Journal of Nursing Education

Research Briefs 

Comparison of Quality and Safety Education for Nurses (QSEN)–Related Student Experiences During Pediatric Clinical and Simulation Rotations

Susan Pauly-O'Neill, DNP, PNP-BC; Susan Prion, EdD, RN, CNE; Helen Nguyen, DNP, NNP

Abstract

Nurse educators are challenged with providing meaningful clinical experiences for students. However, patient safety regulations constrain what nursing students are able to accomplish in the pediatric setting. So, what are students actually doing in their clinical rotation? This pilot observational study was undertaken to provide a snapshot of the experiences available to nursing students that develop the six Quality and Safety Education for Nurses (QSEN) competencies. Students were directly observed during pediatric clinical and pediatric simulation rotations, and their time-on-task was calculated and categorized. Three of the six QSEN competencies were observed more often than the others during both the simulation and clinical experiences. Much work needs to be done to include all QSEN-related knowledge and skills into prelicensure clinical rotations. [J Nurs Educ. 2013;52(9):534–538.]

Dr. Pauly-O’Neill is Assistant Professor, Dr. Prion is Associate Professor, and Dr. Nguyen is Assistant Professor, University of San Francisco School of Nursing and Health Professions, San Francisco, California.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Dr. Judith Lambton for her assistance in data collection.

Address correspondence to Susan Pauly-O’Neill, DNP, PNP-BC, Assistant Professor, University of San Francisco School of Nursing and Health Professions, 2130 Fulton Avenue, San Francisco, CA 94117; e-mail: paulyoneil@usfca.edu.

Received: July 16, 2012
Accepted: March 06, 2013
Posted Online: August 19, 2013

Abstract

Nurse educators are challenged with providing meaningful clinical experiences for students. However, patient safety regulations constrain what nursing students are able to accomplish in the pediatric setting. So, what are students actually doing in their clinical rotation? This pilot observational study was undertaken to provide a snapshot of the experiences available to nursing students that develop the six Quality and Safety Education for Nurses (QSEN) competencies. Students were directly observed during pediatric clinical and pediatric simulation rotations, and their time-on-task was calculated and categorized. Three of the six QSEN competencies were observed more often than the others during both the simulation and clinical experiences. Much work needs to be done to include all QSEN-related knowledge and skills into prelicensure clinical rotations. [J Nurs Educ. 2013;52(9):534–538.]

Dr. Pauly-O’Neill is Assistant Professor, Dr. Prion is Associate Professor, and Dr. Nguyen is Assistant Professor, University of San Francisco School of Nursing and Health Professions, San Francisco, California.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Dr. Judith Lambton for her assistance in data collection.

Address correspondence to Susan Pauly-O’Neill, DNP, PNP-BC, Assistant Professor, University of San Francisco School of Nursing and Health Professions, 2130 Fulton Avenue, San Francisco, CA 94117; e-mail: paulyoneil@usfca.edu.

Received: July 16, 2012
Accepted: March 06, 2013
Posted Online: August 19, 2013

Nursing students need to anticipate and confront the challenges that may be presented in the real world upon graduation (Bambini, Washburn, & Perkins, 2009). However, students reported having little to no exposure to deteriorating patient conditions during their pediatric inpatient clinical rotation (Pauly-O’Neill, Prion, & Lambton, 2011). Exposure to stable pediatric patients is not sufficient to confer competence in caring for children with acute illness; therefore, nurse educators have begun to substitute some of the required patient care hours with high-fidelity simulated scenarios. Although state regulations often dictate the maximum time allowed in simulation, it is vital for nurse educators to create a model of simulation that fills the gap between the competencies required of new nurse graduates and what the clinical setting provides for nursing students. The first step in creating the ideal blend of authentic clinical and simulation experience is an exploration of the experiences currently available in both settings.

Study Purpose

This pilot observational study was conducted to answer the following two questions:

  • Do the pediatric clinical and simulation settings offer the opportunity to practice the six competencies set forth by the Quality and Safety Education for Nurses (QSEN) initiative (Cronenwett et al., 2007): patient-centered care, teamwork and collaboration, safety, evidence-based practice, quality improvement, and informatics?
  • Are the activities available in each setting comparable?

The findings may also help to answer the commonly asked question: Does 1 hour in the simulation laboratory equate to 1 hour of clinical time?

