Dr. Preheim is Associate Professor and Director of the Baccalaureate Nursing Program, Dr. Armstrong is Assistant Professor and Medical-Surgical Coordinator, and Dr. Barton is Associate Professor and Associate Dean for Clinical and Community Affairs, University of Colorado Denver, College of Nursing, Aurora, Colorado.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Gayle J. Preheim, EdD, RN, University of Colorado Denver, College of Nursing, C288-12, Education 2 North, Room 3240, 13120 East 19th Avenue, Aurora, CO 80045; e-mail: Gayle.Preheim@UCDenver.edu.
The traditional fundamentals of nursing course, a constant across prelicensure nursing curricula, introduces basic psychomotor skills essential for patient care. The organizing framework of fundamentals of nursing is important because it identifies priority nursing competencies and professional roles. Time-honored content and teaching approaches focusing on technical skills have lost relevance for contemporary nursing practice.
This article describes a quality and safety framework for the redesign of the traditional fundamentals of nursing course. Within a quality and safety framework, novices begin to identify with professional nursing roles that reach far beyond tasks, skills, and procedures. They develop beginning awareness of safety and quality in the context of a health care system, nurse sensitive quality indicators, and local and national safety initiatives impacting health care delivery. Nurses with a strong foundation in patient safety and quality improvement are better able to assimilate into the current complex health care environment.
Time-Honored Approach to Fundamentals of Nursing
Fundamentals of nursing textbooks often provide the organizing framework for the course content and delivery. The most common framework, which has endured for decades, is based on performance of skills and procedures, such as maintaining asepsis and administering medication (Harmer & Henderson, 1955).
A second common approach is to organize content around physiological systems. Perry and Potter (1985) introduced a dual focus, presenting essential skills of nursing practice and care for the patient’s physiological needs organized around body systems. The iconic Lippincott Manual of Nursing Practice (Mills, 2006) uses biological systems, such as respiratory, cardiovascular, or neurological, as its organizing framework. Continuing the trend, 2009 texts include sections explicitly devoted to either basic nursing skills and therapeutics or physiological systems (Craven & Hirnle, 2009; deWit, 2009).
A third common organizing framework uses the developmental life stages to introduce associated skills and procedures. Although clear organization of content around nursing skills, physiological systems or a developmental context may be logical, a reductionistic perspective of the patient and the nurse’s role is an inadequate approach for preparing new graduates for current complex systems of care.
Quality and Safety Framework for Revision
The context for reformulating fundamentals of nursing is based on the authors’ work with the Quality and Safety Education for Nurses (QSEN) initiative. The overall goal of the QSEN initiative, which has been funded since 2005 by the Robert Wood Johnson Foundation, is:
To meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work.
Six competencies (patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics) were adapted from national initiatives (Greiner & Knebel, 2003) and defined to promote quality and safety within the current complex health care system. In Phase I of the QSEN initiative, leaders developed the KSAs to clarify and provide operational definitions for each competency. Feedback was sought to build consensus for inclusion in prelicensure curricula. In Phase II, a pilot learning collaborative of 15 schools of nursing was established to develop and test teaching strategies (Cronenwett et al., 2007).
Using the QSEN KSAs to redesign fundamentals of nursing was a logical starting point to build on the work in Phase II. During our implementation process, we were overwhelmed with the complexity of incorporating 162 KSAs and sought to “level” them with a developmental approach. After reporting our work to the collaborative and with the support of QSEN core faculty and fellow pilot schools, we conducted a national Delphi survey to gain consensus on the development progression of the KSAs. The study protocol was designated as exempt from full board review and approved by the university’s institutional review board.
Between October 2008 and February 2009, three rounds of the survey occurred. Core faculty and pilot school directors were asked to consider each KSA in light of where it should be introduced and where it should be emphasized in the nursing curriculum. As a result, each participant defined sequential points in the curriculum as beginning, intermediate, and advanced, and then recommended the level at which to introduce or emphasize the KSAs (Barton, Armstrong, Preheim, Gelmon, & Andrus, 2009).
Important insights about competency development were gained by the Delphi survey findings. Patient-centered care and safety are traditional concepts of fundamentals of nursing and continue to be strongly represented in the KSAs, rated important to introduce early. Perhaps one of the more important and surprising findings is that within each of the six competencies, associated KSAs (with the exception of skill elements in quality improvement) were rated to be introduced early in nursing curricula.
Of interest is the finding that introduction of beginning attitudes for all competencies is encouraged. Team-work and collaboration, informatics, and quality improvement traditionally are introduced late in the program of study. Students often question the relevance of systems-focused concepts and perceive them to be peripheral to direct patient care. A lack of valuing the systems context may contribute to difficulty in meeting expectations of current practice, such as participating in interdisciplinary teams and appreciation for unit-based quality initiatives. Early introduction of attitudes that represent the values underpinning the nursing profession supports students’ development of a value-based practice.
