Journal of Nursing Education

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Educational Innovations 

Facilitating a Culture of Safety and Patient-Centered Care Through Use of a Clinical Assessment Tool in Undergraduate Nursing Education

Diana Girdley, MS, RN; Christine Johnsen, MS, RN; Kristine Kwekkeboom, PhD, RN

Abstract

Although delivery of safe, patient-centered care has long been a priority among nursing educators, nursing students may not be able to adequately translate concepts learned within the classroom into nursing practice. Nurse educators must develop teaching strategies to provide nursing students with the knowledge, skills, and attitudes necessary to provide quality patient care. Within the Quality and Safety Education for Nurses project, a set of key nursing competencies was established. This article describes the development and use of a clinical assessment tool in undergraduate clinical nursing courses to enhance mastery of two of these key nursing competencies: safety and patient-centered care.

Abstract

Although delivery of safe, patient-centered care has long been a priority among nursing educators, nursing students may not be able to adequately translate concepts learned within the classroom into nursing practice. Nurse educators must develop teaching strategies to provide nursing students with the knowledge, skills, and attitudes necessary to provide quality patient care. Within the Quality and Safety Education for Nurses project, a set of key nursing competencies was established. This article describes the development and use of a clinical assessment tool in undergraduate clinical nursing courses to enhance mastery of two of these key nursing competencies: safety and patient-centered care.

Ms. Girdley is Clinical Associate Professor, Ms. Johnsen is Post-graduate Nurse Practitioner Student, and Dr. Kwekkeboom is Assistant Professor, University of Wisconsin-Madison, School of Nursing, Madison, Wisconsin.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Diana Girdley, MS, RN, Clinical Associate Professor, University of Wisconsin-Madison, School of Nursing, K6/330 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792; e-mail: dgirdley@wisc.edu.

Received: January 12, 2009
Accepted: August 24, 2009

In 2003, the Institute of Medicine (IOM) issued a report identifying five key competencies that all health care providers should possess to enhance quality care (Greiner & Knebel, 2003). Nurse educators are faced with the need to infuse their teaching with strategies that promote development of these competencies. Failure to educate the next generation of professional nurses in these competencies will result in compromising quality care. The wishes of patients and families will continue to be overlooked, and frequently, potentially dangerous errors will continue to plague the health care system.

A variety of teaching strategies may be used to enhance nursing students’ knowledge, attitudes, and skills in the key competency areas. This article describes the use of a clinical assessment tool designed to help students focus on safety and patient-centered care in an undergraduate clinical nursing course.

Background

The Quality and Safety Education for Nurses (QSEN) project, funded by the Robert Wood Johnson Foundation, was established with the goal of reshaping professional identity formation in nursing to include commitment to quality and safety. Project faculty, including nursing experts and an advisory board of leaders in nursing and medicine, adapted the titles and definitions of the IOM’s key competencies to make them specific to the preparation needed by professional nurses. The team identified six essential nursing competencies (patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics) as well as the basic knowledge, skills, and attitudes needed in each of these areas. Together, the competencies, knowledge, skills, and attitudes provide a framework of learning objectives for undergraduate nursing students (Cronenwett et al., 2007).

Although nurse educators widely believe quality care competencies are addressed in their nursing curricula, evidence indicates current preparation does not meet the QSEN objectives (Smith, Cronenwett, & Sherwood, 2007). In a survey about patient safety conducted with 4,826 U.S. and Canadian students and practicing nurses, nursing students, and nurses with less than 5 years of experience were more likely to identify human failures, rather than systems failures, as the most important source of errors (Manno et al., 2006). Students and nurses with less than 1 year of experience fell below the mean on knowledge of Joint Commission patient safety goals and on knowledge of the IOM report, To Err Is Human (Kohn, Corrigan, & Donaldson, 2000). Thus, nurses are graduating and entering practice without knowledge of historical material on patient safety or current safety standards. New teaching strategies are needed to prepare students for the quality and safety challenges they will face in today’s rapidly changing health care system.

Two of the QSEN competencies, safety and patient-centered care, are most pragmatically learned in clinical coursework. The QSEN faculty defined safety as care that “Minimizes risk of harm to patients and providers through both system effectiveness and individual performance” (Cronenwett et al., 2007, p. 128). They identified seven knowledge objectives, eight skills objectives, and five attitude objectives for undergraduate nursing students. For example, Cronenwett et al. (2007) stated students should be able to:

examine human factors and other basic safety design principles as well as commonly used unsafe practices, participate appropriately in analyzing errors . . . and value [their] own role in preventing errors.

In nursing education, safety discussions typically focus on preventing medication errors through the five rights of medication administration and minimal safety standards such as use of bed rails and falls prevention (Sherwood & Drenkard, 2007). Johnstone and Kanitsaki (2007) suggested safety education should emphasize “the inevitability of human error and . . . [adopt processes] aimed at preventing both the incidence and harmful impact of errors” (p. 188). Therefore, nursing educators need to use strategies that emphasize prevention and also focus discussions on understanding the system and human factors that contribute to errors.

Cronenwett et al. (2007) noted patient-centered care is defined by QSEN faculty as the ability to:

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.