Observation Tool Development

To categorize what students accomplish in each arena, the QSEN competencies were used as a guide by the authors to create the time-on-task/clinical observation tool (TOT-COT). Although the QSEN competencies operationalize the knowledge, skills, and attitudes (KSAs) needed to demonstrate competence in six main areas (Cronenwett et al., 2007), measurable behaviors that demonstrate application of those competencies were included in the TOT-COT instrument (Table 1). Easily observable QSEN behaviors were selected to confirm the feasibility of the TOT-COT instrument in capturing student experiences in clinical and simulation settings. The results of this pilot study will inform further development and testing of the TOT-COT instrument.

Observed Clinical Skills by Quality and Safety Education for Nurses (QSEN) Competency Category

Table 1: Observed Clinical Skills by Quality and Safety Education for Nurses (QSEN) Competency Category

The TOT-COT checklist was used to assess minutes spent by students in nursing care during assigned shifts. The tool was reviewed for content validity by five pediatric nurse experts before its first use to ensure that the nursing activities list demonstrated a reasonable outline of potential interventions. In this pilot study, the tool was used in more than 30 observations, comprising more than 105 hours, and the faculty observers thought it captured all the targeted competencies without need to use the “other” category.

Method

Junior-level baccalaureate students enrolled in the Child Health Nursing didactic course were asked to participate in the study. Fifteen students consented to be observed for one shift in both their inpatient site and in the pediatric simulation laboratory. Students were informed that the collected data were not to be used for evaluation of their performance but rather “for use in improving the pediatric clinical rotation.”

Using the TOT-COT checklist, the nurse investigators observed students in each setting for 210 minutes, which is the time allotted for each pediatric simulation experience. The equivalent time in the inpatient area was deemed to be 7:00 a.m. to 10:30 a.m., capturing shift report, morning medication administration, and morning nursing care. The simulation laboratory experience is a structured, scripted learning experience for which preparation and debriefing are required components. The clinical prelaboratory and postconference structure is individualized by each instructor in the clinical setting and varies greatly. Although in the clinical rotation the care needs vary by patient, the student expectations for the actual clinical experience component are highly structured. Therefore, the measure of student experiences in the two structured sections of the simulation and clinical experience was deemed the most equivalent for comparison.

Observers used the tool to account for the 3.5 hours of time, attributing each minute as “on-task” in various nursing and nonnursing activities. Student activities included collecting patient history, conducting physical assessments, listening to the change-of-shift report, communicating with other health care providers, and performing procedures. In the clinical setting, the faculty–student preconference prior to the beginning of the shift was not observed, nor was the postclinical conference. However, during simulation, these activities were included in the simulation session and were therefore included in the 210-minute observation.

Institutional review board approval was obtained from two large, urban, tertiary care children’s hospitals with a variety of pediatric subspecialty units. University institutional review board approval was garnered for the observation done in the simulation laboratory on campus.

Results

The data were analyzed for two sets of observations with a total of 13 prelicensure nursing students. Each participant was observed in both a pediatric clinical rotation at Hospital A (n = 9) or Hospital B (n = 4) and in the simulation laboratory setting for a total of 210 minutes in each place. Observers carefully noted how many minutes each student was engaged in the defined QSEN activities. The mean number of minutes spent in each QSEN activity was calculated and compared between clinical rotation and simulation laboratory settings. An effect size (Cohen’s d) was computed to quantify the magnitude of difference in time spent in QSEN activities between these two learning environments (Table 2).

Descriptives of Time (Minutes) Spent in Clinical Activities During the 210-Minute Observation (N = 13)

Table 2: Descriptives of Time (Minutes) Spent in Clinical Activities During the 210-Minute Observation (N = 13)

The most significant effect size difference was observed for the QSEN competency, patient-centered care. Table 3 elaborates on the specific activities that comprise this competency. Not surprising, students spend more time in the hospital providing patient-centered care than in the simulation laboratory. The primary activities were, in order of total time, (a) patient education, (b) documenting, (c) establishing rapport with the patient and patient’s family, and (d) assessment. It is important to provide some needed context for these results. Each of the six students in the clinical rotation were assigned one patient, whereas the six students in the simulation laboratory rotation essentially shared a single patient. In addition, the authors recognize a limitation to the research methodology, as the observers had difficulty making the distinction between establishing rapport (i.e., “How are things today?”), patient education (i.e., “Do you have any questions about the care?”), and conducting a patient assessment (i.e., “Is there anything wrong today?” and “How are you feeling?”).

