Dr. Fater is Associate Professor of Nursing, College of Nursing, University of Massachusetts-Dartmouth, North Dartmouth, and Mr. Ready is Director of Professional Development, Southcoast Hospitals Group, Fall River, Massachusetts.
Preparation of this manuscript was supported by funding from the Massachusetts Department of Higher Education and the Johnson & Johnson Promise of Nursing for Massachusetts Nursing School Grant Program. Its contents are solely the responsibility of the authors and do not necessarily represent official views of the funding agencies.
The authors have no financial or proprietary interest in the materials presented herein.
The authors thank Dr. Kristen Sethares for sharing ideas about creative strategies.
Address correspondence to Kerry H. Fater, PhD, RN, CNE, Associate Professor of Nursing, College of Nursing, University of Massachusetts-Dartmouth, Old Westport Road, North Dartmouth, MA 02747; e-mail: email@example.com.
Over the past 12 years, the Institute of Medicine (IOM) has reported safety problems associated with the health care system and has offered recommendations to address the problems (IOM, 1999, 2001a, 2001b, 2003). Among the recommendations is the need for changes in the educational preparation of nurses, including the development of competencies in patient safety and quality improvement. Initially, nursing education responded slowly to these recommendations (Gregory, Guse, Dick, & Russell, 2007), but more recently Ironside and Sitterding (2009) reported that nursing faculty “have begun the important work of assuring that graduates demonstrate safety-quality competencies” (p. 659). This is occurring through a range of strategies, including partnerships between education and service.
Collaborative alliances between education and nursing service have been widely reported in the literature over the past decade. Most noteworthy among successful partnerships that have solved problems and created positive change include those that fostered realities in practice and address the theory-practice gap (Fetherstonhaugh, Nay, & Heather, 2008; Murray, Crain, Meyer, McDonough, & Schweiss, 2010) and those that promoted patient safety (Pappas, 2007). More recently, partnerships were created to achieve outcomes related to safety and quality improvement (MacIntyre, Murray, Teel, & Karshmer, 2009; Mulready-Shick, Kafel, Banister, & Mylott, 2009).
The Future of Nursing: Leading Change, Advancing Health Report Recommendations (IOM, 2010) indicates that academic educators and health care organizations should partner to “develop and prioritize competencies so curricula can be updated regularly...to meet the current and future health needs of the population” (p. 5). The Massachusetts Department of Higher Education Nurse of the Future Competency Committee espoused a similar ideal in a funded activity in the commonwealth described below.
Clearly, education-service partnerships offer opportunities to address the gap in the preparation of new graduates related to the demands and realities in practice. Students need continued opportunities to develop and use safety and quality improvement competencies for practice. The current article addresses several clinical case conferences created through an education-service partnership to promote safety and quality competency development in undergraduate students. The partners included faculty from the University of Massachusetts-Dartmouth College of Nursing and staff from the Professional Development department from the nursing program’s largest clinical affiliate, which consists of three acute care facilities and a home care agency.
Nurse of the Future Core Competencies
In 2007, the Massachusetts Department of Higher Education Nurse of the Future Competency Committee offered funding opportunities for the development of nursing program curricula that reflect the safety and quality demands in health care. The Phase II funding supported the goal of incorporating the knowledge, attitudes, and skills essential to acquiring the Nurse of the Future core competencies, which include nursing knowledge, patient-centered care, teamwork and collaboration, safety, professionalism, leadership, quality improvement, systems-based practice, communication, and evidence-based practice (Massachusetts Department of Higher Education, 2010). The education-practice partnership was central to achieving this goal.
Curriculum Development Regarding Safety and Quality Improvement Competencies
Practice Partner’s Role. The Director of Professional Development and the nurse educators at the largest affiliate hospital system in the region represented the practice partner. As the largest single employer of graduates from the university’s baccalaureate nursing program, and well aware of their strengths and weaknesses, the professional development staff were asked to consider the following: What key experiences are available in the clinical setting to address gaps in needs of the undergraduate students across the curriculum? As a result, a variety of service agency collaborative strategies were identified, several of which are described below.