The QSEN faculty outlined 11 knowledge objectives, 15 skills objectives, and 15 attitude objectives for undergraduate nursing students. For example, Cronenwett et al. (2007) noted students are expected to:

integrate understanding of multiple dimensions of patient-centered care, elicit patient values, preferences, and expressed needs as part of the clinical interview, and value seeing health care situations through patients’ eyes.

In the current educational setting, patient-centered care may be addressed in coursework on therapeutic communication and care planning. However, nursing students traditionally are not provided with the opportunity to observe shared decision making between patients and providers, and do not get practical experience in ways to adapt care plans to include patients’ preferences and values (Sherwood & Drenkard, 2007).

Few formal teaching strategies have been developed to address safety or patient-centered care in nursing practice. The use of a safety and patient-centered care checklist that prompts assessment of these concerns may be useful in educating undergraduate nursing students. This article describes the development and implementation of a clinical assessment tool (checklist) to assist students in prioritizing patient safety issues and focusing attention on patient-centered care.

Clinical Assessment Tool

The primary author (D.G.) participated in a QSEN pilot school collaborative team in which faculty from selected schools of nursing in the United Stated developed teaching strategies to help achieve the QSEN educational objectives. The author developed a clinical assessment checklist to assist student nurses in recognizing safety risks and to focus their attention on patient-centered care. Faculty colleagues reviewed all items and helped refine the final clinical assessment tool, which is available on the QSEN Web site ( http://www.qsen.org/teachingstrategy.php?id=72).

The assessment tool includes two sections, a safety scan and a patient interview. The safety scan is based on potentially hazardous elements typically found in a patient room and includes 3 items related to patient identification, 7 items related to tubes and lines, and 12 items regarding the patient environment. For example, to address patient identification, students check for proper placement of identification wrist bands and assure that members of the care team are identified accurately on the patient’s communication board. To address safety related to tubes and lines (e.g., oxygen, chest tubes, Foley catheters, intravenous lines), students evaluate items such as appropriate setup, documentation, availability of necessary equipment, patency of lines, and skin breakdown around lines and tubes. Students also evaluate environmental safety items such as bed position, obstacles, clutter, and access to call lights and assistive devices.

The patient interview section is designed to encourage students to sit down and talk with the patient for 5 minutes, to focus students’ attention on planning and providing patient-centered care by first identifying the patient’s agenda for the day. The interview questions are:

  • What would you like to see happen today?
  • How would you describe your hospitalization, and is there anything that could have been done to make it better?
  • What should nursing students know about what it’s like being a patient in the hospital?

The questions can be asked in students’ own words but should be open-ended. The patient interview serves to increase patient access to care providers, enhance their participation in care planning, and improve coordination of care (Bergeson & Dean, 2006).

Use of the Tool

The tool was used with students in a baccalaureate nursing program during their first or second clinical rotation on a general medical unit. Students typically were assigned to provide care for one or two patients each day and were instructed to complete the assessment tool within their first 30 minutes on the unit. Any potential safety issues identified were reported to the staff nurse and instructor and resolved by nursing students, if possible.

Students documented true errors in the institution’s event reporting system. As the instructor became aware of errors or near misses during the clinical day, she would discuss the situation with the student privately and encourage the student to talk about the incident in a postconference with fellow students.

A 3-hour postconference was held at the end of each clinical day. The completed clinical assessment tool was used to facilitate discussion of safety and patient-centered care with a primary goal of introducing students to the value of practicing in a “culture of safety” versus a “culture of blame.”

The instructor started the discussion by talking about her own experience with errors and near misses that day. She emphasized the system elements that caught errors before they occurred and reflected on how she may have contributed to the potential for error, for example, through distractions or fatigue. This introduction set a precedent indicating the postconference was a safe environment in which to share safety concerns. The instructor initiated student discussion with a statement such as:

We all make mistakes at some time or another, but the key to improvement in our practice lies in analyzing those mistakes. In light of this, would you all be willing to go around the room and share with each other those times in clinical practice today when you felt you made a mistake or were close to making a mistake?

Students then followed with discussion of their own experiences.

Students’ perceptions of near misses were discussed in relation to the differences between what is taught in nursing school and what actually happens in clinical practice. “Workarounds” (e.g., shortcuts or breaks in standard procedures) observed by students or the instructor were discussed as examples of the potential dangers of not following standards of practice. The instructor challenged students to identify the barriers that contributed to the perceived necessity for such shortcuts and to consider potential solutions to avoid workarounds.

Patient-centered care also was a focus in postconference discussions, primarily during the first few weeks that students used the clinical assessment tool. The instructor prompted students to address communication issues by asking how the patient interview went, specifically, how it felt to ask the patient-centered care questions. After students became comfortable, they recognized the value of asking the questions in helping to form a relationship with patients and to ascertain patients’ concerns. In subsequent postconferences, the instructor left the patient-centered questions for students’ personal reflection, but students often introduced their patients’ goals, concerns, and agendas without being prompted to do so.