Descriptives for Patient-Centered Care Activities (N = 13)

Table 3: Descriptives for Patient-Centered Care Activities (N = 13)

Discussion

In all aggregated categories, students spent more time on the QSEN activities in the hospital than in the simulation laboratory, but the variability of the time students spent in each activity was significantly greater in the hospital than in the laboratory. In other words, students were more consistent in the amounts of time spent on a given activity in the laboratory. This is likely due to the more structured nature of a simulation laboratory.

However, it is interesting to note the variety of QSEN competencies that did not receive significant amounts of time in either the clinical or simulation settings. Students spent less than 10 minutes during a 3.5-hour clinical period or simulation laboratory engaged in (a) quality improvement (2.31 and 0.62 minutes, respectively), (b) evidence-based practice (5.92 and 0.54 minutes, respectively), and (c) informatics (2.96 and 0 minutes, respectively). This is an important finding, as it indicates that the common thinking that students are sufficiently developing these skills in the clinical experience may not be true. Unfortunately, students have limited opportunity to practice these skills in the simulation laboratory.

To better quantify what students were doing in both the clinical and simulation laboratory rotations, the observers also calculated the amount of time students were unengaged in patient-related work and the amount of time spent in observation. Table 4 displays the results of the observed unengaged and observation times. Unengaged was defined as any time that the student was engaged in any nonpatient care–related activity. Observation was defined as the purposeful watching of the clinical activities of another student, another nurse, or the instructor.

Descriptives of Time (Minutes) Spent in Observation or Not Engaged in Patient-Related Activities During the 210-Minute Observation (N = 13)

Table 4: Descriptives of Time (Minutes) Spent in Observation or Not Engaged in Patient-Related Activities During the 210-Minute Observation (N = 13)

Students were more engaged in meaningful work in the simulation laboratory than in the clinical setting (8.77 unengaged minutes in the simulation laboratory versus 25.04 unengaged minutes in the clinical setting). Engagement is a key characteristic of the learning environment, and it is important to recognize that there was a moderate effect size difference (0.62) between the two settings. Also noted is the large variability of unengaged time (mean = 25.05, SD = 35.86) in the clinical setting compared with the simulation laboratory (mean = 8.77, SD = 9.81). Students in the simulation laboratory also spend more time observing other students (mean = 48.62 minutes, SD = 22.58) compared with the same students in the clinical setting (mean = 11.04 minutes, SD = 22.40). According to Bandura (1986), learning through observation can be effective if the four principles of attention, retention, production, and motivation are included in the instructional experience. The observer role in the simulation laboratory is carefully planned to maximize these principles, and the authors of the current study believe research supports that students in the simulation laboratory are indeed learning through careful and purposeful observation of their peers during a simulation experience (Lambton & Prion, 2009).

Limitations

This small exploratory study attempted to compare the amount of time spent on QSEN-related activities in the clinical and simulation laboratory settings. Because this is one of the first studies to attempt this comparison, several significant limitations exist.

Students were observed for an arbitrary amount of time in both the clinical and simulation rotations. It is possible that important activities were overrepresented or underrepresented because of the times chosen to observe the students. This results artifact occurred because the simulation and clinical experiences take different amounts of time to complete, and it was methodologically impossible to observe the students for 8 hours in the clinical setting and only 3 to 4 hours in the simulation laboratory. Another significant limitation is the possibility of a Hawthorne effect (Franke & Kaul, 1978). The trained observers accompanied the students into the patient’s room and could have influenced the student–patient–family interactions. Students could have behaved differently in the presence of the observer, and they could have performed activities that were thought to be socially or professionally desirable to the observer. The QSEN competencies were selected as the organizing framework for the observations, and it is possible that some student-initiated nursing actions were missed because they did not conform to the QSEN model. It is also clear that the instrument requires additional work, but there was no way to assess the validity of the tool, beyond construct by experts, without actually putting it into use. Based on the results, the instrument revision and refinement process will be actively continued.