Education Partner’s Role. The nursing faculty representatives who participated in the project included a senior tenured faculty member who is a curriculum specialist, a junior faculty member, and a recently retired long-term faculty member. All three faculty representatives had broad-based experiences teaching in the undergraduate nursing program over many years.
To begin the curriculum change process, a new program objective—to promote safety through quality practice—was approved by the college faculty. This objective was broad enough to allow for a range of safety and quality learning experiences across the curriculum. Level objectives and course objectives were developed across the 4 years of the program. Aware of the risk of contributing to an additive curriculum, where content and learning are added but nothing is removed, the majority of the learning experiences are incorporated into clinical experiences. Furthermore, the clinical setting is where students would demonstrate the competencies. Case studies and other active learning strategies were identified from a variety of sources that simultaneously contribute to meeting several core competencies in a single learning activity. The case studies presented in this article describe preventable health problems and their complications.
Examples of Jointly Created Strategies to Promote Competency Development
Because the nursing curriculum begins in the freshman year in this undergraduate program, it was clear that the introduction to the Nurse of the Future core competencies must occur in the Introduction to Professional Nursing course. Because several of the competency areas are part of the existing course (nursing knowledge, evidence-based practice, professionalism, leadership, systems-based practice, communication, and teamwork and collaboration), faculty reframed the existing areas, and add those not explicitly addressed (safety, quality improvement, and patient-centered care). These changes facilitate the achievement of the Level One objective: identify safety and quality improvement as essential elements in nursing and health care.
Building on the curriculum from the freshman year, sophomore students in the nursing fundamentals course are assigned to three postclinical conference case studies that address patient safety, quality improvement, awareness of nurse-sensitive outcomes, and evidence-based practice. Our practice partner provided unit-based and agency-based data on fall prevention, pressure ulcer prevention, and infection prevention and hand hygiene, all of which are central concepts in the sophomore curriculum. Through these cases, students achieved multiple competencies and their associated knowledge, attitudes, and skills, and met the Level Two curriculum objectives: describe factors that create a culture of safety and describe the importance of measurement in nursing practice. Multiple opportunities to analyze and interpret data and locate pertinent resources that identify nursing care expectations serve to reinforce the learning. Two of the three sophomore case studies and the senior case are described below.
Students are introduced to the National Database of Nursing Quality Indicators (NDNQI) and nurse-sensitive outcomes in this case. For an explanation of the mission, goals, and services provided by NDNQI, visit the Web site: https://www.nursingquality.org. The agency specific graphs indicate quarterly number of fall findings and injuries per 1,000 patient-days over a 2-year period. Resources the students review in advance of the conference include the Rutledge and Schub (2011) fall prevention evidence-based care sheets located on the CINAHL Web site and the agency’s fall prevention policy. The objectives for the clinical case study are to develop an appreciation for the nurse’s role in preventing patient falls; to use agency policy to determine nursing care expectations; to review unit-based NDNQI data, which reflects the agency’s commitment to quality improvement; and to value use of evidence-based knowledge to guide nursing care and prevent falls. Students compare the fall rates on a given unit with those from similar agencies. Generating possible reasons for the differences in fall rate data and caregiver responsibilities in prevention are part of the case analysis. Student outcomes from their discussion of this clinical conference contribute to their development of competencies in applying quality improvement, using evidence-based practice, and promoting safety through their informed understanding of fall risks on the unit.
Preventing Infection and Hand Hygiene
Students must develop knowledge and appreciation as to how they may contribute unwittingly to nosocomial infections and their complications. This awareness is essential for patient safety and to avoid serious financial burden to the agency as a result of denied reimbursement for services by Centers for Medicare and Medicaid Services (2008). In the case study, students consider agency-based statistics over 4 months obtained through covert observations of hand hygiene practices by nurses. Initially, the observations reflect that only approximately 56% of nurses engaged in hand hygiene as expected. In the second quarter, the percentage dropped somewhat to 50%, followed by 83% in the third quarter, and 100% in the fourth. The resources the students review prior to the case conference include the agency infection control policy, the Joint Commission (2011) National Patient Safety Goals, and Centers for Disease Control and Prevention (2002) factors associated with adherence to hand hygiene practices.
