Journal of Nursing Education

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Guest Editorial 

Embedding Quality and Safety Competencies in Nursing Education

Pamela M. Ironside, PhD, RN, FAAN, ANEF

Abstract

The Quality and Safety Education for Nurses (QSEN) project (Cronenwett et al., 2007) has energized nursing faculty across the country and around the world to begin the important work of assuring graduates demonstrate quality and safety competencies. Indeed, the goal of this project has been to alter nurses’ professional identify formation so when they think about what it means to be a respected nurse, they not only think of knowledge and skills, caring, honesty, and integrity, but also remember the continued commitment to develop and assess quality and safety competencies. This goal has been readily embraced by nursing faculty across program types and levels, and has fostered a critical analysis of the extent to which current pedagogies facilitate (or at times inhibit) the achievement of this goal.

Importantly, the articulation of the specific knowledge, skills, and attitudes needed for competency achievement has drawn attention to the need for faculty members to update and extend their knowledge of safety science and improvement methods (Smith, Cronenwett, & Sherwood, 2007) and to create opportunities for students to participate meaningfully in improvement work. For instance, improving the quality and safety of patient care requires the disposition to continuously improve the care being provided, the knowledge to recognize hazards and improvement opportunities, and the skills to select opportunity-specific methods (e.g., rapid cycle process improvement, Murphy’s Analysis, LEAN 5 S, Six Sigma, and fail-proofing) and enact evidence-based practice change. How well are these aspects of improvement integrated throughout nursing curricula? Do students have consistent opportunities to work collaboratively with staff nurses and other team members to address safety and quality issues?

Similarly, quality and safety education must also account for the complexity of the environments in which practice (and student learning) occurs. Nursing work environments are considered high hazard settings with little margin for human error, and nursing work is cognitively demanding and interdependent, requiring mindful organizing and effective cognitive stacking (Ebright, Urden, Patterson, & Chalko, 2004). Yet nursing research is documenting how nursing students’ clinical experiences often do not account for this complexity or intentionally develop students’ skills (e.g., mindful organizing) in dealing with these demands (Benner, Sutphen, Leonard, & Day, in press; Ironside, Jeffries, & Martin, in press; Ironside & McNelis, in press) even though safety science has documented the relationship between mindful organizing and patient care outcomes (Vogus & Sutcliffe, 2006; Weick, 2009; Weick & Sutcliffe, 2007).

Clearly, the practice settings in which students learn and will eventually practice have become highly attuned to safety processes and tracking the outcomes of care through monitoring nurse-sensitive and other quality indicators. Yet in many cases, students remain “outsiders” or “guests” in these settings, missing important opportunities to observe outcomes of the care they provide (Benner et al., in press), and to investigate quality indicators and sources of variance among patients with similar conditions or across all patients on a particular unit. For example, how likely are students to achieve the competency of teamwork if they are only theoretically part of the care team? How might we engage students more intentionally in practice improvement initiatives as cocollaborators with patients, families, staff nurses, and other members of the care team? In this issue, Mulready-Schick, Kafel, Banister, and Mylott explore new clinical models such as dedicated educational units and Girdley, Johnsen, and Kwekkeboom and Jarzemsky and Voge discuss innovative strategies within existing models that hold great promise for improving students’ experiences and achievement of QSEN competencies.

However, if a central feature of the formation of the next generation of nurses is the development of quality and safety competencies, then these competencies cannot be taught as isolated content within…

The Quality and Safety Education for Nurses (QSEN) project (Cronenwett et al., 2007) has energized nursing faculty across the country and around the world to begin the important work of assuring graduates demonstrate quality and safety competencies. Indeed, the goal of this project has been to alter nurses’ professional identify formation so when they think about what it means to be a respected nurse, they not only think of knowledge and skills, caring, honesty, and integrity, but also remember the continued commitment to develop and assess quality and safety competencies. This goal has been readily embraced by nursing faculty across program types and levels, and has fostered a critical analysis of the extent to which current pedagogies facilitate (or at times inhibit) the achievement of this goal.

