practices and quality improvement efforts. It also addresses the attitudes that students must incorporate in to their personal practice such as a value for ethics with regard to research, the need for continuous improvement and lifelong learning, as well as reflective practice to acknowledge one’s own limitations. Recent evidence suggests that a multifaceted approach to teaching EBP may be best practice (Konstantinos, K., Patelarou, A., Laliotis, A., Wan, A., Matalliotakis, M., Tsiou, C., Patelarou, E., 2016). Nurse educators can use the following activities to enhance learning in this competency area.
Overview of EBP
How to write a PICOT question
Begin writing PICOT questions on assessment forms in clinical
Quality improvement topic during class that focuses on collecting data
Continue to write PICOT questions on assessment forms in clinical
Debriefing focusing on evaluation of evidence
PICOT questions on assessments during clinical
Quality improvement project during practicum experience
Article-Teaching Strategies to Support Evidence-Based Practice
Charlene A. Winters, PhD, ACNS-BC
Rebecca Echeverri, MN, ACNS-BC
Article on using inter-professional simulation-based training to improve management of obstetrical emergencies.
Submitted by Nicole Hall, RN, MSN, MBA, CNE. This is a professional writing assignment including a perioperative clinical experience for first year nursing students. This assignment addresses patient-centered care, teamwork and collaboration, evidence based practice, quality improvement, safety, and informatics. Students are assigned a perioperative patient then follow until the patient is postoperative. Students care for the patient the following day. Following patient care the students write a professional paper according to the instructions. Students are able to “reflect on a surgical experience from the patient’s perspective”.
Clinical strategy for using EBP through QI projects in clinical.
Ashktorab, T., Pashaeypoor, S., Rassouli, M., & Alavi-Majd, H. (2015). Nursing Students’ Competencies in Evidence-Based Practice and Its Related Factors. Nursing and Midwifery Studies, 4(4), e23047. http://doi.org/10.17795/nmsjournal23047
Konstantinos, K., Patelarou, A., Laliotis, A., Wan, A., Matalliotakis, M., Tsiou, C., Patelarou, E. (2016). Educational strategies for teaching evidenced-based practice to undergraduate health students: systematic review. Journal of Educational Evaluation for Health Professions, 13, 34. https://doi.org/10.3352/jeehp.2016.13.34
QSEN Competency # 5: Informatics
The Organization for Associate Degree Nursing (OADN) understands that the future of healthcare hinges on a workforce that is prepared to meet the needs of an ever-changing industry. This requires learners to develop knowledge, skills and attitudes related to technology that empower them to meet the quality and safety needs of their patients. Acknowledging that developing these competencies must start early in the students’ academic career, OADN supports the integration of technology at all levels of nursing education.
Informatics is the use of technology to address the healthcare needs of the patient. Emphasis is placed on improving outcomes for the patient. Definition: Use information and technology to communicate, manage knowledge, mitigate error, and support decision-making. (http://qsen.org/competencies/pre-licensure-ksas/)
The use of technology should first and foremost be considered a function of enhancing safety in patient care. It is important that students and faculty understand the power of informatics to this end. Simultaneously, when developing a lesson plan in the education of pre-licensure nursing students, consider the importance of making critical thinking and clinical reasoning the center of the learning and not the technology. It is for this reason that faculty are encouraged to integrate technology tools that will be useful in multiple learning environments at various levels throughout the curriculum.
Ask students to open their academic EHR during class and respond or record notes. For instance, if the faculty is discussing the drug classification of beta blockers, instead of telling students what will happen when the patient takes the medication (e.g. atenolol) ask students to document teaching needing to be done about the medication’s expected side effects in the patient’s care plan.
This activity allows the students to immediately apply learning in a realistic clinical environment.
Too often nurses and students are not carefully considering the information entered by others in the EHR. They often are quickly moving from screen to screen checking boxes and quickly entering data. This activity is designed to help them consider the potential for safety and the lack thereof in the EHR.
Students will do well to start to consider where safety concerns could arise. This activity helps them explore how informatics can interface with safety in the clinical setting.
Just-In-Time Learning: Encourage use of apps to help guide patient care such as one that gives normal lab values, foreign language apps such as one for medical Spanish, drug information and calculation apps.
Developing habits of using the evidence-base practice immediately is an important part of developing professionally. Too often the business of clinical allows for resource neglect and this puts the patient at risk.
QSEN Competency # 6: Quality Improvement
The content emphasizes the key elements of quality improvement that the pre-licensure graduate should be competent in upon graduation. Nurses are part of the system of care and their actions affect outcomes for patients and families. Small unit changes can improve patient care. It does not always have to be an institutional change.
QSEN Definition: 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.
Clinical Teaching Strategy: Infusing Quality Improvement into Clinical Education
This strategy may be used to educate students on how patient safety may be improved through quality improvement audits and the Plan-Do-Study-Act (PDSA) cycle. The audit subjects were chosen in collaboration with several nurse managers and administrators at clinical facilities utilized by our nursing program.
1) Provide each clinical faculty member the Quality of Care Audit instructor guide (Attachment #1) and a set of audits (Attachment #2): Computer screen; Fall precautions; Hand hygiene; Hourly rounds; IV labeling; and Pain medication reassessment.
2) Have clinical faculty member assign students an audit to complete (Attachment #2). Have students read the directions and perform the audit.
3) Have students discuss their findings and reflections in post conference. Invite the unit manager or charge nurse to participate or provide them a copy of the findings. If the facility allows have the students create a PDSA plan and implement it. Then complete the audit again at a later date and compare the findings to determine if the plan improved care.
Author: Donna B. Lupinski, MSN, RN
Institution: Lorain County Community College
Classroom Teaching Strategy: The Influence of Human Factors in Medication Errors: A Root Cause Analysis
1. Examines the human aspect of nursing practice which influences the delivery of safe patient care.
2. Identifies individual components within a health system and its impact on quality patient outcomes.
1. Demonstrates the use of root cause analysis in identifying human influences in medication errors.
2. Differentiates best practice and local practice in examining nursing medication errors.
1. Values individual responsibility for safety and quality when providing patient care.
Healthcare organizations strive to provide safe, quality care in every patient setting. The complexities of the healthcare environment however, allows prospective errors. Medication related errors are the most common type of error and also account for a sizable increase in healthcare costs (IOM, 2000). Medication errors account for lost wages, disability, and productivity, and are responsible for over 7000 deaths annually (IOM, 2000). The Joint Commission mandates healthcare systems demonstrate strong leadership which creates a fair and just culture of safety. This approach holds both the organization and individual accountable for safe, quality patient care (Joint Commission, 2017). This accrediting body recognizes that individuals human and capable of mistakes in an often flawed system. This case study examines the human factor in a fatal medication error using a root cause analysis.
Author: Robyn B. Caldwell, DNP, FNP-BC, CNE
Title: Assistant Professor
Institution: Auburn University Montgomery
Classroom Teaching Strategy: Understanding and Acceptance of Grief and Loss
PhD(c), MBA, BSN,RN-BC, BCC, CEKGT