Initially, students are presented with current statistics on the number of people who die annually from nosocomial infections. They are asked to recall their knowledge from the previous semester about hand hygiene and its importance in preventing infection. Next, they consider when and how to engage in hand hygiene and where to locate the policies for infection control. Students consider the factors that may have contributed to the improvement in the observations of hand hygiene practices over the four quarters. As a result of participation in this clinical conference, students are developing competencies in the areas of using evidence-based practice, applying quality improvement, and promoting patient safety though their practice.
Deep Sternal Wound Infection
As students progress through the program, instruction on patient safety and quality improvement increases in complexity. The following case study reflects a comprehensive experience, drawing on cumulative learning.
In the final senior semester, students engage in an analysis of a case study involving a cardiothoracic surgery—deep sternal wound infection. The Nursing Director of Cardiac Surgery and the Resource Nurse present the case as a pilot-learning project with senior students in the agency. Once again, students view a graph that plots the percentage of patients who developed wound infections over a 4-year period. The chart reveals initial spikes and drops in the data, then a near plateau at approximately 1% wound infection rate, followed again by a few drops and spikes. For the last seven quarters on the chart, there are no reported infections. The agency-specific data are compared with state average infection rates and Society of Thoracic Surgery averages nationally. Students are asked to identify any areas of concern noted in the data and which members of the health team should be involved in the problem solving.
As the case unfolds, students consider the holistic experience of the patients’ status from preoperative through step-down experience postoperatively and consider a broad range of patient and system variables that influence infection rates and goals for the program. These variables include patient factors such as current medications, comorbidities, and glycemic status. System considerations include preoperative and postoperative monitoring procedures, surgical site preparation procedures, and operating department cleansing routines.
Although systematic evaluation of effectiveness of the curriculum plan is still in process, preliminary evaluation from students and faculty is reported. Expedited review and approval for use of student data was obtained from the University Institutional Review Board. Forty-four sophomore students evaluated the extent to which the objectives (identified previously) for each of the case studies were met based on a 5-point Likert scale. The range of student ratings was between 4.21 and 4.41, with a mean of 4.36, reflecting a high degree of achievement of the objectives. Faculty enthusiastically indicated that the clinical cases were interesting and relevant to practice. A quality improvement overview presentation to junior students by the agency leader on quality was rated as less effective. Therefore, active learning strategies to address quality improvement were substituted the succeeding year.
Most recently, the feedback from seniors was overwhelmingly positive concerning the Director of Professional Development’s facilitation of the deep sternal wound case study. Among the 56 students who considered the complex deep sternal wound case study, the overall rating was 4.5 on 5-point Likert scale. In addition, students’ statements included: “It will always keep me thinking about ways to improve quality health care at the patient level,” “I will think more about how complications occur and their cause,” and “I think I would like to serve on a quality improvement committee.” Informally, faculty indicated that students were highly engaged in the deep sternal wound case study, demonstrating their prior knowledge and effective problem solving. Perhaps the most significant contribution of this education-service partnership is faculty excitement about using relevant examples pertinent to the practice environment and consistent with curricular focus.
In light of the newness of the curriculum plan on the graduates of the program, evaluative data from the practice partner are limited. Currently, the Professional Development staff members emphasize the competencies new graduates need to function in their assigned practice areas. They have expressed interest in collaborating on an assessment tool to determine preparedness of new graduates to the Nurse of the Future core competencies who are newly hired by the agency. Nursing faculty members look forward to contributing to this and related transition program issues.
