The Quality and Safety Education for Nurses (QSEN) competencies have been an integral focus of nursing education since they were developed in 2005 (Cronenwett et al., 2007). Mirroring the Institute of Medicine (now the National Academy of Medicine) competencies (2003), they identify expected behaviors for health care providers of patient-centered care; teamwork and collaboration; evidence-based practice; quality improvement; and the integrated use of informatics, in language that describes nursing work. QSEN added a sixth competency of safety, emphasizing the role of the nurse in mitigating error. Each competency is defined by knowledge, skills, and attitudes required in order to achieve competency.
Nursing education organizations adopted the QSEN competencies and worked to develop strategies that would allow them to be seam-lessly integrated into established nursing education curricula. In 2009, graduate-level QSEN competencies were developed and became part of the fabric of education programs for those seeking leadership roles in health care, supporting the integration of QSEN in practice. With the rapid rate of health care reform, many of those in continuing education/professional development educator roles integrate some level of the QSEN competencies in their efforts to support staff maintaining current and safe practice.
A bridge for the QSEN competencies between academia and practice was reinforced through the work of Lyle-Edrosolo and Waxman (2016), who cross-walked the QSEN competencies with The Joint Commission Standards and Magnet Standards®. Their work created clarity for how the QSEN competencies provide the foundation for the expectations of professional practice and apply to all nursing working throughout one's career. Since then, the QSEN competencies have not only been prominent in nursing education but have also become an integral part of transition to practice programs and continuing education for nurses in the United States.
Of late, there has been increased focus on improving the quality and safety of care globally (Institute for Healthcare Improvement, 2016). The National Academy of Medicine (2017) urges countries to make a commitment to global health by working together to change health care for the better and promote the well-being of all. Recent studies in China have focused on safety attitudes related to patient safety culture, finding there is opportunity for improvement (Kong et al., 2019; Xu et al., 2018; Zhang et al., 2017) and serving as an impetus for international collaboration. Most efforts have been in sharing educational resources and strategies to support nurse leaders and educators as they begin to integrate quality and safety education and best practices into the education and training of nurses in China, where health care reform is beginning to take hold and move the dial in practice. In January's Leadership and Development column (Bleich, Altmiller, & Jun, 2020), we discussed the receptiveness and importance of global sharing among leaders and the responsibilities for translating key concepts into other cultures.
A recent trip to Beijing, China, provided an opportunity to introduce strategies to support achievement of the QSEN competencies for nurses in practice, in leadership positions, in educator roles in the hospital setting, as well as at Peking University, and for nursing students. Communication strategies to advocate for patients and address concerns including CUS (I'm Concerned, I'm Uncomfortable, I don't think this is Safe) and the two-challenge rule—the practice of meeting our obligation as nurses to voice concerns a second time if they are not responded to the first time—were demonstrated with an opportunity for role-play. Examples of teamwork and collaboration, safety practices to mitigate error, and safety support strategies such as rapid response teams and safety huddles were shared. The concept of fair and just culture was discussed with case scenario examples to demonstrate the importance of having a system where mistakes can be reported without fear of punishment as a strategy to improve patient safety. The ease of translation for these strategies indicates that the QSEN competencies can serve as a framework in all cultures that are taking steps to move toward a safer health care system, explicitly describing the knowledge, skills, and attitudes required for safe nursing practice.
Instituting Quality and Safety Initiatives
China's increasing focus on patient safety on a large scale is evidenced through the development of the National Health Commission of the People's Republic of China and the National Patient Safety Reporting and Learning System in China established to serve the entire country's medical and nursing systems. Locally, the Nursing Safety Management Model supports the integrated management of departments within the hospital, the implementation of closed loop management throughout the health care system, and the provision of information support systems. An interprofessional patient safety management team works to identify potential risks, analyze adverse events, formulate improvement strategies, and supervise the implementation of initiatives to support quality improvement.