Due to the intensive nature of gathering observational data, the sample size is small. Because of the limited sample size and great variability, any conclusions should be made with caution. The TOT-COT tool was untested, and further use will assist in determining validity. Some phenomena reported are due to the different periods of time during which students were observed. Students were observed for the entire 210-minute simulation laboratory period, but only for the morning part of the hospital shift. Activities surely took place before the shift began, and likely the evening before, as students consulted textbooks and online resources to develop a plan of care. Postconference, which traditionally occurs at the end of the shift, would add another dimension of learning but was not observed in this pilot study.

Conclusion

This pilot observational study was conducted to answer whether clinical and simulation settings offer equal opportunity to practice the six competencies set forth by the QSEN initiative and, further, whether the time spent in those activities in each setting were comparable. Students in this study completed a traditional pediatric clinical assignment of one patient. Our observations indicate there is significant unengaged time with this assignment and that students busy themselves with activities they can regulate, such as talking to patients and their families and talking to each other. Without control over the more important clinical activities, such as fulfilling medication and treatment orders, students fill their time to the best of their limited clinical abilities. In contrast, the simulation laboratory provides a structured environment in which students can develop skills that are not available or appropriate in the traditional clinical setting.

Table 5 summarizes some of the results of this pilot study. It seems that this particular clinical rotation integrated with simulation is helping students to develop at least three of the QSEN competencies—patient-centered care, teamwork and collaboration, and safety—but are not as focused on evidence-based practice, quality improvement, and informatics. Furthermore, although students have more opportunities in their clinical rotation for patient-centered care and developing effective communication skills, there is still time wasted in nonpurposeful interactions.

Suggested Use of Clinical and Simulation Experiences

Table 5: Suggested Use of Clinical and Simulation Experiences

QSEN competencies are acknowledged as key proficiencies for quality care and patient safety that should be attained during the student’s education in the nursing program (Brown, Feller, & Benedict, 2010; Chenot & Daniel, 2010; Cronenwett et al., 2007; Forbes & Hickey, 2009; Schlar, Ostendorf, & Kinner, 2012). This pilot study seems to demonstrate that students had the opportunity to practice nursing care activities in both settings that correspond with three of the six QSEN competencies: patient-centered care, teamwork and collaboration, and safety. In both the hospital setting and in the simulation laboratory, students were observed to spend little time engaging in the other three QSEN category activities: evidence-based practice, quality improvement, and informatics. It is difficult to conclude from these preliminary results that the clinical and simulation laboratory settings were comparable, except that both environments did not provide experiences that developed all of the QSEN competencies. Our findings are congruent with those of Smith, Cronenwett, and Sherwood (2007) and may represent actual limited opportunities for students or the weakness of the tool in capturing behaviors that signify student opportunity to develop certain QSEN competencies.

If employers expect students to have minimal competency in these important activities, then nurse educators must ensure that current teaching–learning strategies are, in fact, helping students to develop these skills. A mixed educational approach integrating simulation, classroom, and clinical experiences offers significant promise for meeting these expectations.

The potential lack of practice with all six QSEN competencies in both the clinical and simulation settings is not altogether surprising but does cause concern. This presents additional cause for nurse educators and agency leaders to join in meaningful academic–service partnerships and develop integrated learning activities that help students develop all of the QSEN competencies. Educators may use the results of this pilot study to intentionally manage clinical experiences to help students acquire these important quality care and safety competencies.

References

  • Bambini, D., Washburn, J. & Perkins, R. (2009). Outcomes of clinical simulation for novice nursing students: Communication, confidence, clinical judgment. Nursing Education Perspectives, 30, 79–82.
  • Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall.
  • Brown, R., Feller, L. & Benedict, L. (2010). Reframing nursing education: The Quality and Safety Education for Nurses initiative. Teaching and Learning in Nursing, 5, 115–118. doi:10.1016/j.teln.2010.02.005 [CrossRef]
  • Chenot, T.M. & Daniel, L.G. (2010). Frameworks for patient safety in the nursing curriculum. Journal of Nursing Education, 49, 559–568. doi:10.3928/01484834-20100730-02 [CrossRef]
  • Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P. & Warren, J. (2007). Quality and Safety Education for Nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006 [CrossRef]
  • Forbes, M.O. & Hickey, M.T. (2009). Curriculum reform in baccalaureate nursing education: Review of the literature. International Journal of Nursing Education Scholarship, 6(1). doi:10.2202/1548-923X.1797 [CrossRef]
  • Franke, R.H. & Kaul, J.D. (1978). The Hawthorne experiments: First statistical interpretation. American Sociological Review, 43, 623–643. doi:10.2307/2094540 [CrossRef]
  • Lambton, J. & Prion, S. (2009). The value of simulation in the development of observational skills for clinical microsystems. Clinical Simulation in Nursing, 5, e137–e143. doi:10.1016/j.ecns.2009.02.006 [CrossRef]
  • Pauly-O’Neill, S., Prion, S. & Lambton, J. (2011). How often do BSN students participate in pediatric critical events during simulation and hospital rotations?Clinical Simulation in Nursing, 9, e113–e120. doi:10.1016/j.ecns.2011.11.006 [CrossRef]
  • Schar, G.L., Ostendorf, M.J. & Kinner, T.J. (2012). Simulation: Linking Quality and Safety Education for Nurses competencies to the observer role. Clinical Simulation in Nursing. Advance online publication. doi:10.1016/j.ecns.2012.07.209 [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]