New Fundamentals for Contemporary Practice
The six QSEN competencies initially may appear to resemble venerable foundations in nursing education and practice. However, the updated definitions reflect current national quality and safety initiatives and reform in health care professions education. A slight adjustment to fundamentals of nursing will not suffice; the needed fundamentals of nursing redesign is radical. Significant differences in the long-standing traditional definition and the updated definition of the core competencies are evident, resulting in implications for nursing education and practice.
In the following section, the traditional explanation for each competency is contrasted with the QSEN updated definition (Cronenwett et al., 2007). Sample KSAs, rated in the Delphi survey as important to introduce in the beginning curricula, are noted. Exemplars of a redesigned, updated fundamentals of nursing course are provided, using selected readings and recommended teaching strategies. All teaching strategies are available at the QSEN Web site ( http://www.qsen.org/view_strategies.php) and are worthy of exploration.
The traditional concept involves listening to the patient and demonstrating respect and compassion. The QSEN competency emphasizes recognition of 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. The KSAs include:
- K—Integrate understanding of multiple dimensions of patient-centered care: patient, family, and community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity.
- S—Elicit patient values, preferences, and expressed needs as part of the clinical interview, implementation of care plan, and evaluation of care.
- A—Value seeing health care situations “through patients’ eyes.”
When teaching patient-centered care in fundamentals of nursing, the concept of the “patient as full partner” is reflected in providing hygiene care, overseeing nutrition, and assisting with elimination for patients. The end point of teaching is not limited to skills associated with bathing, feeding, or Foley insertion. Rather, skills are centered in the larger context of the patient’s preferences and values. Physical comfort and emotional support are one knowledge aspect of the larger competency.
An example of relevant reading that can provide the contemporary context for patient-centered care is the report by the Picker Institute and the Commonwealth Fund (2007), “Patient-Centered Care: What Does It Take?” The QSEN’s patient-centered care competence acknowledges that self-awareness of the nurse’s own values and beliefs is an important attitudinal aspect of patient-centered care. A teaching strategy, “Teaching Reflective Practice Through the Use of Reflection Papers,” addresses the development of reflective practice through a facilitated process that links classroom discussions and clinical experiences.
Teamwork and Collaboration
The traditional view of teamwork may involve working side by side with other health care professionals while performing nursing skills. The updated QSEN definition calls for functioning effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care. Important beginning KSAs include:
- K—Describe scope of practice and roles of health care team members.
- S—Follow communication practices that minimize risk associated with handoff among providers and across transition in care.
- A—Acknowledge own potential to contribute to effective team functioning.
Students begin to value the nurse’s role in planning care and impact on patient outcomes when the nursing scope of practice is learned within the context of interprofessional teams. Nurse are often at the center of communication for the health care team and frequently facilitate important patient care transitions. Communication of patients’ changing status is vital to successful use of rapid response teams. Teamwork and collaboration are essential in managing complex patients’ plans of care. For example, pain management and end-of-life care best occur in the context of teams. “Teamwork as a Tool for Patient Safety” (CRICO/RMF, 2009) and embedded case studies focus on techniques for effective communication by improving collaboration through briefings and promoting appropriate assertiveness within teams
Traditional practices involve adhering to internal policies to standardize skills execution. The QSEN definition specifies the integration of best current evidence with clinical expertise and patient and family preferences and values for delivery of optimal health care. Important, beginning KSAs reveal significant changes in fundamentals of nursing:
- K—Describe evidence-based practice to include components of research evidence, clinical expertise, and patient and family values.
- S—Base individualized care plan on patient values, clinical expertise, and evidence.
- A—Value the concept of evidence-based practice as integral to determining best clinical practice.
Traditional fundamentals of nursing skills can be taught in the context of evidence-based practice. Recent nursing research highlights emerging best clinical practices related to fluid balance, peripheral intravenous insertion and maintenance, urinary catheter insertion, and nasogastric tube insertion. “Evidence-Based Practice Course Application Strategy” is a developmentally appropriate teaching strategy, introducing levels of evidence in research studies used for classroom case study discussions.
A long-standing approach to quality involves routinely updating nursing policies and procedures. The QSEN updated concept of quality improvement recommends use of data to monitor the outcomes of care processes and use of improvement methods to design and test changes to continuously improve the quality and safety of health care systems. The KSAs recommended for early introduction include:
- K—Recognition that nursing and other health professions students are parts of systems of care and care processes that affect outcomes for patients and families.
- S—The Delphi ratings did not identify a beginning skill in quality improvement but rather recommended introduction and emphasis in intermediate or advanced experiences.
- A—Appreciate continuous quality improvement as essential in the daily work of all health care professionals.
Formal systems-focused quality improvement processes that engage a health care team, such as adverse events reporting, should be introduced early. Root cause analyses and resulting system changes are relevant in fundamentals of nursing. An example of a helpful article about a team approach to quality improvement is “A Lifesaving Checklist” (Gawande, 2007). An additional teaching strategy, “Quality Improvement Exercise for Seniors,” introduces the importance of the quality improvement process.
A simplistic, traditional definition of safety is to use bed rails properly to ensure “that my patient does not fall during my shift.” The QSEN update assures recognition of a culture of safety and minimization of risk of harm to patients through both system effectiveness and individual performance. Safety KSAs rated as important to introduce early include:
- K—Examine human factors and other basic safety design principles as well as commonly used unsafe practices (e.g., workarounds, dangerous abbreviations).