Perceptions of the Tool

The instructor asked nursing students to provide general perceptions about the clinical assessment tool through an informal written evaluation at the end of each semester. Both the safety scan and the patient-centered interview were perceived as beneficial by most of the nursing students. The most common safety risks reported were clutter, mislabeled lines, unopened clamps on IV tubing, and the wrong nurse’s name written on the patient’s communication board. Students reported the safety scan helped them to focus on and prioritize safety assessment and to identify issues the students previously may not have considered as factors that can contribute to patient harm.

Students reported initial difficulty asking the patient-centered care questions but noted it became easier with practice. They were concerned patients would find the questions bothersome and assumed that what patients wanted was to be discharged. Students described being surprised when patient responses did not match those assumptions and actually included reasonable requests (e.g., getting a foot soak, watching a favorite TV program uninterrupted) that they were able to fulfill. Students noted they were able to learn a great deal about their patients in just a 5-minute conversation and overall communication was improved by asking the patient-centered care questions.

Discussion

The clinical assessment tool appeared to be a useful teaching strategy in advancing nursing students’ competency in safety and patient-centered care. In the clinical setting, students can be overwhelmed by many distractions when they first enter a patient room, including noises, family members, medical personnel, and unfamiliar medical equipment. For some students, it may even be the first encounter with a real patient.

Using a checklist format, the clinical assessment tool provided students with structure and clear directions as to what activities they needed to perform or implement. Students were expected to complete the tool within the first 30 minutes on the unit to get in the habit of prioritizing safety assessment. Both students and the instructor identified safety issues that otherwise may have been overlooked and used open discussion of mistakes to allow students to reflect on and learn from the experience. Completing the patient-centered interview furthered students’ understanding of the value and importance of involving patients in their own care.

The safety scan helped students recognize the multiple sources of safety hazards in a rapidly changing health care system. The patient interview oriented students to the vital and central role that patients must play in achieving health care goals. Post-conference discussions introduced students to the potential impact their actions could have on patients, other providers, and the health care system. This teaching strategy is consistent with principles of Complexity Science applied to health care, which suggest that within a complex health care system, all agents (including patients and providers) are interconnected and the actions of one have the capacity to influence and change others (Center for the Study of Healthcare Management, 2003).

One initial challenge to completing the safety scan section of the assessment tool was an assumption that all students had knowledge of equipment encountered in the setting. Certain medical equipment may not have been introduced in previous coursework. Thus, the tool should be adapted to the skill set and educational level of the students using it.

A second challenge was getting the assessment completed within the first 30 minutes of the day if patients were off the unit for diagnostic tests or procedures, if other health care providers were in the room, or if patients were experiencing a medical crisis. In these cases, students were reminded the assessment could be quickly completed during their first patient encounter.

Attempting to introduce a culture of safety through the discussion of near misses and errors was a significant challenge. The instructor recognized that fear of inviting personal blame and retribution in grading could prevent students from sharing and discussing real or potential clinical errors. To move away from a “culture of blame,” the instructor had to adjust her own teaching practices to carry the cultural shift into how she evaluated and graded students. When evaluating performance, she consciously avoided marking students down for the errors they shared and attempted to problem-solve in postconferences. Moreover, the instructor provided positive reinforcement to students who recognized and were willing to report their errors and considered this to be a demonstration of self-evaluation, a valued behavior.

As the semester progressed, students become more comfortable with patient-centered care questions, and less postconference discussion time was focused on this particular competency. In future use of the clinical assessment tool, more discussion could be directed toward the content of patient interviews, on practical steps to alter the plan of care, and on communicating patients’ wishes with other members of the multidisciplinary care team.

The impact of using the clinical assessment tool as a strategy to teach safety and patient-centered care needs further testing and evaluation. Future work should focus on evaluating whether use of the clinical assessment tool increases students’ comfort in reporting errors and improves their ability to plan patient-centered care. The tool should be tested in other educational institutions and across various clinical settings. Evaluations should consider outcomes related to students’ and faculty learning, staff practices, and patient perceptions of care quality.

Conclusion

This clinical assessment tool is one strategy to integrate safety and patient-centered care objectives into clinical education. To prepare nurses who demonstrate a commitment to safe, patient-centered care as part of their professional identity, these concepts need to be fully incorporated into undergraduate nursing curricula. Nursing students need practical educational experiences implementing key quality and safety competencies that can be easily translated into practice as they graduate and enter clinical practice as RNs.

References

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  • Center for the Study of Healthcare Management. (2003). Applying complexity science to health and healthcare. Retrieved June 30, 2009, from http://www.hpm.umn.edu/pubs/centerline/11261.pdf
  • Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J. & Mitchell, P. et al. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006 [CrossRef]
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Authors

Ms. Girdley is Clinical Associate Professor, Ms. Johnsen is Post-graduate Nurse Practitioner Student, and Dr. Kwekkeboom is Assistant Professor, University of Wisconsin-Madison, School of Nursing, Madison, Wisconsin.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Diana Girdley, MS, RN, Clinical Associate Professor, University of Wisconsin-Madison, School of Nursing, K6/330 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792; e-mail: .dgirdley@wisc.edu

10.3928/01484834-20091113-05

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