Significant work that aligns with the QSEN competencies has been the efforts to create a culture of patient safety where patients participate as members of the health care team. Just as many hospitals have done in the United States, in China, patients are invited to participate in the Patients for Patient Safety Program in cooperation with regional health care providers to exchange information, share experiences, and collaborate to improve patient safety. Hospitals have patient safety committees composed of patients interested in helping the hospital improve. The patient members provide feedback on processes for hospital care as well as outpatient treatment. On a national level, China has established the Chinese Patient Safety Cooperation Network, which holds regular meetings, participates in case sharing and the implementation of educational research, and establishes learning organizations for the dissemination of patient safety culture in an effort to improve care.
Most significant is the promotion of life-long learning for nurses. Concepts of quality and safety education are included in the basic education of nurses, where undergraduate nursing students are introduced to patient safety to increase awareness before entering clinical work. Peking University offers an elective course entitled Professional Spirit and Patient Safety for all undergraduate students. Additionally, quality and safety is a prominent focus in postgraduation education, continuing education, and clinical access training. In the hospital setting, the QSEN competencies are included in nursing safety training and reflected in the interpretation of patient safety culture, the reporting and handling of adverse events, and the assessment and management of nursing risk. Just as in the United States, quality improvement efforts for the work environment include addressing nursing staff's physical and psychological safety, as well as the prevention and handling of disputes.
Although there are significant differences between these two cultures, the aspiration nurses have to provide safe and high-quality care creates a common goal and focus for relationship building. The Year of the Nurse and Midwife designated by the World Health Organization aligns with the universal desire for quality and safety in health care delivery that transcends culture and supports global initiatives to improve the well-being of all people. The QSEN competencies provide a framework focused on quality and safety with clear and distinguished knowledge, skill, and attitude attributes that define competency.
Moving forward, those in continuing education/professional development educator roles around the globe can develop quality improvement and patient safety focused education programs and initiatives that align with the QSEN competencies to propel the patient safety movement forward. Opportunity exists for collaboration and cooperation in bringing a renewed and sustained focus of patient safety to all health care systems. Recognizing and respecting cultural values and norms while moving forward to advance patient safety culture and practices will provide opportunities to learn from each other and create and develop strategies to support QSEN competency achievement in professional nurses worldwide.
- Bleich, M. R., Altmiller, G. & Jun, D. (2020). QSEN transcends cultures: Leadership lessons learned from a global experience. The Journal of Continuing Education in Nursing, 51(1), 9–11 doi:10.3928/00220124-20191217-03 [CrossRef]
- Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., Sullivan, D.T. & Warren, J.Quality and safety education for nurses. Nursing Outlook, 55(3), 122–131.
- Kong, L. A., Zhu, W. F., He, S., Chen, S. Z., Li, Y., Qi, L. & Peng, X. (2019). Attitudes towards patient safety culture among postgraduate nursing students in China: A cross-sectional study. Nurse Education in Practice, 38, 1–6 doi:10.1016/j.nepr.2019.05.014 [CrossRef]
- Lyle-Eldrosolo, G. L. & Waxman, K. T. (2016). Aligning healthcare safety and quality competencies: Quality and Safety Education for Nurses (QSEN), The Joint Commission, and American Nurses Credentialing Center (ANCC) Magnet® Standards Crosswalk. Nurse Leader, 14(1), 70–75.
- Institute for Healthcare Improvement. (2016). Vision, mission, and values. Retrieved from http://www.ihi.org/about/pages/ihivisionandvalues.aspx
- Institute of Medicine. (2003). Health professions education: A bridge to quality. The National Academies Press.
- National Academies of Sciences, Engineering, and Medicine. (2017). Global health and the future role of the United States. Retrieved from doi:10.17226/24737 [CrossRef]
- Xu, X. P., Deng, D. N., Gu, Y. H., Ng, C. S., Cai, X., Xu, J. & Chan, C. K. (2018). Changing patient safety culture in China: A case study of an experimental Chinese Hospital from a comparative perspective. Risk Management and Healthcare Policy, 11, 83–98.
- Zhang, F., Tian, L., Shang, X., Li, X., Xue, R., Cheng, S. & Chen, C. (2017). Exploring relationships between first line nurse manager's safety attitudes and safety factors in Henan, China. Journal of Nursing Management, 26, 314–320.