- S—Demonstrate effective use of strategies to reduce risk of harm to self or others.
- A—Value the contributions of standardization and reliability to safety.
Rather than focusing blame on individuals for safety issues, QSEN’s definition of safety emphasizes health care team strategies to promote safe care. For example, asepsis is a component of fundamentals of nursing with multiple associated skills. To address this, teaching hand hygiene and sterile technique in the context of national safety goals, such as National Patient Safety Goals (Joint Commission, 2008), 5 Million Lives Campaign (Institute for Healthcare Improvement, 2006), and Safe Practices for Better Healthcare (National Quality Forum, 2009) help create a meaningful safety context for aspects of nursing practice. Among the safety teaching strategies, the “Environmental Safety Learning Activity” is congruent with a growing sense of the broader context of safety in health care. The Commonwealth Fund (2006) presents 10 case studies of health care organizations, clinical teams, and learning collaborations that have designed innovations in 5 areas for improving patient safety.
Traditionally, documentation consists of timely and accurate charting. However, the QSEN updated definition is expanded and calls for using information and technology to communicate, manage knowledge, mitigate error, and support decision making. The KSAs identified as important for early introduction include:
- K—Explain why information and technology skills are essential for safe patient care.
- S—Apply technology and information management tools to support safe processes of care.
- A—Value technologies supporting decision making, error prevention, and care coordination.
Documentation is a vastly expanding skill in health care, as all members of a health care team contribute to an electronic health record, which is used extensively to determine shifting patient care priorities. The broader context of informatics emphasizes documenting care provided and is useful in teaching about decision management. Relevant reading includes “Ending the Document Game” (Commission on Systemic Interoperability, 2005), in which nurses and other health care providers relate the importance of information technology in providing timely, safe patient care. Another teaching strategy, “Data Mining: Directed Data Collection Exercise,” focuses on navigating an electronic health record to “mine” relevant data.
Participation in the QSEN learning collaborative provided the unique opportunity to build a model of clinical nursing education redesign by starting at the beginning of the curriculum with a single fundamentals of nursing course. The QSEN competencies provide a framework, and the Delphi survey results support an introduction and emphasis of beginning KSAs. The QSEN framework provides a useful organizing scheme, competency definitions, and relevant associations between basic nursing care and contemporary quality and safety national initiatives. Although the traditional focus in fundamentals of nursing has been on psychomotor skills, the early introduction of nursing competencies and roles in a systems context of quality and safety is recommended to prepare graduates for contemporary practice.
- Barton, A., Armstrong, G., Preheim, G., Gelmon, S. & Andrus, L. (in press). A national Delphi to determine developmental progression of quality and safety. Nursing Outlook.
- Commission on Systemic Interoperability. (2005). Ending the document game: Connecting and transforming your healthcare through information technology. Retrieved August 18, 2009, from http://endingthedocumentgame.gov/noflash/index.html
- The Commonwealth Fund. (2006). Committed to safety: Ten case studies on reducing harm to patients. Retrieved August 18, 2009, from http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2006/Apr/Committed-to-Safety--Ten-Case-Studies-on-Reducing-Harm-to-Patients.aspx
- Craven, R.F. & Hirnle, C.J. (2009). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia: Lippincott Williams & Wilkins.
- CRICO/RMF. (2009). Teamwork as a tool for patient safety. Retrieved August 18, 2009, from http://www.rmf.harvard.edu/patient-safety-strategies/communication-teamwork/articles/teamwork-as-a-tool.aspx
- 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]
- deWit, S.C. (2009). Fundamental concepts and skills for nursing (3rd ed). St. Louis, MO: Saunders Elsevier.
- Gawande, A. (2007, December30). A lifesaving checklist. The New York Times. Retrieved August 18, 2009, from http://www.nytimes.com/2007/12/30/opinion/30gawande.html?_r=2&oref=slogin
- Greiner, A.C. & Knebel, E. (Eds.). (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press.
- Harmer, B. & Henderson, V. (1955). Textbook of the principles and practice of nursing (5th ed). New York: Macmillan.
- Institute for Healthcare Improvement. (2006). 5 million lives campaign. Retrieved August 19, 2009, from http://www.ihi.org/IHI/Programs/Campaign/
- The Joint Commission. (2008). National patient safety goals. Retrieved August 18, 2009, from http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/
- Mills, E.J. (Ed.) (2006). Lippincott manual of nursing practice (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
- National Quality Forum. (2009). Safe practices for better healthcare—2009 update. Retrieved August 19, 2009, from http://www.qualityforum.org/Publications/2009/03/Safe_Practices_for_Better_Healthcare%e2%80%932009_Update.aspx
- Perry, P.A. & Potter, A.G. (1985). Fundamentals of nursing: Concepts, process and practice. St. Louis, MO: Mosby.
- Picker Institute & The Commonwealth Fund. (2007). Patient-centered care: What does it take? Retrieved August 18, 2009, from http://www.pickerinstitute.org/Research/shaller.pdf
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