Observed Clinical Skills by Quality and Safety Education for Nurses (QSEN) Competency Category

QSEN CompetencyObserved Skills Related to Competency
Patient-centered careCollects history
Establishes rapport with patient and patient’s family
Performs physical assessment
Develops plan of care
Implements nursing care
Evaluates care
Performs patient education
Contacts health care team regarding patient status
Documents on flow sheets and in nursing notes
Teamwork and collaborationAsks questions to clarify
Receives and provides information
Performs SBAR
Delegates tasks
Gathers equipment
SafetyAssesses emergency equipment
Adheres to infection control
Performs “rights method” in medication administration
Evaluates medication effects
Maintains safe environment
Quality improvementFollow up
Reevaluation
Evidence-based practiceLocates or reviews policies or protocols
Utilizes resources
InformaticsNavigates electronic medical record
Records data on electronic medical record

Descriptives of Time (Minutes) Spent in Clinical Activities During the 210-Minute Observation (N = 13)

QSEN CompetencyHospital, Mean (SD)Simulation Laboratory, Mean (SD)Cohen’s d (Effect Size)
Patient-centered care98.12 (36.03)33.31 (15.26)2.34*
Teamwork and collaboration28.23 (19.38)18.92 (12.33)0.28
Safety36.38 (24.40)21.46 (15.97)0.72
Quality improvement2.31 (4.84)0.62 (1.61)0.48
Evidence-based practice5.92 (9.89)0.54 (1.51)0.76
Informatics2.96 (5.79)0 (0)0.70
Preconference–postconference0 (0)77.77 (17.96)6.12*
Unengaged25.04 (35.86)8.77 (9.81)0.62
Observe11.04 (22.40)48.62 (22.58)−1.67*

Descriptives for Patient-Centered Care Activities (N = 13)

QSEN CompetencyHospital, Mean (SD)Simulation Laboratory, Mean (SD)Cohen’s d (Effect Size)
History12.23 (5.09)2.00 (1.41)−2.74
Rapport18.80 (12.50)7.88 (9.69)−0.98
Assessment18.08 (9.01)6.5 (5.13)−1.58
Developing plan of care7.50 (6.72)0 (0)−1.56
Implementing plan of care14.88 (6.64)21.25 (14.19)0.58
Evaluating plan of care11.00 (4.00)1.0 (0)−3.53
Patient education31.43 (19.52)2.71 (1.60)−2.074
Contacts6.67 (2.89)1.67 (1.15)−2.20
Documenting19.55 (10.62)1.25 (0.50)−2.43

Descriptives of Time (Minutes) Spent in Observation or Not Engaged in Patient-Related Activities During the 210-Minute Observation (N = 13)

QSEN CompetencyHospital, Mean (SD)Simulation Laboratory, Mean (SD)Cohen’s d (Effect Size)
Unengaged in patient-related activities25.04 (35.86)8.77 (9.81)0.62
Observing patient-related activities by other students or instructor11.04 (22.40)48.62 (22.58)−1.67*

Suggested Use of Clinical and Simulation Experiences

RotationEffective forNot Effective for
ClinicalTeamwork and collaborationQuality improvement
SafetyEvidence-based practice
Patient-centered careInformatics
Simulation laboratoryTeamwork and collaborationQuality improvement
SafetyEvidence-based practice
Patient-centered careInformatics
Engagement
Observation

10.3928/01484834-20130819-02

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