Importantly, the articulation of the specific knowledge, skills, and attitudes needed for competency achievement has drawn attention to the need for faculty members to update and extend their knowledge of safety science and improvement methods (Smith, Cronenwett, & Sherwood, 2007) and to create opportunities for students to participate meaningfully in improvement work. For instance, improving the quality and safety of patient care requires the disposition to continuously improve the care being provided, the knowledge to recognize hazards and improvement opportunities, and the skills to select opportunity-specific methods (e.g., rapid cycle process improvement, Murphy’s Analysis, LEAN 5 S, Six Sigma, and fail-proofing) and enact evidence-based practice change. How well are these aspects of improvement integrated throughout nursing curricula? Do students have consistent opportunities to work collaboratively with staff nurses and other team members to address safety and quality issues?

Similarly, quality and safety education must also account for the complexity of the environments in which practice (and student learning) occurs. Nursing work environments are considered high hazard settings with little margin for human error, and nursing work is cognitively demanding and interdependent, requiring mindful organizing and effective cognitive stacking (Ebright, Urden, Patterson, & Chalko, 2004). Yet nursing research is documenting how nursing students’ clinical experiences often do not account for this complexity or intentionally develop students’ skills (e.g., mindful organizing) in dealing with these demands (Benner, Sutphen, Leonard, & Day, in press; Ironside, Jeffries, & Martin, in press; Ironside & McNelis, in press) even though safety science has documented the relationship between mindful organizing and patient care outcomes (Vogus & Sutcliffe, 2006; Weick, 2009; Weick & Sutcliffe, 2007).

Clearly, the practice settings in which students learn and will eventually practice have become highly attuned to safety processes and tracking the outcomes of care through monitoring nurse-sensitive and other quality indicators. Yet in many cases, students remain “outsiders” or “guests” in these settings, missing important opportunities to observe outcomes of the care they provide (Benner et al., in press), and to investigate quality indicators and sources of variance among patients with similar conditions or across all patients on a particular unit. For example, how likely are students to achieve the competency of teamwork if they are only theoretically part of the care team? How might we engage students more intentionally in practice improvement initiatives as cocollaborators with patients, families, staff nurses, and other members of the care team? In this issue, Mulready-Schick, Kafel, Banister, and Mylott explore new clinical models such as dedicated educational units and Girdley, Johnsen, and Kwekkeboom and Jarzemsky and Voge discuss innovative strategies within existing models that hold great promise for improving students’ experiences and achievement of QSEN competencies.

However, if a central feature of the formation of the next generation of nurses is the development of quality and safety competencies, then these competencies cannot be taught as isolated content within a single course or only during the final term of a program. That is, learning about and achieving quality and safety competencies must be learned as part of every aspect of practice. The centrality of quality and safety competencies will also require that learning experiences across the curriculum overcome the narrow conceptualization of knowledge acquisition (in classrooms) and its application (in clinical experiences). To achieve the goal of having the demonstration of quality and safety competencies part of the identity of future nurses, issues of quality and safety must pervade every learning encounter in the program (classroom, clinical, and lab), from beginning to end. To that end, Preheim, Armstrong, and Barton challenge traditional conceptualizations of “fundamentals” in nursing, drawing attention to how the development of quality and safety competencies can begin in the first nursing course. Armstrong, Spencer, and Lenburg describe how the QSEN competencies were integrated throughout an existing competency-based baccalaureate curriculum.

As faculties continue to revise curricula and to develop and implement innovative approaches to developing students’ quality and safety competency, assessment of the effectiveness of these efforts must continue. This issue contains several examples of studies undertaken by faculty to investigate the outcomes of their efforts to promote QSEN competencies in prelicensure and graduate nursing programs. From comparing the presentation of classroom content alone to the presentation of content, clinical discussions and projects (Miller & LaFramboise) to the use of simulation (McKeon, Norris, Cardell, & Britt) and Web-based hazard and near-miss reporting (Currie et al.; Ardizzone, Enlow, Evanina, Schnall, & Currie) these studies provide important insight into how these strategies can impact students’ competency achievement and the challenges involved in conducting this inquiry.

