The Institute of Medicine (IOM) reported that tens of thousands of Americans die each year as a result of medical errors (IOM, 1999, 2001). These reports cited several initiatives to improve patient outcomes, such as Quality and Safety Education for Nurses (QSEN) (Barton, Armstrong, Preheim, Gelmon, & Andrus, 2009). QSEN “addresses the challenge of preparing future nurses with the knowledge, skills, and attitudes…necessary to continuously improve the quality and safety of the healthcare systems within which they work” (Sullivan, Hirst, & Cronenwett, 2009, p. 323). Adapted from the IOM, The QSEN competencies were developed for nursing students to promote safe, quality patient care; they include six competencies: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.
The initial focus of QSEN was on faculty development. Nursing programs across the country were charged with integrating quality and safety content throughout the curriculum. Over a period of 1 academic year, the authors of the current article conducted monthly faculty workshops to facilitate the integration of QSEN competencies across the nursing curriculum. Resources and activities were identified that could be implemented in the classroom, simulation, and clinical settings. A postworkshop survey of faculty revealed perceived enhanced incorporation of the six acknowledged competencies across the curriculum (Bryer & Peterson-Graziose, 2014). The next logical goal was to evaluate student perceptions of quality and safety content and competencies in their nursing curriculum.
A review of the literature resulted in a limited number of studies examining student perceptions of quality and safety content. A study by Mennenga, Tschetter, and Sanjaya (2015) evaluated student perceptions regarding preparedness to perform QSEN-related skills and their perceived importance to nurses in their first year of practice. Findings regarding skill performance indicated that students perceived themselves as least prepared in the competency of quality improvement and most prepared regarding informatics. Overall, students indicated they felt somewhat prepared for most of the 22 individual QSEN related skills. Documenting and planning patient care in the electronic health record received the highest mean score within the competency of informatics. Findings regarding perceived importance indicated that quality improvement was perceived as least important by students. Assessing the presence and extent of pain and suffering received the highest mean score within the competency of patient-centered care.
In 2009, Sullivan et al. developed a QSEN Student Evaluation Survey (SES). Sullivan et al. (2009) stated,
The SES consists of [three] primary questions related to (1) knowledge: whether the content was covered in the curriculum; (2) skills: self-reported level of preparedness to perform skills; and (3) attitudes: perceived importance of the skills included in item 2,
The SES was administered to prelicensure students within 6 months of their graduation from 15 QSEN pilot schools and two bachelor of science (BS) nursing programs with QSEN core faculty. Results revealed that students perceived patient centered care, safety, and evidence-based practice as the competencies most frequently included in their curriculum. Conversely, quality improvement and teamwork and collaboration were perceived by students as the competencies least frequently included in the curriculum. Students reported that they were most prepared in skills related to patient-centered care and informatics and least prepared to perform skills related to evidence-based practice and quality improvement. Finally, students perceived competencies related to patient-centered care as most important and evidence-based practice and quality improvement as least important for nurses to be able to perform in their first year of practice.
In a small study (n = 22), Pauly-O'Neill, Cooper, and Prion (2016) looked to discover whether shortfalls existed in QSEN-related clinical opportunities in a prelicensure baccalaureate nursing curriculum. Trained observers followed students in clinical and simulation settings to see how much time was spent in various activities demonstrating the QSEN competencies. Study findings indicated students spent little to no time in quality improvement and evidence-based practice activities, followed closely by informatics.
In summary, insufficient studies exist in the literature that examine student perceptions of the integration of QSEN competencies into nursing curricula. As we move forward from the initial charge of faculty development, nurse educators need to assess for any gaps in student learning. This supports the need for additional inquiry regarding student perceptions of the QSEN competencies in nursing education. The purpose of this study was to determine student perceptions of the extent to which they acquired the knowledge, skills, and attitudes associated with the QSEN competencies in their nursing program.
Design and Sample
A descriptive cross-sectional design was used to obtain and analyze data from a convenience sample of nursing students enrolled in one of three tracks in a baccalaureate nursing program. The tracks consisted of generic, advanced standing transfer (i.e., program completion in 3 years) and RN-to-BS completion students. All enrolled students who completed at least one clinical course were eligible to participate in the study. After obtaining institutional review board approval and consent from each student, the QSEN SES tool and a demographic questionnaire were administered by the researchers (V.P.G., J.B.) during a regularly scheduled nursing theory class.
The SES was developed in 2009 by Sullivan et al. to measure student perceptions of quality and safety content in nursing curricula, levels of preparedness to perform specific skills, and perceived importance of the QSEN competencies. Survey questions are organized by knowledge, skills, and attitude scales. The knowledge scale includes 19 objectives and requires students to indicate the venues in which content was learned: classroom, course assignments/readings, clinical experiences, laboratory/simulations, or not covered. Preparedness to perform skills is measured by the 22-item skills scale, scored on a 4-point Likert-type scale. Response options include: 1 = very unprepared, 2 = somewhat unprepared, 3 = somewhat prepared, and 4 = very prepared. The attitude scale consists of 22 skill items. Students were asked to rate the importance of these skills as 1 = very unimportant, 2 = somewhat unimportant, 3 = somewhat important, and 4 = very important. The SES was found to demonstrate high reliability in this study (α = .942). The instrument yielded a reliability coefficient of .969 in a previous study by Mennenga et al. (2015).
Data analysis was conducted using SPSS® version 22.0. Item percentages, overall item mean scores, and one-way analysis of variance were calculated to determine student perceived knowledge, preparation, and importance of QSEN competencies in the nursing curriculum, as well as any differences between or within groups of students across three program tracks.
Seventy-three students from the generic (n = 18), advanced placement transfer (n = 40), and RN-to-BS (n = 15) tracks in a baccalaureate nursing program responded to the survey. The sample consisted of 27% men and 73% women ranging in age from 20 to 54 years. The majority self-identified as White (79%), followed by Black (8%), and Asian (7%). Most participants were employed off campus (85%) and had completed seven or more nursing courses (71%).
Knowledge: Student Perceptions of Quality and Safety Curriculum Content
Results obtained from participants indicated whether students perceived that learning within the content areas of QSEN competencies took place and in what venues this learning occurred (e.g., classroom, course assignments/readings, clinical experiences, and laboratory/simulation). Students also had the option to indicate that topics were not covered in the nursing curriculum. The items with the highest percentage, indicating the students' perception of the most frequently included in the nursing curriculum, correspond to the patient-centered care competency (90.4%). The percentage of items least frequently included in the curriculum corresponded to the quality improvement (45.8%) and evidence-based practice competencies (31.5%). The items most often reported as not covered belonged to the quality improvement competency (22.2%). Participants reported learning the knowledge objectives most frequently in the classroom setting (90.4%), followed by assignments/readings (81.7%), clinical setting (79.5%), and laboratory/simulation (67.1%).
Skills: Student Perception of Preparation to Perform Actions and Skills
The QSEN SES skills scale measured students' rating of their preparedness to perform specific actions or skills based on all six QSEN competencies. Higher scores indicated a perception of being better prepared in those areas. The overall mean of skill items was 3.22, indicating that students perceived they were somewhat prepared to very prepared to perform these skills. The patient-centered care competency had the overall highest mean score (3.38), and the highest overall individual item mean skill score was for “assessing the presence and extent of pain and suffering” (3.60). Conversely, the overall lowest mean competency score was in the quality improvement category (3.01), with the overall lowest scoring skill item identified as “evaluating the effect of practice changes using quality improvement methods and measures” (2.94).
Overall mean preparedness scores were calculated for each QSEN competency by program track: generic, advanced standing, and RN-to-BS completion. Participants from all three tracks indicated that they were most prepared in skills and actions related to informatics and least prepared in the quality improvement category. A one-way analysis of variance found statically significant differences between groups for the patient-centered care (F[4.28] = 2, 70; p = .018), informatics (F[2.93] = 2, 70; p = .021), teamwork and collaboration (F[2.52] = 2, 70; p = .006), and quality improvement (F[5.09] = 2, 70; p = .009) competencies. A post hoc Tukey test indicated significant differences in patient-centered care (p = .042), informatics (p = .020), teamwork and collaboration (p = .006), and quality improvement (p = .006) skill preparedness between generic and RN-to-BS completion students.
Attitudes: Perceived Importance of Quality and Safety Competencies
Study participants were asked to rate the anticipated importance of 22 skills for nurses within their first year of practice based on the QSEN competencies. Response choices ranged from 1 = very unimportant to 4 = very important. Among all students, the mean of items measuring importance of skills was 3.71, with a range of 3.53 to 3.83 for the six individual competency categories. Overall, patient-centered care skills were rated most important (3.83) and skills in the quality improvement category were rated least important (3.53). Among the individual skill items, “assess presence and extent of pain and suffering” received the highest mean score (3.88), and the skill item with the lowest mean score was “use quality improvement tools such as flow charts, cause/effect diagrams” (3.46). No statistically significant differences were found between groups of students in each program track related to the importance of identified skills.
Students enrolled in three distinct tracks of the BS program indicated that overall, quality and safety competencies were present in the nursing curriculum, and they were somewhat prepared to very prepared to perform skills related to these competencies. Students in this study perceived that content in their nursing curriculum most frequently related to the QSEN competency of patient-centered care. Students' perceptions of the competencies least frequently included in their curriculum were quality improvement and evidence-based practice. They reported that most of the information was conveyed in the classroom, followed by the clinical setting and lastly, by the college laboratory. This finding reveals an opportunity for faculty to enhance student learning of all quality and safety competencies not only in the classroom, but in the clinical and laboratory settings, as well.
Students perceived that they were most prepared to perform skills related to patient-centered care, most specifically assessing patients' pain. Conversely, students felt least prepared to perform skills related to quality improvement, especially using quality improvement tools and assessing the effects of modifications in practice. Studies by Mennenga et al. (2015) and Sullivan et al. (2009), in which similar results were found, validates these findings. All three tracks of students in the BS program reported being comfortable with the skills associated with informatics. This may be attributed to students being required to use learning platforms for course information and assignment submission. In addition, they are exposed to various clinical agencies' electronic health record systems during their clinical rotations.
Study findings indicated that a significant difference existed in student perceptions of preparedness to perform skills organized by each QSEN competency between generic prelicensure students and RN-to-BS completion students. All RN-to-BS completion students in this study were employed in acute care facilities for at least 1 year, which may account for the increased perception of preparedness among this group, compared with the generic nursing students.
Overall, students perceived the QSEN competencies to be important and valuable to their professional nursing practice. Not surprisingly, patient-centered care skills were rated as most important and skills in the quality improvement category were rated least important. This is consistent with student perceptions throughout the study.
Several limitations exist in the current study that must be considered. This study was conducted at one suburban college in the northeastern United States, and the sample size was small. Students at various levels and different tracks within the program were asked to participate in this study, which could have potentially affected the results. Overrepresentation of advanced placement transfer students is a study limitation. Replication with a larger cohort of students is recommended to ensure consistency in group size.
Considering the findings in this study, gaps remain in student learning, particularly in the area of quality improvement. An assessment of faculty knowledge of current quality improvement practices may be necessary. Focusing faculty education on teaching strategies that address this specific competency would be beneficial. Student participation in unit-based quality improvement projects may narrow the gap in knowledge, skills, and attitudes regarding quality improvement. Faculty analysis identifying where in the curriculum quality improvement teaching takes place and where it can be added may increase student perceptions of content in this competency area.
New nursing graduates must develop the knowledge, skills, and attitudes necessary to deliver safe, quality patient care. Incorporating teaching strategies that support QSEN competencies in the didactic, clinical, and laboratory settings enhances the preparation of students about to enter the health care work-force. More nursing research is needed to develop and disseminate ideas, strategies, and findings related to student perceptions of quality and safety content in their nursing curriculum. Studies that examine QSEN competency curricular integration and patient outcomes would be valuable to improve overall patient safety.
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- Bryer, J. & Peterson-Graziose, V. (2014). Integration of quality and safety competencies in undergraduate nursing education: A faculty development approach. Teaching and Learning in Nursing, 9, 130–133. doi:10.1016/j.teln.2014.04.004 [CrossRef]
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