Active learning strategies were developed to engage students, challenge their critical thinking, and promote competencies essential to practice. Most importantly, students new to the direct patient care role learn that the quality of the care they provide for every patient really matters. As a result, students can either contribute directly to the decline in the nursing quality indicators or contribute to their improvement. In addition, students realize in their fundamentals course that data are monitored and trended over time for each nursing unit and the agency overall. This provides students with an awareness that goes far beyond the typical emphasis on the patients assigned to their care. Students must consider the effects on the quality of care for a given nursing unit, agency, and system and the potential financial losses associated with preventable patient complications.
College of Nursing faculty and our practice partner colleagues continue to be challenged with innovative ways to develop students’ safety and quality competencies. The joint partnership has contributed to creating relevant unit-based and agency-based learning experiences that foster their development. The importance of bridging the gap between nursing education and practice is paramount to the ongoing safety and quality competency development of new nurses.
- Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in healthcare settings. Morbidity and Mortality Weekly Report. 51(RR-16), 1–56. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm
- Centers for Medicare and Medicaid Services. (2008). Hospital-acquired conditions. Retrieved from http://www.cms.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp#TopOfPage
- Fetherstonhaugh, D., Nay, R. & Heather, M. (2008). Clinical school partnerships: The way forward in nursing education, research and clinical practice. Australian Health Review, 32, 121–126.
- Gregory, D.M., Guse, L.W., Dick, D.D. & Russell, C.K. (2007). Patient safety: Where is nursing education?Journal of Nursing Education, 46, 79–82.
- Institute of Medicine. (1999). To err is human: Building a safer health system. Retrieved from http://www.nap.edu/catalog.php?record_id=9728
- Institute of Medicine. (2001a). Crossing the quality chasm: A new health system for the 21st century. Retrieved from http://www.nap.edu/catalog.php?record_id=10027
- Institute of Medicine. (2001b). Envisioning the national health care quality report. Retrieved from http://www.nap.edu/catalog.php?record_id=10073
- Institute of Medicine. (2003). Health professions education: A bridge to quality. Retrieved from http://www.nap.edu/catalog.php?record_id=10681
- Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://iom.edu/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Future%20of%20Nursing%202010%20Recommendations.pdf
- Ironside, P.M. & Sitterding, M. (2009). Embedding quality and safety competencies in nursing education. Journal of Nursing Education, 48, 659–660. doi:10.3928/01484834-20091113-04 [CrossRef]
- Joint Commission. (2011). Hospital national patient safety goals. Retrieved from http://www.jointcommission.org/assets/1/6/2011_HAP_NPSG_EASYTOREAD_docs_112-29.pdf
- MacIntyre, R.C., Murray, T.A., Teel, C.S. & Karshmer, J.F. (2009). Five recommendations for prelicensure clinical nursing education. Journal of Nursing Education, 48, 447–451. doi:10.3928/01484834-20090717-03 [CrossRef]
- Massachusetts Department of Higher Education. (2010). Nurse of the future nursing core competencies. Boston: MA. Retrieved from http://www.mass.edu/currentinit/documents/NursingCoreCompetencies.pdf
- Mulready-Shick, J., Kafel, K.W., Banister, G. & Mylott, L. (2009). Enhancing quality and safety competency development at the unit level: An initial evaluation of student learning and clinical teaching on dedicated education units. Journal of Nursing Education, 48, 716–719. doi:10.3928/01484834-20091113-11 [CrossRef]
- Murray, T.A., Crain, C., Meyer, G.A., McDonough, M.E. & Schweiss, D.M. (2010). Building bridges: An innovative academic-service partnership. Nursing Outlook, 58, 252–260. doi:10.1016/j.outlook.2010.07.004 [CrossRef]
- Pappas, S. (2007). Improving patient safety and nurse engagement with a dedicated education unit. Nurse Leader, 5, 40–43. doi:10.1016/j.mnl.2007.03.009 [CrossRef]
- Rutledge, D. & Schub, T. (2011). Fall prevention in hospitalized patients. Retrieved from EBSCOhost.