The complexity of investigating the outcomes of pedagogical efforts to foster quality and safety competencies also calls for new approaches to evaluation. Ogrinc and Batalden describe a new approach (Realist Evaluation) to evaluation that accounts for the context in which learning occurs and care is provided, the outcomes that are achieved through pedagogical interventions, and the mechanisms that contributed to that achievement. Moore comments on how this approach can inform pedagogical practices and evaluation in schools of nursing as we collectively strive to advance the science of nursing education.

Although the disciplinary work of embedding QSEN competencies in schools of nursing continues, we cannot lose sight of the larger context of health care and the need to overcome the disciplinary silos so common in contemporary academic settings. Forbes-Thompson and Tilden describe one university’s efforts to promote interprofessional education by highlighting both challenges and successes.

Although much has been accomplished since the QSEN project began in 2005, much is left to do if new nurses are to enter the workforce with quality and safety competency as an integral part of their identity as nurses. The need for nursing faculty to focus on the development and assessment of quality and safety competencies across the curriculum has, perhaps, never been greater. For more than a decade, startling reports have documented the risks and consequences of error in health care. For instance, in 1995, Leape, a Harvard School of Public Health professor, and colleagues analogized the prevalence of error in the United States as equivalent to two jumbo jets crashing every 3 days. In 2000, the Institute of Medicine estimated costs of medication administration errors alone to exceed $2 billion annually, and the cost continues to rise. And yet, the most critically important driving force influencing our sustained attention on embedding quality and safety competencies (patient-centered care, teamwork and collaboration, safety, evidence-based practice, informatics, and quality improvement) across the curriculum is the public trust—the expectation that all of those our students serve, now and in the future, will receive safe, reliable, patient-centered, evidence-based, and timely care whenever and wherever needed.

Pamela M. Ironside, PhD, RN, FAAN, ANEF
Associate Professor and Director of the Center for
Research in Nursing Education
Indiana University School of Nursing

Mary Sitterding, MSN, RN, CNS, CNRN
Director of Nursing Research and Professional Practice
Clarian Health
Indianapolis, IN

References

  • Benner, P., Sutphen, M., Leonard, V. & Day, L. (2009). Educating nurses: A call for radical transformation. San Francisco: Jossey Bass.
  • 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]
  • Ebright, P.R., Urden, L., Patterson, E. & Chalko, B. (2004). Theme surrounding novice nurse near-miss and adverse-event situations. JONA, 34, 531–538. doi:10.1097/00005110-200411000-00010 [CrossRef]
  • Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.
  • Ironside, P.M., Jeffries, P.R. & Martin, A. (in press). Fostering patient safety competencies using multiple-patient simulation experiences. Nursing Outlook.
  • Ironside, P.M. & McNelis, A.M. (in press). Clinical education in prelicensure nursing programs: Results from a national survey. New York: National League for Nursing.
  • Leape, L.L. et al. (1995). Systems analysis of adverse drug events. JAMA, 274, 35–43. doi:10.1001/jama.274.1.35 [CrossRef]
  • Smith, E.L., Cronenwett, L. & Sherwood, G. (2007). Current assessments of quality and safety education in nursing. Nursing Outlook, 55, 132–137. doi:10.1016/j.outlook.2007.02.005 [CrossRef]
  • Vogus, T. & Sutcliffe, K. (2007) The safety organizing scale: Development and validation of a behavioral measure of safety culture in hospital nursing units. Medical Care, 45, 46–54. doi:10.1097/01.mlr.0000244635.61178.7a [CrossRef]
  • Weick, K. (2009). Making sense of the organization: The impermanent organization (vol. 2). Chichester, Sussex: John Wiley & Sons.
  • Weick, K. & Sutcliffe, K. (2007). Managing the unexpected: Resilient performance in an age of uncertainty (2nd ed). San Francisco: Jossey-Bass.

10.3928/01484834-